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Clin Med II -VTE, Anemia, PVD > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

Virchow’s triad

A

stasis
vessel wall injury
hyper-coagulability

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2
Q

3rd most common cardiovascular illness

A

VTE

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3
Q

3rd most common cause of hospital related death

A

VTE

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4
Q

most common preventable cause of hospital related death

A

VTE

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5
Q

D Dimer

A

positive in presence of fibrin clot, good to rule out

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6
Q

test of choice for DX of DVT

A

compression ultrasonography

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7
Q

compression ultrasonography result if DVT

A

loss of vein compressibility, no blood flow with droppler tech

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8
Q

gold standard for DVT Dx

A

contrast venography

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9
Q

when do we do venography

A

in low risk pt with abnormal compression ultra

in high risk pt with normal compression ultra

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10
Q

when do we repeat compression ultra

A

in moderate risk pt with normal 1st compression ultra

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11
Q

the purpose of DVT tx

A

prevent PE

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12
Q

complication of DVT

A

post thrombophlebitic syndrome

chronic venous insufficiency

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13
Q

major difference in clinical presentation of DVT vs superficial thrombophlebitis

A

edema of extremity is uncommon in superficial thrombophlebitis

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14
Q

major difference in tx of DVT vs superficial thrombophlebitis

A

anticoagulation rarely required in superficial thrombophlebitis. local heat, NSAIDs are tx.

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15
Q

most common cause of PE

A

DVT (50-60% of proximal DVT embolize vs isolated calf DVT rarely embolize)

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16
Q

PE classifications

A

massive PE

submassive PE

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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

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18
Q

most common PE symptom

A

dyspnea

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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

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20
Q

most common PE sign

A

tachypnea

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21
Q

97% of pt with PE had one or more of three findings :

A

dyspnea, pleuritis chest pain, tachypnea

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22
Q

labs for PE

A

same as DVT, consider troponin and BNP

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23
Q

EKG of PE

A

S1Q3T3

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24
Q

PE signs on CXR

A

hamptons hump and wester mark

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25
Q

gold standard for PE dx

A

pulmonary angio

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26
Q

tx of VTE

A

anticoag med, thrombolytics, thrombectomy/embolectomy, IVC filter, prophylactics

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27
Q

prophylactics for VTE

A

TED hose, sequential compression devices (SCDs), low dose SQ heparin & Lovenox

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28
Q

anti coag meds

A

IV unfractionated heparin, LMW heparin, warfarin, fondaparinux, oral factor Xa inhibitors, oral direct thrombin inhibitors

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29
Q

indication for IV unfrac. Heparin

A

initial tx of VTE

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30
Q

side effects of IV unfrac. heparin

A

bleeding, thrombocytopenia

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31
Q

indication of LMWH-Lovenox

A

FDA approved for output tx of DVT and stable PE

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32
Q

side effects of LMWH-Lovenox

A

bleeding, thrombocytopenia

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33
Q

indication of warfarin

A

long term tx of VTE

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34
Q

contraindication of lovenox-LMWH

A

CrCl<30. elderly, obese

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35
Q

contraindication of warfarin

A

pregnancy category x

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36
Q

side effects of warfarin

A

bleeding

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37
Q

factor Xa inhibitors are

A

fondaparinux, rivaroxaban,

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38
Q

oral direct thrombin inhibitors

A

dabigatran (not approved in US), argatroban, desirudin, lepirudin

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39
Q

duration of anti coag tx if underlying thrombophilia

A

indefinite

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40
Q

duration of anti coat tx if cancer

A

as long as cancer is active

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41
Q

thrombolytics used for ..

A

unstable pt with PE, massive PE and cardiogenic shock, sever hypoxemia, substantial perfusion deficit on V/Q scan, RV dysfunction, entensive DVT

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42
Q

examples of thrombolytics

A

streptokinase, urokinase, rt-PA

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43
Q

IVC filter purpose

A

preventing DVT from propagating to lungs

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44
Q

absolute contraindication of IVC filter

A

active bleeding, anticoag

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45
Q

consideration of inpt vs outpt

A 
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
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46
Q

prognosis for VTE

A

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

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47
Q

RBC life span

A

120 days

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48
Q

Hgb levels in anemia

A

wm <14

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49
Q

Hgb to Htc level ratio

A

1:3

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50
Q

reticulocytes

A

immature RBCs

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51
Q

retic count

A

indication of RBC production (blue on smear)

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52
Q

normal retic count

A

.5-2.5%

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53
Q

polychromasia

A

reticulocytosis (lots of blue)

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54
Q

causes of anemia

A

decreased RBC production, Increased RBC destruction, Blood loss

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55
Q

decreased RBC production causes

A

iron def, B12, folate def, chronic dz

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56
Q

increased RBC destruction causes

A

hemeolysis

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57
Q

nl MCV

A

80-100fl

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58
Q

nl MCH

A

26-34

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59
Q

RDW indicator of what

A

indicator of the degree of variation in the size of RBC

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60
Q

nl RDW

A

11-15%

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61
Q

anisocytosis

A

variation in size

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62
Q

anemia not noticeable till

A

Hgb <7-8

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63
Q

three main categories of anemia

A

hypochromic, microcytic
normochromic, normocytic
macrocytic (megablastic)

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64
Q

hypochromic, microcytic anemia examples

A

iron deg, thalassemias, sideroblastic

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65
Q

normo anemia example

A

hypothyroidsm, liver dz, chronic dz

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66
Q

macro anemia examples

A

folate def and B12 def, hemolysis

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67
Q

ret count in hemolysis and hemorrhage

A

increased

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68
Q

retic count in B12 /folate def

A

normal

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69
Q

most common cause of micro, hypo anemia

A

fe def

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70
Q

most common causes of fe def anemia (IDA)

A

menstrual blood loss, pregnancy, GI blood loss

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71
Q

RDW in IDA is

A

elevated

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72
Q

special tests for IDA

A

serum ferritin (dec), serum Fe(dec), TIBC (inc),bone marrow biopsy

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73
Q

major iron storage and first to fall when IDA

A

serum ferritin <10ng/ml

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74
Q

dignostic of IDA

A

serum ferritin <10ng/ml

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75
Q

determining of the cause of IDA is very important because for example

A

occult malignancy like colon, upper GI CA commonly present w/anemia

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76
Q

tx of IDA

A 
replace iron store
blood transfusion (maybe)
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77
Q

transfusion for IDA?

A

only if cerebrovascular or cardiopulmonary compromise, not recommended for iron replacement

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78
Q

thalassemias definition

A

inherited disorders of hgb production : alpha and Beta

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79
Q

thalassemia minor

A

dysfunction of one beta globulin chain, asymptomatic, hypochromic, microcytic

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80
Q

thalassemia major

A

cooley’s anemia,

severe dysfunction of both beta globulin chains, most die before 30

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81
Q

thalassemia lab eval

A

poikilocytosis (abnormal shapes), target cells, nucleated RBCs, NORMAL RDW (all RBCs are small)

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82
Q

thalassemia vs IDA RDW

A

nl is thalassemia, elevated in IDA

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83
Q

thalassemia tx

A

transfusion, splenectomy, iron chelation

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84
Q

why hgb should be >9 in thalassamia?

A

to prevent skeletal deformities and fractures

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85
Q

approach to micro anemia

A

check serum ferritin:
if low–>IDA
if nl–>check serum Fe nad TIBC

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86
Q

anemia of chronic dz (ACDz)

A

common in longstanding inflammatory dz, malignancy, autoimmune, chronic infection

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87
Q

etiology of ACDz

A

abnl iron metabolism, impaired erythropoeitin production

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88
Q

lab tests for ACDz

A

normo, nl or elevated ferritin, no dx lab test

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89
Q

tx of ACDz

A

treat cause, erythropoetin

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90
Q

myelodysplastic syndrome

A

acquired disorder of hematopoietic stem cells, resulting in a refractory anemia may lead to leukemia

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91
Q

etiology of myelodysplastic anm

A

idiopathic, 2 to radiation, chemotx, toxin exposure

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92
Q

sideroblastic anm

A

heterogenous group of disorders with abnl RBC iron metabolism

93
Q

lab findings of sideroblastic anm

A

anisocytosis, poikilocytosis, ringed sideroblast, iron deposits

94
Q

fe low, TIBC elevated, ferritin low

A

iron def

95
Q

fe and TIBC nl, ferritin nl

A

no iron def

96
Q

fe and TIBC low, ferritin nl/elevated

A

ACDz

97
Q

fe high, TIBC nl, ferritin elevated

A

thalassemia

98
Q

increased ret count due to ?

A

prior of recent hemorrhage, recent hemolysis

99
Q

normal ret count due to?

A

normal bone marrow: with anemia of chronic dz, hypothyroidism, liver dz
abnormal bone marrow: myelofibrosis, leukemia, myeloma, matastases, renal failure

100
Q

megablastic anemias

A

B12 and folate def, hemolysis (can be normo)

101
Q

falsy elevated MCV due to?

A

large number of reticulocyte, RBC clumping

102
Q

if B12 not replaced?

A

subacute combined degeneration of the spinal cord

103
Q

daily B12 requirement

A

1-2 microg

104
Q

pernicious anemia

A

def in IF –> B12 malabsorbtion and megablastic anemia due to autoantibodies against parietal cells

105
Q

neuro findings in PA

A

dec. vibratory and position sense, ataxia, paresthesias, confusion, dementia

106
Q

peripheral smears of PA

A

hypersegmentated neutrophils, anisocytosis, poikilocytosis, macro-ovalocytes, low platlets

107
Q

lab findings of PA

A

low serum B12, positive Schilling test or antibodies to IF, elevated serum methylmalonic acid and homocysteine levels

108
Q

Tx of PA

A

parenteral vitamin B12, Do not tx B12 def with folic acid alone

109
Q

folic acid daily requirement

A

200 microg/day (400-800 for pregnants)

110
Q

how long does it take to show folic acid def macro anemia?

A

4-5 months

111
Q

folate def is common in

A

alcoholism, end of pregnancy, anticonvulsant therapy (enzyme inhibition reduces folate absorption), malabsorption syndromes, hemolytic anemias including sickle cell.

112
Q

lab findings in FA def anemia

A

low serum folate level, homeosystein level is elevated but serum methylmalonic is normal

113
Q

normal marrow can sustain RBC production ….nl

A

2-5 times

114
Q

marrow cannot compensate for RBC survival time less than …

A

20 days

115
Q

clinical findings of H anemia

A

jaundice, gallstones, increased risk of salmonella and pneumococcus

116
Q

classifications of hemolysis

A

intravascular: destruction w/in blood stream
extravascular: destruction in the reticuloendothelia system like spleen

117
Q

lab findings in hemolysis

A

elevated retic count (polychromasia), increased unconjugated bilirubin, elevated serum LDH, plasma hgb increased (hemoglobinuria)

118
Q

serum haptaglobin is low in …

A

intravascular helysis

119
Q

peripheral smear in hemolysis anemia

A

immature RBCs, nucleated RBCs, possible schistocytes

120
Q

polychromasia ?

A

reticulocytosis, lots of blue –> lots of new

121
Q

intravascular hemolysis classification

A

1.fragmentation syndromes 2. red cell enzyme defects 3.paroxysmal nocturnal hemoglobinuria

122
Q

fragmentation syndrome

A
  1. traumatic (macroangiopathic) from prosthetic valve 2. microangiopathic caused by RBC disruption from fibrin strands in vessles
123
Q

red cell enzyme defects

A

G6PD def (Heinz bodies)

124
Q

Heinz bodies a/w

A

G6PD

125
Q

schistocyte a/w

A

fragmentation syndrome

126
Q

extravascular hemolysis

A

1.hereditary spherocytosis 2. sickle cell anemia 3. autoimmune hemolytic anemia 4. incompatible blood transfusion 5. drug-induced hemolytic anemia

127
Q

positive osmotic fragility test for ?

A

hereditary spherocytosis

128
Q

positive coombs test (also called DAT)

A

autoimmune hemolytic anemia

129
Q

RBCs in Hereditary Spherocytosis

A

normal MCV, smaller surface area, dense, globular appearance, lack central pallor , poorly deformable , trapped in splenic sinusoids, phagocytized by splenic macrophages

130
Q

clinical features of HS

A

mild jaundice, scleral icterus, splenomegaly,

131
Q

why need for increased folate in HS

A

chronic hemolysis

132
Q

what test for HS

A

osmotic fragility test : increased hemolysis in hypotonic fluid

133
Q

HS Tx

A

1.splenectomy : RBC lifespan to normal, remove risk of bilirubin gallstones 2. pnemococcal vaccine

134
Q

sickle cell anemia

A
  1. homeozygos form : sickle cell Dz with symptoms

2. heterozygos form: sickle cell trait no symp but carriers

135
Q

male and female affected equally in …

A

sickle cell anemia

136
Q

RBCs in sickle cell anemia

A

sickle shaped when deoxy causing pain

137
Q

sign and symptoms of sickle cell anemia

A

delayed growth, increased susceptibility to infections, dehydration, hypoxia, high altitude, intense exercise

138
Q

clinical features are due to..

A
  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
Q

most common feature of SS dz ?

A

pain in back, ribs, limbs lasting 5-7 days, tx with analg and fluid

140
Q

lab finding of SS

A

low Hb,normo RBCs, elevated retic count, Hb electrophoresis reveals Hb S

141
Q

screen SS with …test

A

sickledex

142
Q

peripheral smear in SS

A

few sickled RBCs, nucleated RBCs, target cells, howell-jolly bodies, thrombocytosis

143
Q

tx of SS dz

A

RBC transfusion PRN, analgesics, fluid, O2, hydroxurea, bone marrow tp

144
Q

chemotx

A

hydroxyurea suppresses bone marrow function of all cell lines

145
Q

auto immune hemolytic anemia

A

RBCs with antigen-antibody complex are phagocytized by macrophages, and spherocytes are formed, they become smaller and destroyed in spleen.

146
Q

smear of AI HA

A

polychromasia, spherocytosis, nucleated red cell

147
Q

tx of Hemolysis

A

cause, corticosteroids, splenectomy, folic acid

148
Q

incompatible blood transfusion

A

results in hemolysis

149
Q

what test for incompatible BT

A

coombs test can detect antibodies

150
Q

hemolytic dz of new born is a

A

incompatible BT (erythroblastosis)

151
Q

aplastic anemia

A

acquired abnormality of bone marrow stem cells selective or total RBC, WBC, platelets

152
Q

causes of aplastic anemia

A

chemical exposure, viral, ionizing radiation

153
Q

hallmark of aplastic anemia

A

pancytopenia (anemia, leukopenia, thrombocytopenia)

154
Q

clinical features of aplastic anemia

A

pancytopenia, absence of precursors for normoblasts, ganulocytes, megakaryocytes in bone marrow, weakness, infections, bleeding.

155
Q

tx of aplastic anemia

A

cause, r/o other infections, hematology referral for blood component replacement, bone marrow transplant, immunosuppressive tx

156
Q

preferred tx for aplastic anemia

A

bone marrow tp

157
Q

infections resembling aplastic anemia

A

acute leukomia, myelodysplasia, PNH, granulomatous infxn such as TB

158
Q

leading cause of disability in US

A

stroke

159
Q

80% of strokes are

A

ischemic, rest is hemorrhagic

160
Q

stroke risk factors

A

hx of neuro symp, degree of carotid stenosis, plaque charachteristics

161
Q

symptomatic pt for stroke

A

contralateral weakness, contralateral sensory deficits, amaurosis fugax or hollenhorst plaque.

162
Q

high risk groups for imaging of carotid bifurcation dz

A

> 60 yo and one of : HTN, CAD, current smoking, 1st degree relative with Hx of stroke

163
Q

management of asymptomatic carotid stenosis

A

tx HTN, Hyperlipidemia, DM, smoking, aspirin

164
Q

indication for surgery/intervention

A
  1. carotid endarterectomy (CEA)

2. carotid artery stenting (CAS)

165
Q

chronic aorto-illiac occlusive dz

A
  1. younger female 2. smoker with hyperlipidemia 3. small infrarenal aorta 4.chronic lower limb ischemia
166
Q

tx of chronic aorto-illiac occlusive dz

A
  1. aortic bypass 2. endovascular angio +/- stenting
167
Q

acute aortic occlusive dz

A

1.vascular emergency 2. saddle embolism 3. in situ thrombosis of already diseased segment

168
Q

presentation of acute aortic occlusive dz

A

neuro def (paralysis), absent femoral pulses

169
Q

tx of acute aortic occlusive dz

A

quick imaging and operation

170
Q

aneurysm definition

A

abnormal vessel dilation

171
Q

dissection

A

a tear in intima and blood penetrates into media which splits longitudinally

172
Q

aortic aneurysmal dz

A

degenerative and remodeling of aortic wall,

173
Q

causes of aortic aneurysmal dz

A

genetic predisp, atherosclerotic, infection (TB, Syphilis), Marfans, Ehlers-Danlos

174
Q

atherosclerotic aneu. 95% affects

A

abdominal aorta

175
Q

AAA dx

A

UTZ: dx and size

CT/MRI: plan endovascular therapy

176
Q

AAA management

A

follow up if 5.5 cm, symptomatic, rapid expansion

177
Q

AAA

A

majority asymptomatic

178
Q

most common complaint in AAA

A

back pain

179
Q

ruptured AAA a/w

A

abd pain, pulsatile abd mass, tenderness, hypotension

180
Q

surgical repair of AAA

A

w/ dacron graft, percutaneous endovascular stent grafts,

181
Q

aortic dissection can occur secondary to ?

A

connective tissue dz,aneurysm, HTN, trauma

182
Q

type of pain in aortic dissection

A

acute onset of tearing pain in either chest or abd

183
Q

aortic dissection medical management

A
  1. beta blockers, 2. add vasodilators like Nipride
184
Q

complication of aortic dissection

A

aortic rupture, cardiac tamponade, acute aortic regurg, acute coronary ischemia

185
Q

Peripheral vascular dz

A

arterial (PAD)

venous

186
Q

PAD

A

asymptomatic, intermittent claudication, critical leg ischemia-limb threat

187
Q

intermittent claudication is a/w

A

PAD

188
Q

peripheral venous dz

A

venous thrombosis, varicose veins, chronic venous insufficiency

189
Q

most common form of PAD

A

chronic arterial insufficiency

190
Q

chronic arterial insufficiency is most common in

A

elderly

191
Q

underlying cause of chronic arterial insufficiency is

A

atherosclerosis

192
Q

physical exam inspection finding in PAD

A
  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
Q

PE palpation findings in PAD

A
  1. pulses: femoral, popliteal, dorsalis pedis, posterior tibial 2. temp: cool 3. capillary refill: delayed
194
Q

ABI (ankle-brachial index) is a/w

A

PAD , >1 nl

195
Q

most common sites of PAD

A

superficial femoral and popliteal

196
Q

atherosclerotic plaques frequently occur at ?

A

bifurcation: aortic, iliac, femoral

197
Q

main symptom of PAD

A

claudication : ischemic pain in lower legs when walking resolve when standing or rest

198
Q

claudication is more common in

A

calves (less frequent in buttocks and thighs)

199
Q

Leriche syndrome

A

aortoiliac dz

200
Q

Leriche syndrome vs venous dz

A

leg/foot pain usually improves when leg in dependent position; worsen when leg is raised. the opposite of venous dz.

201
Q

rest pain?

A

with sever Leriche syndrome.

202
Q

claudication worse prognosis

A

smoking and diabetes with overall amputation risk of 20%

203
Q

non invasive testing for PAD

A

treadmill test/ABI, duplex ultrasound, magnetic resonance angio

204
Q

claudication medical therapy

A
  1. stop-start walking regimen 2. SMOKING CESSATION 3.lipid lowering, 4. aspirin 5. clopoidogrel 6. pentoxifylline 7. cilostazol
205
Q

indications for intervention claudication

A

impacting life style despite therapy, rest ischemia, limb threat

206
Q

claudication surgical approaches

A
  1. endarterectomy 2.percutaneuos transluminal angioplasty(PTA) 3. stents 4. revascularization
207
Q

endarterectomy

A

removal of atherosclerotic plaque

208
Q

PTA

A

for localized dz w/short segments of obstructing plaque

209
Q

stent for claudication

A

alternative to simple angioplasty

210
Q

revascularization for claudication

A

aortofemoral bypass graft, femoral-popliteal, axillary-femoral

211
Q

balloon angioplasty

A

one approach to limited PVD

212
Q

bypass grafts are used for

A

aortoiliac and femoral-popliteal

213
Q

Goretex grafts are most common for

A

fem-pop

214
Q

claudication is a marker for..

A

systemic atherosclerosis

215
Q

focal aortoiliac or iliac dz should be treated w/

A

angioplasty /stenting

216
Q

occlusion longer than 5 cm, concomitant aneurysm, or in common femoral a. are better treated w/

A

surgery

217
Q

initial tx in fem-pop dz

A

prolonged course of medical therapy

218
Q

acute arterial obstruction

A

sudden cessation of blood flow to an extremity due: Acute Emergency

219
Q

cases of acute arterial obstruction

A

embolism ( usually, from heart or aorta), thrombus in situ

220
Q

5 Ps of acute obstruction

A

pain, pallor, paresthesia, paralysis, pulselessness

221
Q

tx of acute obstruction

A

emergency: thrombectomy/embolectomy-dissolve via thrombolytic infusion-anricoag (heparin)-surgical bypass

222
Q

raynaud’s phenomenon

A

episodic digital schemia on exposure to cold or emotional stress

223
Q

triphasic response in raynauds

A

pallor, cyanosis, rubor

224
Q

cause of raynaud

A

arterial vasospasm followed by arteriolar and capillary dilation

225
Q

2 categories of raynaud

A
  1. raynaud dz: primary /idiopathic when 2ndary causes are excluded ~50%
  2. 2ndary raynauds phenomenon
226
Q

drug tx for raynauds

A

ca channel blockers (nifedipine, diltiazem), reserpine (adrenergic blocker), prazosin (alpha 1 adrenergic blocker)

227
Q

varicose vein sx

A

aching/burning sensation, tired/heavy, worse w/standing, better by elevation (UNLIKE ARTERIAL DZ)

228
Q

varicose veins signs

A

prominent surface veins, superficial thrombosis, rupture/local bleeding, stasis dermatitis (dark pigmentation), ulceration esp. NEAR ANKLE, edema

Clin Med II -VTE, Anemia, PVD (1 decks)

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