Exam 3, Darrow, chest pain and fever

Question 1

tick bite in New England 2 mo ago
biphasic high pitched squeaky sound at left sternal border, louder with expiration and leaning forward
inverted T waves on EKG
most likely Dx?

Answer 1

chronic pericarditis

Question 2

firemans cap is concave or convex

Answer 2

convex. pericarditis is concave

Question 3

what position makes pericarditis worse

Answer 3

worse laying down, relieved by sitting

Question 4

what are common causes of pericarditis

Answer 4

viral (coxsackie or echo)
TB
bacterial
uremia
neoplastic
inflammtory reaction/Dresslers
radiation
drugs
myxedema

Question 5

what cause heart block myocarditis or pericarditis or both?

Answer 5

myocarditis

Question 6

do you need a pacemaker if heart block has narrow QRS

Answer 6

no

Question 7

what is classic triad for early disseminated lyme disease

Answer 7

acute neurlologic abnormalities is meninfitis, cranial nerve neuropathy and motor or sensory radiculopathy

Question 8

what is cardiac involvement with early disseminated lyme disease

Answer 8

heart block and myopericarditis

Question 9

DM renal failure
BUN 120
creatinine 6.2
dyspnea, fatigue, neck vein distention, muffled heart sounds and BP 90/70
EKG shows electrical alterans
What does the triad suggest? EKG?

Answer 9

Becks triad

cardiac tamponade

Question 10

what is pulses paradoxus indicative of

Answer 10

cardiac tamponade

Question 11

a decreased y descent (more shallow) is seen in what cases

Answer 11

tricuspid stenosis and cardiac tamponade

Question 12

55 female with chest trauma with fatigue, weakness, inc JVP, edema, hepatomegaly and ascites
Kussmaul sign present
These signs suggest what?

Answer 12

constrictive pericarditis

Question 13

What is Kussmaul sign

Answer 13

vein increases in size during inspiration

Question 14

what conditions are seen with kussmaul

Answer 14

COPD, pulm HTN with RV failure, rarely cardiac tamponade

Question 15

If atrial emptying is abrupt and sharp (steep y descent on jugular curve) what does that suggest? “M configuration or W

Answer 15

constrictive pericarditis

Question 16

What are other signs of constrictive pericarditis

Answer 16

diatolic pericardial knock (like S3) and echo from rapid early filling
square root sign- heart cath, rapid ventricular filling followed by plateau phase durine rest of diastole because of rigid pericardium

Question 17

what are causes of constrictive pericarditis

Answer 17

TB
post radiation
cardiac surgery
viruses and trauma

Question 18

what are some restrictive cardiomyopathies that may present like restrictive pericarditis

Answer 18

amyloidosis, endomyocardial fibrosis, hemochromatosis, sarcoidosis
decreased ventricular filling

Question 19

how do you differentiate restrictive cardiomyopathy vs constrictive pericarditis

Answer 19

look at EDPressure in LV and RV, in constrictive pericarditis they are equal
BNP elevated in restrictive cardiomyopathies or LV diastolic dysfunction

Question 20

What is Tx for constrictive pericarditis

Answer 20

torsemide

pericardectomy

Question 21

homeless man iwth right hemiparesis
had fever 101F covered in lice
total 6 blood cultures had been negative
diastolic decrescendo murmur at Erbs
What is this?

Answer 21

fever of undetermined origin

Question 22

What can cause a FUO fever of undetermined origin

Answer 22

Infection:TB, endocartis, occult abscess
Cancer:lymphoma, leukemia
Autoimmune/CTDisease: Still’s, SLE, cryoglobulinemia, PAN
Mischellaneous: sarcoid, FMF, whipples thyroiditis

Question 23

What are the main criteria for duke criteria endocarditis

Answer 23

two positibe blood cultures
ECHO evidence of endocardial involvement
new regurgitant murmur

Question 24

what are the minor criteria for duke criteria endocardtitis

Answer 24

predisposing condition
fever of 100.4 or higher
vascular emooli: janeway lesion, splinter hemorrhages, mycotic aneurysm, conjunctival or cutaneous hemorrhage, PE, strok, MI
Immunologic phenomena with agglutinating Ab: (osler node- painful and vasculitic), roth spots, RF, GN(hematuria and proteinuria)

Question 25

what is considered a + dukes criteria for endocarditis

Answer 25

2 major criteria one major and 3 minor 5 minor

Question 26

what are predisposing conditions to infective endocarditis

Answer 26

regurgitant valves, bicuspid valves, rheumatic valves, calcific valces, MVP, PDA, coarctation, VSD

Question 27

IV drug use predominately will affect what valve

Answer 27

tricuspid

Question 28

native valve endocarditis are acused by what pathogens

Answer 28

staph, strep viridans, bovis, Group D strep or HACEK

Question 29

what pathogens affect prosthetic valve early on? how about after 2 mo

Answer 29

early- staph | late- strep or staph

Question 30

how do you Dx endocarditis

Answer 30

raw 3 cultues one hour apart

Question 31

If culture for endocarditis is negative what do you do next

Answer 31

think fungi special media to grow legionella, bartonella and abiotrophia now growth on artifical media- whipelli and psittacosis slow growing with prolonged incubation- Brucella anareobes (HACEK + by 5 days)

Question 32

third most common infection from human bite

Answer 32

eikenella

Question 33

how can endocarditis lead to abdominal aortic aneurysm

Answer 33

mycotic aneurysm

Question 34

complications of endocarditis

Answer 34

heart blok, CHF, emboli, mycotic aneurysms, myocardial abscess

Question 35

Patient with cat and endocarditis was most likely what organism

Answer 35

coxiella burnetti

Question 36

coxiella infection is Tx with what

Answer 36

doxy

Question 37

strep endocarditis is Tx how

Answer 37

penicillin

Question 38

enterococcal endocarditis is Tx how

Answer 38

penicillin with gentamicin

Question 39

Staph endocarditis is Tx how

Answer 39

nafcillin, if MRSA- vancomycin

Question 40

if there is staph on prosthetic valve what do you use to Tx

Answer 40

vancomycin gentamycin Rifampin-- kills foreign material

Question 41

strep bovis endocarditis, where did it come from

Answer 41

GI tract | usually GI neoplasms

Question 42

strep mutans endocarditis came from where

Answer 42

dental

Question 43

enterococci endocarditis is common in what population

Answer 43

elderly wiht urinary problems

Question 44

HACEK endocarditis will grow on media when

Answer 44

around 5 days or more

Question 45

no growth on media from endocarditis could be what

Answer 45

tropheyma, Q fever

Question 46

When do you use antibiotic endocardtisi prophylaxis

Answer 46

previous IE prosthetic valves or material cyanotic congenital heart disease (tetralogy of fallot, eisenmenger syndrome) (not so if repaired >6 mo)

Question 47

You give prophylactic antibiotics to patients with high risk endocarditis if they are having surgery in what areas?

Answer 47

teeth, lungs and skin

Question 48

what antibiotic is given for dental procedures in someone with infective endocarditis

Answer 48

amoxicillin

Question 49

fever, weight loss, leukocytosis, elevated sed rate, elevated RF and episodic pulmonary edema and syncope, especially with standing recent troke diastolic rumble with ocassional extra sound at mitral valve area upon standint osler node on right great toe most likley has?

Answer 49

atrial myxoma which is giving off emboli that present like endocarditis with negative cultures.

Question 50

why do you get syncope with standing with an atrial myxoma

Answer 50

gravity pulls myxoma down and occludes mitral or tricuspid valve

Question 51

patient has endocrine neoplasia, pigmented skin lesions and atrial myxoma, what is this

Answer 51

Carney complex

Question 52

What causes Carney complex

Answer 52

cAMP activated PKA with activated cell proliferation, multiple neoplasia syndrome