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PCMIII Ex2 > Exam2 > Flashcards

Exam2 Flashcards

1
Q

Pressure, squeezing, sharp, burning

Radiates to back or jaw, shoulders, arms upper abdomen

A

Acute Coronary Syndrome

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2
Q

Patients with ACS the frequency of atypical presentations is increased in these groups:

A
  1. Older patients >75
  2. Women
  3. Diabetes mellitus
  4. Impaired renal function
  5. Dementia
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3
Q

Atypical symptoms of acute coronary syndrome

A

Epigastric apin
Indigestion
Stabbing or pleuritic pain
Increasing dyspnea in the absence of chest pain

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4
Q

Modifiable Risk factors for Cardiovascular disease

Nonmodifiable Risk factors

A

Nonmodifiable

  1. Age
  2. Family history
  3. Gender

Modifiable

  1. HTN
  2. Obesity
  3. High density lipoproteins/ Dyslipidemia
  4. Diabetes
  5. Smoking
  6. Sedentary lifestyle
  7. Obesity
  8. Stress
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5
Q

Negative risk factor for cardiovacular disease

A

HDL >/= 60 mg/dl

Protective

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6
Q

Nonspecific EKG Findings
May have inverted T wave
Normal Cardiac enzymes

A

Unstable angina

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7
Q

Normal or May have ST depression
T wave inversion
Elevated Cardiac enzymes

A

NSTEMI

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8
Q

ST segment elevation
LBBB
Elevated cardiac enzymes

A

STEMI

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9
Q

Immediate treatment of ACS

A

MONA-B

Morphine: 2 mg IV q4hr
O2: regardless of saturation
Nitroglycerine (NTG): 0.3 mg sublingual 5 min x3 for chest pain
Aspirin (ASA): 325 PO coated chewable
Beta blocker: if not contraindicated
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10
Q

Labs for ACS (6)

A
  1. CBC, CMP
  2. Cardiac markers
    - Troponin I or T immediately repeat Q6h x3
  3. CXR
  4. EKG: Immediately upon presentaion Q8h x3
  5. Lipid panel: fasting
  6. Urine drug screen
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11
Q

What to do if uncontrollable chest pain, new left bundle branch block or STEMI

A

STAT cath lab

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12
Q

NTG and phosphodiesterase inhibitors (Sildenafil- Viagra)

A

Absolue contraindication
-secondary to hypotensive effects secondary to systemic vasodilation

Can result in severe hypotension or even death

Use of phosphodiesterase inhibitors within 24 hr of presentation is a contraindication to use NTG

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13
Q

Chapman reflex of myocardium

A

2nd ICS along sternal border

Intertranserve spaces between T2-3

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14
Q

Chapman reflex of Bronchus

A

2nd ICS along sternal border

Lateral to T2 spinous process

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15
Q

When take immediately to Cath lab

A

Uncontrollable chest pain
New Left bundle branch block
STEMI

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16
Q

Chapman reflex of upper lung

A

3rd ICS along sternal border

Intretransverse space between T2-3 and intertransverse space between T3-T4

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17
Q

Chapman reflex of lower lung

A

4th ICS along sternal border

Intertransverse space between T4-T5

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18
Q

Chapman reflex 2nd ICS along sternal border

A

Myocardium

Bronchus

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19
Q

Chapman reflex 3rd ICS along sternal border

A

Upper lung

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20
Q

Chapman reflex 4th ICS along sternal border

A

Lower lung

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21
Q

Chapman reflex Intertranserve spaces between T2-3

A

Myocardium

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22
Q

Chapman reflex Intertranserve spaces between T2-3 and T3-4

A

upper Lung

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23
Q

Chapman reflex Lateral to T2 spinous process

A

Bronchus

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24
Q

Chapman reflex Intertranserve spaces between T4-5

A

Lower lung

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25
Chest high pitched sounds (5)
``` Use diaphragm S1 S2 AR MR Friction Rubs ```
26
Chest low pitched sounds
``` Use bell S3 S4 MS Carotid bruit ```
27
Steps to CV Exam (4)
1. Inspection 2. Palpation 3. Percussion 4. Auscultation
28
PMI Location
near the 4th -5th ICS in the Mid-clavicular line
29
PMI - size - timing
small brisk beat, measured less than 2.5 cm Impulse should last through the first 2/3 of the systolic period (or less) It should not be felt through the second heart sound
30
R 2nd ICS at SB
Aortic valve
31
L 2nd ICS at SB
Pulmonic valve
32
L 4th ICS at SB
Tricuspid valve
33
L 5th ICS at mid-clavicular line
Mitral valve
34
S1 sound
Closure of the Tricuspid and mitral valves
35
S2 sound
Closure of the aortic and pulmonic valves
36
S3 sound
Dull low pitch best heard w/ bell Due to high pressures and abrupt deceleration of inflow across the mitral valve at end of the rapid filling phase Pathologic > 40 Kent-Tuck-Y
37
Pulmonic valve
L 2nd ICS at SB
38
S4 sound
Dull low pitch best heard w/ bell Atrial gallop from forceful contraction of atria against a stiffened (low compliant) ventricle Can be normal in trained athletes Ten-Nes-See
39
Systolic murmurs
Between S1 and S2 Aortic Stenosis Pulmonic Stenosis Mitral Regurgitation Tricuspid Regurgitation
40
Tricuspid valve
L 4th ICS at SB
41
Diastolic murmurs
``` Falls between S2 and S1 Aortic regurgitation Pulmonic regurgitation Mitral stenosis Tricuspid Stenosis ```
42
``` Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 ```
Grade 1: Very faint Grade 2: Quiet but heard easily w/ stethoscope Grade 3: Moderately loud no thrill Grade 4: Loud w/ palpable thrill Grade 5: Very load w/ thrill, may be heard partially off chest Grade 6: heard with stethoscope entirely off chest
43
Aortic Valve
R 2nd ICS at SB
44
Moderately loud no thrill
Grade 3
45
Loud w/ palpable thrill
Grade 4
46
Grade 4+ on pulse
Bounding
47
Mitral valve
L 5th ICS at midclavicular line
48
Grade +1 edema
Slight pitting 2 mm | disappears rapidly
49
Grade +2 edema
``` Slight indentation (4 mm) 10-15 sec ```
50
Grade +3 edema
``` Deeper indentation (6mm) may be >1 min ```
51
Grade +4 edema
Very marked indentation (8mm) | 2-5 minutes
52
Fatigue, dyspnea, hemoptysis
Nontuberculosis Mycobacterial infection NTM M. Kansaii
53
NTM dx:
sputum culture (Cx) and molecular diagnostic
54
Pneumonia Nodules Cavitation
Fungal infection
55
Fungal dx:
Sputum culture | Regional exposure
56
Fever cough, chest pain, hemoptysis, dyspnea
Lung cancer
57
Lung cancer dx
Histopathology
58
Hilar lymphadenopathy
Sarcoidosis | Can have cavitary lesions
59
Sarcoidosis dx
Histopathology- noncaseating granulomas
60
Septic emboli dx
blood culture | echocardiogram
61
Fever, cough, sputum production
Lung abscess
62
Lung abscess dx
CXR: air fluid levels in cavitary lesion | Other pulmonary infiltrates
63
What to do when positive TST test w/ history of BCG vaccination
IFN-gamma release assay
64
>5 mm induration
HIV Close contact Fibrotic changes consistent w/ TB Immunosuppression
65
>10 mm induration
Silicosis, DM, Chronic renal failure, malignancies, malnourished, IV drug abuse Children <4 Foreign Healthcare employee Homeless/ jail
66
>15 mm induration
Healthy
67
Sputum culture for tuberculosis is a ___ diagnosis
Microbiological diagnosis
68
What is the gold standard for TB diagnosis
Culture
69
Inital screening stain for TB
Rhodamine-auramine stain
70
Confirmatory AFB stain for TB
Ziehl-neelsen and/or Kinyun stain
71
Interferon gamma release assay (IGRA) indicates
There has been a cellular response to tuberculosis
72
Nucleic acid amplification test (NAAT)
utilized in conjunction with a smear that is positive for AFB while cultures are pending
73
NAAT-TB
detects tuberculosis genetic material
74
NAAT-R
detects INH and rifamprin resistance
75
Red orange body fluids
Rifampin
76
Steven johnson syndrome
Rifampin
77
Peripheral neuropathy
Isoniazid (INH)
78
Gout hyperuricemia
Pyrazinamide
79
Optic neuritis, color blindness
Ethambutol
80
Next step after patietn diagnosed w/ TB report
report to state or local public health (24 hrs)
81
TB control hierarchy (3)
1. Administrative controls - management measures to decrease risk of exposure - minimize the number of areas with exposure may occur 2. Environmental controls (negative pressure room) - Prevent spread and reduce concetnration of infectious droplet - control source by local exhaust ventilation (hoods) - control air flow - respiratory protective equipment 3. Respiratory cotnrols - use of personal protective equipment - training health care workers - educate patietns on respiratory hygiene and cough etiquette
82
Types O2 delivery (5)
1. Room air= FiO2 21% 2. Nasal cannula (NC)= 1-6 liters, 24-44% 3. Simple face mask= 6-10 liters, 40-70% 4. Venturi mask= 3-15 liters, 24-50% 5. Non-rebreather (NRB)- 15 liters, bag reservoic 80-100%
83
Tension pneumothorax location needle decompression
2nd ICS just superior to 3rd rib margin at the midclavicular line
84
Chest tube insertion location
4th ICS at mid or anterior axillary line in the 4th intercostal space just superior to the margin of the 5th rib
85
Increased tactile fremitus
pneumonia
86
Decreased/ absent fremitus
COPD Pleural effusions Fibrosis Pneumothorax
87
Dullness replaces resonance
Lobar pneumonia Pleural effusion Hemothorax
88
Hyperresonance
COPD Emphysema Asthma
89
Unilateral hyperresonance
Pneumothorax
90
Breath sound over most lungs
Vesicular | Soft and low pitched
91
bronchovesicular breath sounds
Intermediate in intensity and pitch equally inspiration and expiration Heard best 1st and 2nd ICS anterior and between scapulae
92
Bronchial breath sounds
Loud and high pitched Expiratory sounds heard longer than inspiratory Heard best over manubrium
93
Tracheal breath sounds
Very loud and high pitched Heard equally in inspiration and expiration Heard best over trachea of neck
94
Wheeze that is entirely or predominantly inspiratory in nature
Stridor Medical emergency Partial obstruction of larynx
95
Weber/rinne test
lateralizes to one ear (conduction loss in that ear or sensorineural loss in opposite) Bone conduction>AC then conductive loss to that ear
96
Most accurate place for skin tenting
Forehead
97
Acute phase reactants that go down w/ infection/inflammation
Albumin | Transferrin
98
Positive acute phase reactants
``` ESR CRP Ferritin WBC haptoglobin Ceruloplasmin ```
99
Diagnostic criteria for AKI | KDIGO
Increase serum creatinine > 0.3 mg/dL within 48 hrs or >50% within 7 ways or urine output of <0.5 in > 6 hrs
100
Hyperkalemia
serum k > 7.0 meq/L
101
Tall peaked T waves | Loss of Pwaves
Hyperkalemia
102
Tx hyperkalemia
Give calcium gluconate | Give Insuin & glucose
103
SIRS
2 or more 1) Temp > 38 C (100.4F) or <36 2) HR > 90 3) Resp rate >20 or PaCO2 <32 4) WBC >12,000
104
Most common UTI
E coli
105
Honeymoon cystitis
Staph saprophyticus
106
Viscero-somatic reflex kidneys
T10-11
107
Dialysis therapy
Fluid overload Hyperkalemia Metabolic acidosis
108
BUN:Cr ratio in upper GIB
30:1
109
Division Upper GIB vs lower GIB
Ligament of Trietz
110
Abruptly stopping a beta blocker can lead to
Rebound sinus tachycardia
111
Fast of KCL in peripheral IV
10mEq/ hr
112
When to transfuse
Young patients w/ comorbidities: Hemoglbin <7 g/dL Olderpatients w/ comorbid require >9 g/dL
113
Colorectal cancer screening
regular starting at 45 --> 75 no longer at 85 first degree relative diagnosed before 60 - every 5 years beginning at 40 or 10 years before age of relative Famililal adenomatous polyposos - genetic testing, annual screening by sigmoidoscopy starting at age 10-12 yrs Hereditary nonpolyposis colorectal cancer -genetic testing or colonscopy every 1-2 yrs being at 20-25 or 10 years younger than age of diangosis in family
114
ASCA positive
Crohns
115
Crohns descriptors
``` Skip lesions String sign Non-caseating granuloma Abscesses Fissures Cobble stoning Creeping fat ```
116
UC descriptors
Continous lesions Bloody diarrhea Toxic megacolon Ulcerated pseudopolyps
117
pANCA positive
UC
118
Check what before immunomodulatory or biologic medication
TPMT (Thiopurine methyltransferase) enzyme activity- metabolizes azathiopurine PPD skin test for TB Viral hepatitis serology
119
AAA size
>/= 3 cm
120
Cecum
lateral proximal 1/5th of right thigh | anteriorly on tensor fascia lata
121
Ascending colon
R lateral middle 3/5th of thigh, anterior distribution of IT band
122
Transverse colon
Proximal to knee, anterolateral aspect of thigh bilaterally
123
Sigmoid colon
Lateral proximal 1/5th of left thigh anteror on tensor fascia lata
124
Descending colon
L lateral middle 3/5th of thigh, anterior distribution of IT band
125
Rectum
Medial aspect of proximal thigh over lesser trochanters bilaterally Posterior: sacrum, at lower end of SI articulation bilaterally
126
Colon posteriorly
Transverse process L2 to TP of L4 extending laterally to iliac crest
127
Adrenals chapman
2-2.5 above and lateral umbilicus Intratransverse space T11-T12
128
Kidney chapman
1 above 1 lateral umbilicus intertransverse spaces between T12-L1
129
Ureter chapman
1 above 1 lateral umbilicus Intertransverse spaces between L1-L2
130
Bladder chapman
Periumbilical/ umbilical Superior edge of L2 TP
131
Urethra chapamn
Inner edge of pubic ramus near symphysis Superior edge of L2 TP
132
Viscerosomtics
``` Heart: T1-5 Lungs: T2-7 Esophagus: T2-T8 Stomach: T5-T9 Liver T6-T9 Gallbladder T6-9 SI: T9-T11 Colon: T10-L2 Pancreas: T5-T11 Appendix T12 Kidney: T10-L1 Ureter: upper T10-L1; Lower L1-L2 Bladder T11-L2 ```
133
Murphy sign
palpate deeply under right costal margin during inspiration & observe for pain &/or sudden stop in inspiratory effort Acute cholecystitis or cholelithiasis
134
Courvoiser sign
enlarged non-tender gallbladder secondary to pancreatic disease or cancer
135
Iliopsoas muscle test
flex hips against resistance Increased abdominal pain Irritation of psoas m from inflammation of appendix
136
Obturator muscle test
Flex patietns right thigh at hip, with knee bent, rotate leg internally at hip Right hypogastric pain is positive Irritation of obturator from inflammed appendix
137
Heel strike
Appendicitis or peritonitis
138
Rovsing sign
RLQ pain during left sided pressure Apenditicits
139
McBurney
Rebound tenderness or pain 1/3 of the distance form ASIS to umbilicus Apendicitis
140
Appendicitis test
``` McBurney Rovsing Heel strike Obturator Psoas ```
141
Meningitis birth-2 months
Group B strep E coli Listeria monocytogens
142
Meningitis 2 months-12 years
S. penumoniae (G + diplococci) N. meningitides (Gram - diplococci) H. influenza (gram - coccobacilli)
143
Meningitis adolescents
N. meningitidis
144
Meningitis >60
S. pneumoniae | Listeria monocytogenes
145
CSF - Bacteria - Viral - Fungal
Bacterial - Pressure >300 - WBC >1000 - Glucose <40 Viral - pressure <300 - WBC <1000 - Glucose >40 Fungal - pressure 300 - WBC <500 Glucose < 40
146
Kernig sign
flex patient leg at both hip and knee, the straighten extend knee
147
Brudzinski sign
as flex neck, hip and knees react
148
Meningitis tx
Vancomycina nd ceftriaxone | +ampicillin if >50
149
Bells palsy
upper and lower face loss of taste hyperacusis CN7 lesion
150
CNXII lesion
Tongue licks its wounds
151
Top shoulder
C4
152
Radial aspect forearm
C6
153
Little pinkie
C8
154
Nipple
T4
155
Tip xiphoid
T7
156
Umbilicus
T10
157
Patella
L4
158
Great toe
L5
159
Little toe
S1
160
Continous murmurs (4)
PDA- machinery - patent ductus arterosis - connection between aorta and pulmonary a. AV fistula ASD w/ high LA pressure Coarctation -narrowing or stricture in aortic arch distal to left subclavian artery
161
Mitral regurgitation (MR) due to (chronic)
MVP -myxomatous degeneration (most common) MAC (mitral annular calcification
162
Mitral regurgitaiton (MR) acute causes
Rupture of chordal tendineae Rupture of papillary muscle Ischemic papillary muscle dysfunction Infective endocarditis (IE); valve perforation
163
Systolic murmur Blowing Prominent at apex Radiates into left axilla -may have
Mitral regurgitation - Decreased S1 or normal - Systolic click
164
Severity of MR relates to
Loudness of murmur
165
RHF/LHF murmur
MR
166
``` Pulmonary edema Hemoptysis Arterial emboli Afib Murmur ```
Mitral stenosis
167
Ortner syndrome | - murmur
hoarseness= compression of left recurrent laryngeal nerve Mitral stenosis
168
Malar flush | -murmur
Ruddy cheeks, blue facies Mitral stenosis
169
Diastolic murmur RUmbling Low pitched heard at apex Increased S1
Mitral stenosis
170
Rheumatic heart
Aortic stenosis
171
Angina Syncope Heart failure -Murmur
Aortic stenosis
172
Narrow pulse pressure Decreased SV and systolic pressure Delayed pulses
Aortic stenosis
173
Systolic murmur, harsh 2nd ICS RSB | Radiates into supra sternal notch/ carotids
Aortic stenosis
174
Gallavardin phenomen
Aortic stenosis Murmur radiates to apex like MR
175
Aortic dissection Syphilis Ankylosing psondylitis - Murmur
Aortic regurgitation
176
Wide pulse pressure Whole lots of signs -De musset, corrigan, quincke, traube
Aortic regurgitation
177
Diastolic murmur Decrescendo 3rd ICS, LSD
Aortic regurgitation
178
Murmur assoc w/ pulmonary HTN | Inferior MI/ RV infarction
Tricuspid regurgitation
179
Prominent V wave in JVP
Tricuspid regurgitation
180
Blowing systolic murmur LSB Increase w/ inspiration (carvallos sign) 3-4th ICS
Tricuspid regurgitiation
181
Prominant A wave in JVP, ascites, hepatomegaly
Tricuspid stenosis
182
Diastolic murmur LSB 4th CIS, increase w/ inspiration and decrease with expiration and valsalva
Tricupsid stenosis
183
Diastolic blowing murmur 2nd LSB, 2nd ICS
Pulmonic regurgitation
184
Graham steell
Pulmonic regurgitation
185
Systolic murmur, 2nd-3rd CIS, LSB/ radiates toward left shoulder and incrases on inspiration
Pulmonary stenosis
186
Murmur associated with TOF or TGA
Pulmonary stenosis
187
D-dimer is for
Pulmonary embolism Non-specific, pulmonary complaints
188
When you think patient had stroke what do you get
Duplex
189
What to get if patient has paresthesia, numbness, weakness, loss of sensation, history of nerve complaints
Nerve conduction study
190
Most common use of doppler
Fetal heart sounds
191
Doppler US vs Duplex
Doppler records sound waves reflecting off moving objects such as blood, measures their speed and other aspects of how they flow Duplex is doppler US plus traditional US
192
Head CT: After you confirm thrombus what additional test to confirm how the incident occured?
Transthoracic echocardiogram with bubble study
193
When to use transesophageal echocardiogram
Great for endocarditis | Views of posterior structures of heart
194
Choice to use w/ HF
Transthoracic echocardiogram with EF measurement
195
Bubble study
real time assessment of intracardiac blood flow R-->L shunts in atrium or ventricle, PFO, arteriovenous shunt in pulmonary vaculature
196
Pericarditis + car accident=
Tampanode
197
When to immediately transfer to Cath lab
evidence of MI on EKG
198
FAST Exam
Focused assessment with Sonography in Trauma Tamponade To detect hemoperitoneum & pericardial effusion
199
6 What to use when suspect tamponade
FAST exam
200
Assess for DVT
Compression US of femoral v.
201
Electrical alternates on EKG
Tamponade Heart is swinging back and forth in fluid wave
202
Beck's triad
++JVP Muffled heart sounds -- BP Cardiac tamponade
203
Initial test of choice to evaluate cardiac anatomy and function
Transthoracic echocardiogram
204
Transthoracic echocardiogram used for
Evaluate - Pericardium - ventricles/artia/septa - cardiac valves - ejection fraction
205
Think dissection what exam
Abdominal aortic angiography
206
If bruits in carotids exam
B/L carotid artery US
207
Abdominal aortic aneurysm size
>3 cm Palpable at 5 cm
208
AAA at 5 cm requires If AAA >4 cm then
CTA of the abdominal aorta Computed tomography angiography Refer to vascular specialist
209
Patient in A fib
Transesophageal echo
210
At birth 3 things that happen
1. Foarmen ovale closes 2. ductus arteriosus closes (forms ligamentum arteriosus) 3. Ductus venosus closes (forms ligamentum teres)
211
Patients with a history of sudden death in young people
Idiopathic hypertrophic subaortic stenosis (IHSS)
212
Full cardiac exam on infants if
1. Feeding intolerance 2. Failure to thrive 3. Respiratory symptoms 4. Cyanosis
213
Full cardiac exam on older children if
1. Chest pain (not relasted to musculoskeletal) 2. Syncope 3. Exercise intolerance 4. Hx of sudden death
214
Six things to look for with Mumurs
1. Grade 2. Timing 3. Location of highest intensity 4. Character 5. Changes with position 6. Radiation
215
Thrill
Grade 4 murmur
216
Thrill caused by
Blood flowing from high pressure to lower pressure
217
Splitting of heart sounds
Split S1 is normal Split S2 w/ inspiration normal Fixed split S2 is indicative of an atrial septal defect (ASD)
218
Fixed split S2 is indicative of
atrial septal defect (ASD) Get overfilling of right side of heart, there for closure of pulmonic valve is delayed a little bit behind the aortic valve, doesnt go away w/ inspiration
219
If S1 or S2 obscured tehn 4 causes
Holosytolic murmur 1. VSD 2. AV valve regurgitation murmur 3. Patient ductus arteriosis 4. severe pulmonary valve stenosis
220
VSD causes a ___ murmur
Holysystolic murmur
221
Diastolic murmur (4)
LIsten w/ bell Usually lower pitched "Rumbling" character Never normal on its own
222
Only sound in diastole taht doesnt warrant a referral to cardiology
Venous hum
223
Venous hum caused by
caused by flow of venous blood from the head and neck into thorax
224
Venous hum should disappear (3)
1. When pressure is place on the jugular vein 2. Child heads is turned 3. Child is lying supine
225
What murmur decreases in intensity when child stands
A Still's murmur
226
Only pathologic murmur that changes significantly with standing
Hypertrophic cardiomyopathy Idiopathic hypertrophic subaortic stenosis (IHSS) Murmur increases in intensity when stands up
227
Harsh crescendo descrescendo systolic murmur heard best at apex and left sternal border
IHSS
228
Key features to innocent murmers | -7 S
``` Sensitive (changes w/ position) Short duration (not holysystolic) Single (no clicks or gallops) Small Soft Sweet (not harsh sounding) Systolic ```
229
Referral to a cardiology (12)
1. Grade 4 murmur 2. Diastolic murmur 3. INcrease in intensity when patient stands 4. Murmur symptomatic 5. Heart sounds obscured 6. Femoral pulses weak 7. Clicks 8. Hyperactive precordium 9. Hx of sudden death 10. Abnormal or extra heart sounds 11. Conditions predisposing patietn to congenital heart lesions 12. Get "that feeling"
230
Still's murmur
Innocent murmur Best heard at APEX of heart & L sterna border, w/ bell
231
5 cyanotic congenital defects
1) Big trunk: truncus arteriosus 2) Interchanged vessels: Transposition of great vessels 3) Tricuspid atresia 4) Tetralogy of fallot 5) Total anomalous pulmonary venous return
232
Lesions assoc with critical congenital heart disease (CCHD)
Ductal dependent lesions
233
Before baby goes home
O2 sat test done on upper extremity and lower extremity

PCMIII Ex2 (10 decks)

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