FInal Flashcards
When do you hear systolic vs diastolic murmurs
Systolic btw S1 and 2; diastolic btw S2 and 1
What is S4
Forceful atrial contraction against stiffened low compliant ventricle; atrial Gallop (S3 is ventricular gallop)
What kind of murmur could an atrial myxoma cause
Diastolic
What is the murmur heard with MR
Systolic - radiates to left axilla, decreased S1
What is ortner syndrome
Hoarseness seen with mitral stenosis
What sx does mitral stenosis cause
Malar flush, increased S1, opening snap after S2, diastolic murmur use bell
What do you see on PE of aortic stenosis
Narrow pulse pressure, decreased SV and systolic pressure; delayed pulses (parvis and tardus), harsh 2nd ICS RSB radiates into Suprasternal notch; gallavardin phenomenon (murmur radiates to apex)
What are causes of chronic aortic regurgitation
Syphilis and ankylosing spondylitis
What do you see with aortic regurgitation
Wide pulse pressure, de mussel, corigans, quinces, traubes, durozreys, hills, bisferious, diastolic
What is tricuspid regurgitation associated with
Pulm HTN, inferior MI - see prominent V wave in JVP; blowing systolic murmur
What do you see with tricupsid stenosis
Prominent A wave in JVP, hepatomegaly
What causes most cases of pulmonic regurgitation
Pulm HTN; graham steel murmur
What kind of murmur is heard with pulm stenosis
Radiates toward left shoulder
what is the difference between EMR and EHR
EHR can be shared with other health care providers; contain all info from all caretakers
What are the stages of meaningful use
1: data capture and sharing
2: advance clinical process
3: improved outcomes
What is meaningful use
Use of EHR to improve health care quality and efficiency; goals: Bring about care that is patient centered, prevention oriented, evidence based, effficient and equitable
What is MIPS
Merit based incentive payment system
What must medical students have/do when charting for their preceptor
- have their own username/password
- contribute meaningful data with inclusion of student note; enter rationale for entering;
- notes must be reviewed and signed by supervising physician
What kids do you perform a full cardiac exam on
Kids with heart murmurs, any child who has historical features suggestive of cardiac dz (feeding intolerance, sweating, head bobbing, failure to thrive, resp sx, cyanosis in infants; chest pain, syncope, exercise intolerance, family hx of sudden death in older children)
What is included in a full cardiac exam
Vitals, pulses, cap refill, precordial inspection and palaption, auscultation, murmurs - grade, timing, location, character, changes with position, radiation
Which murmurs have a thrill
IV and up
What is fixed split S2 indicative of
ASD; only normal when split with inspiration
What can cause S1 to be inaudible
VSD, AV regurgitation, patent ductus arteriosus, severe pulm stenosis
What do you use to listen to diastolic murmurs
Bell; lower pitched with rumbling character; NEVER normal on its own
When should venous hums disappear
When pressure placed on jugular vein, when child’s head is turned, when child is lying supine, *only sound in diastole that doesn’t warrant a referral to cardiology
Which pathologic murmurs change with position
Hypertrophic cardiomyopathy: systolic murmur at apex and LSB that increases in intensity when patient stands and with valsalva maneuver *one of the leading causes of death in young athletes - also called IHSS (idiopathic hypertrophic subaortic stenosis)
What are the features of innocent murmurs
Sensitive (changes with position), short duration, single, small, soft, sweet, systolic
When do you refer a child to a cardiologist
Grade 4 murmur or up, diastolic murmur, increased intensity when patient stands, if sx, Heart sounds obscured, fem pulses weak, clicks, hyperactive precordium, hx of sudden death, ab or extra heart sounds (except S3), conditions predisposing to heart lesions
What is a stills murmur
Decreases when standing ; best heard at apex with bell
What are the critical congenital heart diseases checked for in the nursery
Hypoplastic left heart syndrome, pulm atresia, TOF, total anomalous venous return, transposition, tricuspid atresia, truncus arteriosus
What is the study of choice for kids with downs
Echo with Doppler
What is the most common use of a Doppler
Fetal heart sounds
What do you use a transesophgeal echo for
Endocarditis, mural thrombus
What is a FAST exam
Focused assessment with sonography in trauma; detects pericardial effusion and Hemo Peritoneum
What is beck’s triad
JVP, muffled heart sounds, low BP
When is transthoracic echo indicate
Pericardium, ventricles, atria, septa, valves, ejection fraction evaluation; obscured with pulm dz or body habitus
What is an endocrine cause of chest pain
Hyperthyroidism
What are the emergent causes of chest pain
NSTEMI, STEMI, pericardial tamponade, aortic dissection, boorhaves, PE, pneumothorax
Where does pain in acute coronary syndrome radiate
Back, jaw, shoulders, arms, upper abdomen
What is the most common anginal equivalent
Unexplained new onset or increased exertional dyspnea
Who tends to have atypical presentation of ACS
People over 75, diabetics, impaired renal function and dementia; sx include epigastric pain, indigestion, stabbing or pleuritic pain, dyspnea in absence of chest pain
Besides a full cardiac exam what else should you do for someone presenting with cardiac sx
Hepatojugular reflux, rales in lungs or egophany (sign of heart failure), edema
What is the age risk factor for CV dz
Men > 45; women >55
What is the family hx risk for CV dz
Heart attack, bypass surgery or sudden death < 55 in father/brother or <65 for mother/sister
What is considered a sedentary lifestyle
Not participating in moderate physical activity at least 3 days a week for 3 months
What are the obesity and HTN risk factors for CV dz
BMI>30, BP >140/90 or taking medication
What are the lipid risks for CV dz
LDL >130, HDL <40 or taking meds
What is considered pre diabetes
IFG >100; OGTT >140 but <199 by 2 measurements
What is a protective factor for CV dz.
HDL > 60
Does unstable angina respond to nitroglycerin
No
What is the treatment for ACS
MONA-B
- morphine
- O2: even if O2 sat is good
- nitroglycerin
- aspirin: PO chewable
- beta blocker
When do you order cardiac markers
Immediately and then repeat q6hx3
When do you order EKG
Immediately and then q8hx3
When do you order a lipid panel for a cardiac case
In the am; fasting; NOT immediate
When will you send someone straight to the cath lab
Uncontrollable chest pain, new LBBB, or STEMI
How do you diagnose nontuberculosis mycobacterial infection
Sputum culture and molecular diagnostics
How do you diagnose fungal infection in the lung
Sputum culture and regional exposure
How do you diagnose a septic embolus to the lung
Blood culture and echo
What do you do to test for TB if someone has had a BCG vaccine
Use a gamma release assay
What are the sx of an active TB infection
Fever, night sweats, cough (productive or hemoptysis), weight loss, LAD
What kind of hypersensitivity reaction is the PPD test
IV
When is a PPD considered positive
- > 5mm in people with HIV, close contact with active infectious persons, CXR with fibrotic changes consistent with TB, immunosuppressed
- > 10mm in ppl with silicosis, DM, chronic renal ialure with dialysis, malignancies, malnourished, IV drug abuse, kids <4, rom country with high prevalence, residence in jails, nursing homes, homlesss shelters
- > 15 mm in healthy individual
What is the work up for TB
- Morning Sputum culture x3 - gold standard: stain for rhodamine-auramine for screening and Ziehl-Nielsen or Kinyun for confirmatory
- PPD: not used for diagnosis
- IFN gamma release assay
- chest XR: cavitary lesions typically in apices
- NAAT (nucleic acid amplification test): NAAT-TB tests TB genetic material and NAAT-R detects INH and rifampin resistance
What are the side effects of the RIPE drugs
rifampin: orange, hepatitis, Steven Johnson syndrome
Isoniazid: hepatitis peripheral neuropathy
Pyrazinamide: urticaria, hyperuricemia, gout, hepatitis
Ethambutol: colorblind
What monitoring should you do to patients on RIPE treatment
- hepatic enzymes, CBC, serum creatinine and Uric aid
- testing for hep B and C with risk factors and HIV on all patients
- visual acuity
- sputum is collected to monitor treatment efficacy
How do you diagnose latent TB infection
Positive PPD or IGRA -> check chest CXR to make sure no active infection; if negative treat as latent TB with 9 months of INH
What are the TB infection control measures
- administrative controls: decrease the risk or exposure to persons with TB
- environmental controls: admit to negative pressure room
- respiratory controls: use or protective equipment
What is the FiO2 for the diff kinds of oxygen administration
- room air: 21%
- Nasal cannula: 24-44%
- simple face mask: 40-70%
- Venturi mask: 24-50%
- non-rebreather (NRB):: 80-100%
Is OMT indicated in acute TB
No
What are the posterior lung Chapman’s points
Myocardium: intertransverse btw T2-3
Bronchus: lateral to T2 spinous
Upper lung: intertransverse btw T-3 and 3-4
Lower lung: 4-5
