Final Exam Misc Review Flashcards
1
Q
Excess Vitamin D can cause:
Deficient Vitamin D can cause:
A
Excess –> fibrosis
Deficiency–> HTN
2
Q
Which B-vitamins are known to cause PVCs in deficient states?
A
B1 (thiamine/ TPP) and B5 (pantothene)
3
Q
Alternans pulse may present in what conditions?
A
L ventricular CHF, left ventricular systolic impairment (not a good prognosis)
4
Q
Bigeminus pulse may present in what conditions?
A
HOCM
also digitalis toxicity, Ca Channel blocker use, instrumentation, hyptothyroidism, B-blocker use, MI, INFx … (anything causing PVCs)
5
Q
A Bisferiens pulse may indicate:
A
twice striking dicrotic pulse
indicates aortic insufficiency with aortic stenosis or HOCM
6
Q
Pulsus Paradoxicus is:
A
stronger pulse during inspiration
may indicate: PE, COPD, rCHF, emphysems, asthma
7
Q
Pulsus Paradoxus is:
A
pulse falls >20mm Hg on inspiration
Indicates: tamponade, copd, hypovolemic shock, PE, constructive pericarditis
8
Q
Pulsus Parvus
A
small, weak, low output
Indicates: low EF, Cardiomyopathy, CHF, murmurs, shock, MI, arrhythmia, CorP
9
Q
Pulsus Tardus
A
slow rise in pulse
May indicate: output obstruction, atherosclerosis, septal fibrosis
10
Q
What might positive JVD or Hepatojugular reflex indicate?
A
JVD: >4cm may indicate rCHF, pericarditis, atrial failure, obstructed SVC, hypervolemia
HJR: >1cm rise may indicate rCHF
11
Q
Rales heard on inspiration may indicate:
A
bronchitis, pneumonia, fibrosis, CHF
12
Q
Rhonchi or Wheezes may indicate:
A
asthma, bronchitis, CHF
13
Q
Rubs on auscultation may indicate:
A
pleurisy
14
Q
What medications may cause orthostasis?
A
ACE-I, Nitrates, B-blockers, ARBS, Ca-channel blockers
15
Q
What drugs might cause syncope?
A
Anti-hypertensives (clonidine, reserpine, methyldopa) Psychiatric drugs (MAOIs, tricyclics, ADHD amphetamines, dopamine reuptake inhibitors, cocaine, SSRIs)
16
Q
How might you use Nitroglycerin in a patient with angina (stable/unstable)?
A
- Rescue prescription in case angina suddenly worsens
- Can be used during stress testing
- A patient with unstable angina that is not resolving can take up to 3 doses of 0.4mg Nitro (spaced 5 minutes apart) to relieve chest pain.
If no relief–> ER
17
Q
How might we distinguish between aortic stenosis and a carotid bruit?
A
Carotid bruit will be heard with the bell.
AS will get louder as you auscultate closer to the heart.
AS will change based on dynamic auscultation
18
Q
What are some vagal maneuvers and what can they treat?
A
to treat: PSVT, atrial tachycardia, sinus tachycardia
Valsalva with leg lift is most effective maneuver
carotid sinus massage, leg lift, ice also may help
19
Q
Elevated homocysteine increases risk for:
Tx?
A
Increased risk for CAD
Tx: methylated folate, B12, B Complex
20
Q
Elevated fibrinogen may indicate:
Tx?
A
May indicate: hyperviscosity, plaque formation, thrombi, endothelial injury
Tx: ginseng, bromelain, E-complex, Licorice, garlic, curcurmin, ginger, Boswelia, Nattokinase, Bioflavanoids
21
Q
Elevated Lp(a) may indicate:
A
May indicate carotid atherosclerosis and increased 5-year mortality from atherosclerosis
22
Q
Low bleeding time may indicate:
Tx?
A
Increased clot risk
Tx: fish oils, warfarin
23
Q
High CRP may indicate:
A
coronary artery inflammation
24
Q
Which lipids tend to be high in diabetes?
A
TGs
LP-PLA2 is also a useful marker in gauging risk among diabetics
Homocysteine will also be elevated in DM
25
What is Dr. Millers basic protocol for hyperlipidemia?
1. Niacin
2. RYR with CoQ10 and plant sterols
3. Garlic, pantethine, guggul resin, EPA/DHA, Policosanol
26
Which HDL is most protective? Which HDL type is least protective?
HDL 2 is most protective
| HDL 3 is least protective
27
```
What type of lipidemia presents with:
+++high cylomicrons
WNL choelsterol
HDL WNL
+++high Triglycerides
Normal risk profile
```
type I
| Treatment: LF, NA
28
```
What type of lipidemia presents with:
+++ high LDL
+++high cholesterol
normal or slightly high Triglycerides
+++ increased risk
```
Type II
| Treatmetn: LC, LF, IHN
29
```
What type of lipidemia presents with:
IDL mildly elevated
+++ elevated cholesterol
+++ elevated Triglycerides
+++ elevated risk
```
type III
| Tx: LC, LCHO, IHN, GMF
30
```
What type of lipidemia presents with:
+++ high VLDL
- low HDL
Normal or mildly high Cholesterol
+++ high TGs
++ increased risk
```
Type IV
| Tx; LW, LCHO, NA, IHN, GMF
31
```
What type of lipidemia presents with:
WNL or + elevated Cholesterol
+ elevated Chylomicrons
+elevated VLDL
low HDL
+++ elevated TGs
risk unknown
```
Type V
| Tx: LW, LF, NA, IHN, GMF
32
Which cardiac marker might you see elevated 4-6 hours after MI until about 3 days?
CK-M, CK-MB
33
Which cardiac marker might be elevated 1-2 hours after MI until about 20hrs?
Myoglobin
34
Which cardiac marker might be elevated 2 hours after MI until 10 days?
troponin I (heart specific)
35
Which cardiac marker might be elevated earliest and last longest?
troponin T (non-heart specific)
36
EKG shows jagged baseline, some saw-toothed patterns before QRS complexes. No visible p-wave and an irregular rhythm.
Dx?
Atrial Fibrillation
37
What is the CHADS score and what does it indicate?
```
C: CHF, 1 point
H: HTN, 1 point
A: Age >75, 1 point
D: DM, 1 point
S: Stroke/TIA history, 2points
```
Score of 0: Aspirin 81-325mg qd indicated
1: Aspiring qd or Coumadin indicated
2+: Coumadin indicated (target INR 2-3)
38
Treatment goals for A-fib:
slow heart rate, prevent stroke/thrombus formation, cardioversion back to normal rhythm, prevent recurrences
39
What drugs are indicated for cardioversion?
Amiodarone (most effective, least side- effects)
Propafenone (overall safest)
Digoxin (does not convert, just slows ventricular rhythm.
40
Which naturopathic remedy can slow heart rhythm in Atrial fib and is much less toxic than Amiodarone?
Iodine! (SSKI or Lugol's)
| Watch for toxicity: acne, diarrhea, N/V, fatigue, numbness, fever, confusion, tarry stool
41
How would you dose Warfarin?
Dosing: 1, 2, 2.5, 3, 4, 5, 6, 7.5 mg tabs available
Start at 2-5mg PO/IV qd #2-4 days (usually start at 5mg)
Adjust dose q4-5 days based on INR (target is 2-3)
ie. if INR is between 1/1.5, increase dose by 20%
note: Amiodarone potentiates Warfarin
42
How does Ach treat tachycardias?
Ach is the only neurotransmitter used in the motor system of the somatic nervous system.
While it stimulates contraction of skeletal muscle, it inhibits contraction of cardiac muscle.
43
What is the Ach protocol?
2Tbsp lecithin or choline bitartrate (1-2,000mg) mixed with 1,000mg of Pantothenic acid or Pantethine in water/ juice, drunken throughout the day.
If this fails, may increase to 4Tbsp lecithin and 2,000mg PA, then 6tbsp lecithin with 3000mg PA
If this fails, switch PA to Pantethine and restart at original dose
44
Autonomics regulate:
Vagal tone regulates:
(atria/ventricles?)
autonomic regulate the ventricles
| vagal tone regulates the atria
45
What test is 90% definitive for ischemia?
Exercise stress test
(24hr EKG indicated when pt cannot exercise)
Thallium or Echo stress test increases accuracy to 95%
46
CAC vs CT Angiogram?
CAC uses so much radiation, may as well do an angiogram to visualize occlusions (pt must have normal BUN and serum creatinine first though)
47
What is the WORST place to have coronary artery blockage?
Left Main (because it perfuses the whole left ventricle)
48
Stenting is required if arterial occlusion is greater than what percent?
>80%
49
Which cardiac marker is recommended stat if MI is suspected?
Troponin's! (appear early -2 hours- and stay elevated longer -10 days)
50
What changes might you see on EKG after acute cardiac injury? infarction? ischemia?
Injury: ST elevation
Infarction: Q-wave
Ischemia: T-wave inversion
51
How might you DDX MI from pericarditis based on symptoms?
Pericarditis is positional, worse lying down or coughing, worse swallowing or breathing. Pericarditis will respond to NSAIDs, will feel sharp and may radiate to trapezius
52
EKG shows: ST segment elevations in multiple leads. DX?
Acute pericarditis
53
EKG shows: no ST segment elevations, widespread T-wave inversions
chronic pericarditis
54
How might you diagnose a silent ischemia?
24hr Holter monitor
55
Asymptomatic/ silent ischemia is more common in patients with what comorbidity?
Diabetes (due to decreased pain sensation)
56
EKG shows ST segment depression. Dx?
Ischemia
57
Describe percutaneous coronary angiography (aka cardiac catheterization)
insertion of a catheter into artery/vein that is then guided into the heart using XRAY. Contrast dye is then injected, allowing viewing of coronary artery filling
If you're doing this though and exposing to radiation, may as well do CT angiography
58
Describe CT Angiography (Dye-Enhanced)
3D CT view of the heart
Pts must have BUN and Creatinine WNL (dye is really metabolized)
direct visualization of arterial occlusions
59
What type of testing for coronary artery occlusion is most expensive?
Nuclear imaging ($2,000!)
60
How does elevated homocysteine increase CVD risk?
Elevated homocysteine increases HR and BP, increases glycogenolysis and lipolysis, vasoconstricts.
This --> vascular damage, atherosclerosis
61
What are some treatment options to lower homocysteine?
Promote methionine recycling by:
Folic acid, B6, B12, SAMe, Vit C supplementation
Consider checking for MTHFR defects/COMP mutations
Consider neurotransmitter balancing protocol
62
What is an effective natural treatment for hypercholesterolemia?
NIACIN! (B3)
63
How might you monitor Niacin treatment?
SR wax matrix
500mg in morning for 1st week, then BID for 2nd week
slowly increase to 1500-2000mg daily
start labs at 1000mg dosing
Labs: Uric acid (niacin can precipitate gout), Liver enzymes, Lipid fractionation (can increase HDL2), SR wax matrix
64
What naturopathic therapy is a potent fibrinolytic?
| Standard dose and monitoring?
Nattokinase
standard dose: 2,000 FU 1-4 caps BID on an empty stomach
monitor:
Optimal fibrinogen levels: 250-300
Bleeding time 2-10 minutes (target 6-8 in coagulation d/os)
65
What are some indications for the Arginine protocol?
| What are some contraindications?
Indications: HTN, CAD, Erectile Dysfunction
CIs: Herpes, Chronic viral illnesses, Schizophrenia, Chronic cough
Side EffectsL be aware that NO can worsen COPD, asthma and other chronic lung diseases (can aggravate lung epithelium)
66
What is the Arginine protocol?
potent vasodilator, releases NO and reduces atherosclerotic precursors
3-6g BID- Take with Gamma tocopherol
```
Ex: L-Arginine 500mg 4caps TID
L-Citruline 500mg 1 cap TID
Vit C 500mg 1cap TID
Vit E 400IU BID
ALA 30mg TID
```
67
What is ALL therapy? Indications?
Aspirin, Lisinopril, Lovastatin
Indications: diabetic cardiovascular prevention
Alternatives:
nattokinase, Hydrotherapy, Policosanol
Fish Oil, Optimal Hydration, Inositol hexaniacinate
68
What is BALL therapy? Indications?
beta blocker, aspirin, lisinopril, lovastatin
Indictions: early stage cardiovascular disease/ stent patients
69
When might you prescribe diuretics? (what conditions)
HTN with edema, fluid retention, CHF (avoid DM)
70
When might you prescribe B-blockers? (what conditions)
HTN with migraines, tachycardia, PVCs, Type-A personalities (avoid DM)
71
When might you prescribe Ca-Channel Blockers? (what conditions)
HTN with ischemia, tachycardia, PVC
72
When might you prescribe ACE-ARB therapy?
HTN with CHF, cardiomyopathy, (lowers preload and after load), DM nephropathy protection
73
When might you prescribe vasodilators?
systolic VP of elderly, ischemia
74
Mild HTN BP range
140-159/90-99
75
Moderate HTN BP range
160-179/100-109
76
Severe HTN BP range
180+/110+
77
A wide pulse pressure >100 would indicate:
severe atherosclerosis
78
What blood chemistry imbalances might result from ACE inhibitor use?
hyperkalemia
increased BUN, Creatinine
Neutropenia (rare)
79
What blood chemistry imbalances might result from Diuretic use? (Loop/thiazide)
Hypokalemia
Hypomagnesemia
Hyperuricemia
Hyperglycemia
80
What blood chemistry imbalances might results from K-sparing diuretic use?
Hyperkalemia
81
Which diuretic are potassium sparing?
Spironolactone, Triamterene, Moduretic
82
Which diuretics are potassium wasting?
Thiazides (inc HCTZ), Loop diuretics (Lasix)
83
What are classic symptoms of polyarteritis nodosa? Tx?
Fever, abdominal pain, renal failure, HTN
Nephritis leading to arthralgia, muscle tenderness, weakness, nodules, washed, HTN, etc
Tx: high dose corticosteroids
84
How might you diagnose temporal arteritis?
| Tx?
DX: tenderness over temporal artery that is exacerbated by clenching the jaw.
Dx via temporal artery biopsy
Other signs: ESR inc, older age, normocytic/normochromic anemia, inc alkphos
Tx: high dose prednisone, isocort, pregnenalone, DHEA
85
How might you diagnose and treat Thromboangitis obliterates (Buergers Dz)?
Dx: arteriogram showing segmental occlusions of distal arteries, tortuous collateral circulation around occlusive areas
Tx: stop smoking, Walk/Exercise, Unna boot for ulceration, chelation therapy
86
How might you diagnose Raynauds Dz? Tx?
Dx: Allens test
Tx: avoid exposure to temp extremes , stop smoking, Mag supplementation, Mg Phos, EFAs, Niacin, Arginine with Gamma tocopherol
87
How might you diagnose and treat an aneurysm?
Dx: US, follow up with abdominal CT, MRI
Tx: ro zinc overload or deficiency, preserve zinc/copper ratio,
Proanthocyanadins: Crataegus, berries, grapeseed
Surgical repair, maintain BP control
88
How might you diagnose and treat Peripheral arteriosclerosis?
Dx: listen for bruits or spinal XRAY
PVD treatments:
Chelation
Blood thinning: Plavix, ASA, etc
Anti-inflammatory: ASA etc
89
How might you diagnose venous disorders?
Homans sign
palpation
BL edema
90
What are some botanical medicine options for PVD?
```
Horsechestnut seed
Rutin
Arjuna bark
Coleus root extract
Inure root
guggul resin
```
91
What is the imaging of choice for an AAA?
Abdominal US
92
What are some symptoms of an AAA?
Early: bloating, gas, GI upset
auscultate for bruit, sudden worsening of HTN
Progresses to deep, boring, visceral lumbosacral pain
93
What hypertensive symptoms would indicate immediate hospitalization?
Malignant HTN:
| diastole >130 with retinopathy w/ or wo papilledema
94
What are the most common causes of syncope?
acute decreases in cerebral perfusion secondary to limited CO (eg. vasovagal responses, arrhythmias, PVCs)
95
What might dilated cardiomyopathy look like on CXR, EKG, Echo?
CXR: enlarged cardiac silhouette, pulmonary vascular changes, pleural effusions
EKG: chamber enlargement, conduction delays, abnml ST, localized Q waves
Echo: 4 chamber enlargement, valve regurg, decreased EF
96
What might Hypertrophic cardiomyopathy look like on EKG and Echo?
EKG: LVH, prominent Q waves, a and v arrhythmias (afib/vtach)
Echo: most helpful, LVH, wall thickness abnml, outflow obstuction
97
What might Restrictive cardiomyopathy look like on imaging/labs?
similar to pericarditis (need to r/o)
| Transverse endomyocardial biopsy, CT, MRI
98
What might ischemic cardiomyopathy look like on CXR, ECG, Echo, .....
CXR: hypertrophy, pHTN, PEdema
ECG: hypertrophy, arrhythmias, ischemia, T-wave inversion, BBB
Echo: diagnostic, wall thickening, fibrosis, reduced EF
Angiography
non-specific findings on cardiac catheterization,
99
How do the 4 types of cardiomyopathy differ?
Dilated CM: systolic dysfunction
Hypertrophic CM: diastolic dysfunction
Restrictive CM: outflow obstruction
Obliterative CM: (presents as endomyocardial pericarditis)
100
What are the main indications for ACE inhibitors? MOA?
CHF with HTN
| MOA: inhibits Angiotensin II--> vasodilation, reducing preload and after load
101
What is the MOA of ARBs?
MOA: inhibits binding of angiotensin II to ATI receptor --> vasodilation but do not stimulate vasodilatory compounds like ACE-Is
Indicated in: heart failure, HTN
MC ARB= Cozaar (Losartan)
102
Why are loop diuretics popular?
| Why are thiazides primarily used?
loop diuretics are highly potent
thiazides are used for their long duration of action and efficacy/safety
thiazides are not generally used if creatinine clearance is
103
Why might b-blockers be contraindicated in CHF?
they decrease HR, and patients in UNSTABLE chf can go into shock. ONLY USE IN STABLE CHF
104
What is the most common side effect of statin drugs? How might we monitor this?
MC side effect: myalgias- look for rhabdomyolysis
| Monitor Creatinine Kinase levels
105
what naturopathic supplement should accompany any NO-producing prescription?
Vitamin E (antioxidant uses up NO)
106
What blood chemistry imbalances might result from HCTZ use?
hypokalemia, hypomagnesemia, hyperuricemia, hyperglycemia
107
What EKG findings might be caused by digitalis toxicity?
U-shaped downsloping of ST depression, systole shortening
