FINAL Study Guide Flashcards
What is the grading scale for murmurs?
Grade 1: very faint, heard only after tune in
Grade 2: quiet, heard w/ in 1-2 beats
Grade 3: moderately loud w/ stethoscope on chest
Grade 4: loud w/ palpable thrill
Grade 5: v loud w/ thrill, heard w/ stethoscope partly off chest
Grade 6: v loud w/ thrill, don’t need stethoscope
What is the triad of sxs of aortic stenosis?
Angina
Syncope
Dyspnea
What is murmur of aortic stenosis?
harsh systolic murmur @ RUSB that radiates into neck
What are clinical findings assoc w/ aortic stenosis?
S4, pulse delay, slow upstroke in carotid A, paradoxical S2 split
What is murmur of MVP?
systolic murmur w/ OS or late systolic click @ L mid clavicular line
How to dx MVP?
ECHO
What is murmur of TR?
holosystolic murmur @ LLSB, increases w/ inspiration w/ increase in venous return to R heart
NO radiation into axilla
What murmur associated w/ large jugular v waves?
tricuspid regurgitation
fxnal result of RV dilation or rheumatic heart dz, endocarditis, carcinoid
What is murmur of MR?
holosystolic murmur @ L mid clavicular line
best heard w/ bell
What is murmur of VSD?
loud harsh holosystolic murmur @ LLSB
increased intensity w/ smaller size
What is murmur of aortic isufficiency?
high pitch decrescendo diastolic murmur @ LSB
What are clinical findings of aortic insufficiency?
wide pulse pressure
nail pulses
H2O hammer pulse
head bobbing
What murmur is an emergent situation?
acute aortic regurgitation
due to aortic dissection (widened mediastinum on CXR) or endocarditis
What is murmur of MS?
diastolic murmur w/ OS
almost always due to rheumatic fever
What is murmur of ASD?
systolic ejection murmur @ LSB
fixed split S2
What are systolic murmurs?
AS (@ RUSB, reduced carotid pulse)
VSD (@ LLSB w/ no change w/ inspiration)
Tricuspid Regurgitation (@ LLSB, increased w/ inspiration)
MVP (L midclavicular line w/ click)
What are diastolic murmurs?
Aortic Insufficiency (R upper or L midsternal border w/ bell)
Mitral Stenosis (@ apex when L lat recumb, w/ OS)
What are the normal heart sounds?
S1 (start of systole w/ mitral valve closure)
S2 (end of systole, start of diastole w/ aortic valve closure)
What are the abnormal heart sounds?
S3 (if in pt>40yo, indicates volume overload & LV fail)
S4 (never normal, indicates atrial contraction against non compliant ventricle due to increased LV end diastolic pressure)
What are the different patterns of split S2 sound?
wide physiologic split (delayed closure of pulmonic valve)
fixed split does NOT vary w/ respiration & abnormal (ASD, R vent fail)
paradoxical split w/ P2 before A2 (LBBB b/c abnormal delayed closure of aortic valve)
Describe screening recommendations for carotid artery stenosis
NO screening w/ carotid duplex US for asymptomatic
US indicated if sxs or those w/ carotid bruit
What are 3 most predictive findings of acute stroke?
facial paresis
arm drift/weakness
abnormal speech
What is defining sx of PAD?
claudication (pain w/ walking that eases w/ rest)
severe pallor & ischemia of limbs
What are pearls for CVI?
limb discomfort edema ulceration, telangiectasias stasis dermatitis varicose veins vascular ulcer
What is cor pulmonale?
primary right heart failure
setting of pulm HTN, COPD, chronic lung dz
What are 3 main underlying causes of HFpEF?
HTN
CAD
DM
What are criteria for HFrEF?
LV EF<50%
dilated LV w/ low EF (increased LV filling pressure)
systolic dysfxn
What are the keys to pulmonary edema?
sxs: SOB, diaphoresis, wheezing
labs: ECG, cardiac markers, ECHO
dx: w/ PE, CXR
tx: supplemental O2, IV furosemide, mechanical ventilation
What are physical findings of PDA murmur?
continuous, machinery like murmur @ LUSB
CXR w/ calcification of ductus arteriosus in adults
When would you obtain orthostatic VS?
dehydration
blood loss
syncope
What are positive orthostatic VS?
pulse INCREASE of 10bpm
OR
BP DECREASE of 20mmHg or greater
What is the recommended initial testing for PAD?
initial test w/ ABI (if ABI<0.9, diagnostic for PAD & moderate arterial dz)
if initial ABI negative but pt w/ sxs of claudication, exercise stress test & re-measure ABI
What are urine findings of AKI?
low urine output
high serum Cr
need UA+micro, urine albumin:Cr ratio for dx
ATN urine findings
renal tubular epithelial & transitional epithelial cells, granular or waxy casts
AIN or pyelonephritis urine findings
WBC, WBC casts, urine eosinophils
Vasculitis, glomerulonephritis urine findings
dysmorphic RBCs, RBC casts
Nephritic syndrome urine findings
HEMATURIA, dysmorphic RBCs, RBC casts, some protein
Nephrotic syndrome urine findings
heavy proteinuria >3.5/day, lipiduria, min hematuria
Pre renal azotemia urine findings
hyaline cast
UTI urine findings
WBCs, RBCS, BACTERIA
What are common causes of AKI?
Pre renal (hypoTN, hypovol, reduced CO, systemic vasodilation, hyperCa2+)
Intra renal (ATN, acute & chronic IN, glomerulonephritis)
Post renal (bladder or ureteral obstruction, renal papillary necrosis)
When can FeNa & FeUrea be used?
ONLY valid in OLIGURIC PT
used to differentiate btwn pre renal & ATN
What is FeNa in pre renal v ATN?
pre renal w/ FeNa <1%
ATN w/ FeNa>2%
What determines recovery & degree of recovery in AKI?
presence of CKD & degree of initial injury are main determinants
no guarantee that kidney recovers fxn or if recovery will return to baseline
When does AKI become CKD?
if not recovery of renal fxn after 3months?
Grade edema
1+ is 2mm
2+ is 4mm
3+ is 6mm
4+ is 8mm
pitting edema=CHF
What are the cardinal manifestations of HF?
dyspnea
fatigue
fluid retention/volume overload
What is significant about S3 in pts w/ HF?
S3 w/ increased JVP is STRONG predictor of outcome (high risk of death & hospitalization)
What is the recommended screening for abdominal aneurysm?
any pt>50yo w/ current or past SMOKING hx needs AB US to screen for AAA
URI/Acute Bronchitis DX & TX
DX: cough for 1-3 weeks, constitutional sxs, PE w/ rhonchi that clear w/ cough (based on HX & PE)
TX: reassurance & symptomatic relief, avoid Abx
Chronic Bronchitis DX & TX
DX: productive cough w/ sputum for >3mo for 2 consecutive yrs, FEV1/FVC<0.7 on spirometry
TX: pulmonary rehab & pharm tx to improve sxs, exercise capacity, QOL
What are CT findings for chronic bronchitis?
bronchitis w/ airway luminal narrowing, wall thickening
emphysema w/ multi organ loss of tissue
What are work up recs for chronic bronchitis?
any pt w/ pulse ox<90%, ABG for complete assessment
any pt w/ pulse ox<88% or PaO2<55 supplied w/ supp O2
What are specific tx rec based on chronic bronchitis sxs?
intermittent mild sxs: SABA are rescue tx
mild dz: LAMA
more SOB & lung hyperinflate: LAMA w/ LABA
hx of asthma: inhaled GC + LABA (fluticasone + salmeterol)
severe dz: LAMA + LABA + IGC, PDE4i, macrolide, xanthines
Asthma DX & TX
DX: episodic or chronic sxs of wheezing, SOB, cough worse @ night or early AM; PE w/ prolonged expiration & diffuse wheeze
TX: SABA for quick relief of sxs, ICS
What is distinctive of asthma on spirometry?
obstructive pattern that is REVERSIBLE w/ bronchodilator tx
PNA DX & TX
DX: fever, cough, TACHYPNEA, SOB, CXR w/ infiltrates, PE w/ dullness to percussion
TX: CRB65 criteria (new onset confusion, age >65, hypoTN, RR>30), outpt w/ macrolide, inpt w/ resp fluoroquinolone OR macrolide w/ B lactam
DX & manage acute abdomen
painful abdomen
tense abdomen upon palpation
call surgeon (immediate surgical emergency)
What are expected physical findings in COPD?
increased AP diameter (barrel chest)
prolonged expiration on auscultation
hyper resonance w/ percussion of chest wall
pursed lip breathing
What are causes of DVT?
endothelial injury/dysfxn
alteration in blood flow (stasis)
altered blood composition (hyper coaguable state)
What are inherited risk factors for DVT?
Factor V Leiden mutation
Prothrombin mutation
Protein S/C deficiency
Anti thrombin deficiency
What are acquired risk factors for DVT?
malignancy
pregnancy/OCPs
surgery/immobile
anti phospholipid syndrome
What is Wells criteria?
scoring system for likelihood of DVT
higher score=more risk for dx of DVT or PE
What is use of D dimer?
negative D dimer rules OUT PE
What are the components of an asthma action plan?
Instructions for pt to take peak flow & adjust meds based on daily peak flow
education on inhaler use
Identify & avoid of triggers
all pts w/ asthma should receive PNA or annual flu vax
What are the clinical sxs of pertussis?
catarrhal phase (weeks 1-2): malaise, rhinorrhea, mild cough, lacrimation & conjunctivitis
paroxysmal (week 2): severe & vigorous PM cough, post tussive vomiting
convalescent (can last up to 3 months): decreased frequency & severity of cough
How to dx pertussis?
high index of suspicion w/ cough >2 weeks & 1 of following: paroxysms of cough, inspiratory whoop or post-tussive emesis
Culture w/ in 1st 2 weeks of illness
Nasopharyngeal collection for PCR testing
Serology only post 4 weeks of cough
What is tx regimen for pertussis?
Abx w/ in 1st 3 weeks of cough
1st line tx: MACROLIDES (azithromycin, clarithromycin)
avoid opioid based cough suppressants
What is the 2nd line tx for pertussis?
TMP SMX for pts w/ macrolide HSN
What is 1st line tx option for pts w/ COPD?
NIPPV
pt can blood off excess CO2 (ventilation) & delivered higher FiO2 (oxygenation)
What are some indications for tracheal intubation w/ mechanical ventilation?
hypoxemia even w/ supp O2
upper airway obstruction
unable clear own secretions
respiratory acidosis
fatigue of accessory ms
apnea
pt w/ trial of NIPPV that did NOT improve w/ in 30-90 min
