FM/IMC Flashcards
? is the MC type of cardiomyopathy
What PE heart sound is associated w/ this MC
What causes this to occur
Dilated
S3 (fluid overload) w/ low EF
Damaged myocardium weakens, causes all chambers to dilate
Dilated cardiomyopathy is characterized by ?
What two factors increase these Pts risk for sudden cardiac death
What is the best way to Dx this condition
Dec contraction and systolic dysfunction
Ventricular enlargement, Progressive HF
Echo showing LV dilation w/ EF <50%
What is seen on CXR of dilated myopathy
What is seen on PE
How is Dilated Cardiomyopathy Tx and cardiac out put increased
Balloon-heart w/ megaly/pulm congestion
Displaced apical impulse
Inc JVP
Large liver
Edema
Loop+ACEI+BB; Inc CO w/ Digitalis;
Transplant/LVAD
What duo is characteristic for HOCM
How does this present on PE
How is this murmur changes
Septal hypertrophy >1.5cm w/ ventricular outflow obstruction mimicking AS; diastolic dysfunction d/t autosomal dominant mutation of sarcomeres
Bifid pulse
Medium pitched, cres-decrescendo
Prominent A-wave- atria contracting against closed valve
S4 gallop w/ apical lift
Inc w/ dec volume: valsalva, standing, tachycardia
Dec w/: squat, grips
How is HOCM Tx
What drugs are avoided in HOCM and what drug is c/i
Define Restrictive Cardiomyopathy
Metoprolol/Verapamil- dec contractility/HR
ICD if syncope/sudden arrest
Surgical/Alcohol ablation of septal hypertrophy
Dec preload: Nitrate ARB Diuretic ACEI;
Digoxin- inc contractility will inc obstruction
Right HF d/t non-compliant ventricals w/ dec diastolic filling
What is heard on PE of restrictive myopathy
Half of these cases are caused by ?
How is restrictive cardiomyopathy Dx
P-HTN; S4 d/t stiff/thick ventricle
Idiopathic
Echo w/ cardiac cath- high atrial pressure
Uncertain= MRI to eval texture
What is seen on EKG of restrictive myopathy
What is seen on Echo
How is restrictive cardiomyopathy Tx
Non-specific, abnormal ST/T wave w/ low voltage
Dilated atria, Hypertrophy
Diuretics if edema/congestion
Define ASD
ASDs are the ? MC congenital heart Dz and place Pts at risk for ?
ASD Sxs are dependent on size and Sxs don’t present until ? age
Interatrial septal hole- diastolic L to R shunt w/ volume overload of R side (atrial contracted= RV vol overload)
2nd (VSD is 1st); paradoxical emboli
ASx <30
>30: dyspnea, angina
>50: Afib, RVF
What is heard on PE for ASDs
What may be seen on EKG if shunt is significant enough
What will be seen on CXR if ASD is present
Wide, fixed S2 (lub dub-dub) w/ systolic murmur at P-area
P-HTN- pulmonic ejection murmur
RAD, RVH, RBBB- rSR pattern in V1
Megaly w/ R side dilation
Prominent pulm artery w/ inc vasculature
Most ASDs will spontaneously close if ? size or by ? age
When is surgical closure indicated
Pts w/ ASDs are c/i from ? hobby
<3mm; 3-8mm- by 3y/o
RV overload on Echo at 2-6y/o
Diving
Define PDA
What do these sound like
What can be the reporting c/c of PDAs
PD- normal fetal structure connecting PA w/ aorta to bypass lungs causing L to R shunt
Systolic, machinery murmur w/ thrill at P-area w/ wide pulse pressure and low DBP; accentuates in late systole
LE cyanosis, FTT, Tachy/Tachy
What is seen on PE or PDAs
How are these Tx
? is the MC pathologic murmur of childhood
Wide pulse pressure w/ low DBP
Premature: Indomethacin w/ fluid restriction
Surgical/Catheter closure
VSD (ASD- 2nd MC)
Define VSD
What do these sound like
How are these Tx
L-R ventricular shunt overloading pulm artery (P-HTN)
Holosystolic murmur on L sternal border
Watch- refer to Peds Cards for serial echos
Infants w/ large VSDs can develop ? issues and are Tx w/
If the above fails, when is surgical closure performed
? is the classic clinical presentation of Aortic Coarctations
CHF, growth retardation; Tx- Digoxin w/ diuretics
First 6mon
Arm BP > leg BP- Bounding arm pulses
Where do the majority of aortic coarctations occur
Half of the Pts will have ? valve defect that puts them at risk for ?
How are these Tx w/ surgical interventions and what are the indications for emergent closure
Below origin of L sublcavian artery
Bicuspid AV- leads to Berry aneurysm formation
Balloon angioplasty 2-4y/o;
Emergent- HTN Megaly CHF Shock
Neonates born w/ aortic coarctation need to have ductus arteriosus kept open w/ ?
What happens if these Pts live untreated
What is the only cyanotic, congenital heart Dz of blueprint
Prostaglandin E1
Death by 50y/o d/t Rupture, Dissection, CVA
Tetrology d/t R-L shunt through VSD
Why do Tetrology Pts need annual EKGs until Tx
Post-surgical survival is >80% but the MCC of death are ?
What complications can still exist after surgery
QRS lengthening d/t risk for sudden death
Sudden death, HF
HF, Arrhythmias, Residual obstruction, Pulm regurgitation
Define Primary HTN
Ranges for Normal, Elevated, Stage 1 and Stage 2 HTN
ACC/AHA and JNC 8 BP targets
SBP ≥130/DBP ≥80 on two readings on two visits
N: <120/80 and <80
E: 120-129 and <80
1: 130-39 or 80-89
2: ≥140 or ≥90
ACC/AHA: <130/80
JNC: <140/90 for all <60y/o;
<150/90 for all ≥60
How is Normal, Elevated, Stage 1 and 2 HTN Tx
N: lifestyle w/ f/u q12mon
E: lifestyle and f/u q3-6mon
Stage 1, <10%: lifestyle and f/u q3-6mon
Stage 1, >10%/CVD/DM/CKD: lifestyle w/ 1 med, f/u in 30d
Met- f/u q3-6mon
Not- f/u q30d until met
Stage 2: life style w/ 2 meds, f/u in 30d:
Met- f/u q3-6mon
Not- f/u q30d until met
What meds are used for HTN Tx in Non-Black or Diabetic Pts
What is used for black Pts
What is their BP target
ACE/ARB, Amlodipine, Thiazide-like/Indapamide
Stage 2= two meds from different classes
Thzd-type and/or CCBs
<130/80
S/e of CCBs for HTN Tx and specifically used for ?
S/e of ACE/ARB for HTN Tx and specifically used for ? and c/i during ?
S/e of using Spironolactone for HTN Tx
S/e: Edema; Angina pectoris
Proteinuria;
S/e: HyperK Angioedema Cough (c/i pregnancy)
HyperK
S/e of using BB for HTN Tx and are c/i during ?
Two s/e of using hydralazine for HTN Tx
When does USPSTF suggest HTN screenings to begin
Cause: Impotence; C/i: asthma
Lupus-like syndrome, Pericarditis
18y/o;
3y/o if conditions associated w/ HTN
Adults w/ RFs need to be screened for HTN ? often or ? previous measurement
How is BP taken and ? reading indicates need for more evaluation and work up
What PE finding can suggest HTN is present
q6mon; SBP 120-129
Pt rests x 5min
Cuff covers 2/3 of bicep
>15mmHg between both arms
AV nicking w/ fundoscopy- arteriole crosses venule causing compression and venous bulging
When does ACC/AHA suggest starting Rx management for HTN
What life style modifications are recommended to Pts
Define Secondary HTN and when is this Dx considered?
All Stage 2
Stage 1 w/: DMT2 CKDz ASCVDz/Risk ≥10%
DASH diet <2.3g Na/day M: two drink/day W: one drink/day PT 30min/day x 5d/wk
SBP ≥130/DBP ≥80 w/ an identifiable cause:
HTN refractory to meds
What is the MCC of Secondary HTN
Ingestion of ? substances will worsen HTN Tx
What are the four populations that are likely to benefit from statin therapy
Primary aldosteronism
NSAID CCS Cocaine Licorice
LDL ≥190
Any ASCVDz
Non-DM 40-75y/o ASCVD risk ≥7.5%
DM 40-75y/o w/ LDL 70-189
When are lipid screenings started
What medications can be used during Tx and what s/e do they have
Define Xanthomas
USPSTF: 35y/o w/out RFs
NCEP: ≥20y/o regardless
Statin- Inc LFTs, Myalgias
Fibrate- gallstone
Niacin- flushing
Bile acid sequestrant- diarrhea
Lipid rich histiocytes in skin d/t hyperlipidemia
? is the MC area of development for tendonous xanthomas
When are medications used for Tx in Pts ≥21y/o
Secondary Prevention for wo/men ≤75 w/ ASCVD or LDL ≥190 are Tx w/
Achilles
LDL ≥190/Tgc ≥500 w/ high intensity; Goal of 50% reduction
High intensity statin
How is hyperlipiemia Tx in diabetics w/ LDL 70-189
How is hyperlipidemia Tx in non-diabetics w/ LDL 70-189
? are the two high intensity statins and dosages
Moderate intensity;
≥7.5% ASCVD score= high intensity
ASCVD risk ≥7.5%: mod/high intensity
5-7.5%: mod intensity
Average LDL reduction ≥50%:
Atorvastatin 40-80mg
Rosuvastatin 20-40mg
What are the moderate intensity statins w/ dosages
What are the low intensity statins w/ dosages
Average LDL reducion 30-50%: Atorva 10mg Rosuva 10mg Simva 20-40mg Prava 40-80mg Lova 40mg Fluva XL 80mg Fluva 40mg BID Pita 2-4mg
Average LDL reduction ≤30%: Simva 10mg Prava 10-20mg Lova 20mg Fluva 20-40mg Pita 1mg
Define Cardiogenic Shock
What is the MCC
What will be seen on PE
Impaired contractility and overall pump failure
Acute MI
Pulm congestion AMS Tachy Clammy HOTN JVD UOP <20mL
How is Cardiogenic Shock Dx
How is this Tx
Cardiogenic shock d/t free wall ruptures is MC seen after ? type of MI
Inc pulmonary capillary wedge pressure >15mmHg
Fluids and Pressor: Dobutamine, NorEpi
Balloon pump
Q-wave transmural
Lateral wall
Define OHOTN
This is MC caused by ? issue and MC by ? drug s/e
What would be seen in VS if etiology was d/t autonomic dysfunction or d/t low blood volume
SBP dec x 20mm, DBP dec x 10mm
Both <5min after supine to standing
Acute MI complication; MAOIs
Autonomic: HOTN w/ HR inc <10bpm
Volume: HR >15bpm
What VS readings suggest OHTON etiology was hypovolemia
What VS readings suggest a Dx of POTS
How is OHOTN Tx
HR >100bpm or an Inc x 30bpm
+Sxs, no HOTN
Inc Na/Fluids, Fludrocortisone, Midodrine
Define NSTEMI
What will be seen on EKGs
What does the “typical” work up include
Necrosis w/out ST elevation ror Q-waves
ST depression/inversion d/t incomplete blockage
BNP EKG Troponin CXR CBC/CMP
What biomarkers are evaluated during MIs
Myoglobin
1-4h 12hr <24hrs
Troponin:
4-8hr 12-24hr 7-10d
CK-MB:
4-6hr 12-24hr 3-4d
How are NSTEMIs Tx
Define STEMI
What EKG lead indicates location of infarct
BARCHANS:
BBs ACEI Reperfusion-(PCI) Clopidogrel Heparin ASA Ntg Statins
Necrosis w/ ST elevation/Q-waves d/t complete blockage
Anterior: 1, aVL, 2-6; LAD
Inferior: 2, 3, aVF; RCA
Lateral: 1, aVL, 5-6 w/ reciprocals in 3, aVF; CXA
Posterior: depression in V1-3
How are STEMIs Tx
EKG time requirement
How often are markers drawn and assessed
ASA+Clopidogrel at once
PCI <90min
Thrombolytics <180min
<10min
Three sets q8hrs
Absolute c/is for fibrinolytic therapy for STEMI Tx
Suspect dissection
Active bleed/diathesis
Malignant intracranial neoplasm
Ischemic stroke <3mon
Cerebral vascular lesion
Hemorrhage, cranial
Septal MI is d/t blockage in ? vessel
Widow Makers is d/t blockage in ? vessel
? is the MC type of MI
SBA, seen in V1-2
LAD: above LCX, Septal and LAD branch
Inferior
? medication decreases mortality in N/STEMI and TIA Pts
STEMI reperfusion time frame
What thrombolytics can be used if no cath lab is available/indicated
ASA
<12hrs
Gold standard= PCI <3hrs of Sx onset
TPA, Streptokinase
Define Stable Angina
Time frame is ?
? PE sign can be seen
Pain incraeased w/ exertion/emotion but predictably relieved w/ rest/nitro
<15min
Levine Sign
How is Chronic Angina worked up
How is this form Tx
? is a poor prognostic indicator and ? vessel is MC involved
Stress test; definitive w/ angiography
Nitro and BBs
LVEF <50%;
Left main
? medication needs to be used ASAP during HF to decrease morbidity/mortality
What are the 3 BBs used
What lab result is seen in HF and what can cause this to be abnormally low
ACEI
Bisprolol
Metoprolol succinate
Carvedilol
BNP;
Obesity
HF is a syndrome of ? dysfunction
? is the dominant Sx of L-HF
? is the dominant Sxs of R-HF
Ventricular
Dyspnea
Fluid retention
Define Systolic Left HF
How is this Tx
How are acute worsenings Tx
Dilated, thin LV w/ EF <40%
Loop ACEI BB
O2 ACEI Nitro Doubled diuretic via IV; D/c BB
Define Diastolic left HF
This MC occurs in Pts w/ ?
How is this Tx
Thick LV wall w/ impaired relaxation and normal EF
HTN
ACEI and BB/CCB
No diuretics or Digoxin
Define Right HF
What is the gold standard for Dx
Define High Output HF
P-HTN induced inability to pump blood
R sided cath
Inc metabolic demand higher than cardiac output
What are 6 examples of Dxs that can cause High Output HF
What is the first sign of this issue
Best method to Dx HF
BeriBeri/Thiamine deficient Anemia Hyperthyroidism Pregnancy AV fistula Paget's Dz
Tachycardia fading to systolic failure
Echo- most important for prognosis
What is normal EF
EF under ? is associated w/ increased mortality
What can be seen on CXR
55-60
<35, place defib
Kerley B lines in bat wing pattern
Why do ventricles release BNP
BNP levels over ? suggest CHF is likely
What are the four NYHA classifications of HF
Dec RAAS activation to decrease fluid volume and
increase Na excretion
> 100
1: ASx
2: Sx w/ mod activity
3: Sx w/ mild activity
4: Sx at rest
AR
MS
PR
TS
AS
PS
HOCM
MVP
MR
TR
VSD
Sit, lean fwd; Diaphragm at Erbs
L lat-decubits; Bell at mitral
Sit, lean fwd: Diaphragm at Pulmonic
Supine; Bell at Tricuspid
Sit; Diaphragm at Aortic
Supine; Bell at Tricuspid
Supine; Diaphragm at Mitral
Supine, Diaphragm at Mitral
Supine, Diaphragm at Mitral apex
Supine, Diaphragm at Tricuspid
Supine; Diaphragm at Tricuspid LLSB
Triad of AS
What type of murmur is heard
What makes the murmur louder/softer
Syncope Angina Dyspnea
Systolic cres/decres at aortic area w/ radiation to neck/apex w/ split S2
Inc: lean forward/squat
Dec: grips
What PE finding suggest AS is a congenital cause
What type of cells may be reported w/ lab results
MCC of AR
Aortic ejection sound
Helmet- schistocytes
Age
AR can present w/ ? unique c/c
What finding on PE helps w/ Dx
What finding suggests a large regurgitation flow is present
Pt aware of heart when laying down
Water hammer pulse
Austin Flint- diastolic murmur from blood hitting anterior mitral leaflet
What causes MS
Pts can present w/ ? c/c
What is heard on PE
Rheumatic heart dz
Paroxysmal nocturnal dyspnea
Opening snap after S2
MR can present w/ ? issues
What may be heard on PE
What causes MVP
SOB w/ activity/laying down
Inc urination at night
Apical S3
Mitral valve balloons into LA
What is the MC Sxs of MVP
How is this Dx
How are Sxs managed
Palpitations from arrhythmia
TTE/TEE
BB is palpitations present
What is the MCC of TS
What is the MCC of TR
How is the JVP wave different for TR
Rheumatic heart Dz
RV failure and dilation
Large V-waves
How is TR differed from MR
PS is MC found in ? population
What will be heard on PE
Radiates to LLSB and inc w/ inspiration
Peds
Wide split S2 w/ dec P2
What is the MC Sx of PR
What type of murmur is heard
Define Afib
Dyspnea w/ exertion
Graham steel: diastolic pulmonary murmur d/t dilated annulus; mis-Dx as AR
Irregular, irregular w/out P-waves and narrow QRS
Tx AFib aims to keep HR below ?
How is this accomplished
How is rhythm control accomplished
110
Diltiazem Metoprolol Verapamil
<48hr: TEE prior to conversion w/ amiodarone
>48hr: anticoag x 21days then convert
Unstable: synch’d conversion
How is the need for anticoagulation in Afib calculated
CA2DS2VASc:
CHF/LVEF
What DOAC meds are used to anticoagulate Pts w/ Afib
When is Warfarin needed
What is the goal INR for warfarin w/ these Pts
Dabigatran Edoxaban Apixaban Rivaroxaban
Mechanical valves
MS
EGFR <30
Pheyntoin/Antiretroviral meds
2.5
What DOAC has the best balance of safety vs efficacy
What DOAC is best for once daily dosing
What DOAC is reversible
Apixaban
Rivaroxaban
Dabigatran
Define PSVT
These rhythms can be caused by ?
What is the hallmark EKG for one of these
SVT w/ abrupt on/offset d/t short circuited arrhythmia w/out structural heart dz
AVNRT- dysrhthmia above Bundle of His
WPW: accessory path in Bundle of Kent
Short PR, Wide QRS, D-wave
WPW can AKA ?
How are PSVTs Dx
How are these Tx
AV reciprocating tachycardia
Holter monitor
Stable: Vagal Carotid massage Valsalva
Sxs: adenosine
Definitive: ablation
What two meds need to be avoided in WPW
What are the three types of premature beats
How are these Dx
Adenosine, CCBs
PAC: abnormal P-wave
PJC: narrow QRS
PVC: bizarre/wide QRS
EKG or Holter monitor
How do PACs appear on EKG
When do these develop
Where are they commonly seen
Pts w/ heart Dz and develop frequent PACs are at risk for developing ?
Abnormally shaped P-waves
Can occur in normal hearts w/out precipitating factors
COPD
PSVT, Afib/flutter
How do PVCs appear on EKG
What can cause these to develop
Pts that are Sx will complain of ?
Early, wide QRS w/out P-waves
Hypoxemia, E+ imbalance
Palpitations felt in throat
How do PJCs appear on EKG
What causes these to develop
How are premature beats Tx
Narrow QRS w/out P-waves
Irritable site in AV node fires impulse before SA node interrupting sinus rhythm
PAC: reassure
PJC: Tx if >10/min or multifocal= lidocaine or antiarrhythmic
PVC: Tx if Sxs, BBs then ablation
Define V-tach
This rhythm is a common complication for ? two Dxs
How is stable VTach Tx
How is unstable, monomorphic VT Tx
How is unstable, polymorphic VT Tx
≥3 consecutive premature ventricular beats
Acute MI, Dilated myopathy
In order:
Amiodarone Lidocaine Procainamide
Synch’d direct conversion starting at 100j
Defib
Define V-Fib
How is this Tx
What is the MCC of AV blocks
Uncoordinated quivering of ventricles w/out useful contractions
CPR
Defib (non-cynch’d conversion) 120, 150, 180
Amiodarone x 2
Idiopathic fibrosis/sclerosis, Ischemia
Define SSS
What are the 4 categories
What is the MCC
Dyfunction in automaticity and impulse generation
Brady, Pause, Arrest, Tachy/Brady
SA node fibrosis
How is SSS Tachy-Brady Syndrome Tx
Criteria for arrest
What 3 nodal agents need to be avoided
Pacemaker
Absent of P-waves x 3sec
BB, CCB, Digoxin
Infective endocarditis is MCC by ? microbes
Define Acute endocarditis
Define Subacute endocarditis
IVDA endocarditis is MCC by ?
Prosthetic valve endocarditis is MCC by ?
Strep V**, Staph, Fungi
HACEK infected normal valves w/ Staph A
Infected abnormal valves w/ Strep viridians
Staph A
Staph epidermis
What is the MCC of candida endocarditis infections and how does it present
How is this Tx
? is the MCC of endocarditis and it presents as ?
Contaminated lines leading to slow growing but large vegetation
Amphotericin B
Step Viridians w/ small, slow growing vegetation post valve replacement w/ embolization
What are the peripheral S/Sxs of infective endocarditis
What is the gold standard for Dx
Janeway- evidence of septic emboli Osler nodes Splinter hemorrhages in finger nails Hematuria d/t emboli/nephritis Roth spots in retina Petechiae, palate/conjunctiva Splenomegaly
TEE
What criteria is used for Dx endocarditis
What are the major criteris
What are the minor criteria
Modified Duke:
Definite= 2 major//1 major, 3 minor/5 minor
Possible= 1 major and 1 minor/3 minor
Pos Echo
New valve regurgitation
Two positive cultures from different sites
Single pos w/ C burnetti
Previous heart Dx/IVDA
Fever ≥100.4
Vascular/Immune phenomenon
How is IE in native valves w/out IVDA Tx
How is prosthetic valve IE Tx
How is IVDA IE Tx
Naficillin Ampicillin Genta
Vanc Genta Rifampin
Nafcillin (Rosh said Cefepime and Vanc)
What is used for IE prophylaxis to prevent recurrent episodes
Rheumatic fever MC affects ? valve
This follows an infection w/ ?
2g Amox 30-60min prior
Mitral
Step throat d/t antistreptolysin Abs reacting to heart proteins
First episode of acute rheumatic fever is Dx w/ ?
What are the minors of this criteria
Jones Criteria: Joints- polyarthritis Oh no, carditis Nodules, SQ Erythema marginatum Sydenhams chorea
Fever Arthralgia Prolonged PR Elevated ESR/CRP
How is Rheumatic Fever Tx
When is ABX prophylaxis indicated
ASA- fever/pain Pred PCN G benzathine Anti-injection: PCN-V or Sulfadiazine Allergy- erythromycin
Peds w/out carditis: for 5yrs or until 21y/o
Peds w/ carditis and no residual damage: 10yrs
Peds w/ carditis and residual damage: >10yrs
Acute pericarditis can often progress into developing ? issue
? type of pericarditis appears 2-5d post-MI
What is the MCC of pericarditis
Pericardial effusion
Dresslers
Coxsackie
How is pericarditis Dx
What type of JVD abnormality would be seen
How is this Tx
EKG: diffuse, precordial ST elevation w/ PR depression- 2, aVF, V4-6
Kussmaul- inc CVP w/ inspiration
NSAIDs/ASA
CCS if Sxs >48hrs
Myocarditis is MC associated w/ ? cause
How is a Dx definitively made
How does a pericardial effusion present
Viral infection: Coxsackie B
Endomyocardial biopsy
Low voltage QRS
Alternans
Distant sounds
How is pericaridal effusion Dx
How is it Tx
? triad is seen in Cardiac Effusion w/ Tamponades
EKG: low voltage w/ alternans
Echo: swinging heart
CXR: water bottle
Centesis; Window if recurrent
Becks:
HOTN Inc JVD Muffles
? is a classic PE finding for a cardiac tamponade
? is the gold standard for Dx
How does an effusion look differently from a tamponade
Pulsus paradoxus- SBP drops x 10mmHG w/ narrow pulse pressure
Echo showing diastolic collapse of RV
Effusion doesn’t have RV collapse
How are Cardiac Tamponades Tx
What is the triad of a AAA presentation
When does USPSTF recommend screenings
Inc preload prevents RV collapse; Centesis- therapeutic
Back pain
Pulsatile mass
HOTN
65-75y/o w/ +smoke Hx
How/When are AAAs screened for
When is surgical repair indicated
When is monitoring indicated
US in males >65y/o w/ smoking MedHx
> 5.5cm or expands >0.6cm/year
q12mon 3cm-4.4cm
q6mon >4.5-5cm w/ referral
q3mon 5-5.4cm
What is used for Pts w/ Dx AAA prior to surgical repair
How are AAAs different from dissections
What PE finding suggest aortic dissection
BBs
AAA- three layers
Dissection- intima
Different BPs in arms
What is the gold standard for evaluating aortic dissections
How are AAAs assessed
What are the Sxs of an arterial embolism and what is a common cause
MRI angiography**
US then CT then Angiography
6 Ps- Pain Paralysis Pallow Paresthesia Polar Pulseless;
LE > UP d/t Afib or MS
What is the gold standard for Dx of an arterial embolism
How are these Tx
Half of AV malformations inthe brain initially present w/ ?
Angiography
Heparin bolus then infusion
Bleeding > Epilepsy
What is the gold standard for Dx, Tx planning and f/u for brain MVMs
Define AVMs and the MC statistic they hold
What is the MC type of lesion
Angiography
Connected artery and veins bypassing capillaries; most dangerous of vascular malformations
Supratentorial
What are the two RFs for cerebral AVMs
How are these Tx
How does Venous Insufficiency appear on PE
Male, FamHx
Surgical excision- mainstay
Radiosurgery- high risk
Endovascular embolization- adjunct
Hyperpigmentation
Atrophic shiny skin
Stasis dermatitis
Where do ulcers appear in Pts w/ venous insufficiency
Define Postphlebotic Syndrome
How is insufficiency Tx
Medial malleolus
Sx chronic venous insufficiency after DVTs
Wound management
Elevation/exercise
Topical derm agents
What is first line imaging for suspected DVT
What is the gold standard image
How are these Tx
Duplex US
Venography
LMWH/Fondaparinux/Xa inhibitors
How can varicose veins present if Sxs
How are these Tx
How does Peripheral Arterial Dz present
Pain w/ exertion or hyperesthesia
Compression Elevate Wound care Sclerotherapy Surgery
Painful ulcers MC d/t atherosclerosis
What is usually the first Sx of Peripheral Artery Dz
What is the gold standard for Dx
What lab result is used for screening for PADz
Intermittent claudication relieved w/ rest
Angiography
Elevated homocysteine
S/e of Nitro
Where is the location of Type 2 blocks
What is the first drug of choice for mild/mod HTN pregnancy
Reflex tachycardia d/t dec BP
Flushing/HA
Dec cardiac o2 demand and preload
Vein > Coronary artery dilation d/t NO release
1: AV node
2: His-Purkinje system
Methyldopa- central A-agonist
Define Inotropic, Chronotropic, and Drootropic
Drug Tx of choice for HTN Urgency
Drug Tx of choice for HTN Emergency
I: Alters force of myocardial contraction
C: Alters HR
D: Alters conduction
Clonidine
Sodium Nitroprusside
Drug Tx of choice for Malignant HTN (HTN retinopathy)
How quickly should BP be lowered during HTN emergency
When HTN is newly Dx, consider ? lab orders
Clevidipine/Sodium Nitroprusside
No more than 25% first hour
160/100 w/in 2-6hrs
To normal w/in 24-48hrs
UA
Alb/Cr ratio
Cr, K, Na, Fasting glucose, Lipids, TSH
EKG
Hypertriglyceridemia screenings begin at ? age
What level is considered normal
What are the ranges for mild, mod and severe
20y/o then q5yrs
<150
Mild: 150-499
Mod: 500-886
Sev: >886
How is hypertriglyceridemia Tx
What is the goal of Tx
What benefit comes from managing the flushing s/e of meds used for Tx
Fibrates- Gemfibrozil, Fenofibrate
Niacin
Prevent pancreatitis
Inc HDL
When Tx hypertriglyceridemia, using niacin can create ? s/e so caution is needed w/ ? population
How is the flushing s/e managed
Define Prinzmetal Angina
Hyperglycemia, DM
Daily ASA
Coronary artery spasm causing ST elevations
What is the MC and another common RF seen in prinzmetal angina Pts
How is this Tx
What is the MC type of ASD
Smoking- MC; Cocaine
Long acting nitrates w/ Amlodipine
Ostium secundum: incomplete adhesion between foramen ovale flap and septum secundum
? are the MC forms of ASD in order
MOA of ASA
What can cause acquired cases of aortic coarctation
O. Secundum, mid-septum
O. Primum- low septum
Sinus Venosus- upper septum
Irreversible inhibition of cyclooxygenase- catalyzes thromboxane enzymes
Inflammatory Dz: Takayasu arteritis
Characteristics of Venous Hum
What inc/dec hum
What antiarrhythmic med is c/i during CADz/structural heart dz
Innocent murmur from blood flowing into jugular veins
Inc w/ sitting
Dec w/ supine, turning head, applying pressure to vein
Felcainide- inc risk for polymorphic Vtach
Class 1a antiarrhythmics
Class 1b antiarrhythmics
Class 1c antiarrhythmics
Na blockers w/ prolonged refractory: Disopyramide Quinidine Procainamide
Na blocker w/ little effect on refractory: Lidocaine Mexiletine Phenytoine
Na blocker w/ slight prolonged refractory: Flecainide Propafenone
Class 2 antiarrhythmics
Class 3 antiarrhythmics
Class 4 antiarrhythmics
BBs: indirect Ca channel blockage by inc adrenergic activation
K blockers: prolonged action potential w/ delayed repolarization: Dofetilide Amiodarone Dronedarone Ibutilide Sotalol w/ Class 2 effects
CCB: slows Ca channel opening to slow SA pacemaker/conduction (Non-DHPs)
How are stable Pts w/ CHF Tx outpatient
How is PSVT Tx in stable Pt
What side effects are expected
BB ACEI Diuretic +ionotropic
Vagal
Adenosine 6mg, 12mg
Facial flushing
Dysrhythmia
Seizure
Hyper/Hypo-tension
How does Acute Hypertensive HF present
How is this condition managed
What condition develops if too much medication is given
Pulm edema
Nitro O2 Furosemide
Methemoglobinemia
Pts are placed on ? anticoagulant after mechanical tricuspid valve placement
Isolated TR is MC seen in ? population
Define Kussmaul’s Sign and when is it seen
Warfarin
IVDA secondary to tricuspid valve endocarditis
Paradoxical rise in JVP w/ inspiration during restrictive cardiomyopathy/pericarditis
Restrictive cardiomyopathy has poor prognosis if caused by ?
What are the two MCCs of this condition
Pts w/ the MC systemic vasculitis may report ? MedHx fact
Amyloidosis
Tropical Endomyocardial Fibrosis- world
Amyloidosis- MC
GCA; Polymyalgia rheumatica
What does an RBBB look like on EKG
What part of the heart’s conduction system conducts electricity the slowest
When are USPTSTF screening for HTN, cervical Ca, DM, ovarian CA and Vit D deficiency conducted
Wide QRS >120msec
Wide S wave in Lead 1, V5-6
Triphasic QRS V1 (RSR variant)
AV node
HTN: ≥18y/o CCa: ≥21y/o DM: 35y/o weight/obese Pts OCa: none for ASx VitD: no recommendation
? is the MCC of HF w/ dec EF
MCC of pericarditis in USA and world
What form of pericarditis is afebrile
Ischemic cardiomyopathy
US: Viral (Coxsackie)
World: TB
Uremic
Indications to admit pericarditis Pt
What antipsychotic med can cause peri/myocarditis
Rosh question
Fever PO anticoagulation Out Pt failure Myopericarditis ImmSupp Trauma Effusion
Clozapine
Cards #26
MCC of COPD
Why does this MC lead to so many issues
COPD is an umbrella term encompassing ?
Smoking
Vasoconstriction
Chronic bronchitis Emphysema
Define Chronic bronchitis
Most of these Pts will be labeled as ? d/t ? PE finding
What is the single best variable for predicting which Pt will develop COPD
Productive cough 3mon/yr x 2yrs w/out fever (fever= pneumonia Dx)
Blue bloaters: hypoxia
Hx 40 pack/year smoker
What is the gold standard for making a Dx of Chronic Bronchitis
What is seen on CXR
What will be seen on PFT in chronic bronchitis
Lung biopsy w/ inc Reid index (gland layer >50% of bronchial wall)
Inc interstitial markings, thickened bronchial walls and normal diaphragm
FEV/FVC ratio <0.7
What lab results are expected for chronic bronchitis
What is the most effective therapy for Tx Pts w/ chronic bronchitis
When is supplemental O2 indicated
Inc H/H
Inc CO2/Dec O2
Respiratory acidosis- PCO2 >45, BiCarb >30
Cessation
SaO2 <89% or,
PaO2 <55mmHg
What vaccinations doe Chronic Bronchitis Pts need
How are exacerbations managed
What complication can arise from this Dz process
Influenza, Pneumococcal
Pred 40mg/day x 5d
ABX: Azith/Cefur/Doxy
Cor pulmonale d/t hypoxic vasoconstriction
COPD Gold Categories
A: Less Sx, Low risk;
Breathless when hurrying on flat ground, 0-1 exacerbation, 0 hospitalizations
SABA/SAMA
B: more Sx, low risk;
Breathless when walking slower than peers, 0-1 exacerbations, 0 hospitalizations
LAMA/LABA
C: less Sx, High risk
Breathless when hurrying on flat ground, 2/> exacerbation, 1/> hospitalizations
LAMA and SABA
D: more Sxs, High risk;
Breathless when walking slower than peers, 2/> exacerbations, 1/> hospitalizations
LAMA+LABA w/ SABA
What causes structural changes seen in emphysema
Emphysema almost always co-exists w/ ? Dx
What type of breathing habit do these Pts develop
Destroyed alveolar septae d/t elastin loss
Chronic bronchitis
Purse lip, keeps airway from collapsing
What CXR findings are seen w/ emphysema
What lab result will be different compared to chronic bronchitis Pts
What will emphysema PFT results show
Barrel chest
Hyperinflated lungs w/ bullae
Flat diaphragm
Normal Hct
Dec FEV1/FVC ratio
Inc TLC
What causes acute sinusitis
What is the ‘little brother’ to HFlu
What is the gold standard for Dx
Acute: Strep Pneumo
Chronic: Staph A
Moraxella
CT
What are the four indications for ABX to Tx sinusitis
What is used for first and second line ABX Tx
What options are avail if Pt is allergic to PCN containing ABX
Fever >102
Improves then worsens
Purulent d/c
Sxs >10days
First :
Amoxicilli Doxy Levo
2nd: fail to improve in 7days:
Augmentin Levo/Moxi-floxacin
Doxy/Levo/Moxiflox
How is chronic rhinosinusitis Tx
What is used for Peds
What is used if they are allergic to PCN containing ABX
Augmentin
Allergic: Clinda
Augmentin
3rd Gen: Cefpod/Cefdinir
? is the MC type of pneumonia
Typical pathogens typically present w/ ?
Atypical and viral pathogens present how?
Strep pneumo >40y/o;
Mycoplasma <40y/o
F/C/Tachy/Tachy w/ rusty sputum- lobar pneumonia
Fever w/ dry cough- interstitial infiltrate
What are the typical pathogens causing CAP
What are the atypical pathogens causing CAP
What is the exception to the sick/not sick of atypicals
Strep pneumo HFlu Moraxella and more sick
Legionella Mycoplasma Chlamydial and not as sick
Legionella
What microbe causes pneumonia after an influenza infection
What microbe infects CF, COPD, malignancy or ventilated Pts
? are the MC nosocomial infections
Staph A
Pseudomonas
UTI w/ catheter
Pneumonia w/ Strep pneumo
What vaccination reduces risk for pneumococcal pneumonia
What populations should receive this
How is lobar pneumonia Tx in sequential order
23-PPSV
Chronic liver dz/Alcoholics DM Cigarette smokers Asplenic/Sickle cell Native American/Eskimo
Azith/Clarith-romycin
Doxy
Autmentin
Levofloxacin
What is the most virulent microbe to cause lobar pneumonia and what does it look like on CXR
? population are at risk for this form
How is this form Tx in sequence
HFlu w/ patchy alveolar infiltrates
Kids <5y/o in daycare
COPD, HIV
Augmentin
Cefur/Cefdinir/Cefixime
Azithromycin
Levo- unless COPD, then first
? is the MCC of pneumonia in Pts <40y/o
What other PE findings suggest this microbes etiology
What does this look like on CXR
Mycoplasma w/ late summer/early fall outbreaks
Bullous myringitis
Erythema multiforme
Patchy infiltrates that are more extensive than Pt appears on PE
How is Mycoplasma pneumonia Tx in order
What form of Legionairres is most dangerous
What doe they require for replication
Azith/Clarith-romycin
Doxy
Levofloxacin
Serogroup 1
Amoebas in water
What is an early PE finding of Pt infected w/ Legionairres?
What are the two phases of the infection
What does it look like on CXR
Bradycardia
Pontiac fever, Pneumonia
Lower lobe patch w/ pleural effusion (inc LDH)
How is Legionairres pneumonia Dx
How is this Tx in order
What causes pneumonia in HIV/AIDS/Ca Pts
Immunofluorescent Ab and ELISA
Direct fluorescent of sputum
UA
Azith, Levo, Doxy
P. jiroveci, unicellular fungi
How does pneumonia d/t Jiroveci present
What does this look like on CXR
How is it Dx
F/C, dyspnea w/ dry cough x weeks
Interstitial pneumonia w/ inflamed/infected alveolar epithelial cells= bilateral, perihilar infiltrates
Bronchial lavage and biopsy
What lab result reflects the degree of lung injury in PTs w/ pneumonia d/t jiroveci
How is this Tx
When is HIV re-Dx as AIDS
Inc LDH levels
1st: TMP/SMX x 21days
2nd/PCN Allergy: Pentadmie (s/e- Qtc prolongation)
TMP + Dapsone
CD4 <200
How is C Pistacci transmitted
How is this Tx
What are the 3 MCC of viral pneumonia
Inhalation through dried bird droppings
1st: Doxy; 2nd: Azith
Para/Influenza Adenovirus
How is viral pneumonia Tx
The sooner ? med is added the fewer complications Pts tend to have
Pts that have been Tx for pneumonia w/in past ? time and are still sick are Tx w/ ?
1st: Ribavirin; 2nd: Palivizumab
Decadron
<3mon w/ Levofloxacin
How are Peds w/ CAP Tx
First line ABXs for CAP outpatient Tx
What is the risk when prescribing Levofloxacin
<5y/o: Amoxicillin
>5y/o: Azithromycin
Azith/Erythromycin
Clarithro/Doxy
Prolonged QTc
Strep pneumoniae presents w/ ? color productive cough and in ? Pts MedHx
Staph A pneumonia presents as ?
Histoplasmosis pneumonia occurs in Pts w/ ? Hx and mimics ? on CXR
Rust colored, Splenectomy
Salmon colored sputum after influenza infection
Bat/bird droppings from Ohio River valley; Sarcoidosis
What three PE findings are common in pneumonia Pts
How does fungal pneumonia d/t Coccidioides present
? etiology of pneumonia is detected via CSF
Tactile fremitus
Egophony
Dull to percussion
Non-remitting cough unresponsive to ABX
Cryptococcus
How is Crytpococcus and Histoplasma pneumonia Tx
How is Coccidioides and Aspergillus pneumonia Tx
What are the classic findings of TB on PE
Amphotericin B
Flu/Itra-conazole
Fever Anorexia Weight loss Night sweats
What are the PPD rules for TB
>5mm: CXR evidence of TB HIV/ImmSupp 15mg/day x 1mon or equivalent of Pred Close contact w/ infectious TB
>10mm: IVDA Residents of high populations Immigrants GI surgery
> 15mm: No RFs
How is TB Dx
What is seen on CXR
What is seen on biopsy results
Acid fast bacilli smears and cultures
Apical Ghon complexes
Caseating granulomas
What are the two forms of miliary TB
How is TB Tx
Potts Dz: TB in spine
Scrofula: TB to cervical lymph nodes
+ PPD= CXR
Neg CXR: latent TB Tx w/ Isoniazid w/ Vit B6 x 9mon
Active CXR:
Baseline LFTs
RIPE x 8wks
RI x 16wks
All TB Tx meds have ? s/e so ? is needed prior to Tx
What are the s/e of RIPE therapy
What is used for prophylaxis for household members
Hepatotoxic; baseline labs
R: orange fluids
I: neuropaty
P: hyperuricemia
E: red-green blindness
Isoniazid x 12mon
When are TB Pts considered fully Tx
What part of RIPE needs to be adjusted if CrCl is <30
? RIPE adjustment is needed if Pt is also on HIV meds
Two negative AFBs and cultures
P/E- 3 x/wk
Raltegravir, double dose when used w/ Rifampin
What are the 4 indications to test for TB w/ NAAT
? is the traditional test for latent TB
Define Ranke Complex
Previously Tx for TB
Lived in endemic area
Contact w/ MDR TB
HIV seropositive
TST via Mantoux method
Calcified hilar lymph node d/t TB
How are pregnant Pts w/ TB Tx and w/ ? educational piece
Define Asthma
Absence of ? Sx on PE indicates medical emergency
R/I/E x 4-8wks
R/I x 7months
Breast feeding not c/i
Chronic, reversible inflammatory airway dz
Lack of wheeze
Define FEV1
Define FEV
Define FVC
How is asthma Dx and what result is Dx
Amount exhaled in 1 second
Total amount exhaled during forced breath
Total amount exhaled during FEV test
Peak expiratory flow rate; FEV1/FVC 75-80%
Define Intermittent Asthma
Define Mild
Define Moderate
Define Severe
Sxs 2/< days/wk
Awake 2/< x/month
SABA 2/< days/wk
No activity interference
Sxs >2day/wk
Awake 3-4x/mon
SABA >2 days/wk
Minor limitations
Daily Sxs
Awake 1/>/wk
SABA daily
Some limitations
Daily Sxs
Nightly awakenings
SABA several x/day
Extreme limitations
Step 1 Asthma Tx
Step 2 Asthma Tx
Step 3 Asthma Tx
Step 4 Asthma Tx
Step 5 Asthma Tx
Step 6 Asthma Tx
1- Intermittent; SABA PRN
2- Mild; Low ICS daily
3- Moderate; Low ICS + LABA daily
4- Moderate; Med ICS + LABA daily
5- Persistent; High ICS + LABA daily
6- Persistent; High ICS + LABA + PO CCS daily
What is used for acute Tx of asthma exacerbation
? is the MC of all interstitial lung dzs
How is this MC Dx
PO CCS
Ipratropium bromide
Nebulized SABA
O2
Idiopathic pulmonary fibrosis
CXR w/ diffuse, patchy fibrosis and pleural base honeycomb
What type of PFT results are seen in Idiopathic Pulmonary Fibrosis
How is this Tx
Define Pneumoconiosis
Restrictive pattern- dec volume, normal/inc FEV1/FVC
CCS O2 Transplant
Pulmonay fibrosis d/t exposure to mining/dust causing dec lung volume/FVC (restrictive dz)
Asbestosis CXR findings
Coal Workers CXR findings
Sillicosis CXR findings
Linear pattern w/ basilar predominance, opacities and honeycomb
Nodular opacities in upper fields and less prominent hilar adenopathy
Egg shell classifications of hilar nodes
Berylliosis CXR findings
? restrictive lung dz makes Pts at increased risk for TB
? restrictive lung dz needs tobacco cessation more than others
Difuse infiltrates w/ hilar adenopathy
Sillicosis- need serial TST/CXRs
Asbestosis
? tissue finding indicates significant exposure to asbestos
? size lung mass is a nodule or a mass
How are incidental findings of pulmonary nodules managed
Ferruginous body
<3cm- coin lesion, nodule (<30mm)
>3cm- mass
CXR or compare to old CXRs, then CT w/out contrast-
Ill defined, lobular, spiculated= biopsy
<1cm, calcified, smooth/defined border= f/u 3mon, 6mon, annual x 2yrs
Define Carcinoid Tumor
These are primarily found ? and MC mets to ?
What is the MCC of the mets
Neuroendocrine cells w/ excess secretion of serotonin, histamine and bradykinin
GI; Liver then to lungs
Appendix carcinoid tumor
What is the hallmark presentation of carcinoid syndrome
What are the effects of the excess hormone secretion
What water soluble vitamin will Pts be deficient in
Flushing Diarrhea Wheeze w/ HOTN
Seroto: collagen thickening of R sided heart valves
Hist/Brady: vasodilation w/ flushing
Inc serotonin decreases tryptophan which dec niacin/B3 leading to pellagra
How is carcinoid syndrome Dx
What would be seen on CXR
What would be seen on bronchoscopy
CT located tumors
Octreoscan
UA: Inc 5-HIAA, metabolite of serotonin
Pedunculated sessile growth in central bronchi
Pink/Purple lesion w/ vascularization
How is carcinoid syndrome Tx
What are the two categories of lung cancer
What are the 4 subtypes of one of these categories
Surgical excision d/t resistant to chemo/rad
Octerotide to dec serotonin secretion
Niacin supplements
Non/Small cell
Non-Small Cell:
Adeno: non-smoker w/ small peripheral lesion; MC bronchogenic Ca
SCC: single central mass in smoker w/ hemoptysis
Large: fast growth, rarely responds to surgery
Carcinoid- lack differentiation
? is the MC type of bronchogenic carcinoma
What lab results are seen in Pts w/ small cell lung cancer
What syndrome can these Pts develop
Non-small cell adenocarcinoma
HypoNa, HyperCa
Lambert Eaton myasthenic syndrome- limb muscle weakness
How are lung Ca Dx
Pancoast tumors are more likely to be ? types
What two syndromes can pancoast tumors cause
Bronchoscopy w/ biopsy if central or,
Fine Needle Transthoracic aspiration (most useful)
Adeno/SCC in upper lung
Superior VCS: face/arm swelling
Pancoast: shoulder pain w/ Horners and bone destruction
How is Non-Small Cell lung Ca Tx
How is Small Cell Ca Tx
Solitary pulmonary nodule that has not grown in ? time suggests benign etiology
Stage 1-2: surgery
Stage 3: chemo then surgery
Stage 4: palliative
Chemo, no surgery option
≥2yrs and <1.cm diameter
Pulmonary nodule w/ calcification/central location suggests ? etiology
? measurement is indicative of a Dx of PHTN
What is the MCC
Benign, Tuberculoma, Histoplasmona
> 25mmHg at rest
Mitral stenosis
What are the 5 WHO groups of P-HTN etiologies
What is the first Dx test
What is the gold standard for Dx
1: Pulm Aterial HTN
2: L heart Dz
3: Lung Dz
4: blood clots in lungs
5: blood/other d/os
TTE
R sided heart cath
What EKG findings suggest P-HTN
How is P-HTN Tx depending on the cause
Inverted T-waves V1-4 and 2,3, aVF
LVF: Digoxin, Anticoagulate, Diuretics- caution
Cardiogenic: prostanoids, PD-5 inhibitors, endothelin antagonists
PA-HTN: endothelin antagonists, prostanoids
What type of birth control do women who smoke/>35y/o need to be on to reduce DVT risk
How are DVTs Dx
How can a DVT be ruled out in Pts w/ low risks
Progestin only
Fist: Venous US
Gold: venography
D-dimer
If a DVT is found, how are they Tx
What are the 4 specific RFs
What triad would be seen if a fat emboli is the cause
LMWH
Fondaparinux
Factor 10a inhibitors
Cancer OCPs Pregnancy Surgery
Hypoxemia
Neuro abnormals
Petechial rash
Pregnant Pts w/ amniotic fluid emboli can lead to ? complication
What risk stratification method is used for PEs
If the above method results in a score of 0-1, ? is the next step
DIC
Wells:
>4: PE likely
4≤: unlikely, D-dimer to r/o
PE R/o Criteria: HAD CLOTS:
Hormones Age >50 DVT/PE Hx Coughing blood Leg swelling O2<95% Tachy >100 Surgrey/Trauma <28d
How are PEs Dx and If found, how are they Tx
Most PEs arise from where in the body
What old school PE finding was used to Dx DVT
Spiral CT; Renal insuff: VQ scan:
Heparin then Factor 10a/DOACs after x 3mon
LMWH- if pregnant
Thrombolytics if unstable
Embolectomy if unstable and c/i for thrombolytics
Iliofemoral DVTs
Homans Sign- calf pain w/ dorsiflexion
? triad is used for DVTs/PE
What two findings may be seen on CXR
? is the gold standard or imaging modalities for Dx
Virchows:
Trauma Stasis Hypercoag
Westermark, Hampton Hump
Pulm angiography
OSA usually presents d/t obstruction at ? level
What are the 5 RFs for OSA
For a Dx, ? sleep study results are needed
Oropharynx
Obesity Anatomical FamHx ETOH/Sedative Hypothyroidism
5/> events/hr w/ Tired/Waking/Snoring/HTN
15/> events/hr regardless of other Sxs
How is mild/mod OSA Tx
How is severe OSA Tx
Obesity Hypoventilation Syndrome is AKA ? and includes ? criteris
CPAP; PO appliance
CPAP
Uvulo-plasty
Tracheostomy- if life threat
Pickwickian-
BMI >30, Sleep d/o breathing, Chronic hypercapnia >45mmHg
Define Central Sleep Apnea
What causes transudative pleural effusions
What is the MCC
Ventilatory effort absent for duration of apneic period
Thin watery ooze d/t back pressure in circulation and loss of osmotic pressure
CHF
What are some causes of transudative pleural effusions
What are some causes of exudative effusions
Pleural effusions present w/ ? PE findings
HF
Cirrhosis/Ascites
Nephrotic induced hypoalbuminemia
Fluid d/t infection/Ca:
Pneumonia Ca PE TB
Dec breath sounds and tactile fremitus
What criteria is used to Dx pleural exudates
What CXR findings help w/ Dx
Left sided effusions are more than likely ? while right sided are probably ?
Lights; 1 of 3= Dx High protein, LDH Protein >0.5 LDH >0.6 LDH >2/3 upper limit
Meniscus sign, Silhouette sign
L: exudative; R: transudative
How are pleural effusions Tx
Define ARDS
What is the MCC and possible causes
Small- diuretics, Na restriction
Thoracocentesis
Chronic/Recurring: pleurodesis
Inflamed lungs and accumulation of fluid in alveoli w/ low O2 levels and pink froth
Sepsis;
Trauma Aspiration Multiple transfusions
How is ARDS Dx
What would be seen on CXR
How is ARDS Tx
Bilateral Sxs, CXR and PAO2/FIO2 ration <300
Air bronchograms w/ bilateral, fluffy infiltrates
Mechanical PEEP maintaining PaO2 >60/SaO2 >90
What causes the accumulation of the pulmonary edema
What score system is used to predict the mortality of Sepsis
? is an indirect marker of tissue perfusion used in sepsis Tx
Inc permeability of alveolar cap membrane
qSOFA:
New/worse mentation
RR >22/min
SBP 100/<
Lactate
? is the MCC of sepsis and ? is the MC manifestation
Gram-Pos shock is d/t ? microbes
Gram-Neg shock is d/t ? microbes
Pneumonia; Fever
Staph/Strep exotoxin
EColi, Klebsiella, Proteus, Pseudomonas endotoxins
? are the sepsis biomarkers
How are septic Pts Tx
Procalcitonin: peak 12-48hrs
Lactate: >18 are Dx of septic shock
Fluid resuscitation w/ IV crystalloid 30mL/kg in first 3hrs
Empiric ABX w/in 1hr
NorEpi if MAP is not maintained >65mm
What ABG results are seen w/ sepsis
MCC of anaphylaxis
? type of reaction is the usually
Resp alk, Metabolic acid
Ingested foods
MC a Type 1 IgE mediated reaction
What is usually the first sign of anaphylaxis
? is first line Tx
What medication can cause Pts to be resistant to the above first line Tx
Cutaneous pruritus/urticaria/angioedema
IM Epi
BBs
Define Cystic Fibrosis
How is this Dx
What would be seen on CXR
Autosomal recessive d/o causing abnormal production of mucus by exocrine glands
NaCL >60mEq on two tests
DNA testing
Hyperinflation
Atelectasis, focal
Mucus plugging
CF Pts have ? respiratory infections early in life
How are these Pts manged
What would be seen on PE of Dilated Myopathy if severe HF was present
Staph A, HFlu the Pseudomonas
Hypertonic saline cleanings
ADEK supplementation
Cheyne Stokes- fast/shallow breathing followed by slow/heavy breathing
Pulsus alternans
Pts w/ Dilated Cardiomyopathy and dyspnea need ? lab drawn and why
? is the imaging modality of choice for RV dysplasia
A biopsy in Dilated Cardiomyopathy is only useful for ?
BNP- establish prognosis/severity
Cardiac MRI
Transplant rejection
All PTs w/ Dilated Cardiomyopathy, regardless of etiology, need to be Tx w/ ?
If still symptomatic, how is Tx adjusted
? class drug needs to be avoided unless ? is present
ACEI, BB
Add aldosterone antagonist- Spironolactone, Eplerone
Switch ACEI/ARB for ARNI- Sacubitril/Valsartan
CCBs; Afib/flutter ventricular control
All diabetics w/ Dilated Cardiomyopathy need ? drug added if LVEF is lower than ?
What are the 3 indications to use Ivabradine to slow HR in this population
What drug is used second line but is preferred d/t?
Mineralcorticoid antagonist- Spironolactone, Eplerone;
<40%
Resting HR >70
LVEF <35%
Chronic and stable
Digoxin;
Dec hospitalization
? drug combo is recommended for use in AfAm w/ Dilated Cardiomyopathy
When are Pts w/ Dilated Cardiomyopathy w/ Afib candidates for biventricular pacing
When is an ICD implant a reasonable option
Hydralazine-Nitrate
Significant MR and,
QRS >150msec
ASx ischemic cardiomyopathy w/ LVEF <35% on appropriate medical therapy and >40d post-MI
Dilated Cardiomyopathy w/ Afib should be anticoagulated w/ ? unless ?
What are four reversible causes of Dilated Cardiomyopathy
When is the obstruction of HOCM increased
DOAC; Mitral stenosis
Hypothyroid
Alcohol
Toxins
Sarcoidosis
Systole w/ anterior motion of MVs anterior leaflet
What is the end consequence of HOCMs hypertrophy
How is this condition inherited
How is this condition differed from athletic heart
Inc LV diastolic pressure
Autosomal dominant sarcomere defect: myosin heavy chains/Ca regulating proteins
Athletes- no diastolic dysfunction
HOCM in Asians is commonly ? type compared to the other MC
HOCM in older adults is d/t ?
HOCM can present mimicking ? but is differed by ?
Apical; MC- septal
HTN;
Sigmoid interventricular septum w/ cardiac knob below AV
AS- provoking maneuvers are opposite;
HOCM inc w/ stand/valsalva
Dec- squat, grip. leg raise
What are the three most frequent presenting Sxs of HOCM
What will be seen on PE of HOCM
? is a poor prognostic sign and what causes this to develop
Post-exertion syncope
Angina
Dysnpnea
Triple apical pulse
Bisferiens carotid pulse
JVP w/ a-wave
S4 gallop w/ lift
Afib d/t chronically elevated LA pressures
What valvular d/o is commonly seen in HOCM
What EKG finding is nearly universal in all symptomatic Pts
What else would be seen on EKG
MR
LVH
Septal Q-wave (2, 3, aVF)
High voltage precordium
Echos must be done to HOCM Pts to r/o ? other congenital d/o
How can the progression of HOCM be stopped
When are Pts best managed by ICD
Ventricular noncompaction- trabeculation causing incomplete ventricular filling
Dual biventricular pacing
Malignat ventricular arrhythmia
Unexplained syncope w/ +FamHx sudden death
How can HOCM be surgically Tx
How can HOCM non-surgically be Tx
Pregnant Pts w/ HOCM are at greater risk w/ ? measurement and are best managed w/ ?
Myotomy myomectomy w/ Alfieri
Alcohol ablation into LCA
Outflow gradient >50mmHg;
BBs
? test is used to look for amyloid deposition in the heart during Restrictive Cardiomyopathy
? imaging is used for screening
How can systemic disease involvement be confirmed but ? is needed to confirm cardiac involvement
Tech-pyrophosphate bone scan
Cardiac MRI
Rectal Adipose Gingival biopsies;
Endomyocardial biopsy
