IM Shelf Review PPT Flashcards
Which EKG leads affected in an anterior infarct?
V1-V4
Which EKG leads affected in an inferior infarct?
II, III, aVF
Which artery affected in an inferior infarct?
RCA
Which artery affected in an anterior infarct?
LAD
R ventricular infarct s/s
hypoTN, tachycardia, + JVD, CLEAR lungs, NO pulsus paradoxus (looks like they are in shock w JVD)
R ventricular infarct Tx?
fluids; NO nitro bc lack of preload is problem, and that would make it worse
When does myoglobin peak after an MI?
2h
When does CKMB peak after an MI?
24h
When does troponin peak after an MI?
24-48h
What is the best test to check for a recurrent MI?
myoglobin
Name 2 medications that must be d/c’d prior to a stress test.
beta-blockers and Ca-channel blockers
Name 2 medications used for a chemical stress test.
dobutamine, adenosine
How does dobutamine work?
beta1-adrenergic receptor –> increased contractility and HR
What indicates a positive stress test?
+ CP, ST depression, or hypoTN
How do adenosine work?
causes coronary vasodilation and increases blood flow in normal coronary arteries; Slows conduction time through the AV node, interrupting the re-entry pathways through the AV node, restoring normal sinus rhythm
What meds do you d/c an MI pt home on?
aspirin/clopidogrel, beta-blocker, ace-I, statin, nitrates
What is the most common cause of death post-MI?
arrhythmia
S/p MI, new systolic murmur 5-7 days later?
papillary muscle rupture
S/p MI, acute hypoTN, new murmur?
ventricular free wall rupture
S/p MI, persistent ST elevation about 1 month later, with systolic MR murmur?
ventricular wall aneurysm
“Cannon A-waves”
JVP is bounding - tricuspid valve not opening in synchrony with cardiac cycle- atria and ventricles (AV) dissociation
S/p MI, pleuritic CP and low grade temp, 5-10 weeks later?
Dressler’s syndrome
Another name for autoimmune pericarditis?
Dressler’s syndrome
Dressler’s syndrome tx?
NSAIDs, aspirin
Young person, diffuse ST elevation?
pericarditis
CP worse with inspiration (pleuritic), improved with leaning forwards, friction rub
pericarditis
Tx for pericarditis?
NSAIDs
Vague CP + hx of viral infection + murmur?
myocarditis
CP at rest, worse at night, + migraines, transient ST elevation during episodes?
Prinzmetal’s angina
Prinzmetal’s angina tx?
nitrate, Ca++ channel blockers
Prinzmetal’s angina diagnostic test?
ergonovine stimulation test
EKG: progressive prolongation of the PR interval, with dropped beat?
Wenckebach/Mobitz type I
EKG: regular P-P and R-R interval, but not associated with each other?
3rd degree heart block
Physical exam 3rd degree heart block?
Cannon A-waves
EKG: varying PR intervals with >3 morphologically distinct P waves in the same lead
multifocal atrial tachycardia (MAT)
EKG: >3 consecutive beats with narrow QRS and rate >120
v-tach
Tx v-tach?
if pt unstable = shock, if pt stable = lidocaine, amiodarone
EKG: delta waves
WPW
EKG: short PR interval, wide QRS, slurred initial deflection
WPW
Tx WPW?
procainamide
What meds are contraindicated in WPW?
anything that slows AV conduction (beta-blockers, digoxin, verapamil, diltiazem)
EKG: sawtooth
A-flutter
Tx A-flutter?
unstable: shock
stable: beta-blockers, digoxin (kind of like a-fib)
EKG: regular rhythm, ventricular rate 125-150 and atrial rate 250-300
A-flutter
EKG: prolonged QT interval leading to undulating rotation of the complex around the EKG w/ low Mg and K
Torsades
What OD causes Torsades?
tricyclics
EKG: regular rhythm with rate 150-220 and sudden onset and offset palpitations
SVT
1st line Tx SVT?
carotid massage
Drug tx for SVT?
adenosine
EKG: peaked T waves?
hyperkalemia
EKG: Wide QRS, short QT, prolonged PR
hyperkalemia
EKG: undulating, low amplitude, alternate beat variation in direction
tamponade (electrical alternans)
Pulsus paradoxus, hypoTN, distant heart sounds, JVD?
tamponade (electrical alternans)
EKG: undulating baseline, irregular R-R interval
A-fib
Rate control drugs for a-fib?
beta-blockers
SEM cresc/decressc, louder with squat, softer with valsalva, parvus et tardus
aortic stenosis
Causes of aortic stenosis?
old age- calcific stenosis; bicuspid aortic valve
Tx aortic stenosis?
valve replacement
SEM louder with valsalva, softer with squatting or handgrip
HOCM
How does valsalva affect the heart?
decreases preload
Late systolic murmur with a click, louder with valsalva, softer with squatting
MVP
Holosystolic murmur radiating to axilla
mitral regurg
Holosystolic murmur w late diastolic rumble in kids
VSD
continuous machine-like murmur
PDA
wide fixed and split S2
ASD
rumbling diastolic murmur w opening snap
mitral stenosis
blowing diastolic murmur with a widened pulse pressure
aortic regurg
If PE is highly suspected: first step?
give heparin
Hx of CHF and murmur present?
get echo
Tx acute pulm edema?
nitrates, lasix, and morphine
young pt, sxs of CHF w prior hx of viral infection?
myocarditis (coxsackie B)
Reversible causes of CHF?
EtOH, hemachromatosis
Tx CHF?
ace-i, beta-blocker, spironolactone, furosemide, digoxin
CHF tx that improve survival?
ace-i, beta-blocker, spironolactone
CXR: thickened peritracheal stripe and splayed carina bifurcation
LA enlargement from bad mitral stenosis; cancer
Name 3 transudative causes.
CHF, nephrotic syndrome, cirrhosis
Transudative w low glucose?
RA
Transudative with high lymphocytes?
TB
Transudative with blood?
PE or cancer
Name 2 exudative causes.
PNA, cancer
What is a complicated plural effusion?
positive bugs, low glucose, low pH
What is the tx for complicated plural effusion?
insert chest tube for drainage
Lights criteria for transudate?
1) LDH <200
2) LDH eff/serum < 0.6
3) protein eff/serum < 0.5
3 diagnostic criteria for ARDS?
1) PaO2/FiO2 <200
2) bilateral alveolar inf on CXR
3) pulm cap wedge pressure <18 (r/o cardiac causes)
ARDS tx?
PEEP
COPD dx?
productive cough >3mos in 2 consecutive years
COPD tx?
ipratroprium, beta-agonist, theophylline
When is O2 initiated in COPD?
pulse ox <88 or blood gas <55
COPD acute exasherbation dx?
any change with the sputum, increasing dyspnea
COPD acute exasherbation tx?
O2, nebs, corticosteroids, FQ or macrolide
Best prognostic indicator for COPD?
FEV1
What improves COPD mortality?
long-term O2, d/c smoking
COPD pt with clubbing?
lung cancer! get CXR (hypertrophic osteoarthropathy)
Name a long acting beta-agonist.
salmetrol
PCO2 in the middle of an asthma attack?
low
CXR: 1cm nodules in upper lobes with eggshell calcifications?
silicosis
Silicosis predisposes to ___.
TB
Asbestosis predisposes the patient to ____.
cancer
CXR: reticulonodular process in lower lobe with pleural plaques.
asbestosis
CXR: patchy lower lobe infiltrates, thermophyilic actinomyces
hypersensitivity pneumonitis (farmer’s lung)
CXR: hilar lymphadenopathy, increase ACE, erythema nodosum
sarcoidosis
Why hypercalcemia in sarcoid?
microphages make vitamin D
Tx sarcoid?
steroids
Benign lung nodule characteristics?
popcorn calcification (hamartoma), concentric calcification (old granuloma)
Malignant lung nodule characteristics?
> 3cm, eccentric calcification, older pt, smoker
Most common lung cancer in nonsmokers?
adenocarcinoma
Where does adenocarcinoma of the lung arise?
peripheral
Where does adenocarcinoma of the lung metastasize?
liver, bone, brain, adrenals
Plural effusion of adenocarcinoma of the lung?
exudative with high hyaluronidase
kidney stones, constipation, + malaise with low PTH and central lung mass?
paraneoplastic syndrome of squamous cell carcinoma (PTH RH)
shoulder pain, ptosis, constricted pupil, facial edema
pancoast tumor/superior sulcus syndrome- from small cell carcinoma
ptosis better after 1 min of upward gaze
Lambert-Eaton (small cell lung ca)
old smoker, low Na+, moist mucous membranes, no JVD
SIADH from small cell carcinoma
IBD with p-ANCA?
UC
Tx IBD?
ASA, sulfasalazine, corticosteroids
2 liver markers in EtOH?
AST, GGT
ALT>AST and in the 1000s?
viral hepatitis
ALT and AST and in the 1000s
ischemic hepatitis/shock liver
elevated D-bili?
obstruction (biliary tract, gallbladder, Dubin-Johnson, Rotor)
elevated indirect bili?
hemolysis, Gilbert, Criglar-Najar
elevated alk phos and GGT?
obstruction in biliary ducts
elevated alk phos, normal GGT, normal Ca++?
Paget’s disease
ANA+, antismoothmuscle Ab with liver dz?
autoimmune hepatitis
high Fe, low ferritin, low Fe binding capacity, liver problems?
hemachromatosis
low ceruloplasmin, urinary Cu++ high
Wilsons
Tx Paget’s disease?
bisphosphonates
meningitis in young and old bug? tx?
listeria- add ampicillin
meningitis in brain surg bug? tx?
staph- vanc
meningeal Tb tx?
add steroids to RIPE therapy
Lime dz meningitis?
IV ceftriaxone
Most common PNA bug in young, healthy people? tx?
mycoplasma- tx = macrolide
HAP bugs?
Pseudomonas
Klebsiella
E. coli
old smoker with COPD. PNA?
H. influenza- 2nd/3rd generation cephalosporin
PNA after the flu?
Staph
PNA after delivering a baby cow?
Q fever (coxiella)
PNA after skinning a rabbit?
tularemia
Who gets Tb exposure prophylaxis? With what?
kids <4yo with INH
SE rifampin?
red/orange body fluids; CYP450 inducer
SE INH?
neuropathy- give B6 (pyridoxine)
SE pyrazinamide?
hyperuricemia
SE ethambutol?
optic neuritis
most common bug endocarditis of ?
Staph
most common valve endocarditis?
mitral valve
IV drug user endocardidits valve?
tricuspid
What murmur is worse with inspiration?
right-sided
Endocarditis complication?
emboli, CHF
Strep bovis bacteremia?
colonoscopy looking for colon cancer
Strep bovis bacteremia?
colonoscopy looking for colon cancer
When do you start HAART?
CD4<350 or viral load >55,000 (unless pregnant)
What HIV drug causes leukopenia, GI sx, and macrocytic anemia?
zidovudine (AZT)
What HIV drug causes pancreatitis, peripheral neuropathy?
didanosine
Post-exposure HIV prophylaxis?
AZT + lamivudine + nelfinavir for 4 weeks
HIV pt with DOE, dry cough, fever, CP?
pneumocystic pna
Blood test PCP?
elevated LDH
1st line tx PCP?
tmp-smx
2nd line tx PCP?
dapsone, pentamiadine
PCP prophylaxis indicated when? What is used?
CD4<200
tmp-smx
3 bugs causing diarrhea in HIV+ pt?
CMV
MAC
cryptosporidium
HIV+, one ring enhancing brain lesion?
primary CNS lymphoma
Tx toxo?
pyramethamine-sulfadiazine
HIV+ pt with sz and dejavu aura? Tx?
HSV encephalitis- acyclovir
What virus goes to the temporal lobe?
HSV
Most common cause of meningitis in an HIV+ pt? What else is worrysome?
strep pneumo, cryptococcus
Tx Cryptococcus?
amphotericin IV
HIV+ with hemisensory loss, visual impairment, Babinski?
PML from JC polyomavirus
HIV+ with memory problems or gait disturbance?
aids dementia complex
Most common bugs in neutropenic fever?
pseudomonas, MRSA
Target rash, fever, CN7 palsy, AV block, meningitis dx? tx?
Lyme dz
doxycycline (if under 8, give amox)
Rash @ wrists, palms, soles, ankles, fever, HA. Dx and tx?
Rocky Mountain Spotted Fever (Rickettsia); doxy for everyone
Tick bite tx?
doxycycline
gram + branching, partially acid fast?
nocardia
Nocardia tx?
tmp-smx
Numbness, Chvostek or Trousseau, prolonged QT interval?
hypocalcemia
Bones, stones, groans, psycho, short QT?
hypercalcemia
Paralysis, constipated, ST depression and U waves?
hypokalemia
Peaked T waves, prolonged PR and QRS, sine waves?
hyperkalemia
Tx hyperkalemia?
1) calcium gluconate to stabilize cardiac memb
2) insulin + glucose, or kayexalate, diuretics, albuterol, sodium bicarb
3) dialysis
Tx Type 1 renal tubule acidosis?
bicarb
BUN/Cr ration >20:1?
prerenal azotemia
if FENA <1%?
prerenal azotemia
Muddy brown casts?
ATN
protein, blood, and eos in urine + fever and rash 1-2 weeks ago?
AIN
Tx ATN?
fluids, stop drugs
CPK 50,000?
rhabdo
What is the first test in suspected rhabdo?
check K+ or get EKG
envelope-shape crystals on UA?
ethylene glycol intox (antifreeze)
increased Cr s/p cardiac cath or contrast CT?
contrast-induced nephropathy
AEIOU dialysis?
acidosis electrolytes intoxication overload volume uremia
painless hematuria dx?
cancer
terminal hematuria with tiny clots?
bladder CA
dysmorphic RBCs in UA?
glomerular problems
blood in urine 1-2 days after runny nose, sore throat, cough?
IgA nephropathy (Bergers)
hematuria + deafness?
Alport
kid with arthralgias, purpura, abd pain, blood in urine?
Henoch-Schonlein Purpura (IgA)
Tx HSP?
steroids
Tx TTP?
plasmapheresis
DIC-looking but normal PT/PTT?
HUS or TTP
c-ANCA, kidney, lung, sinus involvement, peeing blood
Wegeners
p-ANCA, renal failure, asthma, eos
Churg-Strauss
tx Wegeners?
steroids, cyclophosphamide
tx Churg-Strauss?
cyclophosphamide
p-ANCA, no lung involve, Hep B
polyarteritis nodosa
tx polyarteritis nodosa?
cyclophosphamide
Most common type of kidney stone?
calcium oxalate
Fam hx kidney stones?
cysteine stones
Kidney stones with a chronic indwelling foley?
struvite stones (proteus, pseudo, kleb, staph)
leukemia + kidney stones?
uric acid stones
kidney stone s/p bowel resection?
pure oxylate stone (ca++ not reabsorbed by gut and pooped out)
Best first test for protinurea?
repeat the test
most common cause nephrotic syndrome in kids?
minimal change
most common cause nephrotic syndrome in adults?
membranous
fusion of foot processes?
minimal change dz
minimal change dz tx?
steroids
thick capillary walls with subepi spikes?
membranous
nephrotic syndrome in heroin, HIV?
FSGS
nephrotic syndrome in chronic hepatitis and low complement?
membranoproliferative
nephrotic syndrome with sudden flank pain?
renal vein thrombosis bc peeing out clotting factors
mesangial IgM deposits?
FSGS
tram-tracking basement membrane with subendothelial deposits?
membranoproliferative
unique proteins in multiple myeloma?
Bence-Jones
MCV 70, low Fe, high TIBC, low retic, high RDW, low ferritin.
Fe deficiency anemia
MCV 70, low Fe, low TIBC, low retic, high RDW, low ferritin.
anemia of chronic dz
MCV 60, low RDW
thalassemia
MCV 70, high Fe, high ferritin, low TIBC
sideroblastic anemia
INH for Tb blood SE?
sideroblastic anemia
MCV 100, low retics, high homocysteine, normal methylmelonic acid
folate defic
MCV high with acanthocyte?
liver dz
MCV 100, low retics, high homocysteine, high methylmelonic acid
B12 deficiency
normal MCV, high LDH, high indirect bili, low haptoglobin
hemolysis
sickle cell kid with sudden drop in Hct?
aplastic crisis
hemolysis with cyanosis of fingers, ears, nose, and recent Mycoplasma PNA?
cold agglutinins (IgM mediated)
sudden onset hemolysis after PCN?
warm agglutinins (igG mediated)
dark urine in the morning?
paroxysmal nocturnal hemoglobinuria
sudden onset hemolytic anemia after primiquine, sulfas, or fava beans?
G6PD deficiency
young female, recurrent epistaxis, heavy menses, only CBC abnormal is low plates
ITP
Tx ITP?
prednisone, splenectomy, IVIG
young female, recurrent epistaxis, heavy menses, bleeding time and PTT high?
von-Willebrands
von-Willebrands tx?
replace factor 8
mixing study corrects PTT?
hemophilia- give factor
1st clotting factor depleted in liver dz?
VII (high PT)
Which 2 clotting are made by the endothelium?
VIII, von Willebrands
PT and PTT high, fibrinogen low, d-dimer and split products high?
DIC
Tx DIC?
FFP, plates, correct underlying problem
PT and PTT normal, fibrinogen low, d-dimer and split products high?
TTP or HUS
Tx TTP or HUS?
plasmapheresis
7 days post op, arterial clot, low plates. Dx?
HIT
Mechanism of HIT?
Ab that binds to heparin and PF4
Tx HIT?
stop heparin, start lepirudin
Warfarin, then skin necrosis?
protein C/S deficiency
factor V leiden?
hypercoag state
Clotting on heparin?
ATIII deficiency
