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IMC 2.0 Flashcards

1
Q

Define Cardiomyopathy

? is the MC type of cardiomyopathy

What causes this MC type to develop

A

Heart muscle dz

Dilated; Systolic dysfunction

Injury/damage (CAD/MI/ETOH) to myocardium leading to weakened ventricular contractions

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2
Q

? is the primary indication for cardiac transplant

This condition is also the MC cause of ?

A

Idiopathic dilated cardiomyopathy

Heart failure

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3
Q

What is the hallmark of Dilated Cardiomyopathy

What are the possible etiologies of this Dz

What infections can cause this

A

Dilation and impaired contraction of one/both ventricles

PG CEVICHE:
Post-partum Genetics
Chemo ETOH Viral Ischemic Cocaine Heavy-metal Endocrine

Chagas HIV Lyme

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4
Q

What is seen on PE for Dilated Cardiomyopathy

What is the main Dx modality

What would be seen on CXR

A

Left sided HF:
Dyspnea Fatigue S3 gallop
Cardiomegaly

Echo: ventricular dilation and dysfunction (EF 40% or

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5
Q

How is Dilated Cardiomyopathy Tx

What medication is used if increased contractility is needed

What mnemonic can be used to Tx

A

Loop + ACEI + BB

Digitalis

AABCD:
Anti-coagulation ACEI BBs CCBs Diuretic/Digoxin

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6
Q

What is the MC form of HOCM

How is this conditions passed along

What would be seen on PE since most of these are ASx

A

Septal hypertrophy- narrows LV outflow tract

Autosomal dominant defect of sarcomeric proteins

Bifid carotid pulse
S4 gallop
Dyspnea w/ exertion

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7
Q

What type of murmur does HOCM present with

What causes murmur to be louder/quieter

These characteristics are exact opposite of ? murmur

A

High pitched cresc-decresc at LLSB

Inc: Valsalva/Stand
Dec: Squat, Grip, Leg raise

AS:
Dec w/ valsalva
Inc w/ squat
Dec w/ stand

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8
Q

How is HOCM differentiated from Athletic Heart

How does HOCM appear on EKGs

What is the Dx test of choice

A

Athletes won’t have diastolic dysfunction

Septal depolarization: dagger-like septal q-waves w/ LVH

TTEcho

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9
Q

How is HOCM Tx

What drugs need to be avoided

What drug is c/i

A

Metoprolol and/or Verapamil to dec contractility/HR

Nitrates
Decreasing preload: diuretics, ACEIs, ARBs

Digoxin

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10
Q

When is implantable de-fib considered for HOCM Tx

What definitive tx options are available

A

+ syncope
sudden arrest
LV >30mm thick

Surgical (septal myectomy- considered best) or,
Alcohol ablation of hypertrophy

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11
Q

Metoprolol

Verapamil

Digoxin

A

Class 2, decreases HR, increases PR
B1 selective

Class 4; greater action on heart than peripheral vessels
Dose reduction needed in hepatic dzs

Derived from Foxglove; inhibits NaKATP in cardiac membrane to dec intracellular K levels to increase contraction w/out increasing O2 demands
Overcome/inhibited by sympathetic nervous system
HypoK= inc effect of medication
Antidote: Digoxin Immune Fab (Digibind)

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12
Q

Define Constrictive Cardiomyopathy

What is the MC etiology of this world wide

What other etiologies can cause this

A

RHF w/ Hx of infiltrative process

Tropical Endomyocardial Fibrosis

Amyloidosis-MC
Sarcoidosis
Rad/Chemo

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13
Q

What will be seen on PE of Restrictive Cardiomyopathy

What abnormals will be seen

How is this Dx

What is the next step if Dx is doubtful?

A

P-HTN w/ normal EF, size and wall thickness

Large atria
Early diastolic filling

Echo: dilated atria, hypertrophy, ‘starry night/speckle pattern’

MRI- abnormal textures

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14
Q

What could be seen on EKG of Restrictive Cardiomyopathy

This can mimic ? other Dx, so what test is used to differentiate

What is used for Txs

A

Non-specifics w/ low voltage waves

Constrictive pericarditis- cardiac MRI

Diuretics if edema/pulmonary congestion present
Rate/Rhythm: BB/Verapamil

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15
Q

Define an ASDn and the MC type

What type of murmur does this defect produce and

What condition can chronic defects develop into

A

Non-cyanotic defect w/ diastolic L-R shunt causing volume over load to RA/RV d/t failure of foramen ovale to close;
Osteum Secundum

Wide-fixed split S2: lub, dub-dub
at Pulmonic area

Eisenmenger’s: chronic L-R shunting causing cyanosis/clubbing that dec as shunt progresses

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16
Q

ASDs are the second most common defects behind ? defect

Most Pts w/ small ASDs can be ASx until ? age, but then develop ?

What abnormal clot event can ASDs allow to happen

A

VSD

<30: ASx
>30: dyspnea, angina
>50: Afib, RVF

Paradoxical embolization

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17
Q

How are ASDs definitively Dx

What can be seen on EKG

What would be seen on CXR

A

Echo

R axis deviation
RVH
RBBB w/ rSR pattern in V1

Cardiomegaly w/ dilated RA/RV

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18
Q

How are ASDs Tx

A

<3mm- spontaneous closure, usually by 3y/o

ASx and small: observe w/ serial Echos

Med/Large w/ evidence of RV volume overload on echo- closed between 2-6y/o

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19
Q

Coarctations of the aorta present w/ Sxs of ? and PE findings of ?

Half of Pts w/ have ? defect which puts the at increased risk to develop ?

What will be seen on EKG/CXR

A

L sided HF;
Bounding Arm BP > Leg BP

Bicuspid aorta:
Berry aneurysm

EKG: LVH
CXR: notched ribs, figure-3 sign of aorta

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20
Q

How is a Dx of Coarctated Aorta made

How are these Tx

How are these Tx if found in neonates

A

Echo

Ages 2-4y/o: balloon angioplasty w/ stent placement/surgical repair

Prostaglandin E-1- keeps ductus arteriosus open

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21
Q

When is emergent surgical repair of an aortic coarctation warranted

What happens if these are left untreated

A

Circulatory shock
Cardiomegaly
Severe HTN/CHF

Death by 50y/o d/t:
Aortic rupture/dissection
CVA

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22
Q

What are the 3 types of aortic coarctations by location

A

Preductal: narrowing proximal to ductus arteriosus; life threatening, Turners/Intracranial aneurysm

Ductal: narrowing at insertion of ductus arteriosus, appears when ductus closes

Post-Ductal: narrowing distal to ductus arteriosus; MC in adults

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23
Q

Define a PDA

What ‘saying’ is used to remember this type of defect’s murmur

How do Pts present

A

Blood flows aorta to L Pulm Artery causing transient systolic murmur d/t

Patent for your machine- machinery like murmur at 1st ICS LSB

Poor feeding
FTT
Tachy/Tachy

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24
Q

What are the two “classic findings” of a PDA

What would be seen on EKG

What is best for Dx

A

Wide pulse pressure w/ low DBP
Harsh, continuous machinery murmur at 2nd ICS (pulmonic)

Normal/LVH

Echo

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25
Q

How are PDAs Tx

Normally, a ductus arteriosus closes to form ? structure

? is the MC pathological murmur of childhood

A

Indomethacin, possibly w/ fluid restriction
Surgical/Catheter correction

Ligamentum arteriosum

VSD- hole in interventricular setum (large= L-R shunt)

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26
Q

How do VSDs present on exam

If left un-Tx, what can these defects lead to?

What will be seen on EKG/CXR and what is best for Dx

A

Loud, harsh holosystolic murmur at LLSB w/ systolic thrill

Eisenmengers

EKG: norm/LVH
CXR: inc pulm vasculature
Dx w/ Echo

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27
Q

How are VSDs Tx

When is Tx changed for infants?

A

Watchful expectation: as VSDs become smaller, murmur shortens

CHF and Retarded growth= Digoxin and Diuretics
Tx failure= surgery within first 6mon of life

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28
Q

What are the 4 parts of Tetrology of Fallot

Why is this defect a cyanotic one

What ‘spells’ will be seen here

A

PROVe:
PS RVH Overriding VSD

PS causes R -L shunt through VSD

Tet- hypercyanotic during crying/feeding

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29
Q

Unique fact of Tetrology of Fallot

What kind of murmur occurs

How is this condition Dx

A

Only cyanotic congenital herat Dz on PANCE blue-print

Harsh systolic ejection at LSB

Echo

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30
Q

What is the CXR finding for Tetrology

What would be seen on EKG and why are serial EKGs needed annually

How are these Pts Tx

A

Boot shaped heart

Enlarged RA/RV;
QRS width d/t risk for sudden death/HF

Surgery w/in first year of life

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31
Q

Define NSTEMI

How will Pts present

What drugs are used for Txs

A

Myocardial necrosis w/out ST elevation/q-waves d/t incomplete blockage causing sub-endocardial infarct

SOB
Pain radiation to jaw/shoulder

BB ASA/Clop Statin Heparin Ng ACEI PCI reperfustion

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32
Q

What are the 3 biomarkers used during N/STEMI workups and timing to appear/peak/return to baseline

A

Troponin: most sens/spec
2-4hrs, 12-24hrs, 7-10days

CK/CKMB:
4-6hrs, 12-24hrs, 48-72hrs

Myoglobin-
1-4hrs, 12hrs, 24hrs

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33
Q

Define STEMI

What Tx is done first

How quickly must PCI be done

A

Myocardial necrosis w/ ST elevations d/t fully blocked artery involving full wall thickness

ASA/Clopidogrel

PCI <90min
Thrombolysis <3hrs no PCI ability

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34
Q

What are the absolute c/i’s for thrombolytic therapy for NSTEMIs

What is NOT an absolute c/i

A 
ICH Hx
Cerebral vascular lesion Dx
Malignant intracranial neoplasm
Ischemic stoke <3mon
Suspected ADissection

Active menses

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35
Q

Define Angina Pectoris

What is done for work up

What test provides definitive Dx

A

Chest pain/discomfort inc w/ exertion/emotion, is predictable, lasts <15min, and relieved w/ rest/nitro

Stress Test: reversible wall motion abnormality/ST depression <1mm

Coronary angiography

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36
Q

How is Angina Pectoris Tx

What surgical Txs are avail?

Pts w/ ? Hx have poorer prognosis

A 
Sublingual Nitro (or IV)
BB

Angioplasty and Bypass

LVEF <50%
Left main artery

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37
Q

Define Unstable Angina

What process causes this pain

How is this type Tx

A

Chest pain that inc w/ exertion/emotion and is now increasing/present at rest

Unchanged O2 demand
Decreased supply

Ntg/Morphine
ASA/Clopidogrel
LMWH x 2days
BB
ACEI
Statin
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38
Q

Why is Clopidogrel used in Unstable Angina

Pts that respond to medical therapy have ? next step

What is the next step if they don’t respond to medical therapy

A

Decreases incidence of MIs

Stress test

Revascularization

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39
Q

All Pts w/ Unstable Angina/NSTEMI w/ high LDL get ? Rx’d

Define Prinzmetal Angina

What are possible triggers

A

ACEI and Statin (HMG-CoA reductase inhibitor)

Smooth muscle in coronary artery spasms causing ST elevations w/out clot present

Hyperventilation
Acetylcholine
Ergonovine
Histamine 
Serotonin
NO deficiency
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40
Q

What is the first and second RF for Prinzmetal Angina

What do Pts describe pain as and what may be seen on EKG

How is Prinzmetal Tx

A

1- smokine
2- cocaine

Cyclical in early morning hrs
Inverted U-waves
ST/T abnormalities

Initially: Nitrates
After Dx: Amlodpine and long acting nitrates

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41
Q

HF is a syndrome of ?

LV failure causes ? S/Sxs

RV failure causes ? S/Sxs

A

Ventricular dysfunction

SOB, Fatigue

Peripheral edema
Abdominal fluid accumulation

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42
Q

Systolic L HF will present w/ ?

How is this form of HF Tx

How is an acute exacerbation Tx

A

S3
Thin, dilated LV w/ EF <40%
Displaced down/left apical impulse

Loop and ACEI and BB

D/c BB
O2 ACEI Nitro
IV Diuretic x2 normal dose

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43
Q

Diastolic L HF will present w/ ?

This Dx will increase in severity in Pts older than ? and w/ ? predisposing Dx

What will be seen on Echo

How is this form Tx and what is avoided

A

S4
LVH w/ dec relaxation
Apical heave/lift

> 55y/o w/ HTN

Normal EF

ACEI and BB or CCB
No diuretics in chronic Pts
Never use digoxin

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44
Q

Right HF can be d/t ?

What PE findings will be absent

How is this Dx

A

P-HTN

Rales JVD Edema

Gold standard: Echo and Doppler

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45
Q

Define High Output HF

What can cause this type of HF

What will be the first S/Sx of Dx

A

Increased metabolic demand surpasses heart output

Hyperthyroid
Severe anemia
Beriberi
Thiamine deficient

Tachycardia progressing into systolic failure

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46
Q

A normal EF if between ?

Pts are at risk for increased mortality if EF is below ?

What are these high risk Pts next step

A

55-60

<35

Cardio defib placed

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47
Q

BNP levels >100 indicate ? issue present in a Pt

What are the 4 NYHA classifications

What Tx step needs to be started ASAP in HF Pts

A

CHF

1: no limitations
2: slight limitation
3: marked limitation
4: unable to carry out activities w/out discomfort and have Sxs at rest

ACEI- decreases comorbidity and mortality

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48
Q

What are 3 specific beta-1 drugs used in HF to reduce mortality from HF

Only heart valve to have two leaflets, all other have 3

Diastolic murmurs almost always indicate ?

A

Bisprolol
Metoprolol succinate
Carvedilol

Mitral

Heart Dz

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49
Q

What are the two basic types of diastolic heart murmurs

? category of murmurs is the MC kind

A

Early decrescendo: regurg through incompetent semilunar valve
Rumbling: stenosis of AV valve

Mid-systolic- AS, PS

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50
Q

What are the 4 diastolic murmurs

A

AR: high pitch, blowing murmur
Pt sits, leans fwd
Diaphragm at Erb’s

MS: low decrescendo rumble w/ opening snap at apex
Pt supine w/ bell at mitral

PR: high pitch decrescendo, inc w/ inspiration
Pt leans fwd, diaphragm at pulmonic

TS: mid-diastolic rumble w/ opening snap
Pt supine, bell at tricuspid

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51
Q

What are the four mid-systolic murmurs

A

AS: ejection cresc-decrescen
Pt sits, diaphragm at aortic

PS: harsh mid-systolic crescen-decrescen w/ wide-split S2 radiating to L shoulder/neck
Pt supine, bell at tricuspid

HOCM: mid-systolic murmur w/ S4 and apical lift
Pt supine, diaphragm at mitral

MVP: mid-systole click at apex
Pt supine, diaphragm at mitral

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52
Q

What are the pan/holosystolic murmurs

A

MR: blowing murmur at apex w/ split S2
Pt supine, diaphragm at mitral

TR: high pitched murmur
Pt supine, diaphragm at tricuspid

VSD: harsh murmur w/ wide radiation and fixed, split S2
Pt supine, diaphragm at tricuspid

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53
Q

Define A-Fib

What are two possible etiologies

A

Irregular, Irregular w/ narrow QRS complexes but w/out defined P-waves

Age
ETOH abuse

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54
Q

Define A-Flutter

What are 4 possible etiologies

A

Regular, sawtooth pattern EKG w/ atrial rate between 250-350 and narrow QRS complexes

COPD
CHF
ASD
CADz

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55
Q

How is A-fib Tx

How are unstable Pts w/ rapid ventricular rates Tx

A

Rate control <110 w/:
Diltiazem Metoprolol Verapamil

Rhythym control depends on duration:
Afib <48hrs= amiodarone, TEE, cardioversion
Afib >48hrs= anticoag x 21days, then cardioversion

Synchronized cardioversion

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56
Q

How is anticoagulation for A-fib/Flutter determined

A

CHA2DS2-VASc:
0 pts= 81-325mg ASA/day
1pt: either 81-325mg/day or anticoag
2pts or more= anticoagulation

CHF/LVEF <40-1 
HTN-1 
Age +/>75- 2
DM-1 
Stroke/TIA/Throm-embolism- 2
Vasc Dz- 1
Age 65-74-1 
Female- 1
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57
Q

What DOACs can be used for anticoagulation when Tx Afib/Flutter

When is Warfarin indicated

What is the INR target if Warfarin is used

A

Dabigatran
Edoxaban
Apixaban
Rivaroxaban

Rx- phenytoin/antivirals
Unacceptable cost increase
Mechanical valves
Mitral stenosis
EGFR <30

2-3 (2.5)

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58
Q

Define PSVT

What are 3 etiologies

A

SVT w/ abrupt on and offset d/t short-circuit arrhythmia w/out other structural heart Dzs

AVNRT- tachydysrhythmia starting above BoHis

WPW- abnormal accessory electrical conduction pathway in Bundle of Kent between atria and ventricles

AVNRT: small pathway in/near AV node allows impulse to travel in circles causing fast, regular beating

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59
Q

? is the MC sustained dysrhythmia in adults

A-flutter is seen in Pts w/ ? 4 Dx/comorbidities

What are the 3 EKG characteristics for WPW

A

A-fib

COPD
ETOH abuse
MV Dz
Thyrotoxicosis

D-wave
Wide QRS >120msec
Short PR <120msec

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60
Q

Define Orthodromic tachycardia

Define Antidromic tachycardia

How is PSVT Dx

A

Accessory path to AV to accessory path (tall, deep QRS)

AV node to accessory to AV node (D-wave, tall QRS)

Holter Monitor to catch episodes

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61
Q

How is PSVT Tx vis non-Rx maneuvers

What meds are used if Sxs are present or if only PSVT is present

What is definitive Tx

What needs to be avoided in WPW

A

Vagal
Carotid massage
Valsalva

+Sxs= adenosine
Regular- BB/CCBs
Wide QRS= procainamide

Radio frequency ablation

No adenosine
No CCBs

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62
Q

Define the 3 types of premature beats

These may have an increased frequency d/t ?

What are two variants

A

Atrial- abnormal shape P-wave
Ventrical- early, wide QRS w/out p-wave
Junctional- narrow QRS (0.10msec) no/inverted p-wave

Stimulants (caffeine)

Trigeminy- every 3rd beat
Every other- bigeminy

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63
Q

Premature Atrial Beats are common in ? population

Pts w/ heart Dz, PACs can precedde ? issues

PVCs can be ASx or be felt where?

A

COPD Pts

PSVT
A-fib/flutter

Throat

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64
Q

How are premature beats Dx

How are they Tx depending on the type

Define V-Tach

A

EKG or Holter monitor

PAC: reassure
PVC: BB, consider ablation
PJC: only Tx if >10/min w/ lidocaine/antiarrhythmic

EKG w/ 3 or more consecutive premature ventricular beats (QRS complex loses sharp peak, becomes wide/bizarre)

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65
Q

V-Tach is a common complication from ? two issues

Unstable Pts w/ monomorphic VT should be immediately Tx w/ ?

How is unstable polymorphic V-Tach Tx

Stable Pts w/ V-Tach and adequate end organ perfusion are Tx w/ ?

A

MI
Dilated myopathy

Synchronized direct current cardioversion starting at 100J

Immediate D-fib

In order:
Amiodarone Lidocaine Procainamide

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66
Q

Define V-Fib

How is this Tx

A

Uncoordinated quivering of ventricles w/out useful contractions

CPR
Defib w/ non-synchronized cardioversion (120, 150, 180)
Intubate
Amiodarone x 2 q2-4min
1mg Epi q 3-5min
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67
Q

Define Sick Sinus Syndrome

What are the 4 types of this condition

How are these Dx

How are these Tx

A

Dysfunction of Sinus Node’s automaticity and impulse generation

Brady: resting HR <60
Pause < 3 sec
Arrest > 3 sec
Tachy-Brady Syndrome- alternating tachy/brady

EKG/Holter monitor

Most PTs w/ Sxs= Pacemaker
BB/CCB/Digoxin in Pts w/ tach risk for block/arrest, also prepared for pacing

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68
Q

Define AV Block

What are the 2 MC causes

What are the 3 types

A

Interruption of impulse transmission from atria to ventricles

Idiopathic fibrosis/sclerosis of conduction system
Ischemic heart dz

1st: PR >0.2sec (5 small square)
2nd:
Type 1: longer longer drop, Wenckebach
Type 2: some dropped, some get through, Mobitz 2
3: Ps and Qs dont agree, not you’ve got a 3rd degree

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69
Q

How is a 1st AV Block Tx

How are 2nd* Blocks Tx

How are 3* blocks Tx

A

ASx: none
Unstable: pacing

Type 1: Tx only if Sx bradycardia and other causes have been excluded
Type 2: pacer, these almost always progress to 3* block

R/o ischemic cause
Pacer

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70
Q

Define Cardiogenic Shock

What are the 3 MC causes

How is this Dx

How is this Tx

A

Impaired cardiac contractility and pump failure d/t dec cardiac output

HF
Acute MI
Tamponade

Inc pulm cap wedge pressure >15mm

Fluids
Pressors: dobutamine, NorEpid,
Ultimately balloon pump

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71
Q

Define O-HOTN

What is the MC cause of this in diabetics

What is the next test ordered for these Pts

How is this Tx

A

Dec SBP >20mm
Dec DBP >10mm
Both 2-5min after standing

Autonomic dysfunction; lack of HR increase by >10bpm

Tilt table;
if HR increases >15bpm, d/t low volume

Dec venous pooling
Inc Na/fluid intake

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72
Q

Define Essential/Primary HTN

What are the ACC/AHA Classifications

What are the target goals for Tx

A

Resting SBP 130 or higher
Resting DBP 80 or higher
On two separate visits

Norm: <1120/80 and <80
Elevate: 120-129 and <80
Stage 1: 130-139 or 80-89
Stage 2: 140 or > or 90 or >

+ comorbidiites: <130/80
<60y/o/DM/CKDz: <140/90
60 or >: <150/90

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73
Q

How is normal BP Tx

How is elevated BP Tx

How is Stage 1 Tx

How is Stage 2 Tx

A

Yearly eval w/ healthy lifestyle

Healthy lifestyle and reassess 3-6mon

ASCVD calculator:
<10% risk: healthy life style and reassess 3-6mon
>10% risk/CVD/DM/CKDz: lifestyle mod and 1 medication w/ reassess in 1mon;
Goal met- reassess 3-6mon
Goal not met- different med or titrate w/ montly f/u until goal met

Healthy lifestyle and 2 meds
Goal met at 1mon f/u: reassess 3-6mon
Not met at f/u: different med/titrate up
Continue monthly f/u until goal met

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74
Q

How is Primary HTN in nonblacks, even w/ DM, Tx

How are Black Pts w/ HTN Tx

A

ACEI/ARB
CCB- Amlodipine or,
Thzd like- chlorthalidone/indapamide

Thzd type and CCB

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75
Q

When are the following classes of meds c/i d/t previous Dx:

CCB

ACE/ARB

BB

A

Angina pectoris

Diabetics w/ proteinuria
Pregnancy

Asthma

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76
Q

Side effect of using the following classes for HTN Tx:

ACEI

Spironolactone

BBs

CCBs

Hydralazine

A

Cough Angioedema HyperK

HyperK

Impotence

Leg edema

Lupus-like syndrome
pericarditis

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77
Q

Define Secondary HTN

When does this Dx need to be considered

What is the MC cause and what is a common combo cause

A

SBP 130 or >
DBP 80 or > or,
Both w/ correctable cause

Pt refractory to antihypertensive meds or severe

Primary aldosteronism
OCP + ETOH

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78
Q

What labs are ordered for newly Dx Secondary HTN

Define Infective Endocarditis

What does the infective process cause

A

UA
Spot urine albumin/cr ratio
EKG

Infection of endocardium w/ Strep/Staph/Fungi

Fever* Murmurs Vegetations

79
Q

Define Acute Bacterial Endocarditis

Define Subacute Bacterial Endocarditis

Endocarditis in IVDA is usually d/t ?

Prosthetic valves are usually infected w/ ?

A

Infection of normal valves w/ Staph A

Infection of abnormal valves w/ Strep Viridians

Staph A

Staph Epidermis

80
Q

How is endocarditis caused by fungus differentiated

When are these types of infections commonly seen

How are they Tx

A

Usually from contaminated lines, causes large, slow growing vegetations

Post-valve replacement, <2mon post-op

Amphotericin B

81
Q

What types of microbes can grow on native heart valves and cause endocarditis

? is the MC cause of endocarditis

How does this type present

A 
HACEK:
Haemophilus
Aggregatibacter
Cardiobacterium
Eikenelia
Kingellia

Strep Viridians

Late complication of valve replacement w/ small vegetations and emobli

82
Q

What are the peripheral stigmata of Infective Endocarditis seen on exam

How is this Dx

What is the gold standard for Dx

A 
Splinter hemorrhages
Olser nodes- painful
Roth spots- retinal hemorrhage
Janeway lesion- septic emboli
Petechia, palate/conjunctiva
Splenomegaly
Hematuria

3 blood cultures, 1hr apart

TEE echo

83
Q

What criteria is used for Dx Infective Endocarditis

A

Modified Duke:

Definite:
2 Major or
1 Major, 3 minor or
5 minor

Possible:
1 major and 1 minor or,
3 minor

Fill in, finish

84
Q

How are native valves, no IVDA w/ endocarditis Tx

How are prosthetic valves w/ endocarditis Tx

How are IVDA w/ endocarditis Tx

If any endocarditis Pt is PCN allergic, ? is used for substitution

A

IV Nafcillin, Ampicillin, Gentamicin

IV Vanc Gentamicin Rifampin

IV Nafcillin

Vanc

85
Q

What is used for endocarditis prophylaxis

Define Acute Pericarditis

What is the form of pericarditis seen 3-5d after MI

A

2g Amoxicillin 30-60min prior to procedures

MC Coxsackie infection causing inflamed sac

Dresslers Syndrome

86
Q

How is acute pericarditis Dx

What PE finding may be present

This PE finding is common in Pts w/ ?

A

EKG
Echo: Complications/effusion/tamponade

Kussmaul- inc of CVP during inspiration instead of normal decrease

Constrictive pericarditis

87
Q

How is acute pericarditis Tx

Define Cardiac Tamponade

What are the 3 Ds of this

What triad

A

NSAID/ASA x 7-14d
CCS if Sxs >48hrs

Fluid between sac and heart causing constriction

Distant sounds
Distended jugular vein
Dec arterial pressure

Becks:
HOTN
Muffled sounds
JVD

88
Q

What is a classic finding in cardiac tamponads?

What is seen on EKGs

What is seen on CXRs

A

Pulsus Paradoxus- SBP drop of 10mm w/ inspiration
Narrow pulse pressures

Electrical alternans w/ low voltage QRS

Water bottle heart

89
Q

What is the Gold standard for Dx cardiac tamponades

How are these Tx

What causes Rheumatic Fever

A

Echo

IV fluids- increase preload, prevent RV collapse
Centesis- therapeutic
Balloon pericardiotomy, window- if compensation

Hx of GAS infections

90
Q

How do Pts w/ Rheumatic Fever present

What mnemonic is used for PE

How is this Tx

A

Red skin lesions on trunk
Non-tender lumps on joints

JONES:
Joints
Oh no, carditis
Nodules
Erythema marginatum
Sydenhams chorea

NSAIDs, ABX

91
Q

How do Pts w/ aortic dissection present

What would be seen on CXR

What is the gold standard test for Dx

How are these Tx

A

Sudden, tearing chest pain that radiates between scapula and w/ diminished pulses

Wide mediastinum

MRI angiography

Ascending: surgery
Descending: BB, observe

92
Q

Indications to repair AAA

When is annual monitoring used

When is q6mon monitoring used

What class medicaiton is used for these PTs

A

> 5.5cm or,
Expands >0.6cm/year

> 3cm

> 4cm

BB

93
Q

Define Varicose Veins

What makes these symptomatic

How are these Tx

A

Dilated superficial veins

Pain w/ exertion

Compression
Elevation
Wound care
Sclerotherapy
Surgery
94
Q

Define Chronic Venous Insufficiency

What is a common skin finding in these PTs

What is a common but severe finding

How are these Tx

A

Impaired venous return causing edema/discomfort

Stasis dermatitis

Non-healing ulcer at medial malleolus

Compression
Wound care
Surgery

95
Q

Define Esophagitis

What are the two categories and causes of each

A

Inflammation that can damage tissue

Non-infectious:
Reflux
Medication (BisPhos/NSAID)
Eosinophilic- barium swallow= multiple corrugated rings
Radiation
Corrosive

Infectious, hallmark= odynophagia
Fungal: linear white plaques
HSV: punched out lesions
CMV: solitary ulcer/erosion

96
Q

How is Fungal Esophagitis Tx

How is HSV Esophagitis Tx

How is CMV Esophagitis Tx

How is Corrosive Esophagitis Tx

How is Eosinophilic Esophagitis Tx

A

PO Fluconazole

Acyclovir

Ganciclovir

Steroids

Steroids via inhaler

97
Q

How is Esophagitis Dx

How is Bisphosphonate induced esophagitis prevented

A

Edondoscopy
Biopsy
Double contrast esophogram
Culture

Take w/ 4oz water
Avoid laying down x 30-60min

98
Q

Define Achalasia

What is this a MC of

How is it Dx

How is it Tx

A

LES fails to relax and d/t loss of Auerbach plexus

MC motility d/o w/ dysphagia to liquid and solid

Barium swallow- bird beak

Botulinum injection- temporary

99
Q

How will esophageal strictures present

Define Esophageal Web

Define Schatzki Ring

What is a major contributor to ring development

A

Solid food dysphagia w/ Hx of GERD

Thin membrane in esophagus

Mucosal ring at B-ring junction; associated w/ hiatal hernia

GERD

100
Q

Define Plummer Vinson

What is another term for esophageal strictures

How are these Dx and Tx

A

Esophageal webs and Dysphagia and Fe Deficient Anemia

Steakhouse syndrome- gradually progressive dysphagia to solids that occur when meal is wolfed down

Endoscopy/Dilation

101
Q

Define Esophageal Spasms

How is it Dx

How is a Dx confirmed

How is it Tx

A

Non-peristaltic contraction causing stabbing chest pain after ingesting hot/cold liquids and foods

Barium swallow- corkscrew

Manometry

Nitrate, CCB

102
Q

How does esophageal cancer present

What is the MC type in the world

What is the MC type in the US and d/t ? complications

A

Difficulty swallowing solids to liquids w/ adenopathy

SCC

Adenocarcinoma in distal esophagus- d/t GERD/Barrett’s

103
Q

How is esophageal cancer Dx and staged

What treatment options are available

How often should Pts w/ Barretts have endoscopic screening

A

Dx: endoscopy w/ biopsy
Stage w/ CT

Resection
Radiation
Chemo w/ 5-FU

q3-5yrs

104
Q

SCC of the esophagus is associated w/ ? Hxs

What part of the esophagus is affected

Define GERD

A

Smoking
ETOH use

Upper 2/3

Incompetent LES allows reflux of contents into esophagus

105
Q

What are the risks of long standing GERD

What drugs can cause this issue to develop

What is the gold standard study for Dx

A

Metaplasia
Esohpagitis
Barretts/Cancer
Stricture

Antihistamines
TCAs
Progesterone
Anticholinergics
Nitrates
CCBs

pH probe

106
Q

What is a common c/c of GERD that is easily/commonly overlooked

Typical Sxs of GERD can be Tx w/ trial of ?

What is done if Pt fails to improve, is long standing, or has complications?

A

Chronic cough

PPI

Endoscopy w/ cytologic washings and biopsy

107
Q

What is the only test to consistently detect Barretts Esophagus

What are the red flags that put PTs at high risk for GI malignancy

How is GERD Tx

A

Endoscopic biopsy

GERD Sxs and:
Dysphagia
Recurrent vomitting
Weight loss
Hematemesis
Anemia
Melena
>50y/o
Weight loss
HOB elevated 6"
H2 antagonist
PPI
Tx 8wks after Sxs resolve
108
Q

Define Gastritis

What are the common Sxs that indicate this Dx

What are the two categories of gasgritis

A

Inflammation of stomach lining

Dyspepsia
Abdominal pain

Acute: rapidly developing lesions in gasgric antrum
Chronic:
Type A: slowly developing lesions in fundus from anti-parietal Abs; associated w/ pernicious anemia; risk for adenocarcinoma
Type B: slowly developing lesions in gastric antrum; often ASx; inc risk to develop PUD

109
Q

What is the gold standard test for Dx gastritis

What 3 tests can be used to detect presence of H Pylori

What is the risk of using PPIs during Tx

A

Endoscopy w/ four biopsies

Fecal Ag
Serology Ag
Urea breath test

Dec Ca absorption (hip Fx)
Dec B12/Mg
Inc respiratory infection (pneumonia)
C Diff

110
Q

What meds are used for the Tx of gastritis

What happens if Pts Sxs return after Tx

What are the two types of ulcers seen in PUDz

A

H2RA: Famotidine, Cimetidine
Omeprazole
D/c PPI when ASx x 8wks

Sxs return <3mon- d/c PPI for upper endoscopy

Gastric- pain worse w/ meals
Duodenal- pain better w/ meals and change in stool color

111
Q

What is the MC cause of gastric ulcers

These ulcers are usually anatomically located where?

Rarely, these can develop into ?

A

H Pylori

Anterior duodenum- if develop on posterior, inc risk for bleeding from gastroduodenal artery or causes pancreatitis

Zollinger Ellison Syndrome- gastrinoma, tumor of pancreas causing stomach to make too much gastrin; Dx when gastrin >200pg
Tx: PPI and resection

112
Q

Where are gastric ulcers MC found anatomically

PUD is the MC cause of ? that presents as ?

What is the most accurate method for Dx

A

Lesser curvature of antrum

Non-hemorrhagic GI bleeds that present w/ melena

Upper endoscopy

113
Q

How is a ruptured gastric ulcer Dx

How is H Pylori Tx

What is the next step if biopsy is negative for Pylori

A

Serum amylase
Free air under diaphragm on upright CXR

4wks of:
Clarithromycin
Amoxicillin (metronidazole)
PPI (omeprazole)

Breath test
Stool Ag test

114
Q

MC causes of acute pancreatitis

What two PE findings indicate Dx

A 
GET SMASHED:
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion sting
HyperCa/lipid
ERCP
Drugs

Cullens- umbilical bruising
Grey-Turner- flank bruising

115
Q

What is Ranson’s Criteria used for during acute pancreatitis

A

Predicts severity, 3 or more means severe:

At admission:
Glucose >200
Age >50
Leukocyte >16K
AST >250
At 48hrs:
BiCarb <20
BUN inc by 1.8 or >
Arterial PO2 <60
Ca <8
Hct dec by 10%
Fluid sequestriation >6L
116
Q

How is Chronic Pancreatitis different than Acute

What is the classic triad?

What may be seen on PE imaging

A

Same clinical features + fat malabsorption and statorrhea

Pancreatic calcification
Statorrhea
DM

Pancreatic pseudocyst

117
Q

How is pancreatitis Dx

What is seen on x-ray

What would be heard w/ auscultation on exam

What are the best initial tests for Dx Chronic Pancreatitis

A

Amylase, only if 3x higher
Abdominal CT- TOC

Sentinal loops

Dec bowel sounds

CT pancreatic protocol
MRI w/ MRCP

118
Q

How is acute pancreatitis Tx

What is needed if biliary sepsis is suspected

Why can mild pancreatitis progress to severe <48hrs

What is the only definitive Tx for chronic pancreatitis

A

NPO, IV fluids
Analgesics
Bowel rest

ERCP

Inadequate fluid replacement

Address:
Alcohol/low fat diet

119
Q

What is the MC form of pancreatic cancer

What ‘sign’ is seen on PE

What node can be present

A

Ductal adenocarcinoma at head of pancreas

Courvoisier's Sign:
Jaundice
Abdominal pain
Palpable gallbladder
Light stool, dark urine

Virchows- lymph node in left supraclavicular fossa; take lymph from abdominal cavity
AKA- seat of the devil

120
Q

How are pancreatic neoplasms Dx

Where are they more likely to be found in ascending order

What tumor marker is used to track progression/therapy

How are pancreatic neoplasms Tx

A

Abdominal CT

Head>body

121
Q

Define Celiac Dz

This is a ? d/o

What are 4 common c/c

A

Inflammation of the small bowel d/t ingestion of gluten (wheat, rye, barley) leading to malabsorption

Autoimmune

Diarrhea
Flatulence
Weight loss
Steatorrhea

122
Q

How is Celiac Dz Dx

How is a Dx confirmed

This confirmation is only done after ?

A
  • IgA anti-endomysial Abs- specificity nearly 100%, sensitivity lower than TG-IgA
  • IgA Antitissue transglutaminase Ab- will be +98% of Pts

Mucosal biopsy of proximal/bulb and distal duodenum

IF Pt tested pos for IgA endomysial Ab

123
Q

How is Celiac Dz Tx

Supplementation may be needed if Pt becomes ? deficient

Define Lactose Intolerance

A

Gluten free diet

Fe 
B12 
Folic acid 
Ca 
Vit D

Insufficient lactase enzyme- hydrolysis of lactose to glucose/galactose

124
Q

How is a Dx of Lactose Intolerance made by presumption

How is a definitive Dx made

What other lab results can indicate this Dx

A

Mils Sxs after >2 servings/day or >1 serving not associated w/ meal and,
Resolves in 5-7 days w/ avoidance and,
Reoccurs w/ rechallenge

Lactose breath Hydrogen test-
Pt drinks lactose liquid
Breath into machine q30min
+= >H than usual (>20ppm)

Acidic feces- normally alkaline, acidic indicated lactose intolerance or E Colie/Rotavirus contagion

125
Q

How is Lactose Intolerance Tx

Facts of Crohns: involvement, visual finding, diarrhea type, fistulas, esophageal finding, histology, smoking impact and serology result

A

Avoid dairy
Lactose free food
Lactase supplements

Anywhere in GI rectum spared;
Skip lesions 
Non-bloody w/ abdominal pain
\+fistula
Endoscopy= aphthoid, deep (cobblestone)
Transmural, noncaseating granuloma
Smoking worsens
ASCA
126
Q

Facts of Ulcerative Colitis: involvement, visual finding, diarrhea type, fistulas, esophageal finding, histology, smoking impact and serology result

A 
Only involves colon including rectum
Continuous pattern of involvement
Bloody 
Rare abdominal pain
No fistula/perianal dz
Erythematous, friable tissue
Tubular/lead pipe radiograph finding
Mucosa only crypt abscess
Smoking protects
p-ANCA
127
Q

How does UC present

Where does the inflammation affect the colon

What is the MC site

A

Bloody pus diarrhea w/ pain, fever, urgency

Inflammation only in colon, not transmural

Rectum

128
Q

What is the bimodal distribution of UC

How is it Dx

What Ab tests are run

A

15-25y/o and 55-65y/o

Barium enema w/ lead pipe appearance
Biopsy w/ continuous inflammation w/ lost haustral markings and lumen narrowing

Antineutrophil cytoplasmic Abs (p-ANCA)

129
Q

How does Crohns Present

What is the MC site

What is this conditions distribution

A

Abdominal pain, non-bloody diarrhes and PO aphthous ulcers

Terminal ilium

Mouth to anus w/ transmural cobblestoning and skip lesions

130
Q

What complications can arise from Crohns

What complications can arise from UC

What antibody test is run for Crohns

A

Strictures- string sing w/ barium study

Toxic mega colon
Colorectal cancer

Anti-Saccharomyces cerevisiae Abs (ASCA)

131
Q

How is UC/Crohns Dx w/ colonoscopy

What is the risk in UC if haustral markings are lost

Why are LFTs needed

What annual/2yr monitoring should these PTs have

A

US: continuous inflammation
Crohns- focal ulcerations that alternate w/ normal mucosa

Toxic megacolon

Inc ALT/y-glutamyl transpeptidase suggest primary sclerosing cholangitis

Vit D, B12

132
Q

How are Crohns/UC Tx

What is the MOA of these meds

A

If colon involved-
Sulfasalazine
Mesalamine (UC>Crohns)

No 5-ASA response= Metronidazole

No response to Metro/acute exacerbations=
Budesonide/Predisone

No response to any-
Azathioprine/6-Mercaptopurine

5-ASA block prostaglandin release to reduce inflammation

133
Q

What meds are added to UC/Crohns Tx if terminal ileal dz is present preventing bile acid absorbtion

What meds need to be avoided

How can UC be Tx w/ surgery

What surgical option is avail for Crohns Pts

A

Bile acid sequestrants

Anti-diarrheals- induce ileus

Total colectomy

Segmental resection

134
Q

What criteria is used to Sx-base Dx IBS

What is the criteria for Mixed IBS

What red flags need to be r/o

A

Rome:
Abdominal pain for 3d/mon in past 3mon w/ 2 or more:
Improved w/ defecation
Onset associated w/ change of defecation frequency
Change in stool consistency

More than 1/4 are diarrhea
More than 1/4 are constipated

Rectal bleeding
Weight loss
Fever
+ red flag= imaging/colonoscopy

135
Q

Why are lab results useless in IBS Dx

How is this Tx

How does Acute Mesenteric Ischemia present

A

CBC/Chemistries are normal in IBS

Anticholinergics: Hyoscyamine

Sudden onset severe abdominal PooP to exam w/ Hx of PVDz/Smoking/DM

136
Q

Board review questions will have Pts w/ Acute Mesenteric Ischemia present w/ ? issues

What x-ray sign is seen

What is the MC site of obstruction to cause this

A

Afib/MI/CHF

Thumb-printing

Superior mesenteric artery

137
Q

What can cause younger Pts to have Acute Mesenteric Ischemia

What is the gold standard for Dx

How is this Tx

A

OCPs/Illicit drugs

Mesenteric angiography

Revascularization

138
Q

Define Polyps

Once Dx, what meds can help prevent formation of new polyps

What MC does this cause in Peds

A

Clumps of cells on lining of colon/rectum

ASA
Cox-2 inhibitors

Painless rectal bleeding

139
Q

Where are adenomatous polyps commonly found in the colon

What type of polyp has a 30-70% risk of malignant transformation

Define Familial Adenomatous Polyposis

A

Distal colon/rectum

Villous adenomas

Hundred/thousands of colorectal polyps by 15y/o and cancer by 40y/o

140
Q

What is the recommended screening for 1st degree relatives of Pts w Familial Adenomatous Polyposis

What screening is recommended for family members

How are Polyps Tx

A

Genetic screening after 10y/o

Annual sigmoidoscopy starting 12y/o

Snare/Electrosurgical forceps during total colonoscopy
Unsuccessful colonoscopy removal= laparotomy

141
Q

Colon Ca is the 3rd leading cause of cancer death behind ?

When is colon cancer screenings recommended for average risk Pts w/ stool tests

A

1st: lung; 2nd: skin

Start 50, end 75y/o

Guaiac fecal occult test 1/yr
Fecal immunochemical test 1/year
FIT-DNA test q1/3yrs

142
Q

When is flexible sigmoidoscopy recommended for colon cancer screenings

When is colonoscopy recommended for colon cancer screenings

When is CT colonoscopy recommended

A

Once q5yrs or,
Once q10yrs w/ FIT every year

q10yrs

q5yrs

143
Q

When are colon cancer screening started if single first degree relative is Dx

How is colon cancer Tx

What is monitored during Tx

A

<60 at Dx: start colonoscopy at 40 or 10yrs younger than age of Dx; if negative- q5yrs

5-FU mainstay of chemo
Surgical resection

CEA

144
Q

Define Diverticulosis

How does this present

Define Diverticulitis

How does this present

A

Large outpouching of mucosa in colon

Painless rectal bleeding

Infammed diverticula d/t obstructing matter

LLQ pain
Fever
Inc WBC/CRP

145
Q

What are the 3 clinical indicators used to Dx Diverticulitis

How is this Dx

What needs to be avoided during work up

A

Absent vomiting
CRP >5mg
LLQ tenderness only

CT- fat stranding and bowel wall thickening

Colonoscopy- risk of perf

146
Q

How is mild diverticulitis Tx

How is Constipation defined by Rome 3 criteria

A

Low residue diet
Broad ABX
NG tube if +ileus

Any two x 3mon w/ Sxs onset >6mon prior:
Sensation of obstruction
<3 bm/wk
Straining
Lumpy/hard stool
Incomplete sensation
Digital maneuvers needed
147
Q

How is constipation Tx w/ fiber

What are the bulk forming laxatives used

What is the next step if Pts don’t respond to bulkers

Constipation lasting longer than ? needs to have further investigatory studies

A

20-25gm/day

Psyllium seed
Methylcellulose
Calcium polycarbophil
Wheat Dextrin

Osmotics, start w/:
Polyethylene glycol

> 2wks and refractory to Txs

148
Q

Diarrhea after picnic w/ egg salad is d/t ?

Diarrhea from shellfish is d/t?

Diarrhea from poultry/pork is d/t?

Diarrhea from poorly canned food is d/t?

Diarrhea from daycare outbreak is d/t?

Diarrhea from cruise ships is d/t?

Diarrhea from fresh water consumption is d/t?

A

Staph A

Vibrio cholera

Salmonella

C perfringens

Rotavirus

Norovirus

Giardia

149
Q

How does acute/chronic hepatitis present

How is Hep A passed

How is it Dx and what result shows prior infection

How is it Tx

How is it vaccinated

A

Tea urine, pale stool
Pruritus
Vague abdominal pain

Fecal-oral transmitted

Serum IgM anti-HAV
IgG Ab to HAV distinguishes acute from prior infection;
+IgG= prior infection, acquired immunity

Tx: supportive

Vaccine x 2, first at 1y/o

150
Q

How is Hep B passed

How is it Dx

How is it prevented

What is the risk of this Dx

A

Sex/Sanguineous

HBeAg- highly infectious
HBsAg- ongoing infection
anti-HBc- have/had infection
Anti-HBs- immune

Vaccine x 3: birth, 1mon, 6-18mon

Hepatocellular carcinoma

151
Q

How is Hep C passed

How is this screened for

How is this Dx

What is the risk of the Dx

How is this Tx

A

ASx transmision through IVDA , sex, sanguineous

Anti-HCV Abs

HCV RNA quantitation

Cirrhosis/hepatocellular carcinoma

Antiretrovirals against RNA synthesis

152
Q

How is Hep D passed

What is the risk of the Dx

How is this Dx

How is this Tx

A

Only w/ co-infection of Hep B

Hepatocellular carcinoma

Anti-HDV- active infection

Tx/prevent infection

153
Q

How is Hep E passed

How is this Tx

What lab result suggests alcoholic hepatitis

A

Pregnant mother to baby

Support/vaccinate

AST:ALT ration >2:1

154
Q

3 RFs for Fatty Liver Dz

How is this Dx

How is this Tx

A

Obese Hyperlipid Insulin resistance

ALT>AST
US: steatohepatitis (inc echogenicity and coarse texture)
Biopsy: large fat droplets

Lifestyle mod/DM control

155
Q

Define Cirrhosis

What is the MC cause

What will be seen on lab results

A

Chronic liver dz w/ fibrosis, disrupted liver architecture and widespread nodules

Alcoholic liver Dz

AST > ALT

156
Q

What Syndrome are liver cirrhosis PTs at risk for

What is the MC complication of cirrhosis

When is paracentesis warranted for Tx

A

Budd Chiari: abdominal pain
Ascities
Hepatomegaly

Ascites- abdominal fluid collection from portal-HTN and hypoalbumin

SOB
Early satiety
Tense ascites

157
Q

How does hepatic encephalopathy present on PE

How is cirrhosis Tx

Define Cholelithiasis

A

Asterixis- flapping tremor when Pt flexes hands

Avoid alcohol
Salt restriction
Transplant

Gallstones w/out inflammation

158
Q

90% of cholelithiasis is ? saying

What are the other 10%

What is the cardinal Sx

What referred sign can be seen

A

Fat Female Forty Fertile w/ cholesterol stones

Pigmented- brown/black

Biliary colic from obstructed cystic duct

Boas- right subscapular pain of biliary colic

159
Q

What is the Dx modality of choice for cholelithiasis

What lab result will be elevated during obstructions

What clotting factors does the liver make

A

Abdominal US 8hrs after fasting

ALK-P

1 2 5 7 9 10 12 13

160
Q

Define Cholecystitis

What PE finding helps w/ Dx

Chronic Cholecystitis can develop into ?

A

Inflammed gallbladder d/t cholelithiasis and an obstructed biliary duct

Murphys- pain in RUQ w/ palpation and inspiration

Porcelain GB, premalignant condition

161
Q

How is cholecystitis Dx

Define Cholangitis

What presenting triad can be seen

What pentad can this develop into

A

US- 1st line
Gold standard: HIDA scan if equivocal US/suspected acalculous cholecystitis

Infected obstruction d/t stones w/ E Coli

Charcot’s Triad:
F/C
RUQ pain
Jaundice

Reynolds- HOTN, AMS

162
Q

How is Cholangitis Dx

What tumor marker indicates liver neoplasms

When does hematuria become ‘clinically significant’?

A

Initial: RUQ US
Optimal: ERCP for Dx and Tx
+ Charcots- go direct to ERCP

Alpha-fetoprotein and abnormal images

> 3 RBCs/high power field on two different occasions

163
Q

How does Nephrolithiasis/Urolithiasis present

What are the 4 types of stones

A

Colicky flank pain w/ +CVA tenderness

Calcium oxalate- MC, avoid grapefruit juice

Struvite- chronic UTIs, w/ Klebsiella/Proteus origins

Uric acid- acidic urine; excess meat/ETOH and gout

Cystine- rare genetic, young male w/ stones

164
Q

What is the gold standard for Dx Nephrolithiasis/Urolithiasis

What would be seen on UA

What labs need to be ordered

A

Spiral CT w/out contrast

Microscopic hematuria

BUN, Cr levels to eval renal function

165
Q

How is Nephrolithiasis/Urolithiasis Tx

What are 3 indications Pts need admission

A

IV morphine/ketorolac
Hydration
ABX if UTI present
Flomax- alpha blocker if stone >5mm but <10mm

Pain uncontrolled w/ PO meds
Anuria
Renal colic, UTI and fever

166
Q

What size Nephrolithiasis/Urolithiasis stones are expected to pass naturally

What sizes are not expected to pass and what is done

When is Urology consult needed

A

5-10mm, may require elective lithotripsy

> 10mm- ureteral stend or percutaneous nephrostomy (gold standard)

Stone doesn’t pass in 3days

167
Q

Extracorporeal shock wave lithotripsy Tx for Nephrolithiasis/Urolithiasis is best for ? sizes

What is the next step and indicated for ? size

A

> 5mm <2cm

Percutaneous nephrolithotomy- >2cm

168
Q

Define a UTI

What is the MC and 2nd MC cause

How do these present

A

Infection in any part- kidney, bladder or urethra

1st- E Coli
2nd- Enterococcus/Saprophyticus

Dysuria w/out urethral d/c
No F/C/flank pain

169
Q

Define Honeymoon Cystitis

What is the MC cause of recurrent cystitis in men

How are UTIs Dx

A

Uncomplicated UTI in women preceded by sex

Chronic bacterial prostatitis

Urine dipstick- nitrie, leukocyte esterase
UA: pyuria
Culture- gold standard; 
>100K CFU for women
>1K CFu for men/cath Pts
170
Q

What is an uncomplicated UTI

A

Female w/out comorbidities

Fosfomycin- single dose, expensive

Allergic to TMP and resistance to E coli: Nitrofuantoin/Flqn

TMP/SMX for resistant E Coli strains

Phenazopyridine- urethral analgesic

171
Q

How is a lower UTI in pregnancy Tx

How are post-coidal UTIs Tx

How are complicated UTIs Tx

A

Nitrofurantoin
Cephalexin

TMP-SMX
Cephalexin

Fluoroquinolone
TMP-SMC
Cephalosporin
Avoid- Nitrofurantoin

172
Q

How is pediatric cystitis Tx

How

A

Cephalosporin- first line
Keflex
Cefixime/Cefdinir/Cefibutene if inc likelihood of renal involvement

173
Q

Define Pyelonephritis

How doe Pyelonephritis present

What is the MC microbe to cause this

How is this Dx and what is pathognemonic

A

Ascending UTI that reaches renal pelvis (staph A- hematogenous)

Fever
CVA tenderness
N/V

E coli

UA: WBC casts (nomonic for pyelo and interstitial nephritis)

174
Q

What is the next step if complicated pyelonephritis is seen

How is this Tx outpatient

How is this Tx inpatient

How is this Tx in pregnancy

A

Renal US

Cipro
Levo
Cephalexin

Ceftriaxone

Admit
Ceftriaxone

175
Q

Define Nephrotic Syndrome

What would be seen on a 24hr UA collection

What lab results would be abnormal

A

Peripheral/Periorbital edema
Ascites/effusion
HTN

> 3.5g/day

Hypoalbuminemia
Hyperlipidemia

176
Q

How is nephritic syndrome different from nephrotic syndrome?

What are the two classifications of nephrotic syndrome

A 
Peripheral/Periorbital edema
HTN
Oliguria
Hematuria
Proteinuria 1-3gm/day

Primary- Dx w/ kidney biopsy
Secondary- DM, HIV, Hep B/C, Lupus, Antiphospholipid syndrome

177
Q

Why is proteinuria seen in nephrotic syndromes?

What type of cells make up the basement membrane

What Pt presentation makes nephrotic syndrome a possible Dx

A

Capillary endothelial cells change and unable to filter serum protein by sizes

Podocytes

Young child w/ unexplained edema/ascites:
Edema + 3.5gm of protein on 24hr collection
Fatty casts w/ maltese cross
Oval fat bodies
Hypoalbumin
Hyperlipid

178
Q

What are the MC causes of primary nephrotic syndrome in adults

What is the MC cause in Peds

What form affects IVDA

A

Membranous nephropathy- malignancy/Hep B

Minimal Change Dz: assume Dx if syndrome improves after CCS Txs

Focal Segment Glomerulosclerosis- obese Pt w/ HIV and IVDA, probably black w/ SCDz

179
Q

What are the MC causes of secondary nephrotic syndrome

How is nephrotic syndrome Dx

How is this Tx

A

Lupus
DM
Pre-eclampsia

Proteinuria >3.5g/day
Casts- lipiduria
Hypoalbumin <3.5g
Hyperlipid: LDL >130, Tgly >150

Statin
Angiotensis inhibition
Na restricion
Diuretic

180
Q

How is Minimal Change Dz Tx

What is used for Tx if Pt is a frequent relapser

How is Membranous Nephorpathy Tx

A

ACEI- for mild condition
Prednisone

ImmSupp w/:
Chlorambucil
Cyclo-sporine/phosphamide

High risk progressing to ESRD:
Glucocorticoids and, 
Cyclophosphamide
Low risk:
ACEI 
Persistent- lipid lowering Rx
181
Q

How is Focal Segmental Glomerulosclerosis Tx

How are steroid resistant cases Tx

A

Prednisone- 1st line
ACEI- dec proteinuria

Cyclosporine addition

182
Q

What defines HyperK

What is seen on EKG

What is seen on PE

How is it Tx

A

Serum K >5

Peaked T wave, prolonged QRS

Muscle fatigue

Sodium bicarb
Glucose
Caclidum gluconate

183
Q

What define HypoK

What is seen on EKG

What is seen on PE

How is it Tx

A

Serum K <3.5

Flat/inverted T-wave, Uwave

Muscle cramps, constipation

No dextrose fluids
Replete K/Mg

184
Q

HypoCa is defined as ?

What is the MC cause and other possibles

What is seen on EKG

What is seen on PE

How is it Tx

A

Serum Ca <8.4
Ionized Ca <4.4

MC: hypoparathyroid
Other: thryoid surgery, renal dz

QT prolongation

Trousseaus
Chvosteks

IV calcium gluconate

185
Q

IF suspecting imbalance of phosphorous or Ca, always order ? lab

HyperCa in elderly is Dx as ? until disproven

A

PTH

Ca

186
Q

HyperCa is defined as ?

What is the MC cause and other causes

Saying for remembering PE findings

What is seen on EKG

How is it Tx

A

Serum Ca >10.5
Ionized Ca >5.6

MC: hyperparathyroid
Other: mets, MM, TB, sarcoidosis

Stone Bones Groans Moans

Short QT

IV NS and Furosemide

187
Q

HypoNa is defined as ?

What causes this

What is seen on PE

A

Serum Na <135

ETOH
Hypervolemia- CHF, nephrotic syndrome, RF, cirrhosis
Euvolemic- SIADH, steroids, hypothyroid
Hypovolemic- Na loss

Seizures
Altered gait
Mimics HypoK if <105

188
Q

Why does HypoNa need to be Tx slowly

How is it Tx

How fast should a deficiency be corrected

A

Osmotic demyelination syndrome

ASx: water restriction
Moderate: IV NS, Loops
Sev: 50mL 3% NS

10mEq or less over 24hrs

189
Q

What defines HyperNa

How does it present

How is it Tx

What happens if Tx is too fast

A

Serum Na >145

Poor tugor
Dry skin
Flat veing

IV D5W

Cerebral edema
Pontine herniation

190
Q

What Na lab result indicates Diabetes Insipidus

What are the two possible locations of the issue

What consistent lab result indicates DI

A

Low urine Na
High serum Na
Polyuria

Neurogenic/central- deficient ADH from posterior pituitary

Nephrogenic- kidneys don’t respond to vasopressin or d/t lithium/renal dz

Urine osmolality <250 despite hyperNa

191
Q

What is the 3 step approach to Acid-Base D/o

What causes respiratory acidosis

What causes respiratory alkalosis

A

1st: ph (7.35-7.45)
2nd: PCO2 (35-45)
3rd: HCO3 (20-26)

Lungs fail to excrete CO2

Excessive CO2 loss

192
Q

What is the next step if metabolic acidosis is encountered

What causes a high anion gap

What causes a low anion gap

A

Anion Gap- Na - (Cl+BiCarb)= 10-16

Excess H+ ions >16; MUDPILES:
Methanol Uremia DKA Paraldehyde Infection LAcidosis Ethylene glycol Salicylates

<16Loss of BiCarb- diarrhea

193
Q

What causes metabolic alkalosis

Saying to remember average normal valued for acid-base numbers

A

Loss of H+L vomit, bulemia, OD of antacids
Additional bicard- hyperalimentation therapy

24/7 40/40
BiCarb/pH CO2/acid

IPAP (212 decks)

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