IMC 4.0 Flashcards
? is the MC type of cardiomyopathy
What is the MC non-ischemic cause
What part of the heart if affected
Dilated
ETOH abuse
MCC- ischemic dz
All 4 chambers
Dilated Cardiomyopathy is characterized by ?
What heart sound is present
What Sxs can this present w/
Dec contraction strength- systolic dysfunction
S3- ventricular gallop
Fatigue
Edema
Exertion dyspnea
Displaced apical pulse (megaly)
? is the most definitive method to Dx Dilated Cardiomyopathy
What findings are Dx
What will be seen on EKG
Echo
Dilated ventricles
EF <50%, often <30%
Non-specific ST/T changes
What will be seen on CXR of Dilated Cardiomyopathy
How is this Tx
What med is added if increased contractility is needed
Balloon heart- megaly and pulmonary congestion
Loop+ACEI+BB
Transplant/LVAD
Digitalis
What medication is used in Dilated Cardiomyopathy to reduce remodeling
What medication is used to decrease the effects of excess catecholamines
Chronic use of ? street drug can lead to this
Angiotensin Converting Enzyme Inhibitors- ACEI
BBs
Cocaine
Define HOCM
What type of murmur does this have
What makes murmur louder/softer
Ventricular hypertrophy w/ diastolic dysfunction
Medium, mid-systolic cresc-decresc w/ S4
Dec- squat, grip, raise (increased preload)
Inc- valsalva, stand (dec preload)
How is HOCM genetically linked
This condition presents mimicking ?
What type of murmur is present
Autosomal dominant affect on sarcomeres
AS- angina, syncope, HF
S4 gallop w/ apical lift
What type of JVD wave is present in HOCM
How is this Dx
What is seen on EKG
Prominent A-wave
Echo- LVH, thick septum
MRI
LVH
Non-specific ST/T changes
How is HOCM Tx
What Rxs need to be avoided
What medication is c/i?
Diltiazem/Verapamil/Metoprolol
Exercise cessation
+syncope/arrest= ICD
Decrease preload: Diuretics ACEI Nitrates ARBs
Digoxin- increases contraction/obstruction
How does HOCM cause death
Define Restrictive Cardiomyopathy
What Hx is in the Pts report
Post-exertional ventricular arrhythmia
Noncompliant ventricles (MC- LV) that resist diastolic filling
Myocardial infiltration w/ abnormal tissue-
Amyloidosis- MC
What type of HF and sound is associated w/ Restrictive Cardiomyopathy
Half of these etiologies are ?
How is this Dx
Diastolic HF w/ S4
Idiopathic
Echo- normal EF, dilated atria, hypertrophy
Cath- high atrial pressure
What is seen on EKG of Restrictive Cardiomyopathy
If a Dx is in doubt after an Echo, what is the next step?
What would be seen on CXR
Non-specific ST/T changes
Low voltage complexes
MRI- abnormal textures
Pulmonary vascular congestion
Normal heart size
How is Restrictive Cardiomyopathy Tx
Why must Rxs be used cautiously
What populations are at higher risk for developing this condition
+edema/pulmonary congestion= diuretic
Definitive- transplant
Avoid lowering preload
Northern European men
Define ASD
What does this defect cause to occur
How common are these defects
Atrial wall defect causing L to R diastolic shunt
Volume overload of RA/RV
2nd MC behind VSD
Small ASDs can remain ASx as long as 30y/o but then ? occurs
This defect is often associated w/ ? d/t the stretching
This allows for ? event to occur
> 30: dyspnea, angina
50: Afib, RVF
Arrhythmia- RBBB
Paradoxical embolization- DVT causes stroke/brain abscess if septic
What happens to the S2 in an ASD
What kind of S1/S2 is present
How is this Dx
Shunting of blood equalizes blood volume entering ventricles- eliminates normally wide, split S2
Loud S1
Wide fixed split- lub dub-dub
Echo w/ bubble contrast
What is seen on EKG of ASDs
What is seen on CXR
How is this Tx
RAD
RVH
RBBB w/ rSR in V1
Megaly w/ dilated RA/RV
Small/central <3mm: observe
+Evidence of RV volume overload- surgical closure at 2-6y/o
Define PDA
How do Pts present
What type of murmur is produced
Systolic murmur d/t persistent ductus arteriosus (aorta to L-PA) causes L-R shunt
FTT
Poor feeding
Tachy/Tachy
Continuous machinery at 2nd LICS (patent your machine)
What are two common PE findings of PDA
What is seen on EKG
What is seen on CXR
Machinery murmur
Wide pulse pressure (arm>leg)
LVH, normal
LVH
Prominent LA, PA, aorta
How are PDAs Tx
Since these may be identified at birth, especially if premature, what is the next step
? congenital infection can cause a PDA
Indomethacin- decreases Prostaglandin E1/E2
Fluid restriction
Surgery/Catheter
Re-eval in 24hrs
Congenital Rubella
Define a VSD
? is this murmur the MC of
What type of murmur is created
Hole in septum causing L-R shunt between ventricles
MC congenital defect
MC pathological murmur of childhood
Harsh, loud holosystolic w/ systolic thrill
How is a VSD identified on PE
How is the Dx confirmed
How is this Tx
Pt supine
Diaphragm at tricuspid
Echo
Watchful expectation
Infant w/ CHF + growth retardation- digoxin + diuretic
Medical failure- surgery <6mon old
Peds w/ VSD need ? prophylaxis prior to procedures
What is being prevented
What is the MC outcome and the most UNCOMMON outcome
PCN/Amox
Allergy- Erythromycin
Bacterial endocarditis
MC: spontaneous closure
MUC- CHF secondary to VSD
Define Coarctation of Aorta
What is the usual PE finding
Half of these Pts will have ? defect putting them at risk for ? sequelae
Narrowing of aorta, MC below origin of left subclavian artery
Arm BP > Leg BP
Bicuspid aorta;
Berry aneurysm
What does Coarctation look like on EKG?
What does it look like on CXR
How is it definitively Dx
LVH
Rib scalloping/notching
Figure 3 sign
TTEcho or CT/MRA
How is Coarctation of Aorta Tx
How is Tx different if seen in neonates
Why would emergent surgical repair be needed
Balloon angioplasty w/ stent between 2-4y/o
Prostaglandin E1- keeps ductus arteriosus open
Shock
Megaly
Severe HTN/CHF
What happens if Coarcations are left untreated
Infantile Coarctation is associated w/ ? two defects
Unique fact of Tetrology of Fallot
Death by 50y/o d/t:
Rupture/dissection
CVA
PDA
Turner Syndrome- order karyotype analysis
Only cyanotic congenital heart dz on blueprint
What are the 4 features of Tetrology of Fallot
What makes this a Pentology
What is the resulting shunt created?
PS RVH Overriding VSD
ASD
PS- R to L through VSD
How is Tetrology of Fallot Dx
What is seen on CXR
What serial monitoring do Pts need
Echo
Boot shaped heart
EKG for QRS widening
How is Tetrology of Fallot Tx
What happens if these are left untreated
What are complications that arise after surgical correction
Surgery
Sudden cardiac death/HF <20y/o
HF
Outflow obstruction
PR
Arrhythmias
What hereditary T-cell disorder is associated w/ Tetrology of Fallot
What PE finding measures the severity of this condition
Infants/Peds will have ? common PE finding
DiGeorge Syndrome
PS
Cyanosis
Tet Spell= hypercyanotic
Define Primary HTN
What are the ranges for Normal, Elevated, Stage 1 and Stage 2
According to USPSTF, Pts need HTN screening starting at ? age and how often
SBP 130 or > or,
DBP 80 or >
On two readings, on two separate visits
N: <120 and <80
E: 120-29 and <80
1: 130-39 or 80-89
2: 140 or >, or 90 or >
Start at 3y/o, annual at 18y/o:
Normal- qYear
+RFs/SBP 120-29- q6mon
When measuring BP, Pts reasts x ?min
The cuff needs to cover ? much of arm
How big of width does bladder need
Rest >5min and >30min since tobacco/caffeine ingestion
80% of arm
40% of arm
BP discrepancy of ? in both arms needs further eval
When is anti-hypertensive therapy initiation indicated
What is the target BP for PTs w/ or w/out comorbidities
> 15mmHg
All Stage 2
Stage 1 w/ ASCVDz, DM2, CKDz or 10yr risk of 10% or more
140/90 w/out comorbidiites
<130/80
<60 w/ CAD/CKD/DM: <140/90
60/>: <150/90
When Tx HTN, how much salt intake is recommended
How much exercise is recommended
If medication is needed, ? is used per ethnicity
<2.3g/day (1tsp)
Mod intensity: 30min/day x 5d/wk
Vigorous intensity: 30min/day x 3d/wk
Non-black/DM:
ACEI/ARB
CCB
Thzd (chlorthalidone, indapamide)
What HTN Txs are recommended for Stage 2 HTN
When are ACEI/ARB, BB, or CCBs c/i for Tx
How long are therapies recommended
Two BP meds from different classes w/ lifestyle mod
ACEI/ARB- DM w/ proteinuria
BB- asthma
CCB- angina pectoris
F/u 1mon
Goal not met- increase dose or add 2nd med
What is done for HTN if BP is uncontrolled despite 2 anti-HTN meds
What is done if one med causes to much leg edema
What is done if the diuretic is not tolerated
ACEI/ARB and
Amlodipine and
Thzd-like
Substitude Amlodipine w/ Verapamil/Diltiazem
Use mineralcorticoid receptor agonist (Spironolactone)
S/e of ACEI
S/e of Spironolactone
S/e of BB
S/e of CCB
S/e of hydralazine
S/e of thiazides
Cough Angioedema HyperK (c/i- pregnant)
HyperK
Impotence (c/i asthma)
Leg edema
Lupus-syndrome (and Procainamide)
Pericarditis
HypoK
What are the 5 modifications used for Tx HTN and how much of a decrease is expected
? is the initial medical therapy for DM when starting HTN Tx
What EKG changes would be seen after long standing HTN
Weight loss: 5-20mm DASH diet: 8-14mm Na dec: 2-8mm PT: 4-9mm Dec ETOH: 2-4mm
ACEI- beneficial for neuropathy
LVH
What are two non-modifiable RFs for HTN
? anti-hypertensive agent has alpha and beta blocking activity
Pt w/ BP of 135/85, what is the next step and Tx
Age
FamHx CADz
Carvedilol
10yr HDz/stroke risk:
<10%- start lifestyle
>10%, CVDz, DM, CKD- start meds
Define Secondary HTN
When is this Dx suspected
What is the MC cause
130/80 or higher w/ identifiable cause
Severe BP
Refractory to HTN med
Primary aldosteronism- high Na, low K
What is the MC cause of curable HTN
? sweet diet finding can increase BP readings
When Tx HTN, lifestyle modification can be tried for how long before meds are used
Excessive ETOH and OCP combo usage
Licorice
6mon
When Tx HTN, a initial BP higher than ? indicates starting Tx w/ two med
Define Cardiogenic Shock
What is the MC cause
> 160mg
Pump fails, insufficient CO to maintain perfusion
Acute MI
What PE findings suggest cardiogenic shock
What vitals suggest this Dx
How is this Dx
Pulm congestion
AMS
Tachycardia
HOTN
JVD
UOP <20
SBP <90
Pulmonary capillary wedge pressure >15mm
How is Cardiogenic Shock Tx
How does this Dx present post-MI
What type of MI are at highest risk for this sequel
Fluids/Pressers: Dobutamine, NorEpi
Balloon pump
<72hrs post-MI as free wall rupture
Q-wave transmural
Lateral wall
Define O-HOTN
What criteria is used for Dx
What may be the cause in DM/older aged PTs
Excessive fall of BP when upright
Drop of >20 SBP
Drop of >10DBP
Both 2-5min after supine to standing
Autonomic dysfunction- HR inc <10bpm= tilt table
> 100bpm or inc by >30bpm= hypovolemia
How/why does post-postprandial O-HOTN occur
What is the DDx if during Bp checks Sxs present but no HOTN is present
How is O-HOTN Tx
Insulin response to high carb meal
Blood pools in GI tract
Alcohol worsens HOTN
POTS Dz
Inc Na/fluids
Fludrocortisone
Midodrine
? class of drug has the most common adverse effect of OHOTN
Define NSTEMI
What would be seen on EKG
MAOIs- inhibit enzymes that break down neurotransmitters
Myocardial necrosis w/out ST elevation/Q-waves d/t incomplete block (subendocardial infarct)
ST depression
T-wave inversion
What are the 3 cardiac biomarkers used during N/STEMI work ups
How are NSTEMIs Tx
Myoglobin:
1-4hrs; 12hrs; 24hrs
Troponin: most sensitive
2-4hrs; 12-24hrs; 7-10days
CK/CK0MG:
4-6hrs; 12-24hrs; 48-72hrs
MONA BNAH:
BB ASA Reperfusion-PCI Clopidogrel Heparin ACEI NTG Statin
Define STEMI
Since these are Tx similarly to NSTEMIs, what is done first
Myocardial necrosis w/ ST elevation/Q-waves d/t complete block (full wall thickness)
ASA and Clopidogrel
Reperfusion <12hrs of Sx onset
Gold Standard: PCI <90min
Thromolytic therapy <180min w/ TPA/Streptokinase
Where on EKG would abnormal be seen:
Anterior wall
Inferior wall
Lateral wall
Posterior wall
Anteroseptal
A: 1, aVL, V2-6; LAD
I: 2, 3, aVF RCA- SA/AV nodes
L: 1, aVL, V5-6 w/ reciprocal in 3, aVF; LCX
P: ST depression V1-3; RCA/LCX
AS: V1-V3; LAD/Septal
What are the 6 absolute c/is for fibrinolytic therapy for STEMI Tx
Suspected ADissection
Active bleeding/diathesis
Malignant intracranial neoplasm
Ischemic stroke <3mon
CV lesion
HTN, Intercranial
How long after Sxs do NSTEMI/Unstable Angina need angiography
Why is ASA used in N/STEMIs and TIAs
What is the MC type of MI and what is the ‘widow maker’
24-48hrs later
Decreases mortality
MC: Inferior (2, 3, aVF d/t RCA)
WM: LAD
What meds w/ Pts be d/c home w/ after NSTEMI
What med is held until d/c and why is it started then
When would BBs be with held from PTs
BB ACEI Ntg ASA Statin
ACEI- dec LVH/remodeling to increase EF
2nd/3rd* heart blocks
Why do Pts w/ inferior wall MIs have N/V/weakness and bradycardia
Define Stable Angina
Time frame for this Dx and possible presentation sign
Inc vagal tone
SA involvement
Pain/discomfort increased w/ exertion/emotion, predictable and relieved w/ rest/Nitro
<15min;
Levine sign
How is Stable Angina worked up
How is the Dx definitive and what wold be seen
How is this Tx
Stress test- reversible wall abnormalities/ST depression >1mm
Coronary angiography;
>70% stenosis
Nitro- sublingual/IV
BB
Angioplasty/Bypass
Stable Angina Pts have decreased prognosis if ?
What is the most sensitive clinical findings for Dx this condition
What is the most useful and cost-effective non-invasive test
LVEF <50%
Left main involved
Horizontal/down sloping ST depressions on EKG
Stress test: ST depression >1mm is pos
Pts w/ ? Hx have the highest risk for/are at the same risk for CADz compared to those w/ atherosclerosis
What is the most widely used test to Dx ischemic heart dz in Pts w/ classic angina Sxs
What is the TxOC for HF and what class increases these benefits
DM
Nuclear stress test
ACEI- dec morbidity and mortality B1 selective BBs: Bisprolol Metoprolol succinate Carvedilol
What causes BNP to be released and abnormally low
How is dyspnea early on in HF quantified
HF is a syndrome of ?
Released d/t inc ventricular pressures
Low- obesity
Amount of activity that precipitates Sxs
Ventricular dysfunction
Systolic LHF
S3 w/ dilated, thin LV from CADz/MI
LVEF <40%
Tx: Loop ACEI BB
Worse: O2 ACEI Nitro w/ IV diuretic at x2 PO dose, no BB until d/c
Diastolic LHF
S4 d/t hypertophied LV
Inc >55y/o w/ HTN
Normal EF
Tx: ACEI and BB/CCB; don’t use diuretics/digoxin
Exacerbation Tx- NOAL
RV HF
D/t P-HTN
No rales, JVD or edema
Dx w/ cardiac cath
High Output HF
Increased metabolic demand exceed CO
Hyperthyroid
Severe anemia
Beriberi/thiamine deficient
First- tachy, then systolic failure
How is HF Dx
What is the most important part of determining prognosis
BNP levels over ? amount means CHF is likely
Echo
EF:
Norm- 55-60; <35 increased mortality
> 100
What are the 4 NYHA HF classifications
1: no activity limitations
2: slight activity limitations; ordinary activity causes Sxs but comfortable at rest
3: marked limitation of activity; less than ordinary activity causes Sxs but comfortable at rest
4: unable to carry out activity, also have Sxs at rest
An S3 heart sound on inspiration most likely indicates ? type of HF
An S3 heart sound on expiration most likely indicates ? type of HF
? type of HF is associated w/ paroxysmal nocturnal dyspnea
Right sided
Left sided
Left sided
? antiarrhythmic is used to Tx Afib/flutter in Pts w/ HF
? drug affects RAAS, helps limit remodeling and adds to the effects of ACEIs
? is the most effective diuretic in Tx of HF
Digoxin
Spironolactone
Furosemide
? class medication is recommended in all stages of chronic HF
? 4 med classes are important in Tx HF because they all decrease mortality
How do they accomplish this benefit?
BBs
ACEI/ARB
BB
Spironolactone
Inc sympathetic stimulation and aldosterone production- regulates Na/water in body
Only valve w/ two leaflets
Classic AS presentation
Who gets fed during AS causing Sx
MV
Syncope
Angina
Dyspnea
1- coronary artery
2- carotids
3- L subclavian (arm pain)
Pt w/ angina is given Nitro and passes out, ? is underlying issue
What type of S2 will be heard
What additional heart sound may be heard
AS
Split S2
S4
? is the MC acquired heart valve stenosis
Where can this murmur radiate to
How is this best heard and what maneuvers will make this louder/softer
AS d/t calcification
Neck, apex
Leaning fwd w/ expiration;
Inc w/ squat
Dec w/ grip, straining
AS w/ ? suggests a congenital origin
What will be seen on PE if LVH is present
What type of abnormal microscopy result can be seen
Ejection sound
Apical impulse
Helmet cells (schistocytes)- fragmented RBCs from passing through calcified stenotic AV
What makes AS louder
What makes AS quiet
What is the MC cause of AS in younger PTs
Sit, lean fwd w/ exhale (valsalva)
Squat
Hand grip
Stand
Early onset calcification of congenital bicuspid valve
What is the MC cause of AR
What can Pts present w/ as c/c
What PE finding suggests AS has caused structural changes
Weak valve tissue from aging, floppy flaps
Aware of heart when laying down
Down, displaced apex
What term describes the pulses of the Pt w/ AR
What two findings suggest a large regurg flow is present
? congenital syndrome is associated w/ AR
Water hammer- increased pulse pressure
Mid-systolic
Austin flint
Marfans- MVP and AR
What is the best initial test for Pts w/ suspected AR
What does AR do to pulse pressures
What is the mainstay of Tx of AR
TTE
Widens
Dec after load until surgical correction
What is the difference in severity of mild/severe AR
What is the MC cause of MS
What is heard on exam
Severe AR- shorter murmur
Rheumatic heart dz
Apical opening snap (lateral decubitus)
+PHTN- palpable RV impulse
Loud S1
LAH- Tx w/ ACEI
MR is the MC ? murmur
What type of murmur is produced
What are 4 etiologies of MR
2nd MC (after AS) MCC- MVP
Holosystolic at apex w/ dec S1, split S2 radiating to axilla, and apical S3
CADz HTN Infection Rheumatic heart dz MVP
What are two odd c/c Pts w/ MR may present w/
How is MR different from TR
Female w/ MVP have increased issues w/ ?
SOB worse w/ laying/activity
Inc nocturnal urination
Not louder w/ inspiration
Inc pulses- palpitations w/ exercise
What maneuvers change the features of MVP
What may be seen on EKG
How are these Pts Tx
Squat- delays
Standing- moves closer to S1
ST depression
PVCs
Early inferior repolarization
QTc prolongation
+palpitations: BB
Avoid smoke/caffeine
Surgical repair- especially w/ impaired LV systolic function
Where is TS heard
What makes murmur louder
What is the MC cause of this defect
Diastolic rumble at LLSB
Inspiration
Rheumatic valve heart dz
How is TS Tx
How does TR present
What is the MC cause
Percutaneous balloon valvotomy
Holosystolic at LLSB that radiates to sternum and inc w/ inspiration
RVF/dilation initiated from PHTN/LVF
How does TR change the JVD wave
How does PS present
What is the MC cause
Inc w/ large ‘V’ waves
Systolic murmur at pulmonic area that inc w/ inspiration
Congenital malformation in kids
What will be heard on PE of PS
What type of murmur is heard in PR
What causes PR
Widely split S2 w/ dec P2 w/ R sided S4
Diastolic decrescendo at pulmonic area that inc w/ inspiration
PV annular dilation/damage/congenital malformation
What is this murmur of PR AKA
Since PR can be indistinguishable from AR, how is it differentiated
How is this murmur Tx
Graham-Steel murmur
PR inc w/ inspiration, AR does not
Valve replacement
? is the MC cardiac arrhythmia and what is it’s biggest RF
The prevalence of this MC increases d/t ?
Why does this conduction irregularity develop
Afib d/t HTN- irregular, irregular w/out P-waves and narrow QRS
Age
SA node generation is overwhelmed/disorganized MC by pulmonary veins
What is the most important lab ordered for Afib work up
What two neurological issues can cause Afib
What is the best imaging for Dx
TSH to measure thyroxin (inc cellular metabolic rate); Graves present w/ Afib
Suabarachnoid hemorrhage
CVA
TTE- initial (valves, chamber/wall dimension)
TEE- most accurate (thrombus)
Where/what is the most common site of an embolus to develop during Afib
How is Afib Tx and w/ ? goal
How is rate control achieved w/ Rxs
LA appendage
1- Unstable: Cversion
2- >48hrs: anticoagulate x 21days
3- Afib + RVR= chemical conversion
<110bpm:
IV Diltiazem/SAME-olol
Low dose digoxin, slower/inadequate rate control
What is a s/e of using Sotalol for rate control of Afib
What is the drug of choice for Tx Afib in WPW
What med is best for rhythm control if there is/no CAD/CHF
Torsades
Procainamide- security detail to AV node
Flecainide: -CAD/CHF
Dronedarone: +CAD, -CHF
Amiodarone: +CHF
Why are CCBs used for rate control of Afib
DHP vs non-DHP CCBs
If using Amiodarone/Dronedarone for rhythm control, ? drug can’t also be used
Road block between SA/AV node (5 land to 2 lane)
Pine tree- outdoor
(CCBs w/ -pine, outpatient)
Non-pine (non-DHP)- no out-PT; Verapamil; Diltiazem
Dabigatran- DOAC for Afib d/t non-valvular d/o
When/why would Digoxin be used in the Tx of Afib
What alternatives to Warfarin are available and indication for use
How does AFlutter appear on EKG
HF and dec LV function;
Inc intracellular Ca
Dabigatran- DOAC for Afib d/t non-valvular d/o
Rivaro/Api-xaban: no antidote and no blood testing
Irr/Regular w/ sawtooth P-waves
How is AFlutter Tx
How is rate control in Aflutter different than Afib
If conversion is needed for Aflutter, how much energy is needed
Diltiazem
Flecainide
Dronedarone>Amiodarone
Rate control more difficult
50-100J
How is the need for anticoagulation for Afib/Flutter determined
What DOACs can be used
When/why would Warfarin be used and w/ ? goal
CHA2DS2-VASc:
0- none/ASA 81-325mg
1- ASA 81-325 or anticoag
2 or >- anticoagulate
Dabigatran
Edoxaban
Apixaban
Rivaroxaban
INR goal: 2.5: Prosthetic valves EGFR <30 Rx: Phenytoin, antiretrovirals MS
What does the CHA2DS2-VASc stand for
? DOAC has a reversal agent if needed
Eliquis dosage needs to be lowered if used w/ ? ABX
CHF/LVEF 40% or less HTN Age 75 or >: 2pts DM Stroke/TIA/Emboli: 2pts Vascular dz Age 65-74 Female
Dabigatran
Clarithromycin
Define Paroxysmal AFib
When is this Dx changed to Persistent/Permanent Afib
Define Multifocal Atrial Tachycardia
Intermittent attacks that self resolve <7days
Persist:>7d
Permanent: >12mon
MC in COPD Pts w/ irregular, irregular rhythm and varying P-wave morphology
Nearly 90% of Afib PTs will present w/ ?
AFlutter may develop as a sequelae to ?
Aflutter Pts are more likely to present w/ ? c/c
ASx
Open heart surgery
Fatigue
Exercise intolerance
What is the main difference between Afib/Flutter Txs
? is the most rapid method to lower INR in PTs on Warfarin
Define PSVT
Aflutter cured w/ RFA
FPPlasma
SVT w/ abrupt start and stop in Pts w/out other structural heart Dz
What are the two types of PSVT
How are these Dx
How are these Tx
AVNRT: tachyarrhythmia developing above Bundle of His
WPW: abnormal pathway between atria and ventricles in Bundle of Kent
Holter monitor to capture episodes
Stable: Vagal, Carotid massage, Valsalva
Sxs: Adenosine
Regular: BB/CCBs
Definitive: RFA
What meds are avoided in Tx of WPW
What is the Tx oc choice for long term management
Why is Adenosine used for PSVT Tx w/ fear
Adenosine, CCBs
RFA
Transient asystole d/t T1/2 of 6sec
What are the 3 types of premature beats
What abnormal beat presentation can these have
PVC: wide/bizarre QRS w/out P-wave
PAC: abnormal P-wave, common in COPD Pts
PJC: narrow QRS w/ no/inverted P-wave
Trigeminy
Bigeminy
Pts w/ heart Dz and frequent PACs will soon develop ? issues
What are two etiologies of PVC
If Pt has palpitations, they describe them as ?
PSVT Afib/flutter
Hypoxemia
E+ imbalance
In throat
How are premature contractions Dx
How are these Tx
How is V-Tach Tx
EKG, Holter
PAC: reassure
PVC: BB, ablation
PJC: only Tx if >10/min or multifocal w/ lidocaine/antiarrhythmic
Stable: Amiodarone, Lidocaine, Procainamide
Unstable monomorphic: synchronized cardioversion starting at 100J
Unstable polymorphic: Dfib
How is VTach defined
This is a common complication d/t ?
? antiarrhythmic used for long term can cause hyper/hypo-thyoidism
3 or more consecutive premature ventricular beats
Acute MI
Dilated cardiomyopathy
Amiodarone- similar structure to thyroxine w/ iodine
What are the different classes of antiarrhythmic drugs?
S/e of using Procainamide
How is VFib Tx
1a: Na blocker
1b: fast Na blocker
1c: potent Na blocker
2: BB
3: K blocker
4: Ca blocker
Drug induced lupus eruption
CPR
Defib- non-synch conversion 120 150 180
Epi
Amiodarone 6mg, 12mg
Define VFib
This MC develops d/t ? myocardial abnormal
This rhythm can be caused by abusing ? two drug
Uncoordinated quivering of ventricle w/out useful contractions
MI- ischemia increases excitability of myocardium, predisposes heat to Vfib
Meth, Cocaine
? technique can providers use to Tx VFib if no defibrillator is present
Define 1* Heart Block and the Tx if needed
Define the two types of 2* Heart Blocks and their Txs
Precordial thump
PR >.20 (5 small squares): problem between SA/AV nodes; Tx w/ BBs
Mobitz Type 1: Wenckebach-
Long, long, drop; no Tx unless unstable- pacing
Mobitz Type 2:
Dropped QRS, Pwave w/out QRS; Tx w/ pacemaker
Define 3* Heart Block
What class of drug is c/i in all heart blocks
Only two blocks have constant R-Rs
Constant P-P, R-R interval
Erratic PR; Tx w/ pacer after r/o ischemic dz
CCBs
1st, 3rd degree
? is the MC cause of AV blocks
? is the only complete AV block
Why do Pts w/ Mobitz Type 2 need pacers
Idiopathic fibrosis/sclerosis
Ischemic heart dz
3rd degree
Always pathologic, almost always progress to 3rd degree blocks
? type of Dz infection can cause a 3* heart block
? is the MC cause of 3* blocks
Define Sick Sinus Syndrome
Lyme Dz
Myocardial ischemia
Dysfunction of sinus nodes automaticity and impulse generation
Define 4 abnormals seen in Sick Sinus Syndrome
What is the MC cause of the underlying sinus node dysfunction
Most PTs w/ SSS will need ? Tx
Sinus brady: <60bpm
Pause: <3 seconds
Arrest: >3 seconds
Tachy-Brady: alternates; Tx w/ pacemaker
Idiopathic SA fibrosis
Pacemaker
Use BB/CCB/Digoxin if prepared to transcutaneous pace
Define Acute and Subacute Endocarditis
MC cause in native valves infection is ? group
MC cause in IVDA
MC cause in prosthetic valves
Acute: Staph infects normal valves
Sub: Strep V infects abnormal valves
HACEK
Staph A w/ small vegetations
Staph epidermis
How does endocarditis of a fungal origin present
What is the time frame for presentation
What type of fungus will be cultured and how is it Tx
Contaminated line cause slowly grown, large vegetations
<2mon post-valve replacement
Candidia; Tx w/ Amphotericin B
? microbe is the MC cause of infective endocarditis
How does this microbe origin present
What are the peripheral findings of endocarditis
Strep viridians
Late complication of valve replacement w/ small vegetation/emboli
Splinter hemorrhages Roth spots Janeway- sign septic emboli Osler node- painful Spelnomegaly Hematuria
How is endocarditis Dx
How is this condition Tx depending on valve type
TEE- gold standard
+Blood cultures, 3 sets, 1hr apart
Native w/out IVDA: Nafcillin Ampicillin Gentamicin
Prosthetic: Vanc Gentamicin Rifampin
IVDA: Nafcillin
PCN allergy- Vanc
What are Pts prophylactically Tx w/ post-endocarditis
Four RFs for developing infective endocarditis
Pts presenting w/ ? two Sxs signal suspected Dx
2g Amoxicillin
PCN allergy-Clinda
Prosthetic valve
Rheumatic heart dz
IVDA
Congenital defect
Fever- MC Sx
New murmur- TR/MR
Stroke
What are 3 possible adverse outcomes from infective endocarditis
Non-IVDA endocarditis MC affects ? valve
IVDA MC affects ?
Glomerulonephritis
Septic emboli
Splinter hemorrhages
Mitral
Tricuspid
5 criteria for Pts to need endocarditis prophylaxis
Pericarditis is MC from ? microbe and often leads to ? sequelae complication
? syndrome of pericarditis is seen 3-5d post-MI
Prosthetic valve
Prosthetic material repair
Hx endocarditis
Congential heart dz
Coxsackie;
Pericardial effusion
Dresslers
How is pericarditis Dx
What PE finding may be seen
How is it Tx
EKG w/ diffuse, ST elevation in 1/2, V5/6
Kussmaul sign- increased CVP w/ inspiration; common in constrictive pericarditis
NSAID/ASA x 7-14d
Sxs >48hrs- CCS
What are 3 autoimmune etiologies of pericarditis
What 2 inflammatory Dzs can cause this
What 2 medications can cause this
SLE RA Scleroderma
Sarcoidosis
Amyloidosis
Hydralazine
Procainamide
How do Pericardial Effusions present
What would be seen on EKGs
What would be seen on Echo
Same as pericarditis w/ fluid accumulation around heart
Low voltage QRS
Alternans
Tachy
Swinging heart
Water bottle sign
What are the “3-Ds” of a cardiac tamponade
What Triad is this AKA
What are two possible complications of an effusion
Muffled sounds
Elevated JVD w/ rapid x-descent, attenuated y-descent
HOTN
Beck’s Triad
Tamponade
Constrictive pericarditis
? is a classic finding on PE of cardiac tamponade
What would be seen in PTs VS
What is the gold standard of Dx
Pulsus paradoxus- SBP dec x 10mmHg w/ inspiration
Narrow pulse pressure
Echo
How is pericardial effusion different from tamponade
How is the tamponade Tx
? is the MC cause of non-traumatic tamponade
Effusion doesn’t cause RV collapse
Urgent- centesis
IV fluids to inc preload
Met malignancy
How do tamponades lead to death
? is one of the most consistent tamponade findings
What would make this consistent finding absent
IVC pressure decreases preload
Pulsus paradoxus
Hypovolume
Low press tamponade
LV
How do AAAs present
How do A-Dissections present
When is screening indicated
Back pain
Pulsatile mass
HOTN
Tearing pain radiating to back w/ different arm pulses
Male >65 w/ +smoking history
? is the difference between dissection and AAA in structural involvement
What is the initial and gold standard Dx test of choice for AAA
What is the CXR finding for aortic dissections and how are they Tx
AAA involves all 3 layers
Dissection- one layer, intima
US- initial
Angiography- gold standard
Widened mediastinum;
Ascending- surgery
Descending- BBs
What is the Dx test of choice for aortic dissections
How are AAAs managed depending on size
MRI angiography
<3cm- no more tests 3-4.4cm: annual 4.5-5cm: q6mom, refer 5-5.4cm: q3mon >5.5 or >0.5cm expansion in 6mon- immediate repair even if ASx
Define Venous Insufficiency
What is a common PE finding
If ulcer present, they are commonly located ?
Impaired venous return causing skin change, edema, pain
Stasis Dermatitis
Medial malleolus
How is Chronic Venous Insufficiency Dx
How are they Tx
Define Varicose Veins
US, D-dimer
Elevation, compression
Ulcers- wound care, compression
Dilatd superficial veins in lower extremities w/out obvious cause
If symptomatic, what do varicose veins present w/
How are these Tx
Define Acute Bronchitis
Pain w/ exertion
Full/pressure
Hyperesthesia
Compression Elevation Wound care Sclerotherapy Surgery
Cough lasting >5days
? Sx is unusual for bronchitis and it’s presence should shift Dx to ?
95% of bronchitis is d/t ? etiology
If caused by bacteria, ? microbes can cause this
Fever;
Pneumonia
Viral
M Catarrhalis- MC bacterial cause of acute bronchitits
H influenzae
Strep pneumoniae
How is acute bronchitis Dx
How are these cases Tx
Acute exacerbations of chronic bronchitis d/t bacteria are Tx w/ ?
CXR
Tx Sxs, >95% are viral:
Cough: Dextromethorphan, Guaifenesin
Wheeze/Pulm Dz: albuterol
1st: 2-Gen Cephalosporin
2nd: 2-Gen Macrolide or TMP/SMX
When are ABX indicated for the Tx of Acute Bronchitis
How does Acute Sinusitis present
What is the MC cause
Elderly
+CardioPulm Dz and cough x 7-10days
ImmComp
Sinus pain w/ drainage
Sxs worsen 5-7d or do not improve >10days
Strep pneumo
What is First, Second, and Third Line Tx for Acute Sinusitis
What is the gold standard and other form of imaging method if needed
? microbe is the MC cause of chronic sinusitis
1st: Augmentin
2nd: Doxy
3rd: Levaquin
CT- gold standard
X-ray w/ waters view
Staph A
Time frame for acute sinusitis
When is this converted to chronic sinusitis
Time frame for sub-acute sinusitis
<4wks w/ sudden onset
> 12 consecutive wks
4-12wks
What are the indications to use ABX for Tx of Sinusitis
What ABX are options for first line Tx
Why would second line ABX be needed and what can be used
Sxs >10d w/out improving
Fever >102
+purulent d/c
Improvement w/ rapid worsening of Sxs
Augmentin*
Amoxicillin
PCN allergy- Doxy, Cefixime or Cefpodoxime w/ or w/out Clindamycin
No improvement in 7d; Augmentin 2g BID Levofloxacin Moxifloxacin PCN allergy- Doxy, Levoflox, Moxiflox
How is Chronic Sinusitis Tx
How is sinusitis in Peds Tx
Why do Sinusitis Pts lose sense of smell
3wk Tx course of:
Augmentin
PCN allergy- Clinda
Augmentin
PCN allergy: Cefpodoxime, Cefdinir
Olfactory epithelium destroyed by viral infection/chronic sinusitis
? is the MC microbe to cause acute bacterial sinusitis in adults?
? is the MC type of bacterial pneumonia that is MC seen in Pts >40y/o
This MC type if common in Pts w/ ? MedHx
Staph A
Strep pneumonia- rust colored sputum
Splenectomy
How does Staph A pneumonia present
How is it Tx if MRSA is suspected
Pseudomonas causes pneumonia in ? populations
Salmon colored sputum after influenza
Vanc
ICU ventilator CF w/ Vit A deficiency Bronchiectasis Malignancy COPD
When/where is mycoplasma pneumonia more commonly seen
What two findings indicate this Dx
MC microbe to cause pneumonia in drinkers w/ aspiration
Pts <40y/o in dorms
Cold agglutinins
Bullous myringitis
Erythema Multiforme
Klebsiella
Strep Pneumo, H influenza induced pneumonia usually present w/ ? S/Sxs
Atypicals like Mycoplasma, Chlamydia and viruses present w/ ? S/Sxs
What two Pt populations are most frequently admitted for CAP
Productive cough
Fever, high
Tachy/Tachy
Non-productive cough w/ fever
Elderly
COPD
How do the 3 typical microbes (Hflu, Morax, Strep Pneumo) that cause pneumonia appear on CXR
How do the 3 atypicals (Legion Mycoplasma C-pneumonia) appear on CXR
Lobar pneumonia and sicker Pt
Interstitial infiltrates, Pt not as sick
? is the MC nosocomial infection
? is the 2nd MC
? is the MC type of pneumonia in older adults and is more common in winter month
UTI d/t foley
Pneumonia w/ Strep Pneumo
Pneumococcal pneumonia d/t Strep Pneumo
What vaccine is used to help reduce CAP
What Pts should get this vaccine
? is the biggest lymph node of the body
PCV-13, 1 year later;
PPV-23
Annual influenza
Age >65y/o Smokers Sickle cell dz DM Indian/Inuit Chronic liver Dz
Spleen- largest Ab maker in body
How is CAP Tx outpatient w/ no ABX use x 90days
How is CAP Tx outpatient if +ABX use x 90days or +comorbidities
How is CAP tx in areas w/ macrolide resistance
Macrolide (Azith/Clarith) or,
Doxy
M/L/G-floxacin or,
Macrolide (A/C-mycin) and Augmentin (Beta-lactam)
M/L/G-floxacin or,
Macrolide (A/C-mycin) and Augmentin (Beta-lactam)
How is CAP Tx in ICU
How is this Tx regiment changed it Pt has COPD
? is the MC atypical pneumonia and MC pneumonia in younger adults w/ ? outbreak trend
M/L/G-floxacin or Azith and
Cefotax/Ceftriax or Ampicillin (antipseudomona w/ beta lactam coverage)
Levofloxacin (Levaquin) becomes 1st
Mycoplasma in adults <40y/o w/ summer/fall outbreaks
How does Mycoplasma Walking Pneumonia present on CXR
How is it Tx
How does Legionella induced pneumonia present
Patchy infiltrates more extensive than exam
1- Azith/Clarith-romycin
2- Doxy/Augmentin
3- Levofloxacin (Levaquin)
HypoNa Diarrhea Fever
What is the CURB-65 scale used for
How is anaerobic pneumonia Tx
Pneumonia ICU admission: Confused Urea >20 RR 30/> BP: <90/60 65 or older Each one= 1pt 0-1: low risk 2pts: mod risk, consider admit 3-5: high risk, ICU admit
Augmentin
Amox/PCN and Metronidazole
? PE finding is a constant finding in Legionnaires pneumonia
What are the two distinct clinical presentations of this Dz
What does it look like on CXR
Bradycardia
1st- Pontiac fever; viral-like syndrome
2nd- pneumonia
Mid/lower lobe w/ patchy infiltrate
Inc LDH= pleural effusion
How is Legionairres Pneumonia Dx
How is this form of pneumonia Tx
Define Pneumocystic Carinii Pneumonia
IFA and ELISA
Sputum DFA
Legionella urine Ag
1- Azithromycin
2- Levofloxacin (Levaquin)
3- Doxy
Pneumocystis jiroveci- unicellular fungi in ImmComp Pts (AIDS CD4 <200)
How does Pneumocystis jiroveci present
How does it appear on CXR
How is this type Dx
F/C
Dyspnea, low PO2
Dry cough x wks
Bilateral, perihilar infiltrates w/ inflamed alveolar cells
Bronchial lavage/biopsy
How is the degree of lung injury in Pneumocystis Jiroveci measured
How is this Tx
What s/e may be seen d/t this medication
LDH level
TMP/SMX (+ Dapsone)
Allergy- Pentamidine
Pancreatitis
Renal failure
Prolong QT
Chlamydia pneumonia is associated w/ ? Hx but lacks ? presenting Sx
What 3 forms are pathogenic to humans
How is it passed along
Birds;
Afebrile
Pneumoniae
Psittaci
Trachomatis
Inhalation of dried feces
How is Chlamydia Psittaci Tx
? are the 3 MC causes of viral pneumonia
1- Doxy
2- Azithromycin
Influenza
Adenovirus
Parainfluenza
How is Viral Pneumonia in Peds Dx
How is an RSV etiology tested for
How will they present
PCR testing for Adenovirus
Nasal wash
Tachypneic w/ wheeze
How is RSV pneumonia Tx
What will these Pts be at risk for later in life
Pts w/ pneumonia and Tx w/ Macrolides but bounce back now need to be Tx w/?
1- Ribavirin
2- Palivizumab
Reactive airway dzs
Levofloxacin (Levaquin)
Peds w/ CAP are Tx w/ ?
How is CAP Tx outpatient w/ no comorbidities, recent ABX use and low resistance rate
What is the s/e of using Macrolide or Fluoroquinolone class ABXs
1st- Amoxicillin, <5y/o
2nd- Azithromycin, >5y/o
1- Azith/Erythromycin
2- Clarithromycin/Doxy
Prolonged QT interval
MC cause of viral pneumonia in adults
MC cause of viral pneumonia in kids
MC cause of fungal pneumonia in western states
Influenza
RSV
Valley Fever d/t Coccidioides
MC cause of fungal pneumonia from caves/zoos in Ohio/MS river valley
? fungal spore is found in soil and can lead to meningitis
MC fungal pneumonia etiology in COPD/TB
Histoplasma capsulatum
Cryptococcus
Pulmonary aspergillosis
? is a major RF for CAP
? microbe is a tag along but exacerbator of H Influenza pneumonia
Histoplasma Capsulatum looks like ? on CXR
Recent hospitalization
M Catarrhalis
Sarcoidosis
What are 3 positive PE findings seen in pneumonia
Poor dental hygiene can cause pneumonia from ? type of microbes
? beta-lactam ABX is used in the Tx of CAP
Tactile fremitus
Egophony: spoken ‘ee’ heard as ‘ay’
Dull percussion
Anaerobes
Ceftriaxone
How is Klebsiella Pneumonia Tx
Pneumovax can be given to Pts w/ increased risk of pneumococcal dz starting at ? age
? is the TxOC for Peds w/ Chlamydial Pneumonia
3rd Gen: Cefotaxime
23mon
Erythromycin/Sulfisoxazole
What is seen on CXR of hypersensitivity pneumonitis
How is Coccidioides Pneumonia Dx
How Coccidioides and Aspergillosis Tx ?
Diffuse nodular densities
EIA for IgG/IgM
C/A: Flu/Itra-conazole
How is Crypto/Histoplasma capsulatum pneumonia Tx
When/what is used in AIDS Pts for daily prophylaxis against Jiroveci
Amphotericin B and Flucytosine
TMP/SMX;
Hx of PJP infection
CD4 <200
How is Viral Pneumonia differentiated from Mycoplasma Pneumonia
How is Viral Pneumonia Dx
If Sxs <48hrs, what is used for Tx depending on strain of influenza
Adeno- fast onset w/ GI Sxs x7days
Myco- slow, insidious
Rapid Influenza Ag
RSV nasal swab
Neg agglutinin titer
A/B: Zan/Oselt-amivir
A only: Ama/Riman-tadine
? is the MC cause of lower respiratory tract infections in kids worldwide
This is the leading cause of ? two Dxs in infants
? is the MC pathogen of Bronchiolitis
RSV, almost all will have it by 3y/o
Bronchiolitis
Pneumonia
RSV
How is RSV Dx
What is seen on PE
What does this look like on CXR
How is it Tx
Nasal RSV Ag test
Fever
Wheezing cough
Rhinorrhea
Flaring nares
Diffuse infiltrates
Steroids
When does Pt w/ RSV need to be admitted
When is prophylaxis indicated
What is used for prophylaxis
Feeding difficulty
O2 desat
Retractions
Tachypnea
28wk, 6 day or < and <12mon at start of RSV season <12mon w/ CH/LDz, Congenital airway abnormality ImmComp <24mon w/ CF
Palivizumab
What organism causes TB
How is it transmitted
What are the classic findings on PE
Mycobacterium tuberculosis
Respiratory droplet
Fever
Anorexia
Weight Loss
Night sweat
When are TB PPDs read as positive
Induration= raised area
>5mm: \+CXR ImmComp/HIV Pred equivalent of 15mg/day >1mon Close contacts
>10mm: IVDA High prevelance immigrant High risk living Bypass surgery Medical employees
> 15mm:
No RFs
How is TB Dx
What would be seen on CXR
What would be seen on biopsy results
Sputum smear/culture for Acid Fast Bacilli and staining
Upper cavitary lesion
Apical Ghon complex
Caseating granuloma
What is the name of TB spread out of the lungs
What are two types
Miliary
Potts- TB to spine
Scrofula- TB to cervical nodes
How is TB Tx
How long is Tx done per med type
+PPD= CXR
Neg CXR= Isoniazid x 9mon w/ B6 (Pyridoxine) to prevent neuropathy or sideblastic anemia
Active TB= RIPE w/ baselines prior to Tx: Rifampin Isonizid Pyrazinamide Ethambutol
RIPE x 2mon
IR x 4mon
What are the s/e of RIPE Tx drugs
When is a Pt w/ active TB considered for therapy cessation
What is used for prophylaxis for PTs living w/ +TB
Rif: orange fluids
INH: neuropathy
Pyra: gout
Emb: optic neuritis, red/green blindness
Neg AFB x 2 in a row
Isoniazid x 12mon
What part of RIPE Tx needs to be adjusted if CrCl is <30mL/min
What PT education is given w/ RIPE Tx
Which meds can cause hepatotoxicity
E/P to 3x/wk
Take meds on empty stomach
RIP
RIPE Tx can interact w/ ? other Tx method
CXR finding of a Ghon complex indicated ? Dx
What part of the lung is MC involved w/ these complexes
Raltegravir for HIV, double dose for HIV Tx
Primary TB
Lower lobes
How is L-TB Tx
Administration of ? drug can reactivate a latent infection
Mycobacterium MC affects ? part of lung
INH x 9mon or,
Rifampin x 4mon or,
RIF and PZA x 2mon w/ infected contact
Exogenous CCS
Upper lobes
TB is the MC cause of ? endocrine d/o in the world
PPDs need to be read w/in ? time frame
Why do Pts w/ Rheumatoid Arthritis need TB tests prior to Tx
Addisons Dz
48-72hrs
Etanercept: anti-cytokine agent, can reactivate dormant TB
+HIV Pt w/ positive PPD is Tx how
Define Asthma
What PE finding indicates emergency
INH and RFN
Chronic, reversible, inflammatory airway dz
Lack of wheezing
How is Asthma Dx
Define FEV
Define FVC
Peak expiratory flow rate (Dec FEV1:FVC ratio)
Forced Expiratory Volume- measures how much air exhaled w/ forced breath
Total amount exhaled during FEV test
What are the 4 asthma classifications and Ts
Intermittent:
Sx <2x/wk
or 2/< wake up/wk
Tx: SABA PRN
Mild: Sx >2/wk or 3-4 wake up/mon SABA >2d/wk Minor limitations Tx: Low ICS daily
Moderate: Daily Sxs >1 waking >wk Daily SABA use Some activity limits Tx 3: Low ICS+LABA daily Tx 4: Med ICS+ LABA daily
Severe: Daily Sxs Wake 7x/wk Multiple SABA daily Extremely limited activity Tx 5: High ICS+LABA daily Tx 6: High ICS+LABA+PO CCS
How is an asthma exacerbation Tx
When Tx Asthma, considered SQ allergen immunotherapy for ? Steps
Consider consult at ? step
PO CCS
Iprtropium bromide
Nebulized SABA
O2
2-4
Step 3
How is exercise induced asthma prophylactically Tx
What is the ICS used for Asthma Txs
? PE finding suggests improvement of an asthma attack after Tx
Albuterol- B2 agonist
Nedocromil
Beclomethasone
Cromolyn
Inc FEV1
What is the MOA of Salmeterol for Asthma Tx
COPD is umbrella term for what two Dxs
What causes the risk for infection and loss of lung recoil to occur
Relaxation of bronchial smooth muscles
Chronic bronchitis
Emphysema
Dec ciliary/WBC function
Frayed elastin fibers
How is COPD Dx
What is the criteria for chronic bronchitis Dx
What are common findings seen in these Pts
PFT: FEV1/FVC 50%
Productive cough >3mon x 2yrs
Inc Hgb/Hct (polycythemia)
P-HTN
How is COPD Tx
What is the single most important medication fro Tx
What vaccines are highly recommended
Mild: SABA (FEV1>80)
Mod: LABA (Tiotropium) + ICS (Fluticasone, Salmeterol)
Low O2- too much removed respiratory drive
PaO2 <55mmHg/ PaCO2>55mmHg
SpO2 <88% or 89% w/ CorPulmonale
Flu
Pneumoccocal
? is the inhaler of choice for COPD Pts
Define Emphysema
Why are Blue Bloaters blue and why are Pink Puffers pink
Ipratropium bromide- anticholinergic blocks constrictive effect of Ach on airway muscles
Enlarged air spaces d/t destruction of alveolar septae
Blue: Chronic hypoxia
Pink: CO2 retention
? CXR finding is pathognemonic for Emphysema
Pts <40y/o w/ COPD need ? test
Hallmark of blue bloater
Parenchymal Bullae (subpleural blebs)
Alpha-1 antitrypsin
Productive cough
3 parts of PFT that are decreased in COPD
2 parts that are increased
? drugs is used in COPD Tx for preventing nocturnal bronchospasms
Max vent volume
Tidal volume
Vital capacity
Total lung capacity
Residual volume
Theophylline- xanthing drug prevents spasms and prolongs dilation
What microbes cause infections in COPD PTs
What ABX are used during COPD exacerbation
? are the indications to use these ABX
H influenza
Strep Pneumo
Moraxella
Strep Viridians
1- macrolide
2- Cefuroxime Cefpodoxime, Fefdinir
3- Doxy
Inc quantity and purulence
COPD Pts >65y/o are predisposed to infections by ?
How are these Pts Tx w/ ABX
Blue Bloater is common in ? smoking Hx
Pseudomonas
1- Cipro/Levofloxacin
2- Augmentin
3- Doxy
> 40pk/year
Difference in CXR between Blue Bloater and Pink Puffer
? is the most effective Tx for COPD
What will ABGs of chronic bronchitis show
Blue: diaphragm not flat
Cessation
Resp acidosis
COPD Gold Categories
A: breathless if hurrying on level ground; less Sxs, 0-1 exacerbation past 12mon w/ no admission
Tx: SABA/SAMA
B: walks slower than others; more Sxs, 0-1 exacerbation past 12mon w/ no admission
Tx: LABA/LAMA w/ SABA
C: breathless if hurrying on level ground; less Sxs
2/> exacerbation/year w/ 1 or more admission
Tx: LAMA, SABA
D: walks slower than others; more Sxs; 2/> exacerbation/year w/ 1 or more admission
Tx: LAMA+LABA+SABA
Define Centriacinar Emphysema
This form of emphysema is associated w/ ?
What part of the lung is affected
Morphological pattern of destruction to bronchioles and central acini
Smoking
Upper lobe
COPD Pts w/ ? other Dx have increased risk for mortality
Why do emphysema PTs breathe through pursed lips
COPD exacerbation are managed w/ ? 3 meds
Bronchiectasis
Inc pressure in airway prevents collapse
Systemic steroids
ABX
Antivirals
SABAs for COPD Tx
SAMAs for COPD Tx
LABAs for COPD Tx
LAMAs for COPD Tx
Levabuterol
Albuterol
Pirbuterol
Ipratropium Bromide
Salmeterol
Olodaterol
Formoterol
Arformoterol
Aclidinum bromide
Tiotropiium Bromide
Umeclidinium
Glycopyronium bromide
Interstitial lung Dzs
Which one is MC of the interstitial dzs
This is MC caused by four etiologies
-Pulmonary alveolar proteinosis
-Eosinophilic Pulm -Syndrome
Interstitial pneumonia
-Diffuse interstitial pneumonia
Sarcoidosis
Interstitial pneumonia
Medication
Environment
Occupation
Infection
What is the MC type of interstitial pneumonia
What histological pattern is seen
What is no pattern is seen by the lab
Pulmonary fibrosis
Usual Interstitial Pneumonia
IPF
3 criteria used to Dx Pts >65y/o w/ IPF/UIP
What are the three methods to Dx this condition
How are these Pts Tx as long as they don’t have IPF
Inspiratory crackles
Restrictive PFT
CXR findgins
Pleural honey combing
BAL- esp P Jirovecii
Lung biopsy- standard
Transbronchial biopsy
Pred: 1-2mg/kg/day x 2mon
How are PTs w/ IPF Tx
What is the only definitive Tx fo IPF
How is sarcoidosis Dx and Tx
Nintedanib and
Pirfenidone
Transplant
Biopsy w/ non-caseating granulomas
Tx: Pred 1mg/kg/day
How is Sarcoidosis Tx if refractory to steroid Tx
What is a good/poor prognosis for these PTs
Methotrexate
Azathioprine
Infliximab
Good: only hilar adenopathy
Bad: lung parenchyma involvement
Define Pulmonary Alveolar Proteinosis
MC presenting c/c
CXR findings
How is this Tx
Phospholipid accumulation in alveolar spaces
Dyspnea
Bilateral alveolar infiltrates
Whole lung lavage
GM-CSF: granulocyte macrophage colony stimulating factor
What can cause Eosinophilic Pulm Syndromes
What syndrome can be seen here
One third of cases are idiopathic d/t ?
How is this Tx
Helminth infection
Filariae infecition
Loffler: helminthe larva infiltrate into pulmonary passage
Chronic: female w/ asthma
Acute: febrile illness w/ cough/dyspnea
Pred
What are the 7 types of Occupational Pulmonary Dzs
Pneumoconioses
Hypersenstivity Pneumonitis
Obstructive airway d/o
Toxic lung injury
Cancer
Pleural Dz
Other
Define Pneumoconioses
What are the 3 types of Penumoconiose Dzs
How are all Tx
Fibrotic lung dz from inhaled inorganic dusts
Coal Worker:
Silicosis
Asbestosis
Supportive
How does Coal Worker Pneumoconiosis appear on CXR
? RF does not play into this conditions severity
Complicated Coal Workers is AKA ?
Coal Workers + Rheumatoid Arthritis causes ?
Diffuse opacities in upper lobes
Smoking
Progressive Massive Fibrosis- contraction of upper lobes, similar to Complicated Silicosis
Caplan Syndrome
How does Silicosis appear on CXR
These PTs are at increased risk for ? future Dx
Asbestosis Pts usually don’t seek Tx until ? long after exposure
Egg shell calcification throughout lungs
Pulmonary TB
> 15yrs
