Med II Flashcards
What medication is good for pSVT to slow the heart rate down?
Adenosine
What is an antiarrhythmic that is good for stable wide-complex tachycardias, and can also be used with AFIB and VFIB as well?
Amiodarone
What is the 1st line medication for bradycardia?
Atropine
What class of med is diltiazem and when do you use it?
CCB, antiarrhythmic
Hemodynamically stable pts w/AFIB or A flutter for rate control
Can also use in SVT if vagal maneuvers & adenosine don’t work
When would you use digoxin?
Alternative for AFIB or A flutter when rate is not controlled
In hypertrophic cardiomyopathy, the murmur gets louder with ______ and quieter with ______
Louder: valsalva
Quieter: hand grip
What is the treatment for hypertrophic cardiomyopathy?
Monitor if asymptomatic
Beta blocker (nadolol) or non-dihydropyrinde CCB (verapamil)
What has a harsh, systolic, crescendo-decresendo murmur that radiates to the carotids?
Aortic stenosis
What murmur has a widely split S2 and gets quieter with valsalva?
Mitral regurgitation
What diastolic murmur is heard best at the left sternal border and gets louder with squatting and quieter with valsalva?
Aortic regurgitation
What diastolic murmur has a split S2, an opening snap, gets louder with expiration, and quieter with inspiration?
Mitral stenosis
What is the treatment for CHF?
LMNOP
L: lasix for diuresis
M: morphine to reduce preload
N: nitrates to reduce preload
O: oxygen
P: position
ACEi (unless contraindicated) or CCB if diastolic HF
What CXR finding is common in pts with CHF?
Kerley B lines
A patient presents with substernal chest pain that is relieved with rest. They are provided nitro in the ER which relieves their pain and an EKG shows ST depressions, what does this pt likely have and how would you treat it?
Angina pectoris
Outpt: daily ASA + beta blocker, statin, & PRN sublingual nitro
Revascularization is definitive tx
What classically presents with dyspnea, cough, fever, and new heart murmur?
Endocarditis
What bugs are typically found in pts w/endocarditis?
Native valves: strep. viridans or staph. aureus
IVDU: staph. aureus on tricuspid valve
What is normal BP, and what levels are associated with urgent and emergent HTN?
Normal: < 120 / < 80
Urgent: > 220 / > 125
Emergent: > 220 / > 130
What is the BP goal for the general population and pts with diabetes and HTN?
< 140 / 90
What is the BP goal for pts with HTN over the age of 60?
< 150 / 90
What are the meds of choice for HTN?
Diabetes and/or renal disease: ACEi
AA: thiazide diuretics
Generally: CCB
What type of ulcers have irregular borders w/pink or red base that are commonly seen over the medial malleolar area?
Venous ulcer
What type of ulcers have a punched out appearance and are commonly associated with PAD and severe pain at night?
Arterial ulcer
Which hepatitis viruses are transmitted via fecal-oral route?
A & E
Which hepatitis is a “passenger virus”, and what does that mean?
Hep D; must also have Hep B
What lab values would you see in a pt who has been vaccinated against Hep B?
Neg anti-HBc total
Pos HBsAB
What lab values would you see in a pt who is immune/recovered from Hep B?
Pos HBc total antibody
Pos HBsAB
Pos anti-HBe
What is commonly seen on xrays of pts with osteoarthritis?
Osteophytes and narrowed joint spaces
What are common features seen in pts with RA?
Morning stiffness lasting > 1 hr that improves throughout the day
Symmetric involvement (common in hands & wrists)
Swan-neck deformities of PIP joints
What is the 1st line DMARD for RA when exercise and NSAIDs haven’t worked?
Methotrexate
What is the difference in joint aspirate between gout and pseudogout?
Gout: needle shaped, neg birefringent urate crystals
Pseudo: rod shaped, rhomboidal, pos birefringent
What is the NSAID of choice when treating gout?
Indomethacine
What presents with symmetric proximal muscle weakness, an elevated serum CK, EMG findings of myopathy, and has a characteristic v-sign/shawl sign rash?
Polymyositis
What presents with dry eyes, dry mouth, and arthralgias?
Sjogren syndrome
What tests are performed in pts suspected of having Sjogren’s?
Schirmer test: filter paper in the eye to test lacrimal gland output
Salivary gland biopsy
What is the treatment for Sjogren’s?
Pilocarpine
Artificial tears
NSAIDs
How does the body compensate for a metabolic acidosis?
Decreases CO2 by increasing breathing rate
What labs are seen in a metabolic acidosis?
Low HCO3
Low pH (< 7.35)
What are common causes of metabolic acidosis?
Increase in endogenous acids
Ingested toxins (ethylene glycol, methanol)
Decreased renal excretion of acids (type 1 renal tubular acidosis or uremia)
Renal loss of HCO3 (type 2 renal tubular acidosis)
Diarrhea
What labs are seen in a metabolic alkalosis?
Increased HCO3
Increased pH (> 7.35)
How is a metabolic alkalosis compensated?
Increased CO2 by decreasing breathing rate
What are common causes of metabolic alkalosis?
GI loses (vomiting)
Diuretic use
Hyperaldosteronism (HTN, severe K+ depletion)
Cushing’s syndrome
Renal failure
What labs are seen in a respiratory acidosis?
Increased CO2
Decreased pH
How is respiratory acidosis compensated?
Increase HCO3 via renal bicarb retention
What are common causes of respiratory acidosis?
Hypoventilation
CNS depression
Airway obstruction
Chronic conditions (OSA, COPD)
What labs are seen in respiratory alkalosis?
Decreased CO2
Increased pH
How is respiratory alkalosis compensated?
Decrease HCO3 via renal bicarb excretion
What are common causes of respiratory alkalosis?
Hyperventilation
Anxiety
Stroke
SAH
Aspirin ingestion
Fever/sepsis
In a pt with a metabolic acidosis, how do you calculate an anion gap?
[Na+] - [Cl + CO2]
Normal = 8 - 16
How to tell if there is compensation?
Full: normal pH, HCO3 & CO2 opposite (one high, one low)
Uncompensated: abnormal pH, but HCO3 & CO2 are normal
What are common causes of AIN?
Reactions to meds (PCN, cephalosporins, sulfa)
Strep or legionella infx
What will be seen on a UA in a pt with AIN?
Eosinophils and mild proteinuria
What are signs/symptoms of a nephrotic syndrome?
Hypercoagulable state
Hypoalbuminemia
Hyperlipidemia/fatty acids in urine
Proteinuria > 3.5g/24 hrs
Edema (periorbital in the AM, pedal)
What is the treatment for nephrotic syndrome?
ACEi for HTN
Na+ restrict (2g/day)
Loop diuretics
Steroids
Statins for hyperlipidemia
Anticoagulation for hypoalbuminemia (heparin then warfarin)
What are common causes of nephrotic syndrome?
Minimal change disease (kids)
Membranous glomerulonephritis
Diabetes
SLE
Infections
What are signs/symptoms of nephritic sydrome?
Asymptomatic gross hematuria (tea or cola colored)
Mild proteinuria < 3.5g/24 hrs
What is seen on a UA in a pt with nephritic syndrome?
Dysmorphic RBC
May have RBC casts
Pyuria
What are common causes of nephritic syndrome?
Poststreptococcal glomerulonephritis
Barger disease
Hep C
SLE
What is the treatment for nephritic syndrome?
Steroids + cytotoxic agents (methylprednisolone)
Loop diuretics
Na+/H2O restrict for edema
ACEi if HTN
What is the classic triad for Goodpasture glomerulonephritis?
Proliferative glomerulonephritis
Pulmonary hemorrhage
IgG anti glomerular basement membrane antibody
What are signs/symptoms of Goodpasture?
Rapidly progressive renal failure
Hemoptysis
Cough
Dyspnea
What is the treatment for Goodpasture’s?
Plasmapheresis (remove anti-IgG antibodies)
Cyclophosphamid
Steroids
If a pt presents with hypovolemia and urine Na+ > 20 what diagnoses should be considered?
Renal losses:
Excess diuretic use
Mineralocorticoid deficiencies
Cerebral salt wasting syndrome
If a pt presents with hypovolemia and a urine Na+ < 20 what diagnoses should be considered?
Extrarenal losses:
Vomiting
Diarrhea
Third spacing
Burns
Pancreatitis
Trauma
If a pt is euvolemic but has a urine Na+ > 20, what diagnoses should be considered?
Glucocorticoid deficiency
Hypothyroid
Stress
Drugs
SIADH
If a pt is hypervolemic and has a urine Na+ > 20, what does the pt likely have?
Acute or chronic renal failure
If the pt is hypervolemic and has a urine Na+ < 20, what conditions are more likely?
Nephrotic syndrome
Cirrhosis
Cardiac failure
If a pt is hyponatremic and hypovolemic, what labs should be drawn next?
Urine Na+
In pts who are hyponatremic and hypovolemic with a urine Na+ < 10, what are the likely causes?
Extra renal salt loss from:
Dehydration
Diarrhea
Vomiting
In pts who are hyponatremic and hypovolemic with a urine Na+ > 20, what are the likely causes?
Renal salt loss from:
Diuretics
ACEi
Nephropathies
Cerebral salt wasting syndrome
Mineralocorticoid deficiency
In pts who are hyponatremic and euvolemic, what are the likely causes?
SIADH
Hypothyroidism
Psychogenic polydipsia
Endurance exercise
In pts who are hyponatremic and hypervolemic, what are the likely causes?
CHF
Liver disease
Nephrotic syndrome
Advance renal failure
What are the 3 common signs/symptoms of DI?
Polyuria
Nocturia
Polydipsia
What are common labs seen in DI?
Plasma Na+: > 142
24 hr urine output: > 50mL/kg/d
Urine osmo: < 300
What is a confirmatory test given if DI is suspected?
Water restriction test
If you suspect DI and you administer ADH (desmopressin) and see an increase of > 50%, what does this mean?
Pituitary DI
What labs/findings are seen in pts with central DI?
High plasma Na+
High plasma osmo (280 - 310)
Low ADH
Urine osmo < 150
H2O restrict & ADH test: increase in urine osmo by > 300
What medication is commonly associated with nephrogenic DI?
Lithium
What labs/findings are seen in pts with nephrogenic DI?
High plasma Na+
High plasma osmo (280 - 310)
Normal - high ADH
H2O restrict & ADH test: no increase in urine osmo
What is the treatment for central DI?
Desmopressin
Chlorpropamide
What is the treatment for nephrogenic DI?
High dose desmopressin
Thiazide diuretics
Low Na+ diet
Indomethacin
What occurs in a pts with SIADH?
Excess water retention leads to dilute body fluids
What are common causes of SIADH?
Pulm (pneumonia, TB)
Neoplasm (SCC of the lung)
Meds (SSRIs, TCAs)
What labs/findings would you see in SIADH?
Hypotonic hyponatremia
Plasma osmo < 275
Urine osmo > 100
Euvolemic
What is the treatment for SIADH?
Acute: increase plasma osmo/Na+ by 1%/hr & vasopressin antagonists (vaptan)
Chronic: water restrict to < 1L/day, PO vaptan, loop diuretics
What findings are associated with AML?
Mostly adults
Auer rods
Increased myeloblasts on bone marrow biopsy
What findings are associated with CML?
Philadelphia chromosome (BCR-ABL1)
What findings are associated with ALL?
Most common childhood cancer
What are findings associated with CLL?
Smudge cells on peripheral blood smear
What labs are seen in pts with anemia of chronic disease?
Low serum iron
Low TIBC
Low transferrin saturation
Normal to 3x higher serum ferriten
Can have normocytic normochromic or microcytic hypochromic
Increased ESR
What labs are seen in thalassemia?
Microcytic hypochromic anemia
Normal to high serum iron, ferritin, and transferrin
Normal TIBC
What is seen on a peripheral smear of thalassemia?
Target cells
Basophilic stippling
Elliptocytes
What labs are seen in pts with vitamin B12 deficiency?
Low B12
High homocysteine
High methylmalonic acid (MMA)
Hypersegmented neutrophils
What has pathognomic hypersegmented PMNs?
Folic acid deficiency
When does G6PD present itself?
Hemolysis in the setting of infection, metabolic acidosis, or certain medications
What is seen on a peripheral smear of G6PD?
Bite cells
Heinz bodies
What are the causes of hyperparathyroidism?
Parathyroid adenoma (primary)
Chronic renal failure (secondary)
What are the signs/symptoms of hyperparathyroidism?
Stones
Bones
Groans/thrones
Psychiatric overtones
Decreased DTRs
What lab findings are seen in hyperparathyroidism?
High Ca+
Low phosphorus
High serum PTH
What is the treatment for primary hyperparathyroidism?
Beta blockers
K-phos. supplement
Restrict dietary Ca+
Bisphosphonates
Cinacalcet (calcimimetic)
Parathyroidectomy (definitive)
What is the treatment for secondary hyperparathyroidism?
400 IU Vit D
PO Ca+
Restrict dietary phos
What is a common cause of hypoparathyroidism?
Injury during thyroidectomy
What are signs/symptoms of hypoparathyroidism?
Numbness/tingling
Increased/hyperactive DTRs
Chvostek sign (face tap w/muscle contract)
Trousseau sign (carpal spasm w/inflating BP cuff)
What labs are seen in hypoparathyroidism?
Low PTH
Low Ca+
High phos
QT prolongation on EKG
What occurs in pts with Addison’s disease?
The adrenal gland does not produce cortisol, aldosterone, or sex hormones
What are signs/symptoms of Addison’s disease?
Hyperpigmentation
Abd pain, N/V
Lethargy
Salt craving
Hypotension
What labs are seen in Addison’s disease?
Low serum cortisol
High ACTH
What test is used if you suspect Addison’s?
ACTH or cosyntropin test
If Addisons, cortisol levels will NOT elevate sufficiently
What is the treatment for Addison’s?
Daily PO steroids
Daily fludrocortisone
What labs are signs of Cushing’s syndrome?
Low ACTH
High cortisol
What are the lab signs of Cushing’s disease?
High ACTH
High cortisol
What occurs in pts found to have pheochromocytoma?
Tumors produce, store, and secrete catecholamines from the adrenal medulla
What are the signs/symptoms of pheochromocytoma?
HA
Sweating
Palpitations
Weight loss
HTN
Tachycardia
How is pheochromocytoma diagnosed?
24 hr urine metanephrines
Plasma metanephrines > urine
When preparing to resect a tumor from pheochromocytoma, what medications should be started prior to surgery?
Alpha & beta blockers
What are normal ventricular (QRS) and atrial (P) rates?
60 - 100 BPM
What is a normal PR interval?
.12 - .20
What is a normal QRS complex?
.08 - .12
What is a normal QT interval?
.4 - . 44 (400 - 440)
What is seen in SVT?
HR: 150 - 250
Regular rhythm
Normal or narrow QRS
P waves not usually seen
What is the treatment for SVT?
Vagal maneuvers
Adenosine
IV beta blockers
Non-DHP CCB (diltiazem)
Cardioversion (if hemodynamically unstable)
What is seen in atrial flutter?
HR: 250 - 350
Saw tooth rhythm
Normal QRS
What is the treatment for atrial flutter?
Beta blocker
Non-DHP CCB
Cardioversion (anticoagulation)
What is seen in AFIB?
HR: > 350 - 400
Irregularly, irregular rhythm
No P waves
What is the treatment for AFIB?
Beta blocker
Non-DHP CCB
Cardioversion (anticoagulation)
What is seen on EKG with a 1st degree heart block?
Increased PR interval > .2
What do you see on EKG in a 2nd degree type I (Wenckebach) heart block?
Longer, longer, longer, drop now you have a Wenckebach
PR interval lengths and then QRS is dropped
If necessary, what is the treatment for a 2nd degree type I (Wenckebach) heart block?
Atropine
What do you see on EKG in a 2nd degree type II (Mobitz II) heart block?
If some Q’s don’t get through, then you have a Mobitz II
Normal PR interval, randomly dropped QRS
What is the treatment for Mobitz II?
Transcutaneous pacing until a permanent pacemaker can be placed
What do you see in a 3rd degree heart block?
P’s and Q’s don’t agree then you have a 3rd degree
P’s march in regular rhythm and Q’s march in regular rhythm but they don’t line up with eachother
What is the treatment for 3rd degree heart block?
Transcutaneous pacing
What is the treatment for V tach?
Stable: amiodarone, procainamide
Unstable: synchronized cardioversion
