Medicine Flashcards
fixed splitting of S2 indicates what?
Atrial septal defect
Classification of heart block:
- 1st degree heart block: prolongation of P-R interval
- 2nd degree:
a- wenckbach: P-R interval gradually increases. P wave isnt followed by QRS
b- 2:1, 3:1 block etc: P-R is constant with QRS complexes absent at regular intervals 2:1,3:1,4:1 to P waves
3- 3rd degree: QRS occurs at intervals of 40-50 per min and P waves at usual rate
Note: 3rd degree is a medical emergency.
Tx of 3rd degree block
first episode of symptomatic AF within 24h of presentation. Tx
DC cardioversion
circumstances for urgent cardioversion:
- Active ischemia
- evidence of organ hypoperfusion
- severe manifestations of heart failures
Stable pt with AF. Tx
- Rate control (CCB, BB)
- Anti - coagulation (if CHA2DS2-VASC >2)
Stable AF presentation after 3 days of onset
Tx
- Rate control (BB or CCB)
- anti-coag depending on CHA2DS2-VASC
Pts response to BB or CCB is inadequate or contraindicated. Tx
Digoxin
T/F: stroke risk doesn’t always need to be assessed in stable pts. (topic:atrial fibrillation)
False
atrial fibrillation can cause stroke due to embolism
pt is hemodynamically unstable because of tachyarrhythmia. Tx?
DC cardioversion
Note:
RECALL ACLS!!
For all Tachyarrhythmias:
1- Patient stable?
a. No?
i- DC Cardioversion
b. Yes?
i-Go to 2
2- QRS Narrow?
a. Yes: SVT
i- Vagal Maneuvers
ii-IV Adenosine
b. No: VT or VF
i- VT: IV Adenosine. Consider amiodarone, procainamide, sotalol.
Drugs that can block AV node transmission?
- BB
- CCB
- Diogoxin
a drug that is contraindicated in adult pt with wolff-parkinson-white syndrome?
Digoxin
Hemodynamically stable pts with supraventricular tachycardia should be treated with?
IV adenosine
Initial pharmacologic Tx for supraventricular tachycardia?
Adenosine
Tx of pulseness VT?
same as VF (ACLS)
- CPR
- defibrillation
- CPR
- Epinephrine
Tx for torsades de pointes
Magnesium
symptomatic bardycardia Tx
Atropine
Drugs that contraindicated Torsades
Quinidine, drugs that prolong repolarization i.e. procainamide, phenothiazines, TCA, disopyramide
cardiac arrhythmias that is associated with antipsychotic use?
Ventricular fibrillation (torsades de pointes)
T/F: all antipshychotic agents can prolong ventricular repolarisation.
True.
potentially causing TdeP
How do you evaluate a pt with suspected myocardial infarction?
ST segment changes(depression) in the precordial leads helps to differeniate which artery is affected, pointing towards occlusion of the left circumflex artery. When such changes are absent it is most likely that the affected artery is the right coronary artery rather than the left circumflex artery.
Inferior MI complication (Bradyarryhthmia) is due to?
compromise of blood supply to SA node (RCA)
Inferolateral MI DDx
1- RAD occlusion
2- LCx occlusion
Unstable angina/NSTEMI conservative Tx?
1- MONA
2- Clopi/ticagrelor/prasrugrel
early diastolicdecrescendo murmur is heard best at 3rd intercostal space on left with pt sitting up n leaning forward.
what is the condition?
Aortic insufficiency
T/F: women more often have coronary events without typical Sx
T/F: NSAIDs are contraindicated unstable angina
True
Can you given IV ACEI to unstable angina pts?
How are the following conditions’ murmurs best heard?
- aortic stenosis
- mitral insufficiency
- mitral stenosis
- tricuspid insufficiency
- aortic stenosis: systolic murmur
- mitral insufficiency: holosystolic murmur best heard at cardiac apex
- mitral stenosis: diastolic murmur best heard at cardiac apex
- tricuspid insufficiency: holosystolic murmur best heard at left lower sternal border and it radiates to right lower sternal border
aortic regurgitation murmur
AR is low intensity, high pitched, early diastolic decrescendo murmur which is best heard at left 3rd intercostal space during expiration while pt is sitting up n leaning forward
what is pulsus paradoxus?
an exaggeration of a normally present fall in systolic blood pressure with inspiration. Normal decrease in systolic pressure should be 10mm Hg or less but with pulses paradoxus, it can be 15-20 mm Hg. This is most commonly seen with restrictive and constrictive diseases of the heart or pericardium.
What is pulses alternans?
where one pulse feels large, the next pulse feels small. it is apperciated with severe congestive heart failure
When do you see low amplitude pulse?
Peripheral arteriosclerosis
what is a bifid pulse?
it is seen with hypertrophic cardiomyopathy and is best apperciated by palpation of the carotid artery. this pulse occurs as a result of no obstrution to blood flowing out of the left heart chamber in the beginning, followed by an obstruction in the middle of systole and finally by a lessening of the obstruction at the end of systole
MCC of aortic stenosis:
- calcified valvel >70 years
- bicuspid valve; <70 years
- rheumatic fever
how to minimise the risk of aortic stenosis
ensure Tx of beta-hemolytic streptococcus infections with ABX
can you treat rheumatic fever with aspirin?
No. Aspirin may be employed in the treatment of anti-inflammatory manifestation of acute rheumatic fever but it wouldnt change the risk of valvular disease
pt has Hx of endocarditis
indication for PPx ABX prior to dental op
how do you Dx AS?
Echo
Note: Anginal pain can be a feature of AS
only 2 conditions give murmur accentuated with valsalva strain:
- MVP
- HOCM
Indications for Antibiotic prior to dental op:
- Prosthetic valve
- Valve replacement w/ prosthetic material
- Hx of Endocarditis
- Hx of cyanotic congenital defects (Tetralogy of Fallot, Transposition of Great Vessels).
T/F: If LVEF >45% then there is no systolic failure.
True
most common cause of diastolic dysfunction and failure
chronic hypertension
what is a systolic heart failure?
left ventricular ejection fraction of less than 45%
Pts who cannot tolerate ACEi are unlikely to tolerate ARBs as well.
what do you give?
HYDRALAZINE/ORAL NITRATE
T/F: In chronic Rx of HF, Digoxin DOES NOT need to be loaded.
True
Note: Digoxin shouldn’t be given to a pt with atrioventricular block UNLESS it’s treated with a permanent pacemaker
HOCM Tx:
BB
COR PULMONALE Def:
Complication of pulmonary HTN defined as dilatation of RV in response to chronic lung disease.
T/F: LBBB is a feature of Cor Pulmonale.
False
RVH -> RBBB may be.
how to evaluate LV and RV function in COPD?
x-ray and ECG
Etiology of Isolated Right Heart Failure:
Consider Cor Pulmonale
Features of Right Heart Failure:
- JVD
- Peripheral Edema
- Hepatomegaly
Acute pericarditis Rx:
NSAIDs
Highest risk period post joint replacement operation for DVT/PE is:
90 days post op
AAA Dx
MRI is most sensitive method, but CT, TOE, and Aortography can also be used.
DVT should be treated as OP UNLESS:
- Massive DVT
- Symptomatic PE
- High risk of bleeding
- High comorbidities
DVT PPx:
- Early ambulation
- Mechanical - i.e. compression
- Pharm - i.e. LMWH
Pharmacologic DVT PPx (age and risk)
is not needed for those <40 years old and those at high risk of bleeding (i.e. liver disease, bleeding disorders)
For those needing Pharm DVT PPx:
- LMWH 12 h pre-op
- LMWH 12-24h post-op OR
- Warfarin started post-op
How to prevent post thrombotic syndrome in DVT pts
using of compression stockings in addition to LMWH and warfarin
For Provoked DVT Tx
LMWH for 3-6 months
Venous Ulcers Rx:
- Wound care
- Compression
arterial ulcers Tx
Angioplasty or stenting
T/F: you can use anti coag for venous ulcers
FALSE
varicose veins Tx
Saphenous vein stripping
HTN w/ CAD Rx:
ACEi OR ARB
BB OR CCB in pts w/ stable angina
HTN w/ Recent MI Rx:
ACEi + BB
Rx for Pts >60 yrs HTN
Thiazide
T/F: you can give black pts ACEi for HTN
FALSE
T/F: BB are safe for Asthma pts
FALSE it is CI
Therefore, CCB is alternative if ACEi and Thiazides are CI.
Hypotension due to Sepsis,
1st line Vasopressor:
NOREPINEPHRINE
T/F: BB are CI in Cocaine OD.
True
Chest pain in cocaine use Rx:
ACS Rx + IV Benzo
can you use CCB in cocaine induced ischemia?
it hasn’t been studied but maybe considered if no response to nitroglycerin and benzodiazepines
Cyanid Poisoning Rx:
Sodium Thiosulfate
AE-COPD Rx:
- SABA
- ICS
- Short acting anti-cholinergic
- Abx as necessary
Severe COPD prognostic drug:
ONLY OXYGEN will improve prognosis
Long term COPD monotherapy:
LABA OR long acting anti-cholinergic (i.e. tiotropium)! NOT ICS!
Asthma long-term Rx:
If patient stable, reduce regimen by taking off LABA and keeping ICS.
Asthma Step-Up Rx after SABA:
ICS
DO NOT use LABA as monotherapy.
which medication should be only as additive therapy and not as monotherapy?
Long acting beta2 agonists
Asthma Dx and monitoring:
Asthma Dx: Spirometry
Asthma monitoring: Peak Flow
classification of Asthma
1- MILD:
a. Sx 2days/week or less
b. Nighttime Sx 2nights/month or less
2- MILD PERSISTENT:
a. Sx >2 days/week but <1 episode/day
b. Nighttime Sx >2 nights/month
3- MODERATE PERSISTENT:
a. Daily Sx.
b. Night Sx >1/week
4- SEVERE PERSISTENT:
a. Sx throughout the day
b. Frequent Sx during night
Asthma Rx per severity:
- Mild: No daily meds needed
- Mild persistent: daily low dose ICS
- Moderate persistent: ICS+LABA
- Severe Persistent: high dose ICS+LABA
signs of poor Asthma control:
Asthma triggers
Guideline for Asthma management:
emergency mgm of Asthma
Bronchiectasis CF:
- Cough
- Mucopurulent sputum
- Wheeze
- Pleuritic chest pain
Bronchiectasis Dx:
HR-CT
cough associated with Bronchitis typically lasts less than 2 weeks
False.
more than 2 weeks
Most common cause in acute bronchitis?
Viruses
Note: purluent sputum reflects desquamation of the airway with expectorated matter being mostly epothelial cells.
Tx of acute bronchitis
Reassurance that Sx will resolve on their own within 3 weeks
Causes of Hemorrhagic Pleural Effusion:
- Infection: TB, Anthrax, Klebsiella
- Malignancy: Lung malignancy, lymphoma, leukemia
- Connective Tissue Dz: SLE
- Asbestosis related Dz: Benign asbestosis, Mesothelioma
- Abdomino-pelvic: Uremia, Pancreatitis
- Cardiovascular: Aneurysm rupture
- Bleeding disorder: anti-coag OD
pt with recurrent hemorrhagic pleural effusion who has been exposed to asbestos, silica and hydrocarbons. what is the cause?
either benign or malignant diseases can be the cause.
benign diseases are far more frequent and benign asbestos pleural effusion is more likely to be hemorrhagic
primary pnemothorax, secondary and tension:
Secondary PTX Etiologies are lung diseases:
- COPD
- Asthma
- CF
- TB
- Sarcoid
Spontaneous secondary ptx due to underlying lung dz Rx:
Supplemental O2 via NC
acute Tx of pulmonary edema
5 most common causes of CHF
1- CAD (60-70%)
2- HTN
3- idiopathic (often dilated cardiomyopathy)
4- valvular (AS,AR,MR)
5- Alcohol (dilated cardiomyopathy)
Pulmonary Edema Rx:
LMNOP:
Lasix (furosemide)
Morphine
Nitroglycerin
Oxygen
Position
Pulmonary Fibrosis Dx:
- Restrictive Lung Dz on Spirometry
- Fine crackles
- Non-productive cough
- Dyspnea
Drug causes of Pulmonary Fibrosis:
- Bleomycin
- Amiodarone
- Amphotericin B
- Carbamazepine
Sarcoidosis Dx:
Biopsy of skin lesions. If no skin lesions, biopsy of granulomas in lung.
T/F: Most apneic episodes in OSA happen during REM seep
True
OSA Rx:
CPAP
what is OSA and central sleep apnea:
OSA: apneic episodes with increased respiratory effort
Central Sleep Apnea: Apneic episodes with decreased/zero resp effort
T/F: Any nodule >8mm or growing since last follow up should be biopsied.
True
Haematuria + Hemoptysis:
Goodpasture syndrome
anti parietal cell antibodies found in?
pts with autoimmune disease known as pernicious anemia
anti smooth muscle antibodies found in?
pts with autoimmune Hep
anti neutrophilic cytoplasmic antibodies found in?
pts with wegener granulomatosis
anti-mitochondrial antibodies found in?
pts with primary biliary cirrhosis
Goodpasture Dx:
Anti-GBM Abs
Granulomatosis w/ polyangiitis:
C-ANCA
Churg-Strauss:
P-ANCA
