Online med ed misc Flashcards
Unstable angina vs NSTEMI vs STEMI
UA: no trops, no ST #
NSTEMI: trops, no ST #
STEMI: trops, ST #
If heart failure and EF < 35% but not class IV, give___
AICD
Progression of heart failure management
class I beta-blockers + ACE-i/ARB –> class II Loop diuretics –> class III Isosorbide dinitrate-hydralazine + spironolactone –> AICDif not class IV and EF <35%
Management of CHF exacerbation
Lasix Morphine Nitrates O2 Position
Potential causes of CHF exacerbation
MI
med/diet non-compliance
Pathologic murmurs (2)
systolic grade 3 or murmur
any diastolic murmur
Always get an ECHO
Mitral stenosis: auscultation findings
left atrial stretch and fluid in the lungs –> afib and or CHF sxs
Findings: rumbling diastolic murmur with an opening snap heard best at Apex
NOTE: often from rheumatic heart disease and occurs in younger people
Mitral stenosis: TX
Initial: balloon valvuloplasty (through left heart cath) as valve is not calcified as in other valvular d/os
late: replacement
Aortic regurgitation: auscultation findings
Aortic valve insufficiency –> left venticular dilation
Findings: rumbling diastolic murmur heard at base
Causes of aortic insuffiency
acute: aortic dissection, infection, and infarction
Presentation of aortic insufficiency
acute: cardiogenic shock, flash pulmonary edema, CP
chronic: CHF, CP
Aortic insufficiency: TX
replacement
Aortic stenosis: auscultation findings
left ventricular dilation –> CHF as seen also in aortic insufficiency
Findings: systolic murmur heard best at base in crescendo-decrescendo quality
Causes of AS
ATHEROSCLEROSIS
Mitral insufficiency: auscultation findings
left atrial dilation –> afib and CHF sxs
Findings: holosystolic murmur heard best at apex
Hypertrophic obstructive cardiomyopathy: auscultation findings
systolic murmur like AS, but more blood with physical exam maneuvers in heart makes better
SOB or syncope with exertion in a young athlete
HCOM
HOCM: TX
beta-blockade (want heart to be slow enough for long enough diastole)
AVOID decreases in pre-lod (dehydration, exercise)
Mitral valve prolapse: auscultation findings
Findings: systolic murmur heard at apex, better with physical exam maneuvers that increase preload (leg left and squatting)
MVP: TX
beta-blockade
avoid dehydration
Systolic vs diastolic HF
systolic: Echo shows dilated LV, caused by viruses, alcohol, pregnancy, ischemia, TX with beta-bloackade, ACE-is, and diuretics
Diastolic: Echo shows concentric LVH, caused by hypertension or material restriction from amyloid/sarcoid/hemochromatosis, TX with beta-blockade or CCBs (verapimil or dilt), avoidance of HTN and dyhydration
Diastolic HF with neuropathy =
amyloidosis
Dx: fat pad/gingiva bx
Diastolic HF with pulmonary disease =
sarcoid
Dx: cardiac MRI and endomyocardial bx
Diastolic HF with cirrhosis and bronze DM =
hemachromatosis
Dx: ferritin and genetic testing
Types of causes of pericardial disease (4)
(1) infection (remember TB)
(2) autoimmune (RA, dresslers, uremia)
(3) trauma (penetrating and blunt, dissection)
(4) cancer (breast, lung, lymphoma, esophageal)
Best TX for pericarditis
NSAIDs and colchicine
NOTE: can use steroids, but this makes recurrence more likely
Best imaging modality for pericarditis
MRI
NOTE: EKG used though
Findings on EKG for pericaditis
PRsegment depression and diffuse ST segment elevation
indications for statin therapy
vascular disease (MI, PVD, CAS)
LDL > 190
LDL btw 70-189 + 40-75yo + DM
LDL btw 70-189 + 40-75yo + high ASCVD
syncope considerations
W vasovagal Orthostatic hypotension Mechanical cardiac (can cause SCD) Arrythmogenic cardiac (can cause SCD) Neurologic Psych Electrolytes
High-intensity statins
atrovastatin 40 or 80
ruvastatin 20 or 40
DO NOT use with fibrates
Moderate-intensity statins
atorvastatin 10 or 20
ruvastatin 5 or 10
NOTE: also for people who need statins but contraindicated against high-intensity (GI upset, age > 75yo, liver or renal dysfxn, past myositis or hepatitis with high dose statin)
Causes of secondary HTN
Consider in pts < 35yo with HTN or those with refractory HTN
Hypercalcemia Hyperthyroid Hyperaldosteronism Aortic coarctation Renovascular Pheo Cushings OSA
Initial basic testing for patient diagnosed with HTN (4)
UA, CMP (need initial LFTs), lipid profile, baseline ECG
Aspirin + ____ improves survival in pts following NSTEMI
P2y12 receptor blocer (clopidogrel, prasugrel, or ticagrelor)
Aspirin + _____ for >12 months following drug-elating stent placement
P2y12 receptor blocer (clopidogrel, prasugrel, or ticagrelor)
Lytes criteria
LDH fluid > 2/3 ULN
LDH fluid/serum >0.6
Total protein fluid/serum >0.5
Need any one to be exudate
If all positve = transudate
Causes of exudate vs transudate
exudate: malignancy, PNA, TB
transudate: CHF, nephrosis, gastrosis, cirrhosis
Cell count finds in thoracentesis
PMNS: PNA
Lymphs: TB/malignancy
RBCs: cancer (automatically stage IV)
Virchows triad
(1) venous stasis
(2) endothelial injury
(3) Hypercoaguability
EKG finding in PE
s1q3T3
What to get to reassure self that pt does not have pe
d-dimer (only get with low pre-test probablity)
If PE suspected but pt allergic to contrast or has CKD, give ____
V/Q scan (not Cta) if CXR normal
If massive PE, give ____
tPa
Management in ARDs
CO2: low tidal volume, higher respiratory rate
O2: choose PEEP over FIO2
recruit alveoli!
Pt coming in with chronic insidious progression of hypoxemia, with dry cough and crackles heard on auscultation
Suspect ILD
Imaging for suspected ILD
high res CT (shows ground glass opacities)
Tx of ILD
steroids, sometimes DMARDs
Causes of ILD
rheumatologic disease (RA, SLE, DCSS)
primary (sarcoid)
exposures (asbestos, hypersensitivity pneumonitis, pneumoconiosis)
Idiopathic (acute is < 6wks, chronic >6months)
Drug-induced (amio, bleomycin, radiation)
AA female with hypoxemia, heart block, bells palsy, and erythema nodosum
SARCOID
W/U of ILD
Hi res CT (ground glass opacity)
PFTs (restrictive pattern)
biopsy
Silicosis associations
rock quarry and sand blasting
NOTE: rule out TB
Arthralgias and ILD
coal miners pneumoconiosis
Visualization/biopsy of different locations of lung nodules
if in bronchiole or around: EGUS
if in periphery: CTguided percutaneous
if in middle: VATS
Work up of lung cancer before TX
CT chest
staging
PET
PFTs
Determination of risk with lung nodule
(low-risk qualities) Size (small <2cm) Surface (smooth) smoking Self (age < 45) NOTE: if calcified, less likely cancer
Types of secondary DM
Endocrine diseases (cushing, acromegaly, glucogonoma)
pancreatic conditions
pancreatic cancer
drug-induced
genetic syndromes
Initial testing in an acute asthma exacerbation vs nonacute asthma
acute asthma: ABG and peak expiratory flow
nonacute asthma: methacholine/histamine challenge
NOTE: methacholine is an artifical form of acetylcholine used in diagnostic testing
Asthma in which IgE is eleveated: associations
Atopy, asthma, and allergy triad
allergic bronchopulmonary asperigillosis
Asthma in which IgE is elevated: TX
omalizumab
Asthma that is part of atopy and allergy triad: long-term control agent
leukotriene modifiers (montelukast, zafirleukast, or zileuton)
Acute asthma exacerbation: TX
O2
albuterol
steroids (NOTE: takes a while to kick in)
duonebs (albuterol and iprtropium)
Magnesium will relieve bronchospasm while steroid still kicking in
Possible EKG findings in pt with COPD
RAH and RVH
Afib or MAT
TX progression in COPD not controlled with albuterol
anti-cholinergic (tiotropium), then ICS
Findings of bronchiectasis on CXR
dilated, thickened bronchi, sometimes with tram tracks
NOTE: most accurate imaging is high res CT
An asthmatic patient with recurrent episodes of brown-flecked sputum and transient infiltrates on CXR
Allergic bronchopulmonary aspergillosis
NOTE: can also present with cough, wheezing, hemoptysis, and bronchiectasis
Allergic bronchopulmonary aspergillosis: TX
Oral steroids and
oral itraconazole for severe cases
A young pt with chronic lung disease (cough, sputum, hemoptysis, wheezing, and dyspnea) and recurrent episodes of infection/sinusitis who is infertile
cystic fibrosis
Cystic fibrosis
antibiotics
inhaled recombinant human deoxynuclease
albuterol
pneumococcal and influenza vaccines
lung transplant if tx refractory advanced disease
Ivacaftor increases the activity of CFTR in some patients
3 most common pathogens in COPD exacerbation
strep pneumo
H influenzae
moraxella catarrhalis
Atypical pna =
organisms (mycoplasma, chlamydophila, legionella, Coxiella, and viruses) that are not visible on gram stain and not culturable on standard blood agar
Ventilator-associated pneumonia
3 different agents
(1) anti-pseudomonal beta-lactam (cephalosporin or pip-tazo, or carbapenem)
(2) 2nd anti-pseudomonal agent (aminoglycoside or fluoroquinolone)
(3) MSSA agent (vanc or linezolid)
Aminoglycosides
gentamicin
tobramicin
amikacin
fluoroquinolones
ciprofloxacin
levofloxacin
CAP: TX outpatient vs inpatient
Outpatient:
If previosuly healthy–macrolide or doxycycline
If comorbidities or recent antibx–levofloxacin or moxifloxican (respiratory fluoroquinolones)
Inpatient:
respiratory fluoroquinolone or ceftriaxone+azithro
Macrolides
azithromycin
clarithromycin
Type of vision loss with open angle glaucoma
gradual bilateral loss of peripheral vision over a period of years –> tunnel vision
Central vision spared
Euthyroid sick syndrome =
low T3 syndrome
a fall in total and free T3 levels with normal T4 and TSH levels
Warm vs cold agglutinin disease: TX
Warm: Steroids initially, IVIG with acute episode does not respond to steroid, splenectomy if recurrence, rituximab if all else fails
Cold: warming of limbs, rituximab, sometimes plasmapharesis
G6PD deficiency: Dx
PBS showing heinz bodies ad bite cells
Most accurate test is G6PD level 1-2months after an acute episode of hemolysis
TTP or HUS: TX
severe episodes treated with plasmapheresis or plasma exchange
Paroxysmal nocturnal hemoglobinuria: clinical presentation
episodic dark urine, pancytopenia, clots in unusual places (mesenteric and hepatic veins)
Paroxysmal noctrunal hemoglobinuria: TX
Prednisone, BMT for cure
Eculizumab for episodes of hemolysis and thrombosis
Chronic aplastic anemia: TX
BMT for cure
antithymocyte globulin (ATG) and cyclosporine
Essential thrombocytosis: TX
hydroxyurea
Non-hodgkin lymphoma: diagnostic testing and tx
Dx: excisional biopsy
TX: stage 1&2–local radiation and small course of chemi
stage 3,4, or any B sxs–CHOP (cyclophosphamide, hyrdoxyaunorubicin/adriamycin, vincristine/oncovin, prednisone)
Hodgkin lymphoma: DX and TX
DX: Reed-sternberg cells on patholgy
TX: stages 1&2–chemo and radiation
stages3,4, or B sxs–ABVD (adriamycin, bleomycin, vinblastine, dacarbazine)
Multiple Myeloma: TX
HSCT for cure
Chemo otherwise
Meds: steroids + lenalidomide OR melphalen (in older pts)
Waldentrom macroblobulinemia: TX
rituximab