Oral Boards General Questions

Question 1

List a differential diagnosis to tachycardia (primary and secondary).

Answer 1

Primary tachycardia (ie pathology inherent to the heart):
1- supraventricular arrhythmia
2- ventricular arrhythmia

Secondary tachycardia (ie sympathetic stimulation):
1- Hypoxemia
2- Hypercapnia
3- Decreased oxygen delivery (anemia, decreased cardiac output)
4- Pain (usually associated with HTN, somatic, visceral, sympathetic)
5- Hypovolemia (usually associated with hypotension, absolute like dehydration and hemorrhage, relative like tamponade, pneumothorax, PEEP)
6- Unusual possibilities (inotrope running wide open, pheochromocytoma leaking an inotrope, carcinoid syndrome)

Question 2

List a differential diagnosis for bradycardia (primary or secondary).

Answer 2

Primary bradycardia (ie something wrong with the heart itself)
1- Sick sinus syndrome
2- Complete heart block

Secondary bradycardia (ie vagal stimulation or sympathetic suppression)
1- Drug-induced:
a) digoxin (too much causes heart block)
b) narcotics (a vagal thunderbold)
c) anticholinesterases (forgot the glycopyrollate?)
d) beta blockers (sympatholysis)
e) dexmedetomidine (sympatholysis from x2-stimulation)
f) calcium channel blockers

2- Vagal stimulation

a) oculocardiac reflex
b) traction on viscera
c) laryngoscopy
d) baroreceptor reflex (eg manipulation during carotid surgery)

Question 3

List differential diagnosis to hypertension.

Answer 3

Goes hand in hand with tachycardia.

Primary HTN:
1- Longstanding HTN
2- HTN associated with specific disease entity (preeclampsia, renal failure)

Secondary HTN (ie sympathetic stimulation):
1- hypoxemia
2- hypercapnia
3- Pain (somatic, visceral, sympathetic)
4- Unusual possibilities (inotrope running wide open, pheochromocytoma, carcinoid)

Question 4

List differential diagnosis to hypotension.

Answer 4

Break blood pressure down into preload, afterload, myocardial contractility, blood itself.

1- Preload

a) bleeding, dehydration
b) enough blood, but can’t get back to the heart because of tamponade, positive-pressure ventilation, PEEP, tension pneumothorax, aorto-caval compression, vessel pinched during surgery, bent and twisted heart during off-pump CABG

2- Contractility (Heart itself is insufficient)

a) muscle is not strong enough (cardiomyopathy, infarcted heart muscle)
b) Muscle is fine but not able to deliver enough blood because of bradcardia, tachycardia, or valvular problems

3- Afterload insufficient

a) it is too low (anaphylaxis, vasodilators gone wild, spinal shock)
b) blood insuffient (there is no tenough of it, eg hematocrit of 3) and there is not enough viscosity to generate pressure in the circulatory system.

Question 5

List a differential diagnosis to hypoxemia.

Answer 5

1- From wall to ET tube:

a) wrong gas composition
b) no gas delivery- disconnection, ventilator off

2- ETT to lungs:

a) esophageal or endobronchial intubation
b) kink, clog, or aspiration of big things
c) disconnect
d) tube went subcutaneously as in tracehotomy in the wrong place.

3- Thorax, outermost to innermost

a) chest wall leak
b) kyphoscoliosis, flail chest, phrenic nerve damage
c) pleural
d) parenchyma- aspiration, pneumonia, ARDS, CHF
e) pulmonary vasculature- emboli
f) cardiac plumbing: right to left shunts

4- CNS

a) apnea
b) damage to respiratory center
c) high cervical lesion

Question 6

List a differential diagnosis to hypercapnia.

Answer 6

1- Making too much:

a) malignant hyperthermia
b) thyrotoxicosis
c) sepsis

2- Getting rid of too little
a) hypoventilation

3- Rebreathing

a) exhausted carbon dioxide absorber
b) malfunctioning valve
c) floows too low.

Question 7

Examiner: The blood pressure drops.

Answer 7

Assuming that this is related to blood loss from injury, I would administer fluids, draw an ABG, and decrease potent inhaled agents.

Question 8

What are indications for subacute bacterial endocarditis prophylaxis?

Answer 8

1- prosthetic cardiac valve or prosthetic material used in valve repair
2- previous endocarditis
3- congenital heart disease ONLY in the following categories: a) unrepaired cyanotic congenital heart disease, including those with shunts, b) completely repaired congenital heart disease with during the first six months after the procedure, c) repaired congenital heart disease with residual defects at the site
4- cardiac transplantation patients with cardiac valvular disease.