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Clin Medicine > Pcm Test 2 > Flashcards

Pcm Test 2 Flashcards

1
Q

Aortic valve heard

A

Right 2nd ICS at SB

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2
Q

Where is pulmonic valve heard

A

Left 2nd ICS at SB

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3
Q

Tricuspid valve where

A

Left 4th ICS at SB

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4
Q

Mitral valve where head

A

Left 5th ICS at MCL

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5
Q

Grade 1 murmur

A

Very faint

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6
Q

Grade 2 murmur

A

Quiet, soft, easily heard with stethoscope

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7
Q

Grade 3 murmur

A

Moderately loud

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8
Q

Grade 4murmur

A

Lous with palpable thrill

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9
Q

Grade five murmur

A

Very loud with thrill; can hear with stethoscope partly off chest

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10
Q

Grade 6 murmur

A

Heard without stethescope

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11
Q

Systolic murmur

A

Between S1 and s2

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12
Q

Diastolic murmur

A

S2 and s1 between

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13
Q

S1

A

Closure of TV and MV

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14
Q

S2

A

Closure of AV and PV-may split with inspiration

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15
Q

S2

A

Dull, low pitch; best heard with bell

Kentucky

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16
Q

S2

A

Physiologic in kids, young adults

Pathological in older adults=HF

Ventricular gallop

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17
Q

S4

A

Dull low pitched; best heard with bell
Tennessee

Forceful atrial contraction against stiffened low compliant ventricle

Atrial gallop

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18
Q

Systolic murmur

A 
MR (MVP), TR, AS, PS, VSD
Aortopulmonary shunts (early, mid, late, holosystolic/pansystolic)
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19
Q

Diastolic-AR, PR
-MS, TX

Atrial myxoma

A

Ok

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20
Q

Continuous murmurs

A

PDA-machinery

AV fistula

ASD with high LA pressure

Coarctation

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21
Q

VHD

A

Most common conditions encountered today-degenerative (senile calcification)

Myxomatosis degeneration (MVP)
Congenital (bicuspid aortic valve)

Decline in incidence of RHD

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22
Q

Mitral regurgitaiton chronic

A

MVP most common MAC (mitral annular calcification)

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23
Q

Mitral regurgitaiton acute

A

Rupture of chordal tendineae

Rupture of papillary msucle

Ischemic papillary msucle dysfunction-
CAD/MI : next most common cause f MR

IE; valve perforation

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24
Q

MR symptoms

A

Asymptomatic years-> of fatigue , DOE and palpitations

Acute; volume overload/orthopnea, PND, RHF/LHF

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25
Q

PE MR

A

Systolic murmur 9blowing , prominent at apex; radiates into left axilla)

Loudness of murmur correlated with severity

Decreased D1 or normal; may have a systolic click

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26
Q

Mitral stenosis

A

4th decade

DOE, cough, orthopnea, PND< pulmonary edema, hemoptysis, arterial emboli, A fib

Ortner syndrome: hoarseness d/+ compression of left recurrent laryngeal nerve

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27
Q

MS PE

A

Malar flush-ruddy cheeks, blue fancies. Increase D1; opening snap after s2

Rumbling, diastolic murmur-low pitched; bestheard at apex. Use bell

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28
Q

Aortic stenosis

A

Degenerative (calcific, senile, fibrosis or sclerosis) congenital bicuspid aortic valve )BAV)
1% of pop born with BAV)
Rheumatic or post inflammatory scarring

Normal AoV is 4cm^2

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29
Q

Symptoms AS

A

6th decade: exertional dyspnea, angina, syncope, HF

Without treatment prognosis is poor

Without treatment most will die within three years of developing syncope and within two years of onset of HF

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30
Q

Pathophysiology AS

A

Obstruction leads to pressure overload LVH increased LVED pressure

Gradient across valve

Severe AS if AoV <1cm^2

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31
Q

PE AS

A

Narrow pulse pressure; decreased SV and systolic pressure

Delayed pulses-par is (weak-small/tardus-late)

Systolic murmur, harsh 2nd ICS RSB; radiated into suprasternal notch/carotid

Gallavardin phenomenon-murmur radiates to apex (like MR)

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32
Q

AR

A

Causes acute-IE, aortic dissection, BAV

Chronic causes-syphilis, ankylosis spondylitis

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33
Q

PE AR

A

Wide pulse pressure

De musset sign

Corgi ANS pulse

Traduces sign

Durozreys sign

Hills sign

Bisferious pulse

Diastolic , decrescendo murmur 3rd ICS LSB

Systolic murmur usually present , soft

Austin flint murmur; can mimic MS

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34
Q

Tricuspid regurgitaiton

A

Associated with pulmonary HTN, inferior MI/RV infarction and others

Pathophysiology; prominent V wave in JVP

Blowing systolic murmur LSB; increase with inspiration (Corvallis sign)

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35
Q

TS

A

Associated with MS, TR< and RHD

Pathophysiology; prominent A wave in JVP ascites, hepatomegalia (may pulsate)

Diastolic murmur LSB; increase with inspiration (carvallos sign) and decrease with expiration and valsava

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36
Q

Pulmonic regurgitation

A

Most cases are due to pulmonary HTN

Diastolic , blowing murmur 2nd LSB, 2nd ICS (graham steel)

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37
Q

Pulmonary stenosis

A

Atresia

Congenital

Can cause angina and syncope

Auscultation-systolic murmur , ejection click

2nd-3rd ICS, LSB/radiated toward left shoulder and increases on inspiration /RVH

Maybe associated with TOF or TGA

May require balloon commissurotomy if pressure gradient>50 mmHG

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38
Q

Electronic health records

A

Ok

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39
Q

Electronic medical records

A

Digitalized version of the paper charts int he clinicians office but the information int he EMRs doesn’t travel easily out of the practice. Inf act, the patients record might have to be printed and delivered by main/fax to specialists and othe members of the care team

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40
Q

Electronic health records

A

Do allot he EMR things-and more. They are build to share information with other health care providers, such as laboratories and specialists, so they contain information from all the clinicians involved int he patients care

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41
Q

Do EHR talk to another EHR

A

No

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42
Q

2009

A

Incentives-health informations echnology for economic and clincial health act, which authorizes incentive payments through Medicare and medicaid to clinicians and hospitals that use electronic health records in a meaningful way that significantly improves clincial care

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43
Q

2010

A

President Obama signed the patient protections nd affordable care act

Physicians and hospitals had to prove that they had met 25 different functional objectives with their use of an EHR product to be considered meaningful userspenalties included cuts to Medicare payments for those not implanting EHR

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44
Q

2017

A

As of 2015, nearly 9 in 10 of office based physicians had adopted EHR

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45
Q

Meaningful use (MU)

A

Stage 1-data capture and sharing 2011

Stage 2-advance clincial processes

Stage 20improved outcomes

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46
Q

MU

A

Refers to the use of certified EHR technologies by health care providers in ways that measurably improve health care quality and efficiency

Ultimate goal is to bring about health care that is 
Patient centered
Evidence based
Prevention oriented
Efficient
Equitable
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47
Q

Data

A

Qualitative, or quantative (discrete, continuous)

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48
Q

MU criteria’s 2014

A

Patient portal-contact provider electronically

Clinical decision support tools-computerized alerts and reminders to care providers and patients

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49
Q

MU report a total of 6 ambulatory clincial quality measures to CMS or states

A

Adherence to chronic medications

Adherence to statin therapy for individuals with CAD

Adherence to chronic medications for individuals with DM

Adherence to antipsychotic medications for individuals with schizophrenia

INR for individuals taking warfarin and interacting anti infective medication

Lack monthly INR monitoring for individuals on warfarin

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50
Q

Premium cost

A

Higher for unhealthy than healthy

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51
Q

As medical costs go up, premiums are raised to ensure resources>cost

A

What are the costs administrative, medical, other

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52
Q

Cost of implementation

A

1.5 billion Mayo Clinic over next five years EHR

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53
Q

What is fee for service

A

Volume based, not value

Physician is paid when patients is seen

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54
Q

What is merit based incentive payment

A

Standardizes measures (evidence based)

Incentives care that focuses on improved quality outcomes

Increases access to better care

Enhanced coordination through a patient centered approach

Improved results

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55
Q

MARCA

A

Medicare access and CHIP reauthorization act of 2015

CMS stated that MACRA enacts a new payment framework that rewards health care providers for giving better care instead of more service

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56
Q

Are doctors happy

A

No many unsatisfied and very dissatisfied

57
Q

Why don’t we like EHR

A

Typing-docs become data entry clerks

Average physician gets only 3 hours training in the EHR he/she is expected to use

Inability to capture the interpersonal moments

Too many alerts on most systems

Quantitative data versus free text

Too much time entering data

58
Q

Shortcuts

A

Scribes

Dictation

Templates

59
Q

Etiquette best practice

A

Introduce yourself
Sit down
Get intima history then ask if ok to enter stuff on computer

Invite patient to look at screen with you

When appropriate turn away from computer, get close

60
Q

What is the triangle

A

Computer, provider, patient

61
Q

The quadrangle

A

The medical student, physician , patient, and computer

62
Q

Why don’t we teach EMR

A

900 outpatient EMR systems

277 inpatient EMR systems

63
Q

Medical students must

A
  1. Have their own unique login and password to chart on behalf of the preceptor

Contribute meaningful data to EHR with the inclusion of a student note or, at least, the students review.update of the past, family/social history and ROS
A. Enter needed data into he EHR and the rationale for entering clincial information ins tructured data fields versus the challenges of entering free text
B. Search for data within the EHR
C. Review patient care protocols
D. Find and use disease specific templates, reminders and decision support

Enter data into the appropriate fields int he EHR

Have all notes reviewed, edited and signed by the supervising physician with appropriate instructive feedback given

64
Q

Medical students must know

A

Old system
Redocument HIP and PE

Attending physician can only accept students documentation

Verify in the medical record any student documentation

Physician must verify in the medical record all student documentation

65
Q

Templates

A

Too easy to leave normal history, ROS, or exam findings pre populated without changing them.

Note cloning-all look same

Increased liability if students document in chart

  • juries might be confused
  • erroneous info not refuted by attending
  • documentat correct info that attending ignores
66
Q

Most important

A

At this time the NBOME has you develop a SOAP note from thin air for colles so that’s what we do here

67
Q

Old system

A

Students could not do all soap

Now physician can just verify stuff documented is accurate -makes medical students more important, can do and help physician

Before could just document stuff that nurse could —reduce some of documentation burden to physician , be benefit to physician

68
Q

Pediatric murmurs

A

Ok

69
Q

At birth things that close

A

Foramen ovals, ductus arteriosus, ductus venosus

70
Q

Who gets complete heart exam(over four post)

A
  • any heart murmur
  • history or history consistent of congenital heart (get sweaty when eat, weight gain, blah blah)
  • respiratory symptoms (not thriving, cough, wheezing)
  • if blue
  • any chest pain that you cant say is MSK (costochondritis)
  • anyone who passes out (usually vagovagal in kids and benign)
  • fine exercise tolerance and suddenly cant
  • family history of sudden death in anyone in family (idiopathic hypertrophy sub aortic stenosis(hypertrophy aortic arch), idiopathic its linked to AD so most get)
71
Q

What is a complete cardiac exam

A

Four posts, pulses(radial brachial femoral dorsalis pedis posterior tibial), perfusion (cap refill 2 sec), pulse (2/4),

  • murmur grade timing, position, if it radiates, where loudest, character (machine, soft)
  • know murmur grades
72
Q

Most innocent murmurs

A

Willl change with position

73
Q

Pathologic murmur

A

Won’t change with position

*exception!

74
Q

Pulse top to bottom in kid

A

Pulses top normal and femoral diminished

-coarctation or aorta

75
Q

Bp higher or lower than legs

A

Higher in legs than arms

76
Q

Grade 4

A

Thrill

77
Q

Why s3 normal in kids

A

Left ventricle so much more compliant-blood suddenly hit super coolant left ventricle

78
Q

S3 in adult

A

Systolic heart failure

79
Q

Can S1 split

A

Can

80
Q

S2 split

A

Inspiration , pulmonic and aortic valve close at different times
Overfilling right heart so

81
Q

Fixed slipt (not just with inspiration)

A

ASd in systolic

82
Q

S1 inaudible

A

Holosystolic vsd

Something obscuring it

83
Q

PDA

A

Continuous

84
Q

Diastolic

A

Other than venous hum, Changes with turning the neck

Not normal and do workup

85
Q

Diastolic sound ever normal

A

No

86
Q

What sound in diastolic ok

A

Venous hum

87
Q

Most common cause of innocent murmur

A

Stills/IHSS, hypertrophic cardiomyopathy tay
Systolic ejection murmur heard bt lower left sternal borer and apex

Increase if stand, increases with valsava

88
Q

Key features of innocent murmur

A 
Sensitive
Short duration
Single
Small
Soft
Sweet
Systolic
89
Q

Refer to cardiologist

A 
4 or above 
Diastolic
Increase when stand
If symptomatic 
Obscured, cant hear S1 or s2
Femoral pulse weak (in comparison to UE)
Extra sound
Thin chest wall and hyperactive pericardium 
History sudden death
Congenital /genetic
90
Q

Stills

A

APEX and LL bell

Decreased with inspiration, sitting up, standing,

Systolic, ejection, soft or vibratory, grade 1-2
Normal S1 2, no extra sounds

91
Q

Cyanotic congenital heart

A

One Truncus arteriosus big trunk
Two Interchanged vessels: transposition of the great vessels
Three Tricuspid atresia
Four Tetralogy of fallout
Five Total anomalous pulmonary venous return

92
Q

Diagnosis of congenital heart disease

A

If close, no connection between right and left
Critical congenital heart disease

So go home, ductus close and they die

93
Q

How determine kids have critical lesions

A

Baby counts on ductus to stay alive otherwise no right to left

Check oxygen saturation in left arm and left foot
-or right arm and right foot

If same, pass
All about difference, if too much fail and get and echo

94
Q

Check pre and post ductal

A

If not check for congenital heart condition

95
Q

Surgery

A

Give anticoagulant so don’t get clots

96
Q

Why stop taking statin

A

Muscle soreness

97
Q

Where is PMI

A

5th,

If not could be normal or not

98
Q

D dimer

A

Not specific

99
Q

Duplex of popliteal a and v

A

With knee infection want to look and see what’s there

100
Q

Duplex

A

Bedside Doppler ultrasound
(Sound waves)

Visualize vasculature and assess for clot

Instant picture arteries don’t compress, veins do
Looking for DVT press transducer to see if vein collapse, if non compressible cord like thrombus forming , DVT

101
Q

Most common use of Doppler

A

Fetal heart sounds

102
Q

Doppler

A

Tranducal and doppler, uses both

103
Q

Transthoracic echocardiogram with bubble study

A

Transesophageal-for endocarditis, thrombus, Camera into esophagus put behind heart and see posterior structures

Transthoracic-limitations in viewing but

104
Q

Bubble study

A

IV access get syringe with sterile saline and put stop cock on IV attach saline filled syringe and have empty syringe, agitate saline back and forth, cause bubbles but no air

Release saline into IV with bubbles, go to right atrium first

  • no defect bubbles go through normal
  • if defect bubbles reverse and go right to left atria
105
Q

Bubble

A

PFO look for -no murmurs there and we don’t know

106
Q

If have bubbles right heat

A

ASD patent foramen ovale

107
Q

How close PFO

A

NSAIDS high dose

108
Q

Bubble

A

Real time assessment of

109
Q

Heart accident

A

High risk tamponade

110
Q

I AVF

A

Both up normal

One go down avf up-right axis

One up avf down-left axis

111
Q

Ekg

A

Rate, rhythm, p wave , Pr prolongation,

112
Q

Chest x ray

A

Trachea deviation
Bones
Cardiac silhouette (big or small heart)

113
Q

QRS complex different sizes

A

Electrical alternance

Badddddd

114
Q

When go to cath lab

A

MI, need to see electrical conduction issue on ekg

115
Q

FAST exam after car crash

A

Look for fluid with cardiomegaly

116
Q

Fast exam

A

Focused bedside US good for rapidly excessive if bleed we need to get immediately

Pericardial-see if tamponade

117
Q

Cardiac tamponade

A

JVP up

BP down

118
Q

Transthoracic echocardiogram

A

Initial test of choice for pericardium , EF, ventricular atrial septa

Diffuse pulmonary disease-obscure views, if fat, bac

119
Q

Bruit

A

US for stenosis of carotid

120
Q

Baronial aortic US

A

Dilation-enruysms, occur at INTIMAL layer?
2 cm, anything greater bad

Greater than 5, palpable,
Greater than 3 is aneurysm

121
Q

Greater than 5

A

Get angiography

What is thrombus

122
Q

Refer to vascular specialist

A

If greater than 4 cm

123
Q

Aaa

A

Tunica media and INTIMAL layers

124
Q

St elevation

A

Inferior lead 2, 3, avf,

125
Q

Manage acs

A

CXR, on cardiac monitor, cath lab

126
Q

Cath

A

Radial of femoral ARTERY into circulation to coronary vascularore , can put contrast in to light up vessels if patent see picture, if blocked wont see follow through

127
Q

Use fluoroscopy to visualize coronary arteries, contrast used

A

May use stent to decrease likelihood of roaming

128
Q

Risk of coronary angiography

A

Bruising, bleeding, can have another MI by putting more stress on heart, infection, kidney damage-from contrast (Cr BUN and GFR, if renal disease and CR at 2, lets put on short term dialysis to do this)

129
Q

Faint, irregular rhythm, tachycardia, high bp

A

Check radial artery pulse to see if difference in pulses wil detect arrhythmia,

130
Q

Ekg a fib

A

Rate differs! No consistent rate , not really p wave before qrs

131
Q

LONG QT

A

CAN GO INTO TORSADES

132
Q

Test for a fib

A

Transesophageal echocardiogram-
Clots can form with atrial quivering with Virchow

A fib-clots!!

133
Q

Fast

A

Acute trauma

134
Q

Duplex

A

Arteries, or stroke of carotid

135
Q

Cath

A

MI

136
Q

Clot

A

TEE

137
Q

TEE-clot formation

A

Invasive, thrombus in A fib, prosthetic valve , aortic dissection aortic pathology , US get rapid view

138
Q

How would dissection appear on CXR

A

Widened mediastinum

Clin Medicine (28 decks)

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