UWORLD Flashcards
lab values cholesterol embolism
eosinophilia
eosinouria
hypocomplementemia
ICU patient who was being treated for hypotension develops ischemia of distal fingers and toes; symmetric duskiness and coolness of fingertips noted
norepinephrine induced vasospasm
physical exam findings suggestive of AS
- diminished and delayed carotid pulse “pulses parvus and trades” due to blood flow obstruction
- mid to late peaking systolic murmur from turbulence due to stenosis
- SOFT AND SINGLE S2
how does septic shock affect SVR, pulmonary cap wedge pressure, cardiac output, and mixed venous o2 sat?
- DECREASED SVR (peripheral vasodilation)
- nml to low PCWP
- increased CO initially to make up for low SVR
- increased mixed venous o2 sat because tissues cannot extract o2 effectively, esp during lactic acidosis
patient admitted for MI is being treated medically when one day later develops left leg pain…on exam left leg cold and mottled, minimal swelling, absence of distal pulses…dx and what to do next
acute limb ischemia (usually from cardiac emboli)
get TTEto check for LV thrombus
immediately start anticoagulant and consult vascular
patient with hypercalcemia, recurrent kidney stones, and confusion/depression/psychosis presents with HTN
dx and what to do next
primary hyperparathyroidism
evaluate for MEN 2A (parathyroid, medullary thyroid, pheo)
indication for Holter monitor for arrhythmia
- intermittent arrhythmia in patients with SYMPTOMS (syncope/palpitations)
risk factors and treatment for persistent symptomatic PACs
risk - tobacco and alcohol
rx with low dose beta blockers
acute treatment for afib in patient with WPW (HDS and not HDS)
HDS - rhythm control with IV PROCAINAMIDE or ibutillide
non-HDS - immediate electrical cardioversion
which meds to avoid in WPW
AV nodal blocking agents such as adenosine, beta blockers, CCBs, and digoxin as they may promote conduction across accessory pathway and lead to degeneration of AF into VF
characteristic of MVP murmur
similar to MR murmur sometimes with systolic click….squatting from standing will increase preload and LV volume which will decrease intensity of murmur
CCBs can treat both prinzmental angina and what other process that is physiologicall ysimilar
think vasospasm so
RAYNAUD PHENOMENON
patient complaining of ear pain worse with chewing, has hx of nocturnal teeth grinding…dx?
TMJ dysfunction
patient with hx of childhood eczema and allergic rhinitis being treated for chest pain develops SOB with prolonged expiration and bilateral wheezes…
med side effect nonselective Bblocker (i.e. propanolol) can trigger bronchoconstriction)
Young woman presents with systemic HTN, recurrent headaches, carotid bruit
carotid bruit suggets carotid atherosclerosis…THINK FIBROMUSUCLAR DYSPLASIA
can also have abdominal bruits since these involve renal, ICA, vertebral, iliac, mesenteric arteries as well
pathophysiology of Meniere disease
increased volume and pressure of endolymph (endolymphatic hydrops)
initial mono therapy for HOCM
anything that decreases LVOT obstruction and improves angina symptoms
BETA BLOCKERS good initially
then Verapamil and disopyramide
ST elevation in II, III, aVF with reciprocal ST depression in I and avL
inferior wall MI from RCA
can also be LCX but usually doesn’t have reciprocal depression in I and avL
healthy person develops signs of CHF after cold…pathophysiology of heart abnormality
dilated cardiomyopathy 2/2 viral myocarditis
echo will show dilated ventricles with diffuse hypokinesia resulting in low EF
aortic dissection patient develops acute worsening chest pain, hypotension, pulmonary edema
acute aortic regurg
NOT TAMPONADE (lung fields will be clear and JVP will be elevated)
two consequences of aortic dissection
acute aortic regurgitation
pericardial tamponade
most effective nonpharmacologic way to lower BP
weight control
hours after femoral lower extremity embolectomy, patient has acute pain and paresthesias of leg, worsened with passive extension. pulses present
compartment syndrome (due to repercussion)
causes interstitial edema and increased pressure
malignant HTN vs. hypertensive encephalopathy
malignant HTN - retinal hemorrhages, papilledema, exudates
encephalopathy - cerebral edema and non-localizing neurologic symptoms like progressive headache
common cause conductive hearing loss in adults 20-30s
OTOSCLEROSIS
can also have cerumen impaction and middle ear infection
young patient presents with dyspnea, orthopnea, PND, and hemoptysis…afib on exam
rheumatic mitral stenosis…causes left atrial enlargement which predisposes to afib and STROKE!
ECG findings mitral stenosis
“P mitrale” (broad and notched P wave), RVH (R waves in V1, V2), atrial tachyarrhythmias
physical exam findings mitral stenosis
- mitral facies (pinkish purple patches on cheeks)
- loud S1
- opening snap (high frequency early diastolic sound)
- mid diastolic rumble best heard at apex)
common heart finding in newborn with small head, overlapping fingers, absent palmar creases,, convexity of bilateral soles and limited hip abduction
this is Edwards syndrome (trisomy 18)
more predisposed to VSD!!! holosystolic murmur at left sternal border
initial treatment for claudication due to PAD
after low dose aspirin and statin therapy are started, patient should undergo SUPERVISED EXERCISE PROGRAM to improve exercise tolerance
for newly diagnosed HTN, rank best lifestyle modifications in descending order
- weight control (esp obese patients)
- DASH diet (fruits, veggies, low fat dairy)
- aerobic exercise
- limit alcohol
light smoking linked with slightly less BP…recommended but diet modifications better
inferior MI patient develops new mitral regurg and cardioogenic shock 4 days after MI
papillary muscle rupture
anterior MI patient develops hypotension, JVD, distant heart sounds and death 5 days after MI
left ventricular free wall rupture leading to pericardial tamponade
3 conditions that can lead to new MR after MI
- papillary muscle rupture (usually inferior MI)
- intraventricular septum rupture (usually in LAD or RCA distribution)
- left ventricle free wall rupture (usually anterior MI)
which meds should be held 48 hours before exercise stress test
CCBs, beta blockers, anti anginal agents like nitrates
which meds should be held 48 hours before chemical stress test
dipyridamole
treatment for vfib or pulseless ventricular tachycardia
immediate defibrillation
NOT CARDIOVERSION…this is for non HDS narrow/wide QRS complex tachyarrhythmia (like afib, flutter, VT with pulse)
distant heart sounds, hypotension, JVD
tamponade (pericardial effusion)
how to differentiate intraventricular septum rupture from free wall rupture
both will present with chest pain and shock, but free wall rupture is usually associated with pericardial tamponade (look for pulseless electrical activity, distant heart sounds)
loud mid systolic murmur set heard at first right intercostal space, difference in BP between right and left, palpable thrill present in suprasternal notch
supravalvular aortic stenosois (usually due to congenital left ventricular outflow obstruction)…can cause left ventricular hypertrophy over time and coronary artery stenosis leading to ischemia…can present in younger patients
angina happens during instances of increased myocardial o2 demand
meds that can cause sensorineural hearing loss
aminoglycosides
chemo agents like cisplatin
aspirin (more often tinnitus)
loop diuretics
first line antihypertensives in pregnancy
- methyldopa
- betablockers (labetlol)
- hydralazine
- CCBs
common adverse effect CCBs (esp dihydropyridines like -dipine)
peripheral edema due to preferential dilation of pre capillary vessels
how to counteract peripheral edema due to CCBs
add on ACEI or ARB
what additional treatment besides ASA, statin, and anticoagulant to do in case of acute STEMI with bibasilar crackles in lung fields?
furosemide (flash pulmonary edema)
DO NOT GIVE BETA BLOCKER (c/I in pulmonary edema/CHF/bradycardia since they cause bronchoconstriction)
Which arrhythmia is most specific for digitalis toxicity?
atrial tachycardia with AV block
infective endocarditis patient with AV block and diastolic murmur on left sternal border
raise suspicion for AORTIC REGURGITATION 2/2 PERIVALVULAR ABSCESS
tricuspid regurg is more common but presents with systolic murmur
new fib with acute onset CHF symptoms in otherwise asymptomatic patient
rheumatic mitral stenosis
patient presents with lower extremity edema…how to differentiate between cardiac and liver disease?
cardiac cause - positive hepatojugular reflex (sign of right side heart failure)
liver - normal or reduced JVP and no hepatojugular reflex
Bradycardia, hypotension, wheezing, hypoglycemia, delirium, seizures, cardiogenic shock…suicide attempt
dx and rx
beta blocker overdose
rx with IV atropine and fluids…refractory hypotension treated with IV glucagon
abrupt onset regular tachycardia that resolves with cold water immersion…dx and treatment mechanism
paroxysmal supra ventricular tachycardia (PSVT) usually due to atrioventricular nodal re-entrant tachycardia (usu. seen in younger patients with structurally normal heart)
vagal maneuvers increase parasympathetic tone in heart which will result in temporary slowing of AV NODE conduction and prolonged of refractory period which will terminate AVNRT
how to manage profound hypotension found in patient with right ventricular MI?
normal saline bolus to increase right ventricular preload and increase CO
then if refractory give inotropic agents like dopamine/dobutamine
cyanotic baby with left axis deviation, small/absent R waves, decreased pulmonary markings on chest xray, asd/vsd
tricuspid atresia
which conditions besides cardiac tamponade can cause pulses paradoxus
asthma
COPD
first line pharmacologic treatment for torsades in HDS patient
magnesium sulfate
bounding pulses vs. pulsus parvus trades vs. pulsus paradoxus
bounding pulses - aka water hammer, seen in aortic regurg, due to increased stroke volume and sudden increase in systolic BP (hyper dynamic pulse)
pulsus parvus/tardus - decreased pulse amplitude and upstroke, seen in aortic stenosis
pulsus paradoxus - SBP decrease > 10 mmhg in inspiration, seen in tamponade
reversible H causes of of PEA or asystole
- hypovolemia
- hypoxemia
- hyperkalemia
- hypokalemia
- hypoglycemia
- hypothermia
- H+ ions (acidosis)
reversible T causes of PEA or asystole
- trauma
- tension pneumo
- tamponad
pounding heart sensation, more aware of heartbeat lying on left side, BP 150/45
aortic regurg (widened pulse pressure, collapsing/water hammer pulse)
aortic regurg will increase LV size which will bring enlarged ventricle closer to chest wall and create pounding sensation
bilateral hip pain, thigh and butt claudication, impotence, symmetric atrophy of bilateral lower extremities
aortoiliac occlusion (Leriche syndrome)…due to arterial occlusion at aortic bifurcation into common iliac arteries
leads to chronic ischemia
elderly male comes in with BP 165/75
isolated systolic hypertension (systolic>140, diastolic<90)…primary hypertension caused by increased stiffness/decreased elasticity of arterial walls
cyanosis aggravated by feeding and relieved by crying
choanal atresia (baby can only breathe through mouth)
