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60 Cards in this Set

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Delirium tremens (DTs) is a serious, potentially fatal consequence of alcohol withdrawal. The patient’s history of previous DTs and his ongoing pattern of drinking make the occurrence of DTs likely. most appropriate management of the patient’s withdrawal?
Given this high-risk situation, one should choose the method of withdrawal that is medically safest, which is to use a cross-tolerant agent. Benzodiazepines, such as chlordiazepoxide, are commonly used for this purpose.
The clinical scenario of lightheadedness in the appropriate context—standing in line, no exertion, and normal ECG—suggests
vasovagal syncope.
often presents with substernal pain relieved with leaning forward;
Pericarditis
finding on ECG to suggest pericarditis.
ST elevation
a known adverse effect of clozapine and could present with seizures or mental status disturbances.
Hyponatremia
a known adverse effect of clozapine and should be suspected in individuals who develop fever with tachycardia
Myocarditis
should be suspected in patients presenting with high fever, decreasing mental status and muscular rigidity.
Neuroleptic malignant syndrome
Sialorrhea is excessive drooling and occurs in 30% to 50% of individuals taking clozapine. Most neuroleptics result in a dry mouth through their cholinergic effects, but sialorrhea casued by
clozapine
Regular-rate monomorphic wide QRS complex tachyarrhythmias should be assumed due to a
pre-excitation syndrome such as Wolff-Parkinson-White (WPW) until proven otherwise.
the drug most frequently associated with fatal outcomes in the treatment of patients with Wolff-Parkinson-White (WPW).
Digitalis
is considered first-line treatment in patients with wide complex tachycardia, particularly if ventricular tachycardia cannot be excluded from the diagnosis.
A. Adenosine
B. Amiodarone
C. Digoxin
D. Metoprolol
E. Verapamil
Amiodarone
is classically described in young women as a cause of secondary hypertension. It is an arterial disease of unknown etiology commonly affecting the renal arteries and presenting as renovascular hypertension. The internal carotid artery is the second most common location often effected bilaterally and may cause cerebral ischemia, transient ischemic attack, or thromboembolic stroke.
Fibromuscular dysplasia
Fibromuscular dysplasia is an arterial disease of unknown etiology most commonly affecting the
renal arteries and presenting as renovascular hypertension
is the second most common location in Fibromuscular dysplasia
The internal carotid artery, often effected bilaterally and may cause cerebral ischemia, transient ischemic attack, or thromboembolic stroke.
likely to lower the blood pressure and treat benign prostatic hypertrophy.
α-blocker
patient presents with temporal headache and jaw claudication suggestive of
giant cell (temporal) arteritis
He has experienced this headache for approximately 6 months. Upon questioning he also describes tongue pain and fatigue of the chewing muscles while eating. The physical examination is unremarkable. His erythrocyte sedimentation rate (ESR) is elevated.
Giant cell arteritis
arteriogram shows several small aneurysms in the branches of the superior mesenteric artery, suggestive of
polyarteritis nodosa
the Parkland formula
intravenous fluid resuscitation of a burn victim involves 4 mL/kg/% burn

Half of this is given over 8 hours then the latter half over the next 16.
intravenous fluid resuscitation of a burn victim formula
4 mL/kg/% burn

Half of this is given over 8 hours then the latter half over the next 16.
Skin and mucous membranes are dry. Pupils are dilated and fixed to accommodation. Chest is clear to auscultation and percussion. Cardiac examination shows a regular rhythm tachycardia only. Abdomen is soft and nontender with decreased bowel sounds. The patient is unable to provide a urine sample.
anticholinergic syndrome.
QRS widening in patients with anticholinergic syndrome
A. Diphenhydramine
B. Neostigmine
C. Physostigmine
D. Sodium bicarbonate
E. Syrup of Ipecac
Option D (Sodium bicarbonate) is correct. The patient shows classic signs and symptoms of anticholinergic syndrome. QRS widening in patients with anticholinergic syndrome is one of the few remaining indications for bicarbonate administration.

Option A (Diphenhydramine) is incorrect. Diphenhydramine overdose is a common cause of this syndrome. Obviously, this medication should not be administered.

Option B (Neostigmine) is incorrect. Physostigmine is the only reversible inhibitor capable of directly antagonizing the CNS effects of anticholinergic toxicity. Additionally, QRS widening occurring in the presence of anticholinergic syndrome is a contraindication for acetylcholinesterase inhibitor therapy.

Option C (Physostigmine) is incorrect. Although physostigmine is the antidote for the patient's likely overdose of a substance with anticholinergic properties, the presence of QRS widening is a strong contraindication for this pharmacotherapy.

Option E (Syrup of Ipecac) is incorrect. Ipecac should not be used in patients with anticholinergic syndrome because of the increased risk for aspiration in patients with altered mental status and at increased risk for seizures
high serum sodium, low serum potassium, and low renin levels.
Primary hyperaldosteronism
high serum sodium, low serum potassium, and high renin levels.
secondary hyperaldosteronism
This patient has unexplained syncope following a normal history, physical examination, and ECG. In the absence of any guiding information, the most appropriate next diagnostic step is
A. Electroencephalogram (EEG)
B. Head computed tomography (CT)
C. Holter monitor
D. Psychiatric evaluation
E. Tilt-table test
Option E (Tilt-table test) is correct. This patient has unexplained syncope following a normal history, physical examination, and ECG. In the absence of any guiding information, the most appropriate next diagnostic step is the use of tilt-table testing. The test is performed by altering the angle of the table.

Option A (Electroencephalogram [EEG]) is incorrect. EEG can be useful if epilepsy were suspected, but there is nothing in the history to suspect seizure activity.

Option B (Head computed tomography [CT]) is incorrect. There is nothing suggestive in the history or on physical examination of a specific intracranial pathology detectable on head CT.

Option C (Holter monitor) is incorrect. A Holter monitor is indicated in patients who have underlying heart disease, but no suggestive reason for syncope on history or physical examination.

Option D (Psychiatric evaluation) is incorrect. Psychiatric evaluation is indicated in young patients who do not have a demonstrable pathophysiologic reason for recurrent syncope. The tilt-table test should generally be performed prior to referring a patient for psychiatric evaluation.
patient is in atrial fibrillation. What is the first line of therapy?
A. Heparin
B. Methimazole
C. Propranolol
D. Propylthiouracil
E. Radioactive iodine
Option C (Propranolol) is correct. It is important to reduce cardiac stress.

Option A (Heparin) is incorrect. There is no role for this medication.

Option B (Methimazole) is incorrect. This may be part of the overall therapy, but cardiac protection comes first.

Option D (Propylthiouracil) is incorrect. This may be part of the overall therapy, but cardiac protection comes first.

Option E (Radioactive iodine) is incorrect. This may be part of the overall therapy, but cardiac protection comes first.
Nonconducted P waves are seen in the absence of progressive PR prolongation. AV block type
Second-degree AV block, type II.
atrial tachycardia with a 2:1 AV block. AV block type
Digoxin-induced second-degree atrioventricular (AV) block
prolongation of the P-R interval without dropped beat. AV block type
First-degree AV block
progressive PR prolongation preceding a nonconducted P wave. AV block type
Second-degree AV block, type I (Wenckebach)
wide, fixed split S2 with a systolic ejection murmur over the pulmonic region.
Atrial septal defect, secundum type
neonate demonstrates pronounced cyanosis and a loud, single S2.
Transposition of the great vessels
Atrial septal defect Physical Findings
Parasternal RV impulse Widely and fixed split S2 Ejection murmur across pulmonic valve
Atrial septal defect Chest Radiograph
Large pulmonary artery Increased pulmonary markings
Atrial septal defect Electrocardiogram
Right bundle branch block Left axis deviation with ostium primum defect
Ventricular septal defect Physical Findings
Hyperdynamic precordium Holosystolic left parasternal murmur, ±thrill
Ventricular septal Electrocardiogram
LV and RV hypertrophy
Ventricular septal defect Chest Radiograph
Cardiomegaly Prominent pulmonary vasculature
Patent ductus arteriosus Physical Findings
Hyperdynamic apical impulse Continuous "machinery" murmur
Patent ductus arteriosus Electrocardiogram
LV hypertrophy
Patent ductus arteriosus Chest Radiograph
Prominent pulmonary artery Enlarged LA and LV
the most common congenital heart defect to produce cyanosis within the first 24 hours of life
Transposition of the great vessels
gray baby from birth, hepatomegaly, and dyspnea while feeding. on Doppler echocardiography, there is no forward blood flow through the ascending aorta.
Hypoplastic left heart syndrome
Patients with slight, mild limitation of activity and are comfortable at rest are categorized as CHF class
CHF class II. Addition of digoxin is recommended in these patients.
idiopathic pulmonary arterial hypertension
A. Calcium channel blockers
B. Corticosteroids
C. Glycoprotein IIb/IIIa inhibitors
D. Prostacyclin agents
E. Tumor necrosis factor inhibitors
Epoprostenol is a formulation of naturally occurring PGI2 (prostacyclin) that is used to treat pulmonary arterial hypertension (PAH).

Option D (Prostacyclin agents) is correct. Untreated, idiopathic pulmonary arterial hypertension leads to right-sided heart failure and death with an overall survival of approximately 30% at 3 years. The use of long-term prostacyclin agents resulted in a 5-year survival rate greater than 65%.

Option A (Calcium channel blockers) is incorrect. Calcium channel blockers were, until recently, the most widely used class of drugs for idiopathic pulmonary arterial hypertension. The introduction of long-term prostacyclin agents for treatment of idiopathic pulmonary arterial hypertension has resulted in a improvement in survival from 30% at 3 years to a 5-year survival rate greater than 65%.

Option B (Corticosteroids) is incorrect. Corticosteroids clearly improve survival in patients with SLE. They have no effect on the relentlessly fatal progression of idiopathic pulmonary arterial hypertension and therefore provide no improvement in this patient's prognosis of 30% 3-year survival without prostacyclin therapy.

Option C (Glycoprotein IIb/IIIa inhibitors) is incorrect. Glycoprotein IIb/IIIa inhibitors such as abciximab, eptifibatide and tirofiban are potent inhibitors of platelet aggregation. They have no effect on the progression of idiopathic pulmonary arterial hypertension.

Option E (Tumor necrosis factor inhibitors) is incorrect. Tumor necrosis factor inhibitors, such as infliximab, etanercept, and adalimumab, are promising new agents in the treatment of several autoimmune mediated diseases including juvenile arthritis. There is no evidence that they improve survival in patients with idiopathic pulmonary arterial hypertension.
A postoperative patient who goes into shock and was previously on corticosteroids should be suspected of
A. Adrenal insufficiency
B. Diabetic ketoacidosis
C. Hypoglycemia
D. Postoperative bleeding
E. Small-bowel obstruction
Option A (Adrenal insufficiency) is correct. A postoperative patient who goes into shock and was previously on corticosteroids should be suspected of having adrenal insufficiency as a result of a lack (or insufficient dose) of steroid administration. Prolonged steroid administration results in down-regulation of adrenocorticotropic hormone (ACTH), and if exogenous steroids are removed, ACTH is unable to rise quickly enough to compensate, and the patient can go into shock.

Option B (Diabetic ketoacidosis) is incorrect. Although diabetic ketoacidosis can occur in patients with type 1 diabetes, a high serum glucose is expected.

Option C (Hypoglycemia) is incorrect. The patient is hypoglycemic, but the cause of her symptoms is to the result of adrenal insufficiency. Hypoglycemia can result from lack of glucocorticoids.

Option D (Postoperative bleeding) is incorrect. This patient does have a slightly decreased hematocrit, but that is likely the result of anemia of chronic disease. Massive postoperative bleeding would be less likely following an uncomplicated surgery compared with adrenal insufficiency.

Option E (Small-bowel obstruction) is incorrect. Small-bowel obstruction can present in this manner; it would be unlikely for the patient to rapidly progress into a state of shock.
55-year-old woman sees her internist with a complaint of difficulty breathing when she lies flat on her back. She also reports shortness of breath with exertion and swelling of her ankles. DX?
CHF
Which of the following findings on physical examination is most likely in CHF?
A. Absent abdominal jugular reflux
B. Jugular venous distension at rest
C. Pedal edema
D. Rales
E. Third heart sound (S3)
Option B (Jugular venous distension at rest) is correct. This is found in patients, such as this one, presenting with congestive heart failure.

Option A (Absent abdominal jugular reflux) is incorrect. The absence of abdominal jugular reflux in a patient presenting with congestive heart failure (CHF) would be unusual.

Option C (Pedal edema) is incorrect. Pedal edema would be a likely finding in CHF, but it is often not present on examination in patients with CHF.

Option D (Rales) is incorrect. This finding is not as likely as the finding of jugular venous distention at rest in a patient presenting with CHF.

Option E (Third heart sound [S3]) is incorrect. This has a high predictive accuracy, but it is often not heard in patients presenting with CHF.
An electrocardiogram (ECG) reveals irregularly irregular RR intervals and an absence of P waves. Echocardiography demonstrates a dilated left ventricle, left ventricular ejection fraction of 36% and mild mitral regurgitation.
What is the most appropriate intervention to improve this patient's left ventricular function?
A. Afterload reduction
B. Coronary revascularization
C. Heart rate control
D. Inotropic support
E. Mitral valve replacement
Option C (Heart rate control) is correct. This patient has heart failure as evidenced by his poor ejection fraction (normal is between 50% and 60%). He also has developed atrial fibrillation, which is demonstrated by the irregularly irregular RR interval and absence of P waves on ECG. Normally, the atrial filling of the left ventricle is not overly significant. However, when there is dysfunction of the left ventricle (possibly an alcoholic cardiomyopathy in this case), the atrial kick becomes important. Controlling the heart rate is a method by which to improve the left ventricular ejection fraction (LVEF) by improving left ventricular filling. Importantly, heart rhythm control has been shown to be equally effective in this case.

Option A (Afterload reduction) is incorrect. Afterload reduction is a method of management for congestive heart failure (CHF). However, this patient is in atrial fibrillation and we would expect a more significant improvement if it were treated.

Option B (Coronary revascularization) is incorrect. This patient has a poor left ventricular ejection fraction (LVEF) that could be the result of alcoholic cardiomyopathy or even possibly, coronary artery disease. There is no clear indication in this question as to the specific etiology of this patient's heart failure. There is, however, clear evidence of atrial fibrillation that needs to be addressed.

Option D (Inotropic support) is incorrect. Inotropic support could improve this patient's left ventricular function, but heart rate control would allow for better left ventricular filling and would be a better solution in this case.

Option E (Mitral valve replacement) is incorrect. This patient has a dilated left ventricle, which often results in small mitral valve incompetence. Major cardiac surgery would not be the answer to this patient's problems.
In patients younger than age 45 years with a clinical picture of distal paresthesias, digital ulcers, claudication, normal proximal pulses, and diminished distal pulses with a negative workup for possible diabetic, autoimmune, hypercoagulation, or other thromboembolic etiologies disorders, the most likely diagnosis is
thromboangiitis obliterans (Buerger's disease).
patients younger than age 45 years with a clinical picture of distal paresthesias, digital ulcers, claudication, normal proximal pulses, and diminished distal pulses with a negative workup for possible diabetic, autoimmune, hypercoagulation, or other thromboembolic etiologies disorders, Virtually all patients have a history of
Virtually all patients with Buerger's disease have a heavy smoking history.
inferior wall MI.
A. ST depression is I, AVL
B. ST flattening V4–V6
C. ST segment elevation in II, III, AVF
D. ST segment elevation in V1, V2, V3
E. T wave deflection opposite to QRS deflection
Option C (ST segment elevation in II, III, AVF) is correct. These are the classic ECG changes associated with an inferior wall MI.

Option A (ST depression is I, AVL) is incorrect. This would be seen in an anterior wall MI.

Option B (ST flattening V4–V6) is incorrect. These are nonspecific changes.

Option D (ST segment elevation in V1, V2, V3) is incorrect. This would be seen in an anterior wall MI.

Option E (T wave deflection opposite to QRS deflection) is incorrect. These are nonspecific changes.
anterior wall MI.
A. ST depression is I, AVL
B. ST flattening V4–V6
C. ST segment elevation in II, III, AVF
D. ST segment elevation in V1, V2, V3
E. T wave deflection opposite to QRS deflection
A&D

Option A (ST depression is I, AVL) is incorrect. This would be seen in an anterior wall MI.


Option D (ST segment elevation in V1, V2, V3) is incorrect. This would be seen in an anterior wall MI.
nonspecific changes
A. ST depression is I, AVL
B. ST flattening V4–V6
C. ST segment elevation in II, III, AVF
D. ST segment elevation in V1, V2, V3
E. T wave deflection opposite to QRS deflection
B & E

Option B (ST flattening V4–V6) is incorrect. These are nonspecific changes.

Option E (T wave deflection opposite to QRS deflection) is incorrect. These are nonspecific changes.
Virchow’s triad
stasis, endothelial injury, and hypercoagulability.risk of pulmonary embolism is increased
describe pulsus paradoxus, which is often seen in pulmonary embolism.
Inspiratory increase in arterial pressure greater than 10 mm Hg
very effective in mild to moderate hypertension. They are the agents of choice in African Americans and when there is salt and water retention.
Diuretics, particularly thiazides
Thiazides ineffective when creatinine > X?
Thiazides ineffective when creatinine >2.5 mg/dL
patient’s blood pressure is uncontrolled with amlodipine. The secondary hyperaldosteronism associated with alcoholic cirrhosis leads to salt and water retention and contributes to worsening of hypertension. Hence, addition of what helps ameliorate ascites, edema, and hypertension?
an aldosterone antagonist such as spironolactone
The appropriate antihypertensive agent for patients with diabetes with “micro” or overt proteinuria is
an angiotensin-converting enzyme (ACE) inhibitor. This is based on compelling evidence that ACE inhibitors reduce proteinuria and are renal protective.