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409 Cards in this Set
- Front
- Back
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Essential HTN accounts for over 95% of all HTN. What is the most common cause of secondary HTN?
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Renal Artery Stenosis
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Does HTN usually cause a dialated heart or a concentrically hypertrophied heart?
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Concentric LVH
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A diagnosis of prehypertension calls for lifestyle modification for most patients. What are the systolic and diastolic ranges that are classified as Prehypertension?
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Systolic: 120-139
Diastolic: 80-89 |
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HTN is called the "silent killer" and causes insidious damage primarily to which four target organs?
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Heart
Eyes CNS Kidneys |
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Name three classes of HTN medications that are contraindicated in pregnancy-
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Thiazides
ACEIs and ARBs Calcium Channel Blockers (Beta blockers and hydralazine are acceptable) |
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Which medication is classically indicated in African American patients with HTN?
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Because "salt sensitive" HTN is more common in AAs, thiazide diuretics are the best choice.
If the pt is diabetic, use ACEIs |
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Which HTN medication is preferred in patients with DM?
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ACE inhibitors
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Patients with diabetes or renal insufficiency should get their blood pressure down to AT LEAST what level?
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should be below 135/85
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If a pt with HTN is not responding to their initial medication, is it better to:
-increase the dose -switch classes -or add a second agent |
Change to another first-line agent of a different class before adding a second agent
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How often should a healthy individual's lipid profile be screened?
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Every 5 years starting at age 20
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LDL is not directly measured in a serum chemistry test, but is calculated using which equation?
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LDL = total cholesterol - HDL - TG/5
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Which is the most atherogenic of all lipoprotein particles?
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LDL - levels above 160 mg/dL significantly increase CAD risk
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What is the difference between Xanthelasma and Xanthoma?
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Xanthelasma - lipid deposits on eyelids
Xanthoma - yellowish masses found on tendons |
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If a patient has some form of CHD, what should the LDL goal for the patient be?
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<100 mg/dL
Consider drug therapy if its over 130 Lifestyle changes if its between 100 and 130 |
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A patient with elevated TGs should be treated medically if levels are above what value?
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>500 mg/dL
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What are the best medications to lower TGs?
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Niacin is first line drug
Gemfibrozil is also effective |
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Which Dyslipidemia drug classes require monitoring of LFTs and CPK levels every 3-6 months?
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Statins and niacin
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Name three symptoms that suggest a viral etiology of a URI instead of bacterial?
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Rhinorrhea
Myalgias Headache |
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Name three techniques of physical examination that should be applied when evaluating a patient with suspected sinusitis-
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1. Look for purulent discharge draining from turbinates
2. Transillumination of maxillary sinus 3. Palpate over the sinuses for tenderness |
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What are good choices of antibiotics for a patient with sinusitis?
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Amoxicillin
TMP/SMX Levofloxacin Cefuroxime are all good choices |
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LDL is not directly measured in a serum chemistry test, but is calculated using which equation?
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LDL = total cholesterol - HDL - TG/5
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Which is the most atherogenic of all lipoprotein particles?
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LDL - levels above 160 mg/dL significantly increase CAD risk
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What is the difference between Xanthelasma and Xanthoma?
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Xanthelasma - lipid deposits on eyelids
Xanthoma - yellowish masses found on tendons |
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If a patient has some form of CHD, what should the LDL goal for the patient be?
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<100 mg/dL
Consider drug therapy if its over 130 Lifestyle changes if its between 100 and 130 |
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A patient with elevated TGs should be treated medically if levels are above what value?
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>500 mg/dL
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What are the best medications to lower TGs?
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Niacin is first line drug
Gemfibrozil is also effective |
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Which Dyslipidemia drug classes require monitoring of LFTs and CPK levels every 3-6 months?
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Statins and niacin
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Name three symptoms that suggest a viral etiology of a URI instead of bacterial?
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Rhinorrhea
Myalgias Headache |
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Name three techniques of physical examination that should be applied when evaluating a patient with suspected sinusitis-
|
1. Look for purulent discharge draining from turbinates
2. Transillumination of maxillary sinus 3. Palpate over the sinuses for tenderness |
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What are good choices of antibiotics for a patient with sinusitis?
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Amoxicillin
TMP/SMX Levofloxacin Cefuroxime are all good choices |
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A patient is diagnosed with laryngitis. You should send them home with what advice?
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Rest voice until laryngitis resolves to avoid formation of vocal nodules
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A patient is diagnosed with strep throat. How should he be treated?
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Penicillin for 10 days
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Name four "alarm symptoms" that suggest further work-up in a patient with dyspepsia-
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Weight loss
Anemia Dysphagia Obstructive symptoms |
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Acute diarrhea is most commonly due to what etiology?
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Viral infection
Rotavirus and Norwalk |
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What is the most common cause of chronic diarrhea?
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Irritable Bowel Syndrome
a diagnosis of exclusion |
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What most commonly happens to the acid-base balance and potassium levels in a patient with severe diarrhea?
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Metabolic acidosis
Hypokalemia |
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Name some reasons for hospitalization of a patient with acute diarrhea-
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Dehydration
Inability to tolerate or hold down PO fluids Profuse bloody diarrhea High fever with toxic appearance |
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What is the appropriate empirical antibiotic for a patient with high fever, bloody stools or severe diarrhea?
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Quinolones
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What is the antibiotic of choice for a patient known to be suffering with diarrhea due to Shigella?
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TMP/SMX
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What is the antibiotic of choice for a patient known to be suffering with diarrhea due to Campylobacter jejuni?
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Erythromycin
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What are three recommendations to give to a patient suffering from constipation?
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Increase physical activity
Increase high-fiber foods Increase fluid intake |
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What percent of all adults suffer from Irritable Bowel Syndrome?
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10-15% of all adults
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What is the most common change in acid-base balance and potassium levels seen in a patient with severe vomiting?
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Metabolic alkalosis with hypokalemia
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Which primary neoplasms most commonly metastasize to the spine?
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Breast
Lung Prostate Kidney Thyroid |
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What is the RICE therapy for an ankle sprain?
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Rest
Ice Compression Elevation |
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How would you elicit Tinel's sign in a patient with Carpal Tunnel Syndrome?
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Tap over the median nerve at the wrist crease - which should cause paresthesias in the median nerve distribution
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What are the names of the bony overgrowths seen in the DIPs and PIPs in osteoarthritis?
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Bouchard nodes - PIP
Heberden nodes - DIP |
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What are the most common fractures in a patient with osteoporosis?
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Vertebral body compression fractures
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What is the ideal exercise for a patient with osteoarthritis?
Osteoporosis? |
OA - swimming (avoid excessive walking)
Osteoporosis - weight bearing exercise to stimulate bone formation |
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Did the PROOF trial show calcitonin to be an effective therapy for patients with osteoporosis?
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It had no effect at the hip, but a 40% reduction in vertebral fractures
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What pattern of vision loss is typical in a patient with Age Related Macular Degeneration?
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Loss of central vision, blurred vision, distortion and scotoma (blind spot). Peripheral vision is preserved
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A 75 year old patient complains of loss of visual acuity that has progressed slowly over several years. She especially has trouble driving at night. This is typical of which eye disease?
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Cataracts (present in over half of people over 75yo)
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A 50 year old patient suddenly loses sight in his left eye. What is the most likely diagnosis?
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Amaurosis Fugax
Caused by embolization of cholesterol plaque, usually from carotid artery. Vision returns spontaneously when reperfusion is established. |
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What are behavioral/lifestyle modifications to treat mild/moderate Obstructive Sleep Apnea?
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Weight loss
Avoid alcohol and sedatives Avoid supine position during sleep |
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What are the most important risk factors for erectile dysfunction?
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Those that contribute to atherosclerosis - HTN, smoking, diabetes, dyslipidemia
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How does moderate alcohol use affect HDL and TG levels?
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Increases HDL, but also increases TGs
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In an alcoholic patient in withdrawal, how many days after the last drink does it take for delerium tremens to develop?
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Usually 2-4 days after the last drink
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How often should healthy women have mammograms?
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Every 1-2 years after 40yo
Every year after 50 |
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How often should a sexually active woman receive a Pap smear?
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Within the first 3 years of first sexual activity
Every three years until age 35 Then every 5 years until age 65 |
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During which trimester is it best for a woman to receive the seasonal flu vaccine?
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Either in the 2nd or 3rd trimester.
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Which patients are especially advised to receive the pneumococcal vaccine?
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Adults>65
Asplenic or sickle cell patients Adults with chronic medical problems or immunodeficiencies Women with high risk pregnancies |
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A chest X-ray is taken to check the position of a central line. Where should the tip be seen?
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Above the right atrium in the SVC
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What position should the patient assume for the standard abdominal x-ray?
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A supine view - which is ideal for seeing the gas pattern
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What three EKG patterns suggest a Right Bundle Branch Block?
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Widened QRS complex
rSR wave in the chest leads Wide S wave in lead I |
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In which leads do you expect to see notched R waves in a Left Bundle Branch Block?
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Leads I, V5, V6
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What is the criteria in order for Q waves to be considered significant in an EKG?
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They should be >25% of the QRS amplitude
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In which three conditions may you see peaked T waves on EKG?
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Very early stages of MI
Hyperkalemia Hypermagnesemia |
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Name two common conditions for which fluoroquinolones are indicated as empiric therapy-
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UTI
Acute diarrhea due to enteric bacteria |
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What are two feared adverse reactions to isoniazid therapy?
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Drug-induced hepatitis, which can be fatal
Peripheral neuropathy, which can be treated with pyridoxine |
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For which heart sounds and murmurs is it best to use the bell of the stethoscope?
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S3 and S4
and the murmur of mitral stenosis |
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Which antibiotic is contraindicated in children due to its potential to damage growing cartilage?
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Fluoroquinolones
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What is the pathophysiologic cause of rales (crackles) vs. rhonchi?
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Rales - excessive fluid in the lungs
Rhonchi - high mucus production in the large airways |
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What is the CEA marker useful for clinically in CRC?
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Effective for monitoring CRC disease process and prognosis after surgery. Not effective as a screening test for CRC.
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For which two neoplasms can alpha-feto protein be used as a tumor marker?
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Hepatocellular carcinoma
Non-seminomatous germ-cell tumors of tesis (NSGCT) |
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For which neoplasm is CA-19-9 a useful tumor marker?
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Pancreatic cancer
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If a patient is in a hypertensive emergency, which drugs might be chosen to reduce blood pressure?
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IV labetalol,
Nitroprusside Enalapril BP should not be lowered by more than 25% in the first two hours |
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How is VT treated if the patient is stable? Unstable?
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Stable - IV amiodarone
Unstable - DC cardioversion |
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Which inflammatory skin disorder commonly affects the scalp, hairline, behind the ears, folds of skin around the nose and other skin folds?
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Seborrheic dermatitis (affects 5% of the population, especially those with oily skin)
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Which dermatologic condition appears as a generalized rash with oval shaped lesions, and is described as having a Christmas tree type appearance?
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Pityriasis Rosea
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Herpes zoster typically presents in patients over 50. What should you suspect if it appears in a patient under 50?
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An immunocompromised state
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What is the most common skin cancer?
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Basal cell carcinoma (60-75% of all skin cancers)
Metastasis is extremely rare, but it can be locally destructive |
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What is the most common site of a melanoma?
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On the back
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What is the pathogenesis of a decubitus ulcer (pressure sore)?
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They result from necrosis of tissue that becomes ischemic and ulcerates
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What are common sites that are affected by angioedema?
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Eyelids, lips, tongue, genitalia, hands, feet
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What is the only reasonable method for differentiating between pneumonia and acute bronchitis?
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CXR
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What are clinical symptoms that suggest upper respiratory infection rather than lower respiratory infection?
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Nasal discharge
Sore throat Ear pain |
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A patient with suspected pneumonia has "pulse-temperature dissociation." Describe this phenomenon and what etiology is it suggestive of?
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Pulse temperature dissociation is a normal pulse in the setting of high fever and is suggestive of atypical CAP
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Which patients are more likely to contract Legionella pneumonia?
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Organ transplant recipients
Patients with renal failure Patients with chronic lung disease Smokers |
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Which etiology of pneumonia has a urinary antigen assay as a diagnostic test?
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Legionella
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What is the proper empiric therapy in a young patient with suspected atypical pneumonia?
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Macrolides or doxycycline cover S. pneumonia and all the atypical pneumonias
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How long does a TB culture take?
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4-8 weeks
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What is the prophylactic treatment for latent TB?
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Isoniazid for 9 months
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What is the treatment schedule for a patient with active TB?
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2 months of 4 drug regiment (Rifampin, isoniazid, pyrazinamide, and ethabutol or streptomycin)
And then 4 months using just isoniazid and rifampin |
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What are the two classic physical examination techniques that irritate the meninges to test for meningitis? How is each performed?
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Kernig sign - inability to fully extend knee when patient is supine and hip is flexed at 90 degrees
Brudzinski sign - flexion of legs and thighs that is brought on by passive flexion of neck. Both are only about 50% sensitive |
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Name five tests that should be performed on CSF after a spinal tap in a patient with suspected meningitis-
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Cell count
Chemistry (glucose and protein) Gram stain Culture Cryptococcal antigen/India ink |
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Should a CT of the head always be performed before an LP?
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No, only when there are focal neurologic signs or evidence of a space occupying lesion with elevated ICP
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What is the most sensitive and specific test for diagnosing various viral encephalitides?
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PCR of CSF
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Which two causes of viral encephalitis can be treated with antiviral drugs?
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HSV - acyclovir for 2-3 weeks
CMV - ganciclovir or foscarnet |
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Which is more likely to progress to chronic hepatitis - Hep B or Hep C?
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Hepatitis B progresses in 5-10% of cases. Hepatits C progresses in 85-90% of cases.
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Name two physical exam signs that suggest hepatic encephalopathy-
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Asterixis and palmar erythma
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Is the paralysis of botulism...
Symmetric or asymmetric? Ascending or descending? |
Symmetric and ascending
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Which three organisms cause more than 90% of uncomplicated UTIs?
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E coli
S. saprophyticus Enterococcus spp |
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Which two tests on a urine dipstick indicate UTI?
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Positive leukocyte esterase test
Positive nitrite test Combining the two tests yields a sensitivity of 85% and specificity of 75% |
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In which situations should the physician obtain urine cultures when diagnosing a UTI?
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Patient age >65
Diabetes Recurrent UTIs Symptoms over 7 dyas Use of diaphragm |
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If there is no known resistance in the community, what is the standard empiric treatment for an uncomplicated UTI?
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Oral TMP/SMX for 3 days
Fluoroquinolone if resistance rate is high |
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What would you see in urinalysis that would suggest pyelonephritis instead of uncomplicated UTI?
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Leukocyte casts
Pyuria and bacteriuria as well |
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With which infection are 80% of cases of Reiter's syndrome associated?
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Chlamydial infection
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Which antibiotics are good for treating....
Gonorrhea? Chlamydia? |
Gonorrhea - ceftriaxone 1 IM dose
Chlamydia - azithromycin 1 dose or doxycycline oral 7 days |
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Where in the brain CT are you most likely to see mass lesions from toxoplasmosis?
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Contrast enhanced mass lesions in the basal ganglia and subcortical white matter
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What is the treatment schedule for cryptococcal meningitis?
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Amphotericin B for 10-14 days followed by 8-10 weeks of oral fluconazole (possible lifelong maintenance therapy with fluconazole)
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What is the most common opportunistic bacterial infection in patients with AIDS?
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Mycobacterium-avium complex
Diarrhea and weight loss are constitutional symptoms |
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What three malignancies are common in patients with AIDS?
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Kaposi sarcoma
Non-Hodgkin's lymphoma Primary CNS lymphoma |
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Which classes of drugs are used in triple drug therapy in HAART?
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2 nucleoside reverse transcriptase inhibitors
and either a nonNRTI or protease inhibitor |
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What three vaccines should patients with AIDS receive?
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Pneumococcal
Influenza Hepatitis B |
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Which disease presents with a hard, indurated painless ulcer with a clean base on the penis?
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Primary syphilis
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What are the typical symptoms of secondary syphilis?
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A maculopapular rash is the most characteristic finding
Also, flu-like symptoms, aseptic meningitis, hepatitis |
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What is the definitive diagnosis of primary syphilis?
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Darkfield microscopy of sample from chancre with visualization of spirochetes
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Which disease presents with painful genital ulcer(s) that can be deep with ragged borders and a purulent base?
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Chancroid
diagnosis made clinically from appearance of ulcer |
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What is the treatment for chancroid?
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Azithromycin (oral, one dose)
Ceftriazone (IM one dose) |
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What is the treatment plan for a patient with cellulitis?
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Staphylococcal penicillins (oxacillin, nafcillin) or cephalosporin IV until signs of infection improve. Then oral antibiotics for 2 weeks
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What is the treatment plan for necrotizing fasciitis?
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Antibacterial treatment alone is not enough. Rapid surgical excision of devitalized tissue is a necessity.
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What is the treatment plan for Lyme disease?
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Oral doxycycline for 21 days
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What is the typical order of onset of symptoms in Rocky Mountain Spotted Fever?
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Symptoms present about 1 week after tick bite.
Sudden onset of fever, chills malaise, myalgias, headache. Papular rash usually appears 4 to 5 days later. Starts peripherally, spreads centrally |
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Should a person bitten by an animal with known rabies receive active or passive immunization?
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Both. Passive human Ig administered in the wound and gluteal region. Active immunization in three IM doses over a 28 day period
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What are the classical criteria for "Fever of Unknown Origin?"
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Fever over 38.3 (101F)
Continuing at least 3 weeks No diagnosis despite 1 week of inpatient workup |
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What is the treatment for toxic shock syndrome?
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Hemodynamic stablization is first priority
Source of toxin should be removed Antistaphylococcal therapy (nafcillin, axacillin, vancomycin) |
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Does the monospot test detect antibodies against EBV, CMV or both?
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Just EBV-- detects heterophile antibodies, which do not form against CMV
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What is the treatment for mononucleosis?
|
No specific treatment is indicated. Rest, analgesics, no contact sports to avoid splenic rupture
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Where on the body is the pallor of anemia best visualized?
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Conjunctiva
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How much does Hb and Hct increase with one pack of packed RBCs?
|
Increases Hb by 1
and Hct by 3 |
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What are the important contents of cryoprecipitate?
|
Factor VIII and fibrinogen
also contains vWF and factor XIII |
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What should you suspect with macrocytic anemia and normal folate and B12 levels?
|
Liver disease
|
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Which two pathologies should you suspect with a reticulocyte index over 2?
|
Acute blood loss
Hemolysis |
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Which microcytic anemia also has an abnormal RDW?
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Iron deficiency anemia
|
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What is the best way to differentiate between iron deficiency and anemia of chronic disease?
|
Serum ferritin levels are high in anemia of chronic disease
|
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What other molecules can be assayed besides B12 to determine if a patient has low B12?
|
Methylmalonic acid and Homocysteine should both be high
|
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If a patient has pernicious anemia, what is his treatment schedule?
|
Cyanocobalamin (B12) IM once per month
|
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What is the most common cause of folate deficiency?
|
Inadequate dietary intake - tea and toast diet
|
|
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Where on the body is the pallor of anemia best visualized?
|
Conjunctiva
|
|
|
How much does Hb and Hct increase with one pack of packed RBCs?
|
Increases Hb by 1
and Hct by 3 |
|
|
What are the important contents of cryoprecipitate?
|
Factor VIII and fibrinogen
also contains vWF and factor XIII |
|
|
What should you suspect with macrocytic anemia and normal folate and B12 levels?
|
Liver disease
|
|
|
Which two pathologies should you suspect with a reticulocyte index over 2?
|
Acute blood loss
Hemolysis |
|
|
Which microcytic anemia also has an abnormal RDW?
|
Iron deficiency anemia
|
|
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What is the best way to differentiate between iron deficiency and anemia of chronic disease?
|
Serum ferritin levels are high in anemia of chronic disease
|
|
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What other molecules can be assayed besides B12 to determine if a patient has low B12?
|
Methylmalonic acid and Homocysteine should both be high
|
|
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If a patient has pernicious anemia, what is his treatment schedule?
|
Cyanocobalamin (B12) IM once per month
|
|
|
What is the most common cause of folate deficiency?
|
Inadequate dietary intake - tea and toast diet
|
|
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What laboratory tests are abnormal in hemolytic anemia?
|
Elevated reticulocyte count
High LDH Decreased haptoglobin Decreased Hb and Hct Elevated indirect bilirubin |
|
|
What is the treatment of choice in Hereditary Spherocytosis?
|
Splenectomy
|
|
|
What is the normal range of platelet counts?
|
150,000 - 400,000 per microliter
|
|
|
What bleeding disorder has increased bleeding time, PT and PTT?
|
DIC
|
|
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Does heparin affect PT or PTT?
|
Prolongs PTT
|
|
|
What are the indications for heparin use?
|
Venous thromboembolism - DVT, PE
Acute coronary syndromes Atrial fibrillation in acute setting After vascular bypass grafting |
|
|
What is the best treatment for a patient who is severely bleeding on heparin?
|
Administer FFP.
The effectiveness of protamine sulfate has not been proven |
|
|
Does Low Molecular Weight Heparin affect the PT or PTT?
|
Neither!
|
|
|
What are the advantages of LMWH over regular heparin?
|
Greater convenience - no PTT monitoring necessary, given subcutaneously.
Also decreased risk of side effects (HIT, osteoporosis) |
|
|
What is the target INR for a patient on warfarin anticoagulation?
|
2-3 is usually therapeutic
|
|
|
What laboratory tests are abnormal in hemolytic anemia?
|
Elevated reticulocyte count
High LDH Decreased haptoglobin Decreased Hb and Hct Elevated indirect bilirubin |
|
|
What is the treatment of choice in Hereditary Spherocytosis?
|
Splenectomy
|
|
|
What is the normal range of platelet counts?
|
150,000 - 400,000 per microliter
|
|
|
What bleeding disorder has increased bleeding time, PT and PTT?
|
DIC
|
|
|
Does heparin affect PT or PTT?
|
Prolongs PTT
|
|
|
What are the indications for heparin use?
|
Venous thromboembolism - DVT, PE
Acute coronary syndromes Atrial fibrillation in acute setting After vascular bypass grafting |
|
|
What is the best treatment for a patient who is severely bleeding on heparin?
|
Administer FFP.
The effectiveness of protamine sulfate has not been proven |
|
|
Does Low Molecular Weight Heparin affect the PT or PTT?
|
Neither!
|
|
|
What are the advantages of LMWH over regular heparin?
|
Greater convenience - no PTT monitoring necessary, given subcutaneously.
Also decreased risk of side effects (HIT, osteoporosis) |
|
|
What is the target INR for a patient on warfarin anticoagulation?
|
2-3 is usually therapeutic
|
|
|
What laboratory tests are abnormal in hemolytic anemia?
|
Elevated reticulocyte count
High LDH Decreased haptoglobin Decreased Hb and Hct Elevated indirect bilirubin |
|
|
What is the treatment of choice in Hereditary Spherocytosis?
|
Splenectomy
|
|
|
What is the normal range of platelet counts?
|
150,000 - 400,000 per microliter
|
|
|
What bleeding disorder has increased bleeding time, PT and PTT?
|
DIC
|
|
|
Does heparin affect PT or PTT?
|
Prolongs PTT
|
|
|
What are the indications for heparin use?
|
Venous thromboembolism - DVT, PE
Acute coronary syndromes Atrial fibrillation in acute setting After vascular bypass grafting |
|
|
What is the best treatment of a patient who is severely bleeding for a patient on heparin?
|
Administer FFP.
The effectiveness of protamine sulfate has not been proven |
|
|
Does Low Molecular Weight Heparin affect the PT or PTT?
|
Neither!
|
|
|
What are the advantages of LMWH over regular heparin?
|
Greater convenience - no PTT monitoring necessary, given subcutaneously.
Also decreased risk of side effects (HIT, osteoporosis) |
|
|
What is the target INR for a patient on warfarin anticoagulation?
|
2-3 is usually therapeutic
|
|
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A 60 year old African American patient presents with low hemoglobin, high serum protein, high calcium, and poor renal function. What condition is suggested by these findings?
|
Multiple Myeloma
|
|
|
What is the most common cause of death in Multiple Myeloma patients?
|
Infection - lung or urinary tract most common
Secondary to deprivation of normal immunoglobulins - impaired humoral immunity |
|
|
What is the treatment plan for a patient with MGUS?
|
No specific treatment necessary - just close observation
Fewer than 20% develop Multiple Myeloma |
|
|
What is the treatment plan for a patient with polycythemia vera?
|
Myelosuppression with hydroxyurea or interferon alpha.
Repeated phlebotomies to lower hematocrit |
|
|
What are the most common clinical symptoms of a patient with ARF?
|
Patients are usually asymptomatic. Maybe weight gain and edema
|
|
|
Brownish granular casts on urinalysis is suggestive of what pathology?
|
Acute Tubular Necrosis
|
|
|
Why is the BUN/Cr ratio elevated in prerenal failure?
|
There is low perfusion to the kidneys, but the kidney is still fully functional. Urea is mostly reabsorbed, while Cr is freely filtered as usual. So the serum urea is elevated and Cr relatively lowered.
|
|
|
What are the two most common causes of chronic renal failure?
|
DM (30%) and HTN (25%)
|
|
|
What is the treatment plan for a patient with Chronic Renal Failure?
|
Diet - Low protein and salt
ACE inhibitors Strict BP control Glycemic control |
|
|
What is the normal range of urine pH?
|
4.5 - 8 with an average of 6
|
|
|
What is the most common cause of membranoproliferative glomerulonephritis?
|
Hepatitis C infection
also HepB, syphilis, lupus |
|
|
What is the classic presentation of Acute Interstitial Nephritis?
|
ARF
Rash, fever, eosinophilia maybe pyuria and hematuria |
|
|
What is the defect in Type 1 Renal Tubular Acidosis?
|
Inability to secrete H+ in the distal tubule
|
|
|
What is the defect in Type 2 Renal Tubular Acidosis?
|
Inability to reabsorb HCO3 in the proximal tubule
|
|
|
What is the defect in Type 4 Renal Tubular Acidosis?
|
Hypoaldosteronism or renal resistance to aldosterone
|
|
|
Which types of Renal Tubular Acidosis result in hyperkalemia vs. hypokalemia?
|
Hypo - Type 1 and 2
Hyper - Type 4 |
|
|
What is the diagnostic test of choice for Adult Polycystic Kidney Disease?
|
Ultrasound
|
|
|
What is the treatment plan for a patient with Adult Polycystic Kidney Disease?
|
Drain cysts if symptomatic
Control HTN Treat infection with antibiotics |
|
|
If a patient is found to have HTN due to renal artery stenosis, which antihypertensive agents should be avoided?
|
ACE inhibitors
|
|
|
What is the typical presentation of nephrolithiasis? Describe the pain and accompanying symptoms-
|
Flank pain that radiates anteriorly towards groin
Nausea and vomiting are common Hematuria in 90% of cases |
|
|
What is usually the initial imaging test for detecting renal stones?
|
Plain abdominal X ray
Though cystine and uric acid stones are not usually visible on plain films |
|
|
Stones larger than what diameter are unlikely to pass spontaneously?
|
1cm
Shock wave lithotripsy is good for stones up to 2cm and percutaneous nephrolithostomy good for stones over 2cm |
|
|
What is usually the initial imaging study for a patient with suspected urinary tract obstruction?
|
Renal ultrasound. Shows urinary tract dialation and hydronephrosis
|
|
|
In which region of the prostate does prostate cancer usually originate?
|
Usually starts peripherally and moves centrally - thus obstructive symptoms occur late (often after cancer has already metastasized)
|
|
|
In prostate cancer screening, what is the next step if digital rectal exam is abnormal?
|
Transrectal ultrasonography (TRUS) regardless of PSA levels
|
|
|
What are common sites of metastasis for Renal Cell Carcinoma?
|
Lung, liver, brain, bone
|
|
|
What are risk factors for testicular cancer?
|
Cryptorchidism (even after surgical correction)
Klinefelter's syndrome |
|
|
What is the best next step when physical examination reveals a suspicious testicular mass?
|
Testicular ultrasound
|
|
|
A patient presents with severe testicular pain. What are two good ways to differentiate between testicular torsion and epididymitis?
|
Testicular torsion usually has a more acute onset and is not associated with fever
|
|
|
What is the best next step if you suspect a patient has testicular torsion?
|
Immediate surgical detorsion. If surgery is delayed beyond 6 hours, infarction may occur and the testicle may not be salvagable.
|
|
|
What fluid is most commonly used in a trauma situation for fluid replacement therapy?
|
Lactated Ringer's solution
|
|
|
Using the 100/50/20 rule, what is the appropriate fluid replacement rate for a 100kg man?
|
100 mL/kg for the first 10kg = 1000
50mL/kg for the next 10kg = 500 20mL/kg for the next 80kg = 1600 =3100mL per day /24 hours = 129 mL/hr |
|
|
When treating a patient with hypovolemia, you should correct the fluid deficit and hope the patient can maintain what rate of urine output?
|
0.5 - 1 mL/kg per hour
|
|
|
Name four common fluid retaining states that may cause hypervolemia-
|
CHF
Nephrotic syndrome Cirrhosis ESRD |
|
|
What is pseudohyponatremia?
|
An increase in plasma solids lowers the plasma sodium concentration, but the amount of sodium in the plasma is normal
|
|
|
If a patient has low serum sodium, how fast should you aim to correct the Na levels?
|
Give hypertonic saline to increase serum sodium by 1 to 2 mEg/L per hour until symptoms improve
Rapid increase may produce central pontine demyelination |
|
|
What diuretics may be given to a patient with hypocalcemia?
|
Thiazide diuretics lower urinary calcium
|
|
|
Is renal failure more likely to result in hypercalcemia or hypocalcemia?
|
Hypocalcemia
|
|
|
What three major categories of pathologies should comprise your DD for hypercalcemia?
|
Endocrinopathies
Malignancies Pharmacologic |
|
|
How may hypercalcemia show up on a EKG?
|
Shortened QT interval
Hypocalcemia shows a prolongation of QT interval |
|
|
Which diuretic is indicated in a patient with hypercalcemia?
|
Furosemide
|
|
|
Does administering insulin increase or decrease serum K levels?
|
Insulin administration may cause hypokalemia because it shifts potassium into the cells
|
|
|
What's a simple way to determine whether hypokalemia is due to GI loss or renal loss?
|
Check urine K levels. High in renal loss, low in GI loss
|
|
|
Does alkalosis tend to lead to hyperkalemia or hypokalemia?
|
Hypokalemia
|
|
|
Name two EKG changes that are consistent with hypokalemia-
|
T wave flattens out, maybe even inverts
U wave appears |
|
|
What is the safest method of replacing potassium in a patient who is hypokalemic?
|
Oral KCl
10mEq of KCl increases K levels by 0.1 mEq/L |
|
|
Name three EKG changes consistent with hyperkalemia-
|
Peaked T waves
Prolonged PR interval Widening QRS |
|
|
What's the best first treatment for a patient with severe hyperkalemia with EKG changes
|
Give IV calcium.
Calcium stabilizes the resting membrane potential of myocardial membranes Glucose, insulin, and sodium bicarbonate also help shift K into cells |
|
|
Is renal failure more likely to lead to hypermagnesemia or hypomagnesemia?
|
Renal failure is the most common cause of hypermagnesemia
|
|
|
What is the most common cause of death from scleroderma?
|
Pulmonary involvement - interstitial fibrosis or pulmonary hypertension may be present
|
|
|
Which autoantibodies are specific for the limited form of scleroderma and the diffuse form?
|
Limited - anticentromere
Diffuse - anti-topoisomerase I |
|
|
Which autoantibody is specific for Mixed Connective Tissue Disease?
|
Anti-U1-RNP
|
|
|
What is the usual age of onset for Rheumatoid Arthritis?
|
20-40 yo
More common in women than men (3:1) |
|
|
Rheumatoid arthritis is a symmetrical inflammatory polyarthritis that can involve every joint in the body except for which?
|
DIP joints
|
|
|
What is Felty syndrome?
|
A variant of rheumatoid arthritis including anemia, neutropenia, splenomegaly and RA
|
|
|
What is the most popular first line treatment for Rheumatoid arthritis?
|
Methotrexate. Combination therapy with other first line drugs (hydroxychloroquine and sulfasalazine) produces higher remission rates
|
|
|
What is the treatment for asymptomatic hyperuricemia?
|
Should not be treated - over 95% of patients remain asymptomatic and do not progress to acute gout
|
|
|
What are the typical complaints of a patient with Polymyalgia Rheumatica?
|
Bilateral muscle pain (hip and shoulder most commonly) that begins abruptly and is worse after periods of inactivity. Occurs when trying to initiate movement
Profound morning stiffness |
|
|
What is the treatment and management of a patient with fibromyalgia?
|
Advise the patient to stay active and productive.
Cognitive behavioral therapy and exercise. Medications are generally not effective |
|
|
Name five organisms that most commonly can be associated with reactive arthritis-
|
Salmonella
Shigella Campylobacter Chlamydia Yersinia |
|
|
40% of patients with temporal arteritis have which other rheumatic disease?
|
Polymyalgia rheumatica
|
|
|
What is the treatment plan for a patient with suspected temporal arteritis?
|
Start treatment immediately with high-dose steroids to prevent blindness. Continue treatment for at least 4 weeks, then taper gradually but maintain steroid therapy for 2-3 years
|
|
|
What two body systems are most commonly involved in Churg-Strauss syndrome?
|
Respiratory tract findings (asthma, dyspnea) and skin lesions (subcutaneous nodules and palpable purpura)
|
|
|
What two body systems are most commonly involved in Wegener's Granulomatosis?
|
Kidneys and Respiratory system
|
|
|
What is the mechanism and major clinical use of Propylthiouracil?
|
Used in Hyperthyroidism
Inhibits thyroid hormone synthesis and conversion of T4 to T3 |
|
|
What is the most common therapy in the US for Graves hyperthyroidism?
|
Radioiodine 131
Hypothyroidism results after treatment in the majority of patients |
|
|
Is treatment for Graves disease indicated during pregnancy?
|
Yes, avoid radioiodine, but PTU is fine
|
|
|
What are the two most common causes of hypothyroidism?
|
Hashimoto's disease
Iatrogenic after treatment of hyperthyroidism (radioiodine, thyroidectomy) |
|
|
What characteristics of a thyroid nodule on physical exam may suggest malignancy?
|
If the nodule is fixed, unusually firm, and solitary
|
|
|
Are hot or cold thyroid nodules more suspicious for malignancy?
|
Cold - 20% are malignant, while hot nodules are rarely malignant
|
|
|
What is the only reliable test to differentiate between benign and malignant thyroid nodules?
|
Fine Needle Aspiration
|
|
|
What is the imaging study of choice to investigate pituitary adenomas?
|
MRI
|
|
|
Are "parasellar symptoms" (headache, visual field defects) more common in men or women with a prolactinoma?
|
More common in men because other symptoms usually present earlier in women (menstrual irregularities, dyspareunia, vaginal dryness, glactorrhea)
|
|
|
What is the treatment for a symptomatic prolactinoma?
|
Bromocriptine, a dopamine agonist that diminishes production and release of prolactin. Continue treatment for 2 years before attempting to stop. If symptoms continue, then consider surgery
|
|
|
What are the first conditions to consider when a patient presents with polydipsia and polyuria?
|
DM
Diuretic use Diabetes insipidus Primary polydipsia |
|
|
What are the treatments for Central Diabetes Insipidus vs. Nephrogenic DI?
|
Central - Desmopressin
Nephrogenic - Thiazide diuretic |
|
|
What is pseudohyperparathyroidism?
|
End organ resistance to the action of PTH. Serum calcium is low and PTH is high
|
|
|
The clinical features of which condition is remembered by "stones, bones, groans and psychiatric overtones"?
|
Primary hyperparathyroidism
Features nephrolithiasis, bone aches and pains, muscle pains and weakness and various psychiatric conditions (depression, anxiety, sleep disturbances) |
|
|
What is the difference between Cushing's syndrome and Cushing's disease?
|
Cushing's syndrome is when there is an excess of glucocorticoids for any reason
Cushing's disease is when Cushing's syndrome is caused by a pituitary adenoma |
|
|
What are good urine markers to test for pheochromocytoma?
|
Metanephrine - the best marker
Vanillylmandelic acid, mormetanephrine also |
|
|
What condition should you suspect in a patient who is hypertensive and hypokalemic but not on a diuretic?
|
Hyperaldosteronism
|
|
|
What are the treatments for hyperaldosteronism if it is caused by
-an adenoma? -bilateral adrenal hyperplasia? |
Adenoma - surgery is often curative
Bilateral Hyperplasia - Spironolactone, surgery not indicated |
|
|
How often should HbA1C be monitored in a diabetic patient? What is the target level?
|
Should be monitored every 3 months and should be kept under 7.0
|
|
|
What are the LDL, TG and HDL goals for a patient with DM?
|
LDL under 100
TG under 150 HDL over 40 |
|
|
What glucose levels qualify as Impaired Glucose Tolerance during
-Fasting glucose test? -2-hr postprandial? |
Fasting - 110-126
2-hr - 140-200 |
|
|
The HbA1C gives a good indication of glycemic control over what period of time?
|
The past 2-3 months
|
|
|
Which hypoglycemic treatment is OK to use during pregnancy?
|
Most oral hypoglycemics are contraindicated in pregnancy (potentially teratogenic). Treat with Insulin.
|
|
|
Which is the best hypertensive medication for a patient with DM?
|
ACE inhibitors
|
|
|
What is the treatment for a patient with DKA?
|
Insulin immediately, and continued until anion gap closes
Fluids Potassium with the IV fluids |
|
|
Which three endogenous molecules help to guard against hypoglycemia?
|
Glucagon
Epinephrine Cortisol |
|
|
What is hypoglycemic unawareness?
|
With longstanding diabetes, patients lose their neurogenic symptom response to hypoglycemia and do not recognize the impending hypoglycemia
|
|
|
What is the classic triad of Somatostatinomas?
|
Gallstones
Diabetes Steatorrhea |
|
|
What are typical clinical features of a VIPoma?
|
Watery diarrhea
Achlorhydria Hyperglycemia Hypercalcemia Treatment is surgical resection of the tumor |
|
|
What is the risk of developing CRC by age 40 in patients with Familial adenomatous polyposis?
|
100%. Prophylactic colectomy is usually recommended
|
|
|
Which typically has a better prognosis - colon cancer or rectal cancer?
|
Colon cancer. Rectal cancer has a higher recurrence rate and lower 5-year survival rate than colon cancer
|
|
|
What is the diagnostic test for diverticulosis?
|
Barium enema
|
|
|
What is the diagnostic test for diverticulitis?
|
CT scan of abdomen and pelvis with contrast.
Barium enema and colonoscopy are contraindicated |
|
|
What test is run on abdominal fluid believed to be ascites to determine if it is caused by portal hypertension?
|
Serum ascites albumin gradient. If it is >1.1g/dL, portal HTN is very likely.
|
|
|
What are possible therapeutic options for a patient with ascites?
|
Bed rest, low-sodium diet, diuretics
Therapeutic paracentesis Peritoneoveous shunt or TIPS to reduce portal HTN |
|
|
What are common infectious agents in spontaneous bacterial peritonitis?
|
E. coli
Klebsiella S. pneumonia |
|
|
Short of liver transplant, what are possible therapies for Wilson's disease?
|
D-penicillamine - a chelating agent
Zinc - which prevents uptake of dietary copper |
|
|
What is the treatment for Budd-Chiari syndrome?
|
BC syndrome is a liver disease caused by occlusion of hepatic venous outflow.
Medical therapy (anticoagulants, diuretics) are usually insufficient. Surgery is eventually necessary in most cases (balloon angioplasty with stent, or portocaval shunts) |
|
|
What underlying pathology should you think of if the patient says he has dark urine and pale stools?
|
Conjugated hyperbilirubinemia
Can be caused by Hepatocellular diseaes (hepatitis, cirrhosis), Dubin-Johnson syndrome, PBC, PSC |
|
|
Would you find bilirubin in the urine in a patient with conjugated hyperbilirubinemia, unconjugated hyperbilirubinemia, both, or neither?
|
Conjugated hyperbilirubinemia
|
|
|
Which is more sensitive and specific for liver damage - AST or ALT?
|
ALT.
AST is found in many tissues like skeletal muscle, heart, kidney and brain |
|
|
Elevated Alk Phos and GGT is highly suggestive of liver disease - specifically the bile ducts.
What should you consider if ONLY Alk Phos is elevated and GGT is normal? |
Pregnancy
Bone disease |
|
|
What is the primary diagnostic tool for visualizing gall stones?
|
RUQ ultrasound has high sensitivity and specificity for stones >2mm
CT and MRI are alternatives |
|
|
What is Murphy's sign?
|
Inspiratory arrest during deep palpation of the RUQ. Pathognomonic for acute cholecystisis but not present in many cases.
|
|
|
What's the definition of choledocholithiasis?
|
Refers to gallstones in the common bile duct.
Patients may be asymptomatic for years |
|
|
What imaging techniques are used to diagnose choledocholithiasis?
|
RUQ ultrasound is usually the initial technique, but it is not a sensitive study, so it cannot rule out the diagnosis.
ERCP is the gold standard, and follows a negative ultrasound. It also follows a positive ultrasound as a therapeutic technique (sphincterotomy and stone extraction with stent placement) |
|
|
What is the general prognosis of carcinoma of the gallbladder?
|
Dismal. More than 90% of patients die of advanced disease within one year of diagnosis
|
|
|
What autoantibodies are found in Primary Biliary Cirrhosis?
|
Antimitochondrial antibodies in 90-95% of patients
|
|
|
What are the top two causes of acute appendicitis?
|
Hyperplasia of lymphoid tissue (60% of cases)
Fecalith obstruction (35%) |
|
|
What are typical clinical signs of acute appendicitis?
|
Tenderness in RLQ
Rebound tenderness Low grade fever Rovsing's sign (Deep palpation in LLQ causes pain in RLQ) Psoas sign (RLQ pain when right thigh is extended) Obturator sign (pain in RLQ when flexed right thigh is internally rotated) |
|
|
How is acute appendicitis diagnosed?
|
Clinically, by signs and symptoms. Lab findings and imaging are usually just supportive
|
|
|
What are the top two causes of acute pancreatitis?
|
Alcohol abuse (40%)
Gallstones (40%) |
|
|
What is the most accurate test for diagnosing acute pancreatitis?
|
CT scan of abdomen
|
|
|
What is the proper management of pancreatic pseudocysts?
|
Cysts <5cm: observation
Cysts >5cm: drain either percutaneously or surgically |
|
|
What is the general treatment plan for a patient with acute pancreatitis?
|
Bowel rest - nothing per os (NPO)
IV fluids Analgesics Antibiotics (controversial) |
|
|
Patients with three or four of Ranson's criteria for acute pancreatitis should be hospitalized. What are the five Ranson's criteria?
|
Glucose >200
Age >55 LDH >350 AST >250 WBC >16,000 |
|
|
What is the classic triad of chronic pancreatitis?
|
Steatorrhea
Diabetes Mellitus Pancreatic Calcification on imaging |
|
|
Are serum amylase and lipase levels elevated in acute pancreatitis, chronic pancreatitis, both, or neither?
|
Just acute pancreatitis, not chronic
|
|
|
What is the most established risk factor for developing pancreatic cancer?
|
Smoking
Others include chronic pancreatitis, Diabetes, Heavy alcohol use, and exposure to certain industrial chemicals |
|
|
What is the most common source of lower GI bleeding in patients under age 60?
|
Diverticulosis
|
|
|
What is the most common source of lower GI bleeding in patients over age 60?
|
AV malformations, but you must consider it CRC until proven otherwise
|
|
|
What are the major risk factors for adenocarcinoma of the esophagus?
|
GERD and Barrett's esophagus
|
|
|
What pathology is suspected when there is a corkscrew appearance of the esophagus on barium swallow?
|
Diffuse Esophageal Spasm (DES)
Inappropriate contraction of esophagus that prevents advancement of food bolus |
|
|
What is the best diagnostic test for esophageal diverticula?
|
Barium swallow
|
|
|
What is the next step if you see a gastric ulcer on upper endoscopy?
|
Biopsy it. 5-10% are malignant, while malignancy in duodenal ulcers is very rare.
|
|
|
Which generally has higher complication rates - gastric or duodenal ulcers?
|
Gastric. They have malignant potential, a higher recurrence rate and are more likely to perforate
|
|
|
What is the GOLD STANDARD for diagnosing an H. pylori infection?
|
Biopsy and histologic evaluation of endoscopic biopsy
|
|
|
What is the most sensitive test for detecting perforation of a a peptic ulcer?
|
Upright CXR or CT scan to visualize air under the diaphragm
|
|
|
Is hematochezia more common in Chron's disease or Ulcerative Colitis?
|
UC
|
|
|
What are indications for surgery in Crohn's disease?
|
Small Bowel Obstruction
Fistulae Disabling disease Perforation or abscess |
|
|
Is surgical treatment generally more effective for UC or Crohn's disease?
|
Ulcerative colitis, because removal of entire colon generally eliminates risk of recurrence, while Crohn's disease extends into the small bowel.
|
|
|
What are the limits of PaO2 and O2 saturation that indicate long-term oxygen therapy is needed for a COPD patient?
|
PaO2 less than 55mmHg
O2 saturation less than 88% |
|
|
What is the only therapy proven to improve survival in patients with COPD?
|
O2 therapy. Some patients require continuous therapy and others only during exertion and sleep
|
|
|
"All that wheezes is not asthma"
What other diseases can cause wheezing? |
Any condition that mimics large-airway bronchospasm:
CHF - due to edema in airways COPD - inflamed airways Lung cancer Cardiomyopathies and pericardial disease can lead to edema around the bronchi |
|
|
What is the quickest method of diagnosis of asthma for a patient in an acute setting who is short of breath?
|
Peak expiratory flow measurement
|
|
|
Which hypertensive drugs should be avoided in asthmatics?
|
Beta blockers
|
|
|
Half of all cases of bronchiectasis are caused by what underlying disease?
|
Cystic fibrosis
Other causes include infection, humoral immunodeficiency, airway obstruction |
|
|
What is the diagnostic study of choice in bronchiectasis?
|
High resolution CT
CXR is abnormal in most cases, but findings are non-specific |
|
|
What is included in the differential diagnosis of a solitary pulmonary nodule appearing on CXR?
|
Infectious granuloma
Bronchogenic carcinoma hamartoma Bronchial adenoma |
|
|
What are the most common sites of metastasis for lung cancer?
|
Brain
Bone Adrenal glands Liver |
|
|
Is Eaton-Lambert syndrome more common in SCLC or NSCLC?
|
Small cell lung cancer
Clinical picture similar to MG - proximal muscle weakness, diminished reflexes, paresthesias |
|
|
Is surgery or chemotherapy the treatment of choice for SCLC? NSCLC?
|
SCLC - chemotherapy
NSCLC - surgery |
|
|
What is the treatment plan for empyema?
|
Aggressive drainage of the pleura via thoracentesis and antibiotic therapy
|
|
|
If tension pneumothorax is suspected clinically, what is the next step?
|
Immediately decompress with a chest tube or large bore needle.
Do not wait for CXR to confirm |
|
|
A young patient with constitutional symptoms, respiratory complaints, erythema nodosum, blurred vision comes into the office. Her CXR shows bilateral hilar adenopathy. What is the most likely diagnosis?
|
Sarcoidosis. Most cases resolve or significantly improve in 2 years and do not require treatment
|
|
|
Which cause of hypoxemia is unresponsive to oxygen therapy?
|
Shunting
Causes include atelectasis, severe pneumonia, congenital heart disease |
|
|
In which cause of hypoxemia is there a normal A-a gradient?
|
Hypoventilation
|
|
|
Pulmonary capillary wedge pressure is the most useful parameter in differentiating ARDS from cardiogenic pulmonary edema. Is PCWP high or low in in ARDS?
|
Low, especially compared with cardiogenic pulmonary edema
|
|
|
Where in the bronchial tree do you hope to see the endotracheal tube on CXR after an intubation?
|
About 3-5 cm above the carina
|
|
|
What is the most common cause of Cor Pulmonale?
|
Usually secondary to COPD
Other causes include recurrent PE, ILD, asthma, CF, sleep apnea, pneumoconiosis |
|
|
What are findings on EKG of a patient with Cor Pulmonale?
|
Right axis deviation
P pulmonale - peaked P waves RV hypertrophy |
|
|
What is the gold standard for diagnosing a PE?
|
Pulmonary angiography, but usually, leg ultrasound, D-dimer and/or spiral CT would have been performed first
|
|
|
What is the proper clinical use of the D-dimer test?
|
Should be used when PE is suspected, but clinically unlikely. In this situation, it can be used to rule out PE, but not to diagnose.
|
|
|
What is the treatment plan for a patient diagnosed with PE?
|
Give supplemental oxygen to correct hypoxia
Acute anticoagulation with heparin, and then continue on anticoagulation for 3-6 months Thrombolysis is not proven to decrease mortality rate |
|
|
What pulmonary pathologies cause a low DLCO?
|
Emphysema
Sarcoidosis Interstitial fibrosis Pulmonary vascular disease Generally, conditions that destroy lung parenchyma |
|
|
Exercise in a stress test produces ST depression in a positive stress test. What type of ischemia is this consistent with?
|
Subendocardial ischemia
|
|
|
What is the next step for a patient with a positive stress test?
|
Cardiac catheterization
|
|
|
Name three drugs that can be used in a pharmacologic stress test-
|
Adenosine, dipyramidole: Both cause generalized coronary vasodialation
Dobutamine: causes increased myocardial oxygen demand |
|
|
In which patients with IHD is CABG indicated?
|
Patients with left main disease, three vessel disease with decreased LV function, or two vessel disease including the proximal LAD
|
|
|
What is used clinically to differentiate unstable angina from NSTEMI?
|
NSTEMI has elevated cardiac enzymes, while UA does not
|
|
|
What medications are indicated for the treatment of Prinzmetal's angina?
|
Vasodialators - Ca channel blockers or nitrates
|
|
|
Name the contraindications for thrombolytic therapy-
|
Uncontrolled HTN >180/110
Recent trauma Active bleeding (including PUD) Previous stroke Recent surgery Dissecting aortic aneurysm |
|
|
What is the schedule for drawing cardiac enzymes in a patient with suspected MI presenting to the hospital?
|
On arrival and every 8 hours after that.
|
|
|
A patient with chest pain has an EKG that shows large R waves in V1 and V2, ST depression in V1 and V2, and upright, prominent T waves in V1 and V2. Where is the most likely site of the ischemia?
|
This is the classic EKG finding of posterior infarction
|
|
|
What seven drugs are indicated for a patient with an acute MI?
|
Oxygen
Nitroglycerin Beta blocker Aspirin Morphine ACE inhibitor IV Heparin |
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What is the difference in treatment of a patient with a Mobitz I vs. Mobitz II 2nd degree AV block?
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Type I: not serious, no treatment needed
Type II: get the patient connected to a transcutaneous pacemaker |
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How long after an MI does a free wall rupture typically happen?
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90% within 2 weeks, and most commonly 1-4 days after MI.
90% mortality rate - causes hemopericardium and tamponade |
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In the differential diagnosis of chest pain, what five body systems should be considered?
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Cardiac
Pulmonary GI Musculoskeletal Psychiatric |
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What are the causes of high output heart failure?
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Chronic anemia
Pregnancy Hyperthyroidism AV fistulae Wet beriberi Paget's disease Valvular problems (AR, MR) |
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What are the typical symptoms of CHF?
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Dyspnea
Orthopnea Paroxysmal nocturnal dyspnea |
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Name 4 possible signs of left-sided heart failure on physical examination-
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Displaced PMI (usually to left)
S3 S4 Crackles at bases of lungs |
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A patient with heart failure develops dyspnea when she climbs stairs or lifts heavy packages. The condition slightly limits her daily activities. What NYHA classification would she be diagnosed as?
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NYHA class II
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What abnormalities might you see on CXR of a patient with CHF?
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Cardiomegaly
Kerly B lines indicating pulmonary congestion Prominent interstitial markings Pleural effusion |
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What two drugs should be the initial treatment of a patient with symptomatic CHF?
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A diuretic and ACE inhibitor
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What is the difference between cardioversion and defibrillation?
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CV - in synchrony with the QRS complex - used to terminate Afib, Aflutter, VT with a pulse, SVT
Defibrillation is not in synchrony with QRS - used for VFib and VT without a pulse |
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What is the treatment for a patient with hemodynamically unstable Atrial Fibrillation?
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Immediate electrical cardioversion
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Did the AFFIRM trial show that rate control or rhythm control was the superior treatment for AFib?
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Rate control
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If a patient with AFib is hemodynamically stable and known to be in AF for at least 48 hours, what is the next step?
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Obtain a transesophageal echocardiogram to image the left atrium in search of a thrombus. If no thrombus - cardiovert.
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Which underlying disease is most commonly associated with atrial flutter?
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COPD
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In which leads on an EKG are the saw-tooth patterns of atrial flutter most easily seen?
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Inferior leads
II, III, aVF |
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An EKG shows a regular rhythm of 160bpm with no discernable P waves. What is the most likely diagnosis?
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Paroxysmal Supraventricular Tachycardia
Usually caused by multiple pathways in the AV node |
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What is the first treatment for PSVT?
And what if that doesn't work? |
Vagal maneuvers - carotid massage and Valsalva
If that doesn't work, IV adenosine is the next step. DC cardioversion if drugs fail |
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What is the treatment of choice for Wolf-Parkinson-White syndrome?
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Radiofrequency ablation of one arm of the reentrant loop (the accessory pathway)
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What is the first treatment to try in a hemodynamically stable patient with VT?
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IV amiodarone, IV procainamide, or IV sotalol
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What is the treatment in a hemodynamically unstable patient with VT?
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Immediate synchronous DC cardioversion
Follow with IV amiodarone to maintain sinus rhythm |
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What are the indications for a cardiac pacemaker?
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Symptomatic heart block (Mobitz II 2nd degree or 3rd degree)
Symptomatic bradyarrhythmia |
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Where anatomically is the site of the block in a Mobitz Type I vs. Mobitz Type II 2nd degree heart block?
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Type I: in the AV node
Type II: in the His-Purkinje system |
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What are the complications of acute pericarditis?
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Pericardial effusion
Cardiac tamponade (in up to 15% of pts) |
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What EKG change is highly specific for acute pericarditis?
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PR depression is specific
Also likely to see diffuse ST elevation and T wave inversion |
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How is the quality of the chest pain in acute pericarditis differentiated from ischemic chest pain?
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It is pleuritic in nature - associated with inspiration
Often aggravated by lying supine or coughing, and relieved by sitting up and leaning forward |
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What is the typical treatment for acute pericarditis?
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Most cases are self-limited and resolve in 2-6 weeks.
NSAIDs are the mainstay of therapy |
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What are signs of constrictive pericarditis?
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Jugular venous distention - very prominent
Pericardial knock Ascites Dependent edema |
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What is the treatment for constrictive pericarditis?
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Surgical - complete resection of pericardium is indicated in many patients, although it has a significant mortality rate
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What is the imaging technique of choice for pericardial effusion?
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Echocardiogram - can show as little as 20mL of fluid
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How might the EKG be altered in a patient with pericardial effusion?
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Low QRS voltages and T wave flattening
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What condition is characterized by equalization of pressures in all four heart chambers?
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Cardiac tamponade
This impairs diastolic filling of the heart |
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Name four causes of cardiac tamponade-
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Penetrating trauma
Iatrogenic - central line, pacemaker, pericardiocentesis Pericarditis Post-MI free wall rupture |
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What is Beck's triad for cardiac tamponade?
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JVD
Hypotension Muffled heart sounds |
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Which cardiac abnormality do you suspect if you hear an opening snap followed by a low-pitched diastolic rumble?
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Mitral stenosis
If the OS is close to S2, the stenosis is worse |
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How might long-standing aortic stenosis affect the mitral valve?
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The LV dialates, pulling the mitral annulus apart causing mitral regurgitation
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Describe the quality of the murmur in aortic stenosis-
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Harsh crescendo-decrescendo systolic murmur that radiates to the carotid arteries
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What are some signs of aortic regurgitation on physical examination?
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Widened pulse pressure
Decrescendo diastolic murmur Water-hammer pulse Head-bobbing, pulsing uvula |
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What is the treatment for a patient with MVP?
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If asymptomatic, just reassurance, the condition is generally benign
If accompanied with chest pain, beta blockers can be used |
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What is the most common valvular abnormality in rheumatic heart disease?
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Mitral stenosis
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How is acute rheumatic fever treated?
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NSAIDs. It is not infectious, it's post-infectious, so there's no need for antibiotics
C-reactive protein is used to monitor treatment |
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What is the best imaging technique for endocarditis?
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Transesophageal echocardiogram - better than transthoracic approach
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What should you suspect if a patient presents with fever and a new cardiac murmur?
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Endocarditis
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Name four complications of coarctation of the aorta-
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Severe HTN
Rupture of cerebral aneurysms Infective endocarditis Aortic dissection |
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What's the best diagnostic technique for aortic dissection in an acute situation?
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Transesophageal echocardiogram - high sensitivity and specificity and can be done at the bedside
CXR shows widened mediastinum |
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What are Type A vs. Type B aortic dissections? How does the treatment differ for each?
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Type A - in the ascending aorta - treat with surgery
Type B - in the descending aorta - treat medically with beta blockers and nitroprusside |
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What is the test of choice to evaluate the location and size of an abdominal aortic aneurysm?
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Ultrasound
CTs are also good, but Abdominal radiographs cannot be used to exclude AAAs |
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What is Homan's sign?
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Calf pain on dorsiflexion - a sign of DVT
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What is the initial test for DVT?
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Doppler analysis and Duplex ultrasound - high sensitivity and specificity but highly operator dependent
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Which is the only form of shock with increased cardiac output?
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Septic shock
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Which is the only form of shock with elevated pulmonary capillary wedge pressure?
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Cardiogenic shock
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What is usually the initial drug used as a vasopressor in treating cardiogenic shock?
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Dopamine is often the initial drug
Dobutamine may be used in combination Epinephrine may be used in resistant cases |
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What are the four criteria for diagnosing SIRS (Systemic Inflammatory Response Syndrome)?
-SIRS is diagnosed with 2+ criteria |
Fever >38
Hyperventilation >20 Tachycardia >90 Increased WBC >12K Sepsis = SIRS + positive blood cultures |
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What is the most common cause of death in the ICU?
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Septic shock
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What are possible treatments for septic shock?
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IV antibiotics
Fluid administration Vasopressors if hypotension persists |
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What is neurogenic shock?
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Shock resulting from a failure of the sympathetic nervous system to maintain adequate vascular tone (sympathetic denervation)
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Metastases to the heart make up 75% of cardiac neoplasms. Which primary neoplasms most commonly metastasize to the heart?
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Lung
Breast Skin Kidney Lymphoma Kaposi sarcoma |
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Where is the most common anatomical site from which atrial myxomas arise in the heart?
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Interatrial septum
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In a patient with hemoptysis, a 30 year pack history and negative CXR, what further test must be performed to rule out bronchogenic carcinoma?
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Bronchoscopy
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If Cushing syndrome is suspected, what test confirms the diagnosis?
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Overnight dexamethasone suppression test
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How is ACTH dependent Cushing syndrome differentiated from ACTH independent Cushing syndrome?
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High dose dexamethasone suppression test
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A 70yo patient is diagnosed with a fractured hip on X-ray after experiencing sharp pain when getting up from a chair and no history of fall or trauma. What needs to be worked up in this situation?
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Metastatic cancer should be considered and a primary neoplasm searched for.
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A 75yo patient with a history of CAD and HTN presents with sudden onset severe abdominal pain out of proportion to physical exam findings. What is the likely diagnosis and next step?
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This is the classic description of acute mesenteric ischemia and an emergent mesenteric angiogram is necessary.
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