Ditt Step 2 Day 4 Cardio & Trauma

Front 1

What is the tx for hyperparathyroidism due to parathyroid hyperplasia?

Back 1

- remove 3.5 glands, mark the remaining half gland with surgical clip
- autotransplant from neck region to forearm

Front 2

What are the high potency neuroleptics?

Back 2

Haloperidol (Haldol)
Fluphenazine (Prolixin, Permitil)
Thiothixene (Navane)
Droperidol (Inapsine)

"High Five Thio after he THINX he DROPped his number for a girl"
(Haldol, Fluphenazine, ThioTHIXene, Droperidol"

Front 3

LIst the low potency typical neuroleptics

Back 3

Chlorpromazine (Thorazine)
Thioridazine (Mellaril)

there's LOW (low potency) CHLORine in the Pool (chlorPromazine) after THIO gets RID of the chlorine

Front 4

List the moderate potency typical neuroleptics

Back 4

Molindone
Loxapine
Trifluorperazine

"just TRI MOLin' around, there's LOX of boys around here"

Front 5

List the Atypical Antipsychotics

Back 5

Clozapine (Clozaril, FazaClo)
Olanzapine (Zyprexa)
Risperidone (Risperdal)
Quetiapine (Seroquel)
Aripiprazole (Abilify)
Paliperidone (Invega)

Front 6

What mineralcorticoid medication is used in the treatment of aldosterone deficiencies such as adrenal insufficiency & 21-hydroxylase deficiency?

Back 6

fludrocortisone (Florinef)

Front 7

Where is the brain lesion?

pt presents w/ contralateral hemiballismus (rapid, unpredictable flailing movements of arm, leg)

Back 7

subthalamic nucleus

Front 8

Where is the lesion?
pt presents with hemispatial neglect syndrome

Back 8

right parietal lobe

Front 9

where is the brain lesion if pt presents in coma?

Back 9

Pons - specifically reticular activating system (RAS)

Front 10

Where is the brain lesion if pt presents with poor repetition

(meaning patients can speak relatively well and have good auditory comprehension but cannot put parts of words together or conjure up words)

Back 10

termed conduction aphasia, lesion of the arcuate fasciculus, in the white matter underlying the temporal–parietal junction; this lesion disconnects Wernicke's area from Broca's area.

Front 11

where is the brain lesion?

The patient has difficulty naming even simple objects. Repetition is impaired, but comprehension of spoken language is normal. The patient is usually aware of the deficit and appropriately concerned about it.

Back 11

Broca's aphasia caused by a lesion in the inferior frontal gyrus in the dominant hemisphere

Most lesions that involve Broca's area also involve the neighboring motor cortex. Patients are often hemiplegic, with the arm more affected than the leg. Broca's aphasia often occurs as a result of strokes, most commonly affecting the middle cerebral artery territory.

Front 12

Where is the brain lesion?

Pt has fluent speech, but repetition and comprehension are impaired. Has difficulty naming objects and produces both literal paraphasias (eg, "wellow" instead of "yellow") and verbal paraphasias (eg, "mother" instead of "wife"). Neologisms (meaningless, nonsensical words) are used commonly and speech may be circumlocutory (ie, wordy but meaningless). Patient does not appear concerned about, or even aware of speech disorder.

Back 12

Wernicke's aphasia: caused by a lesion in or near the superior temporal gyrus. Because this part of the cortex is not located adjacent to the motor cortex, there is usually no hemiplegia.

Wernicke's aphasia commonly occurs as a result of embolic strokes.

Front 13

Where is the brain lesion?

When pt is asked to touch his or her nose with a finger, the arm exhibits tremor during movement, often more marked as the target is reached.

Back 13

INTENTION TREMOR = occurs during activity.

results from a lesion affecting the superior cerebellar peduncle (or more generally, from cerebellar hemisphere)

(note: this form of tremor is sometimes mistaken for limb ataxia, but the latter has no rhythmic oscillatory component)

Front 14

where is the brain lesion?

pt exhibits a tremor that occurs when the limb is at rest.

Back 14

RESTING TREMOR - tremor apparent when arm is at rest, characteristic of Parkinson's disease

results from lesion to the Basal Ganglia

This tremor may appear as a "pill-rolling" maneuver—rhythmic, opposing circular movements of the thumb and index finger. There may be alternating flexion and extension of the fingers or hand, or alternating pronation and supination of the forearm.

Front 15

Pt presents with hyperorality (a tendency to explore objects by placing them in the mouth together with the indiscriminate eating or chewing of objects and all kinds of food); hypersexuality, psychic blindness, or visual agnosia, in which objects are no longer recognized; and personality changes, usually with abnormal passivity or docility.

Where is the brain lesion?

Back 15

KLÜVER–BUCY SYNDROME, bilateral amygdala lesion

Front 16

pt presents with personality changes - where would you suspect a brain lesion to be?

Back 16

frontal lobe

Front 17

Pt presents with dysarthria (dysfunction of the phonation, articulation, resonance, or respiration aspects of speech)

where is the brain lesion?

Back 17

cerebellar vermis

Front 18

Pt presents with ataxia & acalculia

Back 18

left parietal lobe

Front 19

at what age do physicians begin to dose dexamethasone with, or prior, to the first dose of antibiotics in cases of suspected bacterial meningitis?

Back 19

6mos of age

Front 20

What drugs are most commonly used in renal disease to bind phosphate in order to prevent hyperphosphatemia?

Back 20

Calcium carbonate & calcium acetate

DO NOT used calcium citrate

Front 21

What is the classic presentation of a pt with aspirin overdose?

Back 21

tinnitus, starts as respiratory alkalosis, then becomes mixed respiratory alkalosis and metablic acidosis with increased anion gap

other signs: hyperthermia, altered mental status, N/V, dehydration

Front 22

What is the antidote for salicyclates

Back 22

charcoal
NaHCO3
dialysis

Front 23

What is the antidote for
beta-blockers (or verapamil)

Back 23

atropine
glucagon
calcium
insuline & glucose

Front 24

What is the antidote for
digoxin

Back 24

charcoal
Digoxin FAB fragments

Do NOT give calcium

Front 25

What is the antidote for
Iron

Back 25

Deferoxime

Front 26

What is the antidote for
Copper

Back 26

Penicillamine

Front 27

What is the antidote for
tPA, streptokinase

Back 27

Aminocaproic acid

Front 28

Describe the blood supply to the heart

Back 28

see above

Front 29

label the vessels of the heart

Back 29

see above

Front 30

Label the vessels of the heart

Back 30

see above

Front 31

Which coronary artery is the most common site of occlusion?
Which ECG leads correspond to this artery?

Back 31

LAD
V1-V4

Front 32

In which phase of the cardiac cycle do coronary arteries fill with blood?

Back 32

Diastole

Front 33

What are the equations used to find mean arterial pressure (MAP)?

Back 33

MAP = 2/3 diastolic + 1/3 systolic

MAP = CO x TPR

MAP = DBP + 1/3 Pulse Pressure
(Pulse Pressure = SBP - DBP)

Front 34

What is the electrophysiological reason that a QRS complex would become widened?

Back 34

There are a couple ways you can get a wide QRS:
1) depolarization that originates somewhere distal to the AV node , ie starting somewhere in the ventricles - and then has to travel thru both the ventricles (rather than depolarizing the ventricles at the same time)
2) delay somewhere in the interventricular conduction system - either a interventricular conduction delay or bundle branch block

Front 35

Stress testing is done as a screening test. If angina or ischemia occurs with these tests, what test should follow?

Back 35

coronary angiogram

Front 36

At what age should screening for hyperlipidemia begin?

Back 36

35 yrs for men
45 yrs for women
earlier if pt has risk factors

note: these are the ages that screening should begin, the ages in the chart reflect at which age becomes a risk factor

Front 37

At what total cholesterol value should tx begin in a pt with no risk factors?

Back 37

LDL>160

Front 38

What are the two most common adverse effects of statin use, and what labs would reveal these effects?

Back 38

hepatotoxicity - check LFTs
myopathy, myositis - check CK levels

Front 39

What lipid lowering drugs should NOT be combined?

Back 39

statins & fibrates

they both can cause myositis and increased LFTs

Front 40

what is the first line medication to raise HDL?

Back 40

niacin

Front 41

ST segment elevation only during brief episodes of chest pain

dx?

Back 41

Prinzmetal angina

Front 42

Pt is able to point to localize the chest pain using one finger

dx?

Back 42

musculoskeletal chest pain

Front 43

Pt has CC of chest pain
On PE, there is chest wall tenderness on palpation

dx?

Back 43

Musculoskeletal chest pain

Front 44

Pt presents with rapid onset sharp chest pain that radiates to the scapula

dx?

Back 44

aortic dissection

Front 45

Pt presents with rapid onset sharp pain in a 20yo and assoc with dyspnea

dx?

Back 45

Spontaneous Pneumothorax

Front 46

Pt has chest pain that occurs after heavy meals and improved with antacids

dx?

Back 46

GERD or esophageal spasm

Front 47

PT has sharp chest pain lasting hrs-days and is somewhat relieved by sitting forward

dx?

Back 47

Pericardiitis

Front 48

Pt has chest pain made worse by deep breathing and/or motion

dx?

Back 48

Musculoskeletal pain

Front 49

Pt has chest pain in a dermatomal distribution

dx?

Back 49

Zoster (varicella zoster virus)

Front 50

What is the most common cause of non-cardiac chest pain?

Back 50

GERD

Front 51

Acute onset dyspnea, tachycardia, and confusion in a hospitalized pt

dx?

Back 51

Pulmonary Embolism (PE)

Front 52

Pt c/o chest pain that began the day following an intensive new exercise program

Back 52

musculoskeletal pain

Front 53

Pt with chest pain is found to have widened mediastinum on CXR

dx?

Back 53

aortic dissection

next step: CT scan of chest

Front 54

What medications are used in the treatment of Prinzmetal's angina?

Back 54

Nitrates
Calcium Channel Blockers (Verapamil, Diltiazem)

**Avoid beta-blockers and aspirin (can exacerbate coronary vasospasm)

Front 55

What is the role of Percutaneous Transluminal coronary angioplasty (PTCA) in a pt with Coronary Artery Disease?:
(1) pt with stable angina, NO h/o MI ?
(2) if medical therapy fails to improve a pt's stable anginal symptoms ?
(3) pt with angina meets high-risk criteria ?
(4) pt with severe CAD (such as significant proximal left main CAD, or 3-vessel CAD in pt with LVEF <50%) ?

Back 55

(1) COURAGE trial showed that angioplasty with stenting is NO BETTER than medical management alone

(2) PTCA (or CABG) is recommended if pt fails med tx

(3) PTCA or CABG, before med tx, if pt is high risk

(4) CABG is better than PTCA if pt has severe CAD

Front 56

What medication is used to treat Prinzmetal's angina?

Back 56

Calcium Channel Blockers (Nifedipine, Verapamil)

Front 57

Which patients are more likely to have atypical angina (or no angina) during an episode of cardiac ischemia?

Back 57

Diabetics & women

Front 58

How does nitroglycerin work acutely in a cardiac ischemic episode?

Back 58

nitroglycerin dilates peripheral veins

decreases PREload, and decreases myocardial oxygen demand

Front 59

Why should relief of chest pain with nitroglycerin administration not be used as a diagnostic test for whether or not the chest pain is cardiac in nature?

Back 59

Nitroglycerin will also relieve chest pain due to GERD & esophageal spasms

Front 60

What is a helpful mneumonic to remember some of the drugs used to treat acute angina in the ER?

Back 60

"MOAN"
Morphine
Oxygen
Aspirin
Nitroglycerin

Front 61

Which vein is typically used in CABG?

Back 61

Saphenous vein

Front 62

Which medication types have a proven reduction in mortality following MI?

Back 62

Beta-blockers
ACEI & ARBs
Statins - shown to reduce mortality

Front 63

In what time frame do thrombolytics need to be given in a MI? how does this differ from the time frame in which they need to be given for a stroke?

Back 63

MI - up to 12 hrs
Ischemic stroke - up to 3 hrs

Front 64

In addition to ST & T wave changes and new Q wave, what other EKG findings may indicate MI?

Back 64

LBBB
Arrythmia (VTach, V Fib)

Front 65

What are specific labs ordered in pts suspected of having an MI?

Back 65

serial cardiac enzymes : 3 sets of troponin- I, CK-MB taken every 8hrs

Front 66

What electrolytes are important to optimize to prevent arrhythmias in pts suffering from an MI?

Back 66

Keep K+ >4mEq/L
keep Mg+ >2mEq/L

Front 67

When is a post-MI pt at greatest risk for ventricular wall rupture?

Back 67

4-8days post-MI

Front 68

A pt that you treated 3wks ago for MI is now found to have fever, pericarditis, and an elevated ESR - dx?

Back 68

Dressler Syndrome

Front 69

Which coronary artery is involved with EKG changes in:

V2, V3, V4

Back 69

LAD - supplies anterior wall

Front 70

Which coronary artery is involved with EKG changes in:

V1, V2, V3

Back 70

Septal Branch (distal branch of LAD) - supplies interventricular septum

Front 71

Which coronary artery is involved with EKG changes in:

AVL, V5, V6

Back 71

LAD or Circumflex - supplies lateral wall

Front 72

Which coronary artery is involved with EKG changes in:

II, III, AVF

Back 72

Posterior Descending Artery (PDA) or Marginal Branch - supplies inferior wall

Front 73

HYQ: What is the most common cause of CP in a pt with sudden tearing chest pain radiating to the back?

Back 73

Aortic Dissection

Front 74

HYQ: What is the most common cause of death in pts with acute myocardial infarction?

Back 74

Ventricular Fibrillation

Front 75

Which lipid-lowering agent causes Facial flushing?

Back 75

Niacin

Front 76

Which lipid-lowering agent causes elevated LFTs & myositis?

Back 76

Statins & Fibrates

Front 77

Which lipid-lowering agents cause GI discomfort & have a bad taste?

Back 77

Sequestrants

Front 78

Which lipid-lowering agent have best effect on HDL?

Back 78

Niacin

Front 79

Which lipid-lowering agent has best effect on Triglycerides?

Back 79

Fibrates

Front 80

Which lipid-lowering agent has the best effect on lowering LDL/cholesterol?

Back 80

Statins

Front 81

Which lipid-lowering agent binds C. diff toxin?

Back 81

cholestyramine

Front 82

What are the recommendations for LDL levels in pts based on their CAD risk?

Back 82

LDL <160 (if no risk factors)
LDL <130 (if pt has at least 2 risk factors)
LDL <100 if pt has high risk for CAD

to assess risk: Framingham Risk Assessment
“A CHILD”→
Age – men > 45yr, women >55yrs
Cigarette smoking
Hypertension
Infarct
Low Levels of HDL (40mg/dL) Remember: HDL > 60 gives a bonus pt!!!
Diabetes

Front 83

What is the MOA of
Streptokinase (Streptase)

Back 83

converts plasminogen to plasmin

Front 84

What is the MOA of
Aspirin

Back 84

COX-1 and COX-2 inhibitor to prevent platelet aggregation

Front 85

What is the MOA of
Clopidogrel (Plavix)

Back 85

blocks platelet ADP Receptor, prevents platelet aggregation

Front 86

What is the MOA of
Abciximab?

Back 86

Glycogen IIb/IIIa inhibitor - blocks platelet aggregation

Front 87

What is the MOA of
Tirofiban?

Back 87

Glycogen IIb/IIIa inhibitor - blocks platelet aggregation

Front 88

What is the MOA of
Ticlopidine

Back 88

blocks platelet ADP receptor

Front 89

What is the MOA of
Enoxaparin

Back 89

(Enoxaparin = LMWH = Lovenox)

catalyzes activation of antithrombin III

Front 90

What is the MOA of Eptifibatide?

Back 90

Glycogen IIb/IIIa inhibitor - blocks platelet aggregation

Front 91

EKG shows: prolonged PR interval more than 0.2sec (5small boxes)

What type of heart block?

Back 91

1 degree heart block

Front 92

EKG shows: no relationship btw P waves and QRS

What type of heart block?

Back 92

3 degree heart block

Front 93

EKG shows: PR interval becomes progressively longer until a beat is dropped

What type of heart block?

Back 93

2 degree heart block, Mobitz Type 1 (Wenckebach)

Front 94

EKG shows: PR interval fixed, but with occasional blocked beats

What type of heart block?

Back 94

2nd degree heart block, Mobitz type II

Front 95

What medications should all post-MI pts receive as outpatients?

Back 95

- Aspirin & Clopidogrel (Plavix)
- beta-blocker (metoprolol, carvedilol)
- ACEI, ARB
- Statin
- Aldosterone Antagonist (Spironolactone)

Front 96

Narrow QRS not associated with p waves, rate 60

Dx?

Back 96

Third Degree Heart Block/ Junctional Rhythm

Front 97

EKG shows erratic, wide QRS

Dx?

Back 97

Ventricular Fibrillation

Front 98

EKG show wide QRS not associated with p waves, rate >40 but <100

Dx?

Back 98

Accelerated Idioventricular Rhythm (AIVR)

Rate: Atrial not discernable, ventricular 40-100 beats/minute

Rhythm: Ventricular rate regular, atrial rate not discernable

P waves: Absent

PRI: None

QRS: > .12

May be due to: Heart disease (e.g., acute myocardial infarction, digitalis toxicity, at reperfusion of a previously occluded coronary artery), may occur During Resuscitation, Drugs (e.g., digoxin), dilated cardiomyopathy, and during Outpatient procedures (due to spinal anesthesia).

Front 99

Narrow QRS not assoc with P waves, rate >100

Back 99

Junctional TACHYCARDIA

NOTE: the picture is acclerated junctional rhythm - it's the same except that the rate is >100bpm

Front 100

Wide QRS, not assoc with P waves, rate 20-40

Back 100

Ventricular Rhythms = Ventricular impulses come from the ventricles.

Inherent rate of ventricles is: 20-40 beats per minute
can be Idioventricular Rhythm (IVR) or Ventricular Escape Rhythm

Front 101

Wide QRS, not assoc with P wave, rate >100

Back 101

Ventricular Tachycardia (VTach)

Front 102

Narrow QRS not assoc with P waves, rate >60 but <100

Back 102

Accelerated Junctional Rhythm

Front 103

What is the diff btw a wandering pacemaker (WAP) and multifocal atrial tachycardia (MAT)?

Back 103

- Wandering pacemaker has atleast 3 diff P wave morphologies with a ventricular rate of <100

- Multifocal atrial TACHYCARDIA (MAT): atleast 3 diff P wave morphologies with ventricular rate >100

- Multifocal atrial bradycardia (MAB) = 3 diff P waves , vent rate <60

Front 104

How to treat this?

Back 104

Multifocal Atrial Tachycardia (>100) or Wandering pacemaker (<100)

Acute Tx: CCB or Beta-blockers (If you have to choose between the two, go with beta-blockers)

Chronic tx: catheter ablation or surgery to eliminate abnormal pacemakers

Front 105

Which heart blocks need a pacemaker?

Back 105

2nd Degree Heart Block, Mobitz Type II

3rd Degree Heart Block

Front 106

How would you treat this?

Back 106

Wolff-Parkinson White (WPW) - a type of Supraventricular tachycardia due to AV reentry (often thru Bundle of Kent)

Treatment:
Amiodarone (class 3)
Procainamide (class 1A)
Beta-blockers (Class 2)
CCBs (class 4)

Do NOT give Adenosine

Front 107

What endocrine disorder can cause atrial fibrillation?

Back 107

hyperthyroidism (check TSH!)

Front 108

A pt is in the hospital and begins to have atrial fibrillation with RVR (rapid ventricular rate). This pt has had chronic atrial fib previously. What study should be performed before the pt can be cardioverted?

what meds can be used in the meantime?

Back 108

transesophageal echocardiogram (TEE)

beta-blockers, CCBs (NON- dihydropyridines - ie Diltiazem, Verapamil, amlodipine), Digoxin

Front 109

Why must heparin be started in conjunction with Warfarin?

Back 109

Warfarin causes temporary hypercoagulable state by depleting protein C & protein S

so heparin is used for ~3-5 days

Front 110

Type of heart block in which the PR interval is progressively lengthened with each beat until a ventricular beat is dropped:

Back 110

2nd degree heart block, Mobitz type 1 (wenckeback)

mneumonic: Wencke is #1, and Warns you before he drops a beat

Front 111

Which type of Heart block?
PR interval prolonged more than 0.2 sec (5 small boxes)

Back 111

1st degree heart block

Front 112

Which type of Heart block?
No relationship btw P waves and QRS complexes

Back 112

3rd degree heart block

Front 113

Which type of Heart block?
PR interval becomes progressively longer until a beat is dropped

Back 113

2nd degree Heart block, Mobitz Type 1 (Wenckeback)

Remember: Wenckeback is #1, and he gives you a Warning (or Wink) before he drops a beat

Front 114

Which type of Heart block?
PR interval is fixed, but with occasional blocked beats

Back 114

2nd degree heart block, Mobitz Type 2

Front 115

HYQ: What is the treatment for premature atrial contractions (PAC) or premature ventricular contractions (PVC)?

Back 115

these are not pathological, observation is all that's needed

may be related to caffeine intake (cut down on the caffeine!) or hyperthyroidism

PAC occurs when a site within the atria discharges before the next SA node is due to discharge

PVC is when a site within the ventricle discharges early, and causes a weird looking QRS complex.

PVCs become concerning when there are >3 PVCs in a minute

Front 116

HYQ: What is the DOC for acute-onset atrial fibrillation with RVR in a pt with WPW?

Back 116

Electrocardioversion or Procainamide (Class 1A)

Front 117

HYQ: An EKG shows complete independence of P waves and QRS complexes. What is the next step in management?

Back 117

Pacemaker

(3rd degree heart block)

Front 118

HYQ: What type of heart block -

PR interval is progressively lengthened with each beat until a ventricular beat is dropped?

Back 118

2nd degree heart block, Mobitz Type 1 (Wenckebach)

Front 119

HYQ: What is the DOC in paroxysmal supraventricular tachycardia?

Back 119

- Carotid Massage (avoid in someone with carotid artery disease - you could dislodge a plaque and cause a stroke)
- Valsalva maneuvers
- IV adenosine is DOC

Front 120

Which drug is avoided in Wolff-Parkinson White but used in all other forms of paroxsymal supraventricular tachycardia?

Back 120

IV Adenosine

Front 121

What EKG finding may indicate a very early sign of Heart Failure?

Back 121

Left Ventricular Hypertrophy

Front 122

Whats a normal range for the ejection fraction?

Back 122

55-75%

Front 123

Which type of cardiac dysfunction can be thought of as the ventricle being a floppy, wet bag trying to squeeze blood (decreased contractility)

Back 123

systolic dysfunction

Front 124

Which type of cardiac dysfunction is like trying to force 1.5L of Coke into a 1L bottle? (decreased ventricular compliance)

Back 124

Diastolic dysfunction

Front 125

What medications are important in the OUTPATIENT tx of CHRONIC CHF?

Back 125

- ACEI/ ARBs
-Beta-blockers
-Loop Diuretics
- Aldosterone Antagonists (Spironolactone)
- Digoxin
- Aspirin

Front 126

What is the ACUTE tx for exacerbations of CHF?

Back 126

"LMNOP"
Lasix/ Loop Diuretics
Morphine
Nitrates
Oxygen
Positioning/ Pressors

Front 127

When should a physician consider a biventricular pacemaker in a CHF pt?

Back 127

ejection fraction <35% for >3 months

Front 128

HYQ: Which antiarryhtmic should be avoided in pts with preexisting lung disease?

Back 128

Amiodarone

Front 129

When should PVCs be concerning?

Back 129

>3 PVCs per min
- optimize Mg++ and K+ levels
- consider a beta-blocker

Front 130

Which heart valves should blood be flowing thru during systole?

Back 130

aortic & Pulmonic

Front 131

What are the systolic heart murmurs?

Back 131

aortic stenosis
pulmonic stenosis
mitral regurgitation
tricuspid regurgitation
VSD

Front 132

What heart valves should blood be flowing thru during diastole?

Back 132

Tricuspid & mitral

Front 133

What are the diastolic heart murmurs?

Back 133

tricuspid stenosis
mitral stenosis
aortic regurgitation
pulmonic regurgitation

Front 134

Explain the difference btw Kussmaul's sign and Pulsus Paradoxus

Back 134

see above

Front 135

in what condition will having the pt perform the Valsalva maneuver while auscultating the heart will increase the murmur?
In what condition will it decrease the murmur?

Back 135

INCREASE - with hypertrophic obstructive cardiomyopathy & Mitral Valve Prolapse (MVP)

DECREASE:
- aortic stenosis
- pulmonary stenosis
- tricuspid & mitral regurgitation
- aortic & pulmonic regurgitation
- tricuspid & mitral stenosis

QUICK HIT: Standing & the Valsalva & leg raise maneuvers diminish the intensity of ALL murmurs EXCEPT MVP & hypertrophic cardiomyopathy - these maneuvers decrease left ventricular volume
SQUATTING increases the intensity of ALL murmurs except MVP & Hypertrophic Cardiomyopathy
Sustained Handgrip increases the intensity of MVP murmur, but diminishes the intensity of Hypertrophic cardiomyopathy - sustained handgrip increases systemic resistance

Front 136

What 4 murmurs are possible during diastole?

Back 136

mitral/ tricuspid stenosis
aortic/ pulmonic regurgitation

Front 137

50 yo M comes to the ER with symptoms of CHF. He is a known alcoholic and his exam is notable for having both systolic & diastolic murmurs. What is the true diagnosis of this man's disease?

Back 137

Dilated cardiomyopathy

Front 138

A 66yo M presents to the ER c/o CP, esp with the action of breathing. 4wks ago he had an MI, and now he is afraid he is having another one. The pt seems most comfortable sitting up & leaning forward. Altho proper w/u for acute MI must be performed, what is the likely cause of his pain?

Back 138

Dressler's syndrome - Pericarditis

Front 139

What will cardiac catheterization show in a pt with chronic constrictive pericarditis?

Back 139

equal pressures in all 4 chambers

Front 140

What is Beck's triad, what condition do you see it with, and what are the EKG findings associated with this condition?

Back 140

Triad: hypotension, distended neck veins, distant heart sounds

Dx: Cardiac Tamponade

EKG: low voltage sinus tachycardia

Tx: pericardiocentesis, STAT

Front 141

Which heart murmur is assoc with syncopal episodes?

Back 141

aortic stenosis

Front 142

Which valve is most frequently damaged in rheumatic heart disease?

Back 142

mitral valve

Front 143

What is the classic appearance of the heart on a CXR of a patient with pericardial effusion?

Back 143

enlargement of cardiac silhouette - Globular heart - "water bottle" shaped heart

Front 144

In what scenarios might you see Kussmaul's sign (increased JVD with inspiration)

Back 144

constrictive pericarditis
Restrictive cardiomyopathy
R ventricular infarct
massive PE

Front 145

What disease has signs of heart failure + diabetes mellitus + elevated LFTs?

Back 145

Hemachromatosis

Front 146

In which etiology of restrictive cardiomyopathy is the pathology reversible with phlebotomy?

Back 146

hemachromatosis

Front 147

What is the next step in the w/u of a low-grade systolic murmur in an otherwise healthy asymptomatic patient?

Back 147

no further workup necessary

Front 148

What is the next step in teh w/u of a diastolic murmur in an otherwise healthy, asymptomatic pt?

Back 148

echocardiogram

Front 149

Short systolic murmur at the apex that decreases with squatting and is sometimes assoc with a benign chest pain and lasts only a few seconds - Dx?

Back 149

Mitral valve prolapse

Front 150

When might subclinical mitral stenosis from rheumatic heart disease become clinically apparent?

Back 150

when blood volume is increased

Front 151

What commonly causes heart failure in young pts?

Back 151

myocarditis

Front 152

What is the tx for cardiac tamponade?

Back 152

immediate pericardiocentesis

Front 153

What medications are important in the outpt management of chronic CHF?

Back 153

ACEI/ ARBs
Beta-blockers
Loop Diuretics
Aldosterone Antagonists
Digoxin
Aspirin

Front 154

What is the acute tx for exacerbations of CHF?

Back 154

LMNOP
Loop Diuretics
Morphine
Nitrates
Oxygen
Position/ Pressors

Front 155

Diastolic murmur heard best at LLSB, that increases with inspiration

Back 155

Tricuspid Stenosis

Front 156

Late diastolic murmur with an opening snap (no change with inspiration)

Back 156

Mitral Stenosis

Front 157

Systolic murmur heard best in second right interspace

Back 157

aortic stenosis

Front 158

systolic murmur heard best in second left interspace

Back 158

Pulmonic stenosis

Front 159

Late systolic murmur best heard at apex

Back 159

mitral valve prolapse

Front 160

Diastolic murmur with a widened pulse pressure

Back 160

aortic regurgitation

Front 161

holosytolic murmur that is louder with inspiration at the left lower sternum

Back 161

tricuspid regurgitation

Front 162

holosystolic murmur heard at the apex and radiates to the axilla

Back 162

mitral regurgitation

Front 163

What is the treatment for premature atrial contractions?

Back 163

observation

Front 164

Crescendo-decrescendo systolic murmur best heart in 2nd-3rd right interspace close to sternum

Back 164

Aortic stenosis

Front 165

Rumbling late diastolic mumur with an opening snap

Back 165

Mitral stenosis

Front 166

Pansystolic (aka holosystolic) murmur best heard at the 4th-6th left intercostal spaces

Back 166

Tricuspid regurg or VSD

Front 167

Continuous machine-like murmur

Back 167

PDA

Front 168

high pitched diastolic murmur
assoc with widened pulse pressure

Back 168

aortic regurgitation

Front 169

Explain the ABCDEs of Trauma assessment

Back 169

Front 170

What are the classic physical findings in a basilar skull fracture/

Back 170

Raccoon eyes
Battle’s sign – bruising over mastoid process
Hemotympanum
CSF from nose (rhinorrhea) or ears (otorrhea)

Front 171

What is Cushing’s triad (4*)

Back 171

1. Hypertension
2. Bradycardia
3. Bradypnea

Front 172

What interventions can be used to lower intracranial pressure in a head injury patient?

Back 172

Front 173

What is the treatment for anterior spinal cord syndrome following a traumatic injury?

Back 173

Front 174

A pt involved in a motorcycle accident arrives in the ER on a stretcher with his neck in a hard cervical collar. His left leg and foot are mangled. His GCS is 15 & in between his moans of pain he asks to have the uncomfortable collar removed b/c his neck isn’t bothering him. Can you remove the collar?

Back 174

NO!

Front 175

A patient presents to the ER after being involved in a motor vehicle collision (MVC). He doesn’t open his eyes or make any sounds, but he does withdraw to painful stimuli. What is his Galsgow coma score (GCS)? What needs to be done?

Back 175

GCS = 6
Next step: intubation

Front 176

Another MVC victim arrives to the ER. He is able to carry on a conversation and even comment on how nice one of the nurses’ hair looks. He is able to move all of his extremities on command, and he had a significant periorbital ecchymosis and surround superficial scrapes. What is his GCS? What radiological study does he definitely need?

Back 176

GCS = 15
Next step: noncontrast CT of head

Front 177

Yet another motor vehicle collision victim presents to the ER with a profusely bleeding wound to the leg. She is complaining loudly about her pain. What is your next step in assessment?

Back 177

Next need to assess breathing (you know the airway is patent b/c she is talking) to assess breathing, auscultate the lungs

Front 178

What imaging is commonly utilized in an MVC pt with no neck pain & low risk of cervical injury in order to r/o cervical fracture?

Back 178

Cervical XRAY series – A/P, Lateral, Open-mouth odontoid

Front 179

What imaging is required to definitely r/o C-spine fracture?

Back 179

Cervical CT scan

Front 180

What are the different zones of the neck and structures contained in each zone?

Back 180

Front 181

What work-up is indicated for a penetrating injury to the different zones of the neck when the platysma has been violated?

Back 181

Airway, breathing, circulation
Very low threshold for intubation in these patients
Asses for injury to the lung, esp in zone I injuries
Oxygen, 2 large bore IVs (eg 14 gauge), type & cross blood
If unstable as a result of this injury or obvious bleeding or rapidly expanding hematoma → stat to the OR for surgical exploration (Do not explore the wound in the ER). While waiting, do the following:
Direct pressure to any bleeding sites
If bleeding persists, consider placing a Foley cath into the wound & fill with normal saline to control bleeding
If stat surgery consult is delayed & bleeding persists, consider attempt to explore wound & clamp bleeding
Zone I – assess with 4 Vessel Arteriogram (CTA)
Zone II – Surgical Exploration or (Doppler U/s + selective exploration) (Institution dependent)
Zone III – 4 Vessel Arteriogram (CTA) + triple endoscopy

Front 182

What CXR findings might indicate a ruptured thoracic aorta?

Back 182

Widened mediastinum, loss of aortic knob, pleural cap, deviation of the trachea and esophagus to the right, and depression of the left main stem bronchus

Front 183

(5*) What are the signs of tension pneumothorax? What is the treatment?

Back 183

Signs: absent breath sounds and hyperresonance to percussion (hollow sound) on the affected side, distended neck veins, hypotension
Treatment:
Immediate chest tube placement
If delay in chest tube placement, needle decompression on the affected side (2nd or 3rd IC space at midclavicular line or 5th IC space at midaxillary line)

Front 184

What is a flail chest and what is the classic presentation?

Back 184

Flail chest is a free-floating portion of the chest wall that moves paradoxically to the rest of the chest wall (inward motion with inspiration) and results from 3 or more sequential rib fractures
Patient may have muscle splinting due to pain which may conceal the paradoxical motion of the chest wall
Mechanism of injury is usually direct impact of the steering wheel or crush injury

Front 185

What is the treatment for a flail chest?

Back 185

Oxygen supplementation
Close monitoring for early signs of respiratory compromise
(placing an object (ie sandbag) to the affected region to stabilize the segment is no longer done due to the consequence of restricting chest expansion)
BiPAP by mask or endotracheal intubation with mechanical ventilation
Analgesia for pain (otherwise patient may become hypoxic from limiting breathing due to pain

Front 186

What are the initial steps in the management of an abdominal stab wound presenting to the ER?

Back 186

Front 187

What are the next steps in the management of blunt abdominal trauma in a patient with stable vital signs?

Back 187

Airway, breathing, circulation (primary survey then secondary survey)
Establish IV access at two sites with large bore IVs
NG tube and Foley
*****CT of abdomen & pelvis
Stat H&H +/- Blood type & cross

Front 188

What are the next steps in the management of a patient with blunt abdominal trauma and unstable vital signs?

Back 188

Front 189

What is the treatment for a retroperitoneal hematoma?

Back 189

Front 190

What is the next step in managing an expanding hematoma in the neck?

Back 190

Intubation

Front 191

A trauma patient arrives in the ER after being the driver in a high speed collision. Airway is intact, but on inspection of the chest, a portion of his chest wall seems to move in the opposite direction than it should when he breathes. What is the problem here?

Back 191

Dx: Flail chest – suggests multiple rib fractures

Front 192

While you were observing the odd chest movements above, the mental status and BP of the patient plummeted. Quickly you listen for chest sounds, which are absent on the anterior right side. This area is hyper-resonant to percussion, and there may be some deviation of the trachea to the left. What now?

Back 192

Dx: Tension pneumothorax
Tx: large gauge hollow needs into the 2nd intercostal space, midclavicular line, then place chest tube

Front 193

A psychiatric patient stabbed himself in the umbilicus with a knife. The patient is tachycardic and hypotensive. The wound appears to penetrate the abdominal wall. What is the next step in management?

Back 193

Patient needs to go to the OR – evaluate for injury to intraabdominal structures

Front 194

A MVC victim has evidence of significant blunt trauma. On the way to the CT scanner, his BP plummets. What is the next step?

Back 194

Bypass CT scanner & pt needs to go to the OR

Front 195

What is the immediate treatment for a patient with a pelvic fracture?

Back 195

Front 196

What are the classic signs of urethral injury? What study can be used to confirm this?

Back 196

Look for blood at the urethral meatus, a high-riding “ballotable” prostate, or absence of palpable prostate
If signs of injury → retrograde cystourethrogram to r/o injury prior to Foley catheter placement

Front 197

What is the classic sign for a bladder injury? What study can be used to confirm this?

Back 197

Hematuria is most frequently seen in bladder injuries
A Retrograde cystourethrogram can be used to diagnose the bladder injury and determine if it is an intraperitoneal or extraperitoneal rupture
If extraperitoneal rupture → Foley catheter for 10 – 14days
If intraperitoneal ruptures → Urgent laparotomy for bladder repair

Front 198

What antibiotic prophylaxis should be provided for rape victims? What other prophylatic measures should also be taken?

Back 198

Front 199

What is the next step in the evaluation of a male trauma patient with blood at his urethral meatus & a high riding prostate? What is contraindicated?

Back 199

Next step: retrograde urethrogram
Contraindications: do NOT attempt to place a foley!

Front 200

What should be done to evaluate an extremity trauma?

Back 200

Full sensory & motor exam

Front 201

What should you be looking for in a fetal ultrasound in the pregnant patient that has been involved in a MVA?

Back 201

Placental abruption

Front 202

Since bleeding between the fetus & mother is a concern in trauma, what actions should be taken once the patient and the fetus are stabilized?

Back 202

Test mother’s Rh status

Front 203

What criteria must be met before a pregnant trauma pt can be discharged from the hospital? (Hint: these are essentially the opposite of the symptoms found in placental abruption)

Back 203

1. Contraction frequency ( < 1 every 10 min)
2. Normal fetal heart tracing
3. Absence of vaginal bleeding & abdominal pain

Front 204

What antibiotics should be given in a case of sexual assault?

Back 204

Ceftriaxone, Azithromycin, Metronidazole

Front 205

What are some classic signs of physical abuse?

Back 205

Multiple bruises, inconsistent/vague history
Burns/ bruises in shapes of objects
Rib, skull, long bone fractures

Front 206

HYQ: What radiographic study is used to diagnose injury to the urethra?

Back 206

Retrograde cystourethrogram

Front 207

HYQ: Chest trauma + hypotension + JVD + distant heart sounds → what is the next step in the management of this patient?

Back 207

Dx: Cardiac tamponade
Tx: Pericardiocentesis; pericardial window

Front 208

HYQ: Chest trauma + hypotension + JVD + respiratory distress → what is the next step in the management of this pt?

Back 208

Dx: Tension Pneumothorax
Next steps: needle decompression of the chest & placement of a chest tube

Front 209

HYQ: What is the next step in the evaluation of penetrating injuries to the different zones of the neck?

Back 209

Zone 1: 4 –Vessel arteriogram
Zone 2: surgical exploration
Zone 3: CT angiogram + triple endoscopy

Front 210

HYQ: What is the next step in the evaluation of penetrating injuries to the different zones of the neck?

Back 210

Zone 1: 4 –Vessel arteriogram
Zone 2: surgical exploration
Zone 3: CT angiogram + triple endoscopy

Front 211

HYQ: What interventions are effective in the management of elevated intracranial pressure?

Back 211

Elevate head of bed to 30°
Intubate/ hyperventilate temporarily
Mannitol
Decompressive craniectomy

Front 212

What is the next step -

Pelvic fracture + DPL shows blood in the pelvis

Back 212

Emergent laparotomy

Front 213

What is the next step :
Pelvic fracture + DPL shows urine in the pelvis

Back 213

Urgent laparotomy

Front 214

What is the next step
Pelvic fracture + DPL shows nothing + hemodynamic instability

Back 214

Angiography with possible embolization

Front 215

What is the next step
Blunt abdominal trauma + unstable vital signs + FAST shows fluid in pelvis

Back 215

Emergent Laparotomy

Front 216

What is the next step
Blunt abdominal trauma + unstable vital signs + FAST shows no fluid in pelvis

Back 216

Angiography with possible embolism

Front 217

What is the next step
Blunt abdominal trauma + unstable vital signs + FAST inconclusive

Back 217

DPL

Front 218

What is the next step
Blunt abdominal trauma + stable vital signs

Back 218

CT of abdomen & pelvis

Front 219

What is the next step
Abdominal stab wound + hypotensive or signs of peritonitis

Back 219

Emergent laparotomy

Front 220

What additional studies can be performed in the case of a stable patient with an abdominal stab wound that penetrated the peritoneum?

Back 220

Diagnostic laparotomy best
DPL
Upright CXR
Diagnostic Ultrasound
Contrast CT of the abdomen & pelvis