Ditt Step 2 Day 5 Cardio & Critical Care

Front 1

What are the common viruses that cause myocarditis?

Back 1

coxsackie virus, Echovirus, Adenovirus, EBV, CMV, Influenza

Front 2

A south American immigrant has cardiomegaly and achalasia. What is the organism likely responsible for this patient's disease?

Back 2

Chagas Disease - Trypanosoma Cruzi

Front 3

What are the major JONES criteria in the diagnosis of rheumatic heart disease?

Back 3

Joints (polyarthritis)
Heart - pancarditis & vallve damage
Nodules (subcutaneous)
Erythema marginatum (painless rash)
Syndenham's Chorea

Front 4

What is the mneumonic to remember the classic physical exam findings of endocarditis?

Back 4

"FROM JANE"
Fever
Roth Spots
Osler's Nodes
Murmur
Janeway Lesions
Anemia
Nail-bed hemorrhages
Emboli

Front 5

Tiny septic emboli fly off the infected valve in endocarditis and travel to peripheral vessels, causing tiny hemorrhages. What are the names of some of these sites of micro-hemorrhages?

Back 5

Janeway lesions - peripheral petechiae
Osler's nodes - tender nodules on finger & toe pads
Roth's spots - retinal hemorrhages
Splinter hemorrhages - sublingual petechiae

Front 6

What is the best study to visualize a vegetation on a heart valve?

Back 6

TransEsophageal Echocardiogram (TEE)

Front 7

What is the treatment for endocarditis?

Back 7

long-term IV antibiotics (4-6wks)

Front 8

What blood pressure defines prehypertension? How should prehypertension be managed?

Back 8

PreHTN = SBP 120-139, DBP 80-89

- if pts SBP is >130 or DBP >80 and has DM, Chronic Kidney Disease, end organ damage, or cardiovascular disease then medical management with an antihypertensive agent is indicated
-if none of the above comorbidities, then non-pharmacologic management with weight reduction, sodium restriction, increased physical activity, and avoidance of excess alcohol

Front 9

What blood pressure range is considered pre-HTN?

Back 9

SBP 120-139
DBP = 80-89

management:
weight loss
decrease salt intake
decrease alcohol
increase exercise

Front 10

How many consecutive abnormally high readings are needed before prescribing BP medications?

Back 10

3

Front 11

What is the typical first line agent prescribed in treating newly diagnosed HTN?

Back 11

Thiazide diuretics (HCTZ & chlorthalidone)

Front 12

what is the chemical that increases as a result of ACE inhibitors, and is though to cause the adverse effects of cough & angioedema?

Back 12

bradykinin

Front 13

Which BP medication should all DM, CHF, and post-MI pts take as part of their BP regimen?

Back 13

ACE inhibitor or ARB

Front 14

Which antihypertensive can cause first dose orthostatic hypotension?

Back 14

alpha-blockers

Front 15

Which antihypertensive can cause hypertrichosis?

Back 15

minoxidil (Rogaine)

Front 16

Which antihypertensive can cause dry mouth, sedation, severe rebound hypertension?

Back 16

Clonidine

Front 17

Which antihypertensive can cause bradycardia, impotence, asthma exacerbation?

Back 17

non-selective beta-blockers

Front 18

Which antihypertensive can cause reflex tachycardia?

Back 18

Nitroprusside (vasodilator)

Front 19

Which antihypertensive can cause cough?

Back 19

ACE Inhibitors

Front 20

Which antihypertensive should be avoided in pts with sulfa allergies?

Back 20

Thiazide & loop diuretics

Front 21

Which antihypertensive can cause angioedema?

Back 21

ACE Inhibitors

Front 22

Which antihypertensive can cause drug-induced lupus?

Back 22

Hydralazine

Front 23

Which antihypertensive can cause cyanide toxicity?

Back 23

nitroprusside

Front 24

which antihypertensives can be used in pregnancy?

Back 24

labetalol, methyldopa, hydralazine, nifedipine

Front 25

What tests can be used to diagnose renal artery stenosis?

Back 25

Renal arteriogram - gold standard, but invasive
MRA of renal arteries - most freq used screening test
Renal artery duplex scan - capable of detecting bilateral renal artery stenosis (unlike CT or MRA) but time consuming (2 hrs) and must have well-trained operator
Helical CT of renal arteries with IV contrast
Captopril renal ultrasound

Front 26

What is the most common cause of secondary HTN?

Back 26

Renal disease (renal artery stenosis, chronic renal disease, end stage renal disease)

Front 27

What can be offered as an alternative contraceptive to a woman whose current estrogen-containing OCPs are causing HTN?

Back 27

Progestin-only methods (progestin-only pills, DepoProvera, Implanon, Mirena)

Front 28

Hypoperfusion and resultant tissue ischemia are the concern in shock pts. What is the chemical marker of this?

Back 28

elevated lactic acid level

Front 29

What is the mechanism behind cardiogenic shock?

Back 29

failure of the pump

Front 30

What is the mechanism behind extra-cardiogenic shock?

Back 30

compression of the pump (tension pneumothorax, massive hemothorax, cardiac tamponade)

Front 31

What is the mechanism behind hypovolemic shock?

Back 31

not enough fluid to pump

Front 32

What is the mechanism behind anaphylactic shock?

Back 32

widespread vasodilation & release of vasodilatory agent in response to allergen

Front 33

What is the mechanism behind neurogenic shock?

Back 33

widespread vasodilation & loss of autonomic regulated vascular tone

Front 34

What is the mechanism behind septic shock?

Back 34

widespread vasodilation & massive release of inflammatory mediators

Front 35

HTN + depression + kidney stones

Dx?

Back 35

hyperparathyroidism

Front 36

What complication can arise from the use of vasopressors such as norepinephrine (NE) in treating shock?

Back 36

peripheral vasoconstriction & ischemia (finers & toes, mesenteric ischemia, renal failure)

Front 37

What intervention is most effective at reducing blood pressure?

Back 37

weight loss

Front 38

What is the preferred initial antihypertensive in a pt with no comorbidities?

Back 38

Thiazide diuretic

Front 39

Which anti-HTN is first line in pts with diabetes

Back 39

ACE inhibitor/ ARB

Front 40

Which anti-HTN is first line in pts with BPH

Back 40

alpha-blockers

Front 41

Which anti-HTN is first line in pts with heart failure

Back 41

ACE Inhibitor/ ARB,
beta-blocker
Aldosterone Antagonists

Front 42

Which anti-HTN is first line in pts with left ventricular hypertrophy

Back 42

ACE inhibitor/ ARB

Front 43

Which anti-HTN is first line in pts with hyperthyroidism

Back 43

Propanolol

Front 44

Which anti-HTN is first line in pts with osteoporosis

Back 44

Thiazide diuretics

Front 45

Which anti-HTN is first line in pts with benign essential tremor

Back 45

beta-blocker

Front 46

Which anti-HTN is first line in post-menopausal females?

Back 46

thiazide diuretics

loops lose Calcium, thiazides dont

Front 47

Which anti-HTN is first line in pts with migraines?

Back 47

beta-blockers

Front 48

HTN measures in arms but low BP in lower extremity

What is the most likely cause of HTN?

Back 48

coarctation of aorta

Front 49

What is the most likely cause of HTN?

pt found to have proteinuria

Back 49

renal disease

Front 50

What is the most likely cause of secondary HTN with the follow finding:

hypokalemia

Back 50

hyperaldosteronism

Front 51

tachycardia + diarrhea + heat intolerance

What is the most likely cause of HTN?

Back 51

hyperthyroidism

Front 52

What is the most likely cause of secondary HTN with the follow finding:
hyperkalemia

Back 52

renal failure or renal artery stenosis

Front 53

pt has episodes of excessive sweating + tachycardia

What is the most likely cause of HTN?

Back 53

pheochromocytoma

Front 54

oompare the vasodilating effects of:
Nitroglycerin
Dihydropyridine CCBs
Hydralazine
Nitroprusside

Back 54

Nitroglycerin = venous vasodilator
Dihydropyridine CCBs = dilates both arteries & veins
Hydralazine = arterial vasodilator
Nitroprusside = dilates both arteries & veins

Front 55

What are the HACEK bacteria?

Back 55

Haemophilus
Actinobacillus
Cardiobacterium
Eikenella
Kingella

Front 56

What are the indications for the repair of AAA to prevent future rupture?

Back 56

Diameter > 5.5cm
↑ in diameter by more than .5cm in a 6mo interval (should be receiving abd sono q 6mos)
symptomatic (ie tenderness, pain in abdomen or back)

Front 57

What is the w/u for a pt with peripheral artery disease (PAD) considering surgical corrections?

Back 57

Generally the steps of surgical evaluation for PVD are as follows: physical exam → ankle-brachial index (ABI) (to confirm diagnosis) → segmental pressures and/or LE duplex/Doppler (to determine lesion location, morphology) → lower extremity arteriogram (to map the disease extent and locations in order to determine the best tx option) → surgery
Cardiac stress test prior to surgery b/c pts are likely to also have CAD needing intervention prior to PAD surgery

Front 58

What are the components of medical, conservative management of peripheral artery disease (PAD)?

Back 58

Smoking cessation; Glucose & BP control
Daily exercise to ↑ collateral flow
Cilostazol (pletal) 100mg BID to improve flow to LE and ↓claudication. It is better than pentoxifylline (Trental) 400mg tid. Contraindicated if any heart failure due to ↑mortality.
Aspirin or Plavix qd to ↓ cardiovascular events
Statin therapy to ↓ cardio events and ↑ pain-free walking distance
Other possibly effective therapies: Trental (2nd line to Pletal) Ginko biloba
Not Effective: Vit E

Front 59

What options are available to treat varicose veins?

Back 59

Weight reduction, avoidance of prolonged stockings, leg elevation
Compression stockings: OTC support stockings, Class I stockings (20-30mmHg), or Class II stockings (30-40mmHg)
Sclerotherapy: injection of substance directly into the vein that causes injury & thrombosis
Surgery: involving ligation of the long sphenous vein or short saphenous vein

Front 60

What is an Unna boot, and when is its used indication?

Back 60

Inelastic banadage that is impregnanted with zinc oxide paste + calamine lotion + glycerine + gelatin
Indicated for ulcer arising from chronic venous insufficiency
Pts preder to use hydrocolloid dressing that can be changed at home q5-7 days instead of the Unna boot which must be placed by trained personnel q1-3wks. The effectiveness in ulcer healing is the same for both

Front 61

What are the different methods available for the primary prevention of DVT?

Back 61

Front 62

What is the treatment for superficial thrombophlebitis?

Back 62

Front 63

What study should be ordered for a pt suspected of having an Abdominal aortic aneurysm (AAA)?

Back 63

Ultrasound of the abdomen

Front 64

What are recommendations for screening for AAA with u/s?

Back 64

All males btw the ages of 65-75yrs with any h/o smoking & men ages 65-75 yrs who have never smoked but who have a 1st degree relative who required repair of AAA or died from ruptured AAA

Front 65

What are the first recommendations to pts with claudication besides medication optimization?

Back 65

Stop smoking, ↑ exercise/walking
If these fail, consider surgical option

Front 66

What are several methods to prevent DVTs in hospitalized pts?

Back 66

Place SCDs
Ambulate
Anticoagulate – Enoxaparin/ Heparin or warfarin

Front 67

What should be ordered in a pt suspected of having a DVT?

Back 67

D-dimer (good for ruling out)
Bilateral lower extremity duplex U/S

Front 68

A pt comes to the ER following a MVC and CXR reveals a widened mediastinum. What imaging would confirm dx?

Back 68

Contrast CT scan of the chest

Front 69

How is Kawasaki’s disease diagnosed?

Back 69

“CRASH & burn”
Conjunctivitis – bilateral, nonexudative, painless
Rash - truncal
Adenopathy- of the cervical lymph nodes
Strawberry tongue – and diffuse mucus membrane erythema
Hands & feet have edema with induration, erythema & desquamation
Fever > 5 days (>40C or 104°F)
Note: coronary artery aneurysms can occur w/in weeks of the illness onset, but are not indicated in diagnostic criteria

Front 70

How is Kawasaki’s disease treated?

Back 70

IVIG (2g/kg over 8-12 hrs) – ideally w/in the first 10 days
High-dose aspirin (80-100mg/kg/day in 4 divided doses) in the acute phase of the illness continued until 48hrs after fever resolution, followed by low-dose aspirin (3-5 mg/kg/day) until inflammatory markers (ESR, platelets) return to normal (usually 6 weeks)
(steroids are not indicated and are of no proven benefit)
Echocardiogram in the acute phase & 6-8 wks later

Front 71

A 55yo F presents with c/o new headache, jaw claudication, and tenderness of the temporal artery. What test will reveal dx? What is the treatment?

Back 71

Dx: Temporal artery biopsy
Tx: steroids & aspirin

Front 72

Why should steroids be started immediately in pts in which you have a high suspicion of temporal arteritis?

Back 72

Prevent vision loss

Front 73

35 yo Japanese-American F has fever, malaise, and ↓ carotid & limb pulses. What will be seen on radiology? Biopsy?

Back 73

Radiology: defects along the aorta & its branches
Biopsy: fibrosis, giant cells, plasma cells & lymphocytes w/in the media & adventitia of affected vessels

Front 74

A known asthmatic develops ↑ fatigue, fever & rash. What vasculitis might she have? What might be seen on blood tests?

Back 74

Dx: Churgg-Strauss
Blood tests: ↑ serum eosinophils, ↑ ESR, (+) pANCA

Front 75

What are the signs & symptoms of Kawasaki disease?

Back 75

“CRASH & burn”
Conjunctivitis, Rash, Adenopathy, Strawberry tongue
Hands & feet have edema with induration, erythema & desquamation
Fever > 5 days

Front 76

What is the tx for Kawasaki disease? What complication is the treatment trying to prevent?

Back 76

Tx: Aspirin + IVIG, trying to prevent aneurysms

Front 77

What is the treatment for ventricular septal defects?

Back 77

Front 78

What are the characteristics of Ebstein’s Anomaly?

Back 78

a/w maternal Lithium use
Tricuspid Leaflets are displaced into right ventricle, hypoplastic right ventricle, tricuspid regurg or stenosis
80% have a patent foramen ovale with R → L shunt
Dilated right atrium = ↑ risk of SVT & WPW
Exam: widely split S2, tricuspid regurgitation
Tx: PGE, digoxin, diuresis, propanolol for SVT

Front 79

What are the unique structures of the fetal circulation that close after birth?

Back 79

Umbilical vein, umbilical arteries (2)
Ductus arteriosus, ductus venosus
Foramen ovale

Front 80

HYQ: What medication is used to close a PDA?

Back 80

Indomethacin
Note: Prostaglandin E keeps it open
think: to open the door, you gotta "push it, push it real good" (Push/Prost)

Front 81

A newbown is found to have a congenital heart disease that causes early cyanosis. What drug does this newborn need?

Back 81

Prostaglandin E

Front 82

What is the most common congenital heart defect?

Back 82

VSD

Front 83

Describe briefly the sequence of events in Eisenmenger’s syndrome:

Back 83

L to R shunt → ↑ blood in pulmonary vasculature, ↑ resistance → shunt reverses R to L

Front 84

What are the abnormalities a/w Tetrology of Fallot?

Back 84

VSD, overriding aorta, RVH, RV outflow obstruction/stenosis of pulmonary artery

Front 85

What heart defect are Down syndrome pts at higher risk for?

Back 85

Endocardial cushion defect

Front 86

HYQ: 6wk old infant presents to the pediatric ER for irritability & is found to have signs of left-sided heart failure. An EKG is interpreted as a left-sided MI. What is the most likely dx?

Back 86

Anomalous origin of the left coronary artery
Arises from the pulmonary artery rather than the aorta & carries deoxygenated blood

Front 87

HYQ: What class of medications is indicated in pts with a hereditary prolongation of the QT interval in order to prevent episode of ventricular fibrillation?

Back 87

β-blockers (propanolol)

Front 88

What type of vasculitis:
Weak pulses in upper extremity

Back 88

Takayasu’s

Front 89

Necrotizing granulomas of lung & necrotizing glomerulonephritis

Back 89

Wegener's

Front 90

Necrotizing immune complex inflammation of visceral/ renal vessels in young male smokers

Back 90

Buerger’s

Front 91

What type of vasculitis is seen with young asthmatics?

Back 91

Churg-Strauss

Front 92

What type of vasculitis is seen in Infants & young children; involves coronary arteries

Back 92

Kawasaki

Front 93

Most common vasculitis

Back 93

Temporal (Giant cell) arteritis

Front 94

what type of vasculitis is assoc with hep B infection

Back 94

Polyarteritis nodosa

Front 95

In which type of vasculitis can you see occlusion of ophthalmic artery that can lead to blindness?

Back 95

Temporal (giant cell) arteritis

Front 96

Perforation of nasal septum

Back 96

Wegener's

Front 97

Unilateral headache, jaw claudication

Back 97

Temporal (giant cell) arteritis

Front 98

What is the next step in the management of a pt with a DVT that has a high likelihood of falling?

Back 98

IVC filter

Front 99

What are the components of the medical management of peripheral artery disease (PAD)?

Back 99

Smoking cessation
↑ exercise
glucose control
diet
BP control
Cilostazol

Front 100

What are the indications for operating on an AAA?

Back 100

Size >5.5 cm
Rate of increase > 0.5cm in 6 mos
Symptomatic

Front 101

Who should be screened for an abdominal aortic aneurysm?

Back 101

All males btw the ages of 65-75yrs with any h/o smoking & men ages 65-75 yrs who have never smoked but who have a 1st degree relative who required repair of AAA or died from ruptured AAA

Front 102

What are some of the complications/ reactions that can arise from blood transfusions?

Back 102

Front 103

In a Swan-Ganz catheter (pulmonary artery catheter), the wedge pressure is equal to what?

Back 103

Left atrial pressure

Front 104

Which blood products replace clotting factors?

Back 104

FFP, Cryoprecipitate, Whole blood
Clotting factors from donors
Recombinant factors, Autologus blood

Front 105

A pt is brought to the ER s/p MVA. It appears he has sustained blunt trauma & is hypOtensive. You immediately order a type & cross and start IVF. The pt is found to be type O neg so the lab sends up 6units of AB+ pRBCs. What is the next step?

Back 105

Send it back! He needs O neg blood

Front 106

For what indications would you use the following?

Back 106

Front 107

What is the cause of acute hemolytic transfusion reaction? Anaphylactic reaction?

Back 107

Acute hemorlytic: ABO incompatibility

Anaphylactic: anti-IgA IgG Abs react in IgA deficient pts

Front 108

What are some agents used to treat shock due to a weakly beating heart?

Back 108

Dopamine, Dobutamine, Epinephrine, Isoproterenol, Norepinephrine

Front 109

What commonly used agents cause peripheral vasoconstriction?

Back 109

Norepinephrine, Vasopressin, Epinephrine, Phenylephrine

Front 110

What medications are used to treat febrile & urticarial transfusion reactions?

Back 110

Acetominophen & Diphenhydramine

Front 111

What is the typical ER lab work-up for a pt with acute abdominal pain?

Back 111

CBC with differential
Chem 14
β-hCG if female
urinalysis
amylase, lipase
stool guaiac

Front 112

What are the signs & symptoms of acute mesenteric ischemia?

Back 112

Sudden onset of severe abdominal pain (periumbilical) that is OUT OF PROPORTION TO THE EXAM
Vomiting & diarrhea
Condition that could cause emboli formation (ie atrial fibrillation)
Early exam: mostly normal, abdominal distention +/- occult blood on stool
Late exam (bowel infarction): abdominal distention, absent bowel sounds, peritoneal signs, feculent odor to the breath

Front 113

What is the treatment for acute mesenteric ischemia?

Back 113

Front 114

What are the classic signs/symptoms of chronic mesenteric ischemia?

Back 114

Aka intestinal angina
Dull, crampy, postprandial epigastric pain within the first hour after eating then subsiding over 2 hrs
Weight loss (due to food aversion to avoid postprandial pain)
Possibly nausea, vomiting, and early satiety
Abdominal bruit (50%)

Front 115

What are the treatment option for chronic mesenteric ischemia?

Back 115

Bypass, endarterectomy, angioplasty

Front 116

Which oral hypoglycemia medicine should NOT be given when a pt is to have a radiologic procedure in which he will need IV contrast?

Back 116

Metformin
Note: metformin + contrast dye → lactic acidosis

Front 117

A patient taking warfarin chronically for a h/o thromboembolism requires surgery. What can be given in the perioperative period to keep the patient anticoagulated?

Back 117

Heparin or LMWH

Front 118

What are the 5 W’s of post-operative fever? To what do they refer?

Back 118

Wind – atelectasis / pneumonia
Water – UTI (foley catheter)
Walking – DVT / PE
Wound – wound infection
Wonder drugs – drug reaction
“Wein” (Vein) – thrombophlebitis, DVT
also think sinusitis if NG tube in place

Front 119

What studies are ordered to evaluate the cause of a fever in a postop patient?

Back 119

CXR, UA, urine culture, blood cultures
Sputum culture, wound culture

Front 120

What is used to evaluate patients that may have a lower extremity DVT?

Back 120

D-dimer and/or bilateral lower extremity ultrasound

Front 121

What should be prescribed to abdominal post-op patients to help reduce atelectasis?

Back 121

Incentive spirometry
Deep breathing exercises
Physical therapy
+/- bronchodilators & inhaled steroids

Front 122

Other notes:

Back 122

LMWH should NOT be restarted until at least 2 hrs after removal of epidural catheter to avoid epidural hematoma

Renal protective measures:
Hydration, IV bicarb, NAC (n-acetylcysteine)

Front 123

Clean-contaminated wounds involve an incision through disinfected skin & would involve one or more of the following structures?

Back 123

GI tract, respiratory tract, vagina

Front 124

What is seen on abdominal x-ray or CT scan that indicates a ruptured viscus?

Back 124

Free air (radiolucent/ black)

Front 125

What is the classic finding in the abdominal exam of a patient with mesenteric ischemia?

Back 125

Pain out of proportion to the exam

Front 126

During a surgical procedure, the anesthesiologist notices that the patient’s temperature has climbed quickly and her muscles are rigid. Recognizing this feared complication, the doctor should administer which medicine?

Back 126

Dantrolene (think malignant hyperthermia)

Front 127

What are a few contraindications to the transplant of the following organs?

Back 127

Heart – smoking, pulmonary hypertension
Lung – smoking, poor cardiac/liver/renal failure
Liver – alcoholism, multiple suicide attempts

Front 128

What is the type of rejection that is treatable with immunosuppressive agents? What is the mechanism of this rejection? Within what time frame may it show up?

Back 128

Acute rejection

Front 129

What is the usual lab panel ordered in a pt presenting to the ER with generalized abdominal pain?

Back 129

CBC with differential, Chem 8 / BMP, LFTs, Urine analysis
β-hCG (if female)
stool guaiac
amylase, lipase
EKG & cardiac enzymes if > 45 yrs old

Front 130

What is the usual time frame for stopping warfarin prior to surgery?

Back 130

3 – 4 days prior to surgery

Front 131

What interventions are helpful in optimizing lung function in the post-op period in patients with pre-existing lung disease?

Back 131

Incentive spirometry
Pain control
Deep breathing
Physical therapy
Bronchodilators
Inhaled steroids

Front 132

What type of immunodeficiency increases the risk of anaphylactic transfusion reaction?

Back 132

IgA deficiency

Front 133

What lab findings suggest hepatic disease during a pre-op work-up?

Back 133

↑ PT/PTT
↓ platelets
↑ bilirubin
↑ or ↓ transaminases
↓ albumin

Front 134

What are the preferred vessels in the placement of a Swan-Ganz catheter?

Back 134

Right IJ or Left Subclavian

Front 135

When is the greatest risk for a post-operative MI? What is recommended perioperatively for pts with known CAD?

Back 135

With in first 48 hrs
Telemetry monitoring

Front 136

Which vasopressor matches the following statement?

Back 136

you forgot to fill this in

Front 137

Which blood product is most appropriate in the following scenarios?

Back 137

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