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445 Cards in this Set
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How to calculate Rate based on ECG using # of boxes
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1=300, 2=150, 3=100, 4=75, 5=60, 6=50, 7=30 (i.e. if a QRS every 3 boxes, rate is 100 bpm); 1 big box = 0.2s & 1 small box = 0.04s
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How to calculate Rate based on ECG using the whole strip
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total number of QRSs x6
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Normal sinus heart rate.
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60-100 bpm
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Define bradycardia.
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heart rate <60 bpm
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Define tachycardia
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heart rate >100 bpm
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Define sinus rhythm.
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P before every QRS and QRS for every P
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Rhythm regulated by the atria is at what rate?
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60-80 bpm
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Rhythm regulated at the AV junction is at what rate?
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40-60 bpm
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Rhythm regulated by ventricular septum or other ventricular cells is at what rate?
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20-40 bpm
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QRS width in PAC.
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narrow
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QRS width in PVC
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wide
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Normal Axis via Rule of Thumbs
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Left thumb up for positive Lead I and Right thumb up for positive Lead II (there are variations to leads used)
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Left Axis Deviation via Rule of Thumbs
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Left thumb up for positive Lead I and Right thumb down for down for negative Lead II (there are variations to leads used)
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Right Axis Deviation via Rule of Thumbs
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Left thumb down for down for negative Lead I and Right thumb up for positive Lead II (there are variations to leads used)
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Normal PR interval.
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120-200 msec (< 1 big box)
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Normal QRS width
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<100 msec (about 2 small boxes)
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PR interval greater than 200 msec (more than 1 big box).
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AV block
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Name the 2 types of secondary AV block.
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mobitz I and motbitz II
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Mobitz II pattern on ECG (AKA secondary AV block type 2).
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PR interval remains the same, but occasional dropped beat. Measure it!
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Mobitz I pattern on ECG (AKA Wenckebach or secondary AV block type 1).
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PR interval "marches out" (increases in length for each subsequent conduction) until QRS is dropped. Measure it!
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Third degree AV block pattern on ECG.
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interval between P waves not associated with interval between QRSs.
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ECG shows no association between p's and qrs's.
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3rd degree (complete) heart block.
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Bundle branch blocks show what variation in qrs?
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Wide (>120 ms)
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What will V1 be missing in LBBB?
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There will be no R wave.
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RBBB will have what variation in I, V5, & V6?
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Wide s wave.
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WiLLiam MaRRoW mnemonic to distinguish RBBB vs. LBBB:
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Left: W shape (positive qrs) in V1-V2; M shape (rabbit ears) in V3-V6.
Right: M shape in V1-V2; W shape in V3-V6. |
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Millisecond definition of Long QT syndrome.
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QTc >440 ms
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Long QT syndrome (congenital disorder) predisposes to what arrhythmia?
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Ventricular tachyarrhythmia
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ST elevation in I & aVL and V5-V6: where is the MI?
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Lateral
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st ELEVATION in V1 & V2: where is the MI?
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Septal
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ST elevation in V3 & V4: where is the MI?
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Anterior
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ST elevation only in V5 & V6: where is the MI?
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Apical
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ST elevation in II, III, and aVF: where is the MI?
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Inferior
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st DEPRESSION in V1 & V2: where is the MI?
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Posterior
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What is poor R-wave progression?
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R wave should get progressively positive from V1 to V4. If not, it is "poor" progression.
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A "significant" (pathologic) Q-wave is how long?
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>40 msec (or more than 1/3 of the QRS amplitude)
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Right Atrial Enlargement evidence in lead II:
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Tall p-wave (>2.5 mm)
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Left Atrial Enlargement evidence in lead II:
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Long p-wave (>120 ms)
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First thought if R&S waves are so large they overlap.
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Left Ventricle Hypertrophy (LVH)
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LVH Cornell criteria.
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R in aVL + S in V3 >28mm (men), or >20mm (women)
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LVH Sokolow-Lyon criteria.
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S in V1 + R in V5 or V6 >35 mm.
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Tall R wave in V1 (longer than 7mm).
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Think Right Ventricle Hypertrophy (RVH).
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JVD hieght definition.
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>7cm above sternal angle
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What is Kussmauls' sign?
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increase in JVP with inspiration
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Classic aortic stenosis murmur description.
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systolic, crescendo-decrescendo
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aortic stenosis murmur can radiate where?
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carotids
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Classic mitral regurgitation murmur description.
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holosystolic, blowing
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Classic mitral valve prolapse murmur description.
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midsystolic click
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Classic aortic regurgitation (insufficiency) murmur description.
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Diastolic, early decrescendo murmur
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Mitral stenosis murmur description.
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diastolic, low-pitched rumbling, plus or minus a late crescendo
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What are the 2 gallop sounds?
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S3 or S4
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S3 can be normal in what patients?
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young or PREGNANT
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S3 may indicate what pathology of the ventricle?
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dilated cardiomyopathy (floppy ventricle)
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When is S3 in relation to S1 and S2?
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just after S2
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When is S4 in relation to S1 and S2?
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just before S1
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Which valve may S3 indicate has pathology?
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Mitral
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S4 can be normal in what patients?
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young or ATHLETES
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What pathology is classically associated with an S4 heart sound?
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stiff ventricle (diastolic dysfunction)
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Pulmonary edema is caused directly by:
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increased left atrial pressure (left heart failure)
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Usually the first noticed sign of right heart failure.
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lower extremity edema (peripheral edema)
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Right wrist pulse stronger than femoral pulse.
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coarcation of the aorta
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What palpation physical exam finding for compensated aortic regurgitation?
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increased peripheral pulse strength
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Patent Ductus Arteriosis has what pulse finding?
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increased strength of peripheral pulse
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Periphearl Artery Disease physical exam pulse finding.
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diminished pulses
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What is pulsus peridoxus?
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decreased systolic BP (decreased pulse strength) with inspiration
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Classic pulse finding in pericardial tamponade.
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pulsus paradoxus
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What is it called when pulse varies in strength between beats.
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Pulsus alternans
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Where do you classically find pulsus parvus et tardus (weak and delayed pulse)?
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aortic stenosis
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ABCD management of Atrial Fibrillation
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Anticoagulate, Beta-blocker, Cardiovert/Ca Channel blocerk, Digoxin
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How slow is "bradycardia"?
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<60 bpm
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Bradycardia can be normal in what population?
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athletes
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Beta-Blocker over dosing will have what effect on heart rate?
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slow (brady)
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Calcium Channel blocker (CCB) over dosing will have what effect on heart rate?
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slow (brady)
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vagal stimulation does what to the heart rate?
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slows (brady)
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2 common drug classes that cause first degree AV-block.
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Beta blocker, or CCB
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Increased PR interval with NO dropped beats.
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first degree heart block
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3 drug causes of Wenckebach (Second degree AV block-Mobitz 1).
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Beta-blocker, Calcium Channel Blocker (CCB), and digoxin.
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Symptoms Wenckebach (Second degree AV block-Mobitz 1)
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usually assymptomatic
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Symptoms of Mobitz II AV-block.
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occasional syncope
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Which second degree AV-block is more likely to progress to complete AV-block (third degree): Mobitz I or Mobitz II?
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Mobitz II.
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Treatment for Wenckebach block not caused by drugs.
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Atropine or Pacemaker
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Treatment in symptomatic bradycardia
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Atropine (or pacemaker in severe cases)
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What is Wenckebach?
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second degree AV-block type 1 (Mobitz I)
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What is Mobitz I?
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second degree AV-block type 1 (Wenckebach)
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First step in management of Mobitz I.
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Check for medication induced causes.
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Treatment of Mobitz II.
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pacemaker
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Treatment of third degree heart block.
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pacemaker
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Treatment for 1st degree heart block (increased PR interval)?
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no treatment necessary
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symptoms of third degree heart block
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hypotension, dizziness, syncope
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What is a cannon A wave?
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pressure wave in the jugular veins with contracting atria
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Classic etiology of a cannon A wave?
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third degree (complete) AV block
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ECG findings in sinoatrial (SA) conduction disease diagnoses what?
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AV block
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Treatment for Tachy-Brady Syndrome (a type of Sinus Sick Syndrome).
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Pacemaker
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HEARTFAILED mnemonic for Congestive Heart Failure etiologies.
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HTN
Endocrine Anemia Rheumatic Heart Disease Toxins Failure to take Meds Arrhythmia Infection Lung (pulmonary embolism) Electrolytes Diet (sodium) |
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inability of the heart to pump enough blood to meet bodies needs
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Congestive Heart Failure
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3 heart pathologies that are risk factors for CHF:
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CAD, valve disease, cardiomyopathy
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Common endocrine abnormality which can cause tachycardia.
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hyperthyroidism
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Dehydration findings on exam: heart, skin, mouth.
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tachycardia, poor skin turgor, dry mucous membranes
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3 "Normal" causes of tachycardia.
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Exercise, fear, pain.
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Suspect this in patient with leg swelling and now tachycardic.
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Pulmonary Embolism
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SIRS criteria
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3Ts and 1 W:
Temperature elevated Tachycardic Tachypneic WBC abnormal (<4 or >12) |
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Causes of Acute Atrial Fibrillation (mnemonic PIRATES)
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Pulmonary disease
Ischemia Rheumatic heart disease Anemai/Atrial myxoma Thyrotoxicosis Ethanol Sepsis |
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2 common causes of Chronic Atrial fibrillation.
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HTN, CHF
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Pulse is irregularly irregular. Diagnosis?
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Atrial Fibrillation
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ABCD treatment of Atrial Fibrillation (not just the rate control).
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Anticoagulate
Beta Blocker Cardiovert Digoxin |
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2 rules before cardioverting a stable patient in Atrial Fibrillation.
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<48 hours of sx and don't suspect stroke
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If over 48 hours of sx in Atrial Fibrillation, when to initiate cardioversion (2 options).
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After TEE shows no clot OR after 3 weeks of adequate Coumadin tx.
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INR goal in Atrial Fibrillation
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2-3
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Anticoagulation in Atrial Fibrillation if In-Patient.
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Heparin bridge to Coumadin.
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Anticoagulation in Atrial Fibrillation if Out-Patient.
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Coumadin
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Rate control options in Atrial Fibrillation (name 4 drugs).
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Beta Blocker
Calcium Channel Blocker Digoxin Amiodarone |
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When to cardiovert an unstable patient with Atrial Fibrillation.
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immediately
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Sawtooth p-waves on ecg is called what?
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Atrial Flutter
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What is the rate of Atrial FLUTTER?
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240-320 (remember 300) times per minute or 1 "sawtooth" per big box.
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What is the pathophysiologic mechanism for Atrial FLUTTER?
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1) circular electrical activity around the atrium
2) varying degrees of heart block |
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Treatment of Atrial FLUTTER?
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Treat like AFib: antiocoagulate and rate control
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2 diagnostic criteria for Multifocal Atrial Tachycardia (MAT) on ecg.
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1) tachycardia (>100bpm)
2) 3 or more unique p-wave forms in one lead for 1 strip (6 seconds). |
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Treatment for Multifocal Atrial Tachycardia (MAT)?
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treat the underlying disorder. rate control is not very effective.
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ECG shows 3 unique wave forms in a COPD patient with hypoxemia. Diagnose the rhythm.
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Multifocal Atrial Tachycardia (MAT)
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Wandering Atrial Pacemaker ECG definition.
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variable p-wave morphology; normal rate (>100bpm=MAT)
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When to cardiovert an unstable patient with an arrhythmia?
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Immediately
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Arrhythmia symptoms (for gross location think head, chest, heart, lungs; doing a catholic sign of the cross.)
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syncope/lightheadedness/dizziness
angina/chest pain palpitations shortness of breath |
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Medical treatment for re-entry tachycardias.
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Adenosine.
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2 non-medication treatments to try for re-entry tachycardias.
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carotid massage and/or valsalva
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P-wave vs. the QRS-wave in Atrioventricular NODAL Reentry Tachycardia (AVNRT) vs. Atrioventricular Reciprocating Tachycardia (AVRT)?
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AVNRT: P-wave BURIED IN the QRS-wave
AVRT: P-wave often comes AFTER the QRS-wave |
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Premature Ventricular Contraction appearance on ECG?
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wide QRS with compensatory pause
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3 known causes of PVCs
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hypoxia, electrolyte abnormalities, hyperthyroidism
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Treatment for VFib.
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Immediate electrical cardioversion and ACLS chest compression protocol.
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3 general types of Superventricular Tachycardia (SVT)s by location of origin?
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SA, Atria, AV
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1st line therapy for symptomatic PVCs.
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Beta Blocker
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Electrical orgin of a PVC.
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Ventricular.
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Why immediately cardiovert a Ventricular Tachycardia (VT)?
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It often progresses to VFib.
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On ECG: wide QRS complexes (consistent and repeating), regular rhythm, rapid rate, with AV dissociation. Diagnosis?
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Ventricular Tachycardia (VT)
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Electrolyte abnormality often associated with Torsades de pointes.
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Hypokalemia.
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Sudden onset, very rapid rate with variable QRS shapes on ECG often associated with long QT syndrome.
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Torsades de pointes.
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Can try infusion of this element to treat Torsades de pointes.
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Mg
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Chronic shortness of breath, fatigue, exacerbated by exercise. What heart disease is in the differential?
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CHF
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Diabetic patient with hypertension. 1st line for HTN?
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ACEI
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Non-treatable risk factors of heart disease (four).
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Age>65
Male Family History Black |
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Treatable diseases that are risk factors of heart disease (four).
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HTN
Obesity HLD DM |
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Treatable behaviors that are risk factors of heart disease (four).
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Smoking
over-eating/poor diet innactivity/lack of exercise alcohol abuse |
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Treatment for CHF without symptoms.
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Diet
Exercise & treat risk factors! |
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Treatment for CFH pts with known structural disease but little to no symptoms.
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ACEI and Beta Blocker
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When to consider adding diruretic to CHF treatment regimen.
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SOB or fatigue
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A specific diet modification for CHF patients.
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Sodium restriction
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When to consider adding Digitalis to CHF treatment regimen.
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ACEI, Beta Blocker, and Diuretic fail to control or can't be used.
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When is it indicated to NOT anticoagulate an AFib patient?
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<65 years and zero CHADS2 risk factors for stroke.
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CHADS2 risk for stroke for AFib patients.
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CHF (+1)
HTN (+1) Age>75 (+1) DM (+1) Sx previously of TIA/stroke (+2) |
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S3 gallop is a sound created by . . .
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the end of diastolic rapid ventricular filling; the sound is turbulence in the setting of fluid overload.
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S4 gallop is a sound created by . . .
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turbulent blood hitting a stiff ventricle
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Location of the pressure that we call the "preload."
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fluid of a full ventricle
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Location of the pressure that we call the "afterload."
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fluid in aorta
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AHA Stage A Congestive Heart Failure.
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1) has risk factors for CHF
2) no symptoms |
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AHA Stage B Congestive Heart Failure.
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1) known structural heart disease (e.g. MI)
2) no symptoms |
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AHA Stage C Congestive Heart Failure.
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1) heart disease
2) symptomatic (SOB, fatigue, etc.) |
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AHA Stage D Congestive Heart Failure.
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1) marked symptoms 2) at rest 3) despite maximal medical therapy
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Left sided heart failure: lung exam finding.
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bilateral basilar rales (crackles in lower lobes)
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JVD occurs in which type of heart failure?
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Right sided.
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Pleural effusions, pulmonary edema, orthopnea, paroxysmal nocturnal dyspnea. Which side is the heart failure?
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Left.
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Hepatojugular reflex, hepatomegaly, ascites. Which side is the heart failure?
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Right.
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Cardiomegaly on CXR in CHF: what is the dysfunction?
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Systolic dysfunction
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Restrictive/Hypertrophic Cardiomyopathy and LVH.can cause CHF through what mechanism?
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Diastolic dysfunction
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Dilated cardiomyopathy or valvular heart disease can cause heart failure through what mechanism?
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Systolic dysfunction
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PMI abnormality in Dilated Cardiomyopathy.
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displaced
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PMI abnormality in Left Ventricular Hypertrophy
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sustained
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Patient with congestive heart failure due to diastolic dysfunction now has decreasing ejection fraction. What does this mean?
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There is now some systolic dysfunction.
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First symptom of CHF.
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exertional dyspnea
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What is the most common cause of right sided heart failure?
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left sided heart failure.
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How does inadequate left ventricular contractility and increased afterload show up on Echo reads?
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Decreased ejection fraction (<50) and ventricular dilation.
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What level of BNP is specific for CHF?
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>500
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Why get an ECG in CHF patient with acute symptoms (2 diseases)?
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could be AF or MI.
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Why treat CHF patients with a diuretics?
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symptomatic relief only (no mortality benefit); if co-morbid L ventricular systolic dysfunction, Spiranolactone may decrease mortality.
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First line class of diuretic in CHF.
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Loop diuretics (e.g. Furosemide)
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What causes chronic cough in CHF patient?
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pulmonary edema (Left sided)
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What are cheyne-stokes respirations?
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Episodes of crescendo/decrescendo, deep/fast breathing alternating with apneic periods.
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Bumetanide and Torsemide are what class of diuretics?
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Loop Diuretics.
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An osmotic diuretic.
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Mannitol
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Electrolyte abnormality caused by Spiranolactone.
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Hyperkalemia (it's a Potassium sparing diuretic)
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Hypocalcemia can be caused by what class of diuretics?
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Loop Loses calcium.
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What type of diuretic is ototoxic?
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Loop diuretics
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What is the mechanism by which Spiranolactone can cause gynecomastia, hirsuitism, or sexual dysfunction?
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aldosterone receptor antagonist
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What is the first line diuretic for mild hyperkalemia?
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Furosemide, a Loop diruetic
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This diuretic is contraindicated in CHF or anuria.
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Mannitol
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This diuretic decreases Calcium excretion and can cause hypercalcemia.
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Thiazides
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CHF or DM patient on ACEI has a dry, chronic cough. What do you do?
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Switch to an ARB
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Furosemide overdose exam findings
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dehydrated and hypotensive
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When an ACEI is indicated for a CHF patient.
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Anyone who can tolerate them. If ACE cough, give an ARB.
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When to start a Beta Blocker (e.g. Carvedilol) in a patient with acute decompensated CHF.
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once the patient is euvolemic
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ACEI + Beta Blocker prevents what in MI or CHF patients.
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neurohormonal remodeling of the heart.
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Most important management patients with mild CHF.
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control co-morbid conditions (e.g. DM, HTN, obesity), and limit dietary sodium.
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CHF patient with comorbid ischemia. Treatment?
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Daily aspirin and statin to prevent further ischemic events.
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CHF with EF less than 30 plus CAD. Treatment?
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ICD (implantable biventricular cardiac defibrillator)
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LMNOP mnemonic for acute exacerbations of CHF.
|
Lasix
Morphine Nitrates Oxygen Position |
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CHF refractory to maximal medical therapy. Last resort treatment?
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mech. left ventricular assist device or cardiac transplantation
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decreased ventricular compliance with normal systolic function defines what?
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Diastolic Dysfunction
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First line agents for Diastolic Dysfunction.
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Diuretics
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Beta Blockers, ACEIs, ARBS, or CCBs, for what purpose in patient with Diastolic Dysfunction?
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BP and rate control.
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3 types of cardiomyopathies.
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Dilated, Hypertrophic, and Restrictive
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The most common type of cardiomyopathies of the 3 types.
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Dilated.
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How to confirm diagnosis of dilated cardiomyopathy.
|
low ECF (systolic dysfunction) and left ventricular dilation
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2 most common causes of Secondary Dilated Cardiomyopathy
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Ischemia or Long-Standing HTN
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What is the most common cause of dilated cardiomyopathy?
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Idiopathic
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What social history is important in finding an etiology of dilated cardiomyopathy?
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alcohol or cocaine
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Coxsackievirus can be associated with what heart disease?
|
Dilated Cardiomyopathy.
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Most common cause of death in patients with Acromegaly (like Andre the Giant).
|
Cardiomyopathy induced heart failure.
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Gallop associated with Dilated Cardiomyopathy (Systolic Dysfunction)?
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S3
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Endocrine test to order when suspecting dilated cardiomyopathy.
|
TSH
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Diagnostic test for cardiomyopathy.
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Echo
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Which block is common in dilated cardiomyopathy?
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LBBB
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Major physiologic abnormality in Dilated Cardiomyopathy?
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Impaired contractility
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Major physiologic abnormality in Hypertrophic Cardiomyopathy?
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Impaired relaxation of the left ventricle (diastolic dysfunction)
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Major physiologic abnormality in Restrictive Cardiomyopathy?
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Impaired elasticity
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Left ventricular cavity size in Hypertrophic Cardiomyopathy.
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Small (wall hypertrophy)
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Ejection Fraction (EF) in Dilated Cardiomyopathy.
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Low (systolic dysfunction)
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Wall thickness in Hypertrophic Cardiomyopathy.
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Thick (LVH)
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Which Cardiomyopathies are diastolic dysfunction?
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Hypertrophic and Restrictive. (Dilated=systolic dysfnct)
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History of sx in dilated cardiomyopathy.
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gradual onset of CHF symptoms
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Classic ECG finding in Dilated Cardiomyopathy.
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non-specific ST-T changes
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CXR shows enlarged, balloon-like heart and pulmonary congestion. Diagnosis?
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Dilated Cardiomyopathy/CHF
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Treatment for Dilated Cardiomyopathy induced heart failure.
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Treat the CHF.
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Most common cause of sudden death in a young, healthy athlete.
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Hypertrophic Cardiomyopathy.
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Congenital Hypertrophophic Obstructive Cardiomyopathy (HOCM) shows what inheritance pattern?
|
autosomal-dominant
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How to differentiate murmur of Hypertrophic Stenosis from (Valvular) Aortic Stenosis.
|
HCM murmur will increase with valsalva (decreased preload). Also, HCM murmur will not radiate to carotids.
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Usual location of hypertrophy in Hypertrophic Cardiomyopathy.
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Interventricular Septum
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Gallop associated with Hypertrophic Cardiomyopathy.
|
S4
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What ECG finding is often found with Hypertrophic Cardiomyopathy?
|
LVH (overlapping S&R waves in V-V6)
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2 most common causes of LVH.
|
HTN and Aortic Stenosis
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Echo findings in Hypertrophic Cardiomyopathy?
|
asymmetric LVH and changing outflow obstruction
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Medical treatment for symptomatic Hypertrophic Cardiomyopathy.
|
Beta Blocker
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Behavior changes in kids with Hypertrophic Cardiomyopathy
|
Avoid competitive sports and rigorous exercise.
|
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Hemochromatosis can cause what type of cardiomyopathy?
|
Restrictive
|
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Amyloid and Sarcoid can cause what type of cardiomyopathy?
|
Restrictive
|
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Radiation can cause what type of cardiomyopathy?
|
Restrictive
|
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Infections such as HIV, Chagas' disease and some parasites can cause what type of cardiomyopathy?
|
Dilated
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Wet Berberi can be associated with what type of cardiomyopathy?
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Dilated
|
|
2nd line medical treatment for Hypertrophic Cardiopathy (if can't do Beta Blockers)?
|
CCBs
|
|
Predominant symptoms of Restrictive Cardiomyopathy.
|
Right sided Heart Failure: JVD and peripheral edema
|
|
Cardiac biopsy shows infiltration. What is the cardiomyopathy?
|
Restrictive
|
|
Heart transplants often must be considered because this type of cardiomyopathy is so difficult to treat.
|
Restrictive
|
|
Which is worse: Apple obesity or Pear obesity?
|
Apple AKA Central AKA Abdominal obesity is worse that thigh/butt obesity
|
|
Prinzmetal's Angina is caused by what pathophysiology?
|
vasospasm of coronary vessels.
|
|
Young woman often has substernal chest pain at rest in the morning. Found to have ST elevation, but normal troponins. Diagnosis?
|
Prinzmetal's Angina
|
|
What is the physiology of Ischemia?
|
Not enough oxygen for the tissue's demand.
|
|
Definition of Angina Pectoris.
|
Substernal chest pain secondary to myocardial ischemia.
|
|
Classic triad of Angina symptoms (stable).
|
1) Substernal chest pain
2) Provoked by exertion 3) Relieved by rest (or nitro) |
|
Levine's sign
|
fist on chest: often described as pressure (e.g. "elephant on chest") rather than pain
|
|
Suspect abnormal presentation for MI in what patients?
|
Women, Elderly pts with AMS, Post-heart transplant pts, or Diabetic pts
|
|
Things to check for on physical exam to suggest atherosclerosis as the cause of chest pain.
|
carotid and peripheral bruits, HTN
|
|
Indications for Exercise Stress Test.
|
symptomatic with some risk of CAD
|
|
Indications for testing an asymptomatic patient with Exercise Stress Test.
|
No absolute indications; can consider in pilots and bus drivers, or patients with high risk for CAD.
|
|
Medical treatment for acute stable or unstable angina (MONA-B).
|
Morphine - IV
Oxygen Nitroglycerin Aspirin Beta Blocker |
|
Medical treatment for chronic stable angina.
|
Daily Aspirin and Beta Blocker, plus PRN Nitroglycerin
|
|
Second line agent (if Beta Blockers are contraindicated) for treatment in chronic heart disease.
|
a nondihydropyridine CCB (Diltiazem or Verapamil)
|
|
3 independent criteria for unstable angina.
|
new pain
worsening pain pain at rest |
|
Elevated troponin and CK-MB without ST-elevations. Diagnosis?
|
NSTEMI
|
|
How to diagnose NSTEMI.
|
Serial cardiac enzymes (positive) and ECG (negative).
|
|
Low risk patient has Unstable Angina without elevation of cardiac enzymes or ECG changes. Next 2 tests in work-up?
|
Stress Test and Echo
|
|
What is the cut off time for clinic vs. ER referral for Unstable Angina?
|
Symptoms in the last 2 days goes to ER.
|
|
High risk Chest Pain characteristics that will prompt ER referral instead of a clinic appointment (go through OPQRST-A).
|
O >20 minutes
P pain at rest Q typical triad R right arm/jaw S severe T <2 days A SOB or LOC |
|
2 STAT tests for patient in the ER with acute unstable angina.
|
Troponin and ECG
|
|
When to order BNP and CXR in patient with unstable angina.
|
if Heart Failure sx
|
|
ECG change besides ST changes that may indicate acute MI.
|
New LBBB
|
|
When NOT to give Beta Blocker in acute angina.
|
If CHF suspected.
|
|
ST depression in these leads indicates Posterior Infarction.
|
V1-V2
|
|
What is the best predictor of survival after MI?
|
left ventricular EF
|
|
Troponin vs. CK-MB: which is the better test?
|
Troponin most sensitive and specific.
|
|
Diffuse ST-Elevation (across all leads).
|
Pericarditis
|
|
If ACS suspected in patient with Angina, add these 2 drugs in addition to Aspirin.
|
Clopidogrel and Enoxaparin
|
|
When to add GP IIb/IIa inhibitor in patient with ACS.
|
If planning angiography/PCI. Especially if there will be a delay.
|
|
PCI vs. CABG: which has more complications?
|
CABG
|
|
PCI vs. CABG: which patients are more likely to require repeat procedures?
|
PCI
|
|
Why test CK-MB as well when testing Troponin?
|
CK-MB can help in timing of MI onset
|
|
Why test CRP as well when testing troponin?
|
CRP helps with risk stratification, especially long term.
|
|
What makes an ACS patient "high risk" and therefore in need of the Invasive Strategy? (3 independent criteria)
|
TIMI risk score (TRS) 3 or more, positive Troponin, or positive ECG.
|
|
What is the door-to-balloon time preferred when performing PCI on an ACS patient?
|
<90min.
|
|
When is thrombolysis with tPA or Streptokinase the preferred treatment over PCI (in ACS)?
|
If time to PCI >90 minutes after sx onset AND sx have been present for less than 3 hours.
|
|
If ACS patient has sx over 3 hours at presentation, what is the preferred treatment?
|
PCI
|
|
In ACS, if PCI or CABG is not available, consider thrombolysis for how long?
|
some benefit remains if <12 hours of symptoms
|
|
If there is 3 vessel disease found in MI patient, what procedure is indicated after PCI?
|
CABG
|
|
Indications for CABG (mnemonic DUST).
|
Depressed ventricular fnct
Unable to perform PCI Stenosis of L main Coronary a. Triple vessel disease |
|
How long to continue Clopidogrel after PCI.
|
4 weeks
|
|
3 long term medications after acute MI other than Aspirin (mnemonic "cover your BAceS").
|
Beta Blocker, Ace Inhibitor, Statin
|
|
If there is Left Main Coronary Artery disease in MI patient, what procedure is indicated after PCI?
|
CABG
|
|
If cannot give Beta Blockers, what is its 2nd line medical therapy (in ACS)?
|
ACEI or ARB
|
|
Overall most common complication after acute MI.
|
Arrhythmia
|
|
Most common cause of death after acute MI.
|
Arrhythmia
|
|
Most common complication post acute MI in the first 24 hours.
|
Heart failure
|
|
Most common complication post acute MI on day 2-4.
|
Arrhythmia
|
|
2 most common complications post acute MI on day 5-10.
|
Papillary muscle rupture (Mitral Regurg.) or Left ventricular wall rupture (and Tamponade)
|
|
over 10 days post MI, watch for complications especially with this certain pathology of the ventricle.
|
aneurysm
|
|
When is pericarditis most likely to occur post-MI?
|
2-4 days
|
|
Hypercholesterolemia definition: total cholesterol level.
|
>200
|
|
Hyperlipidemia definition: LDL level.
|
>130
|
|
Hyperlipidemia definition: triglyceride level.
|
>500
|
|
Dyslipidemia definition: HDL level.
|
<40
|
|
What is a Xanthoma?
|
fatty skin nodules over the tendons associated with Hyperlipidemia
|
|
Yellow patches of skin around eyes and on eyelids. Diagnosis?
|
Xanthelasmas caused by Hyperlipidemia (HLD)
|
|
Creamy appearance of retinal vessels caused by Hyperlipidemia (HLD).
|
Lipemia Retinalis
|
|
Screening for Hyperlipidemia. Begin? Frequency?
|
start at 20 y/o; q5 years
|
|
ATP III: LDL goal in Diabetics etc.
|
<100 (ATP IV may say <70)
|
|
What HDL level is considered a negative risk factor?
|
>60
|
|
ATP III: LDL goal in patients with NO risk factors.
|
<160
|
|
ATP III: LDL goal for patients with 2+ RFs.
|
<130
|
|
What age defines early CAD? (males and females)
|
Male <55, Female <65
|
|
What age is considered an independant RF for CAD? (males and females)
|
Male >45, Female >55
|
|
When can you to try diet and exercise to lower lipids.
|
If no known athersclerotic disease
|
|
How long to try diet and exercise to lower lipids?
|
12 weeks
|
|
2 Hyperlipidemia medications which raises HDL.
|
Niacin and Fibrates (Gemfibrozil)
|
|
1st line Lipid Lowering agent.
|
Statins
|
|
Mechanism of action of statins
|
HMG-CoA reductase inhibitor
|
|
Main side-effect of Cholestyramine, a bile-acid binder.
|
Constipation
|
|
Hyperlipidemia medication that causes facial flushing.
|
Niacin
|
|
Baseline blood test before beginning a statin.
|
Liver Function Tests
|
|
What is the mechanism by which Ezetimibe (Zetia) causes "floating" diarrhea?
|
decreases the absorption of cholesterol which creates the steathorrhea
|
|
What is the mechanism of the fibrates (Hyperlipidemia med)?
|
lipoprotein lipase stimulator
|
|
2 hyperlipidemia meds known to lower triglyceride levels.
|
Statins and Fibrates (Gemfibrozil)
|
|
Definition of Hypertension.
|
>140 syst or >90 diast.
|
|
Systolic lower limit definition of Pre-Hypertension
|
>120
|
|
Systolic definition of Stage 2 Hypertension.
|
>160
|
|
1st line treatment for Hypertension
|
Thiazide (HCTZ)
|
|
Stage 2 HTN usually requires 2 agents: usually what 2 drugs?
|
Thiazide+ACEI (HCTZ+Lisinopril)
|
|
Which of the following lifestyle changes effects BP the best? Na restriction, wt. loss, exercise, decreased EtOH consumption.
|
Wt. Loss (BP decrease is abt. 20)
|
|
Adequate exercise will decrease BP by how much?
|
abt. 10
|
|
BP goal for a diabetic.
|
<130/80
|
|
There is known benefit in CVE prophylaxis for lowering BP less than 120. What is the limiting factor on the goals set by JNC-7?
|
symptoms of Relative Hypotension
|
|
Why order baseline labs (UA, CBC, BMP) when HTN is diagnosed?
|
to assess end organ damage.
|
|
Cotton Wool Exudates as a sign of end-organ failure. Diagnosis?
|
Hypertensive Retinopathy
|
|
Hypertensive patient with CAD. What is the indicated medication/s?
|
ACEI (or ACEI+CCB)
|
|
Hypertensive patient with Stable Angina. What is the indicated medication/s?
|
Beta Blocker
|
|
Hypertensive patient post-MI. What is the indicated medication/s?
|
Beta Blocker and ACEI
|
|
Hypertensive patient with CHRONIC heart failure. What is the indicated medication/s?
|
ACEI or ARB and Beta Blocker; (likely be on a diuretic as well for edema)
|
|
Hypertensive patient with ACUTE/decompensated Heart Failure. What medication is contraindicated?
|
Beta Blocker
|
|
Hyptensive patient with DM. What is the indicated medication?
|
ACEI (or ARB)
|
|
Hypertensive patient with CKD. What is the indicated medication?
|
ACEI (or ARB)
|
|
Most common etiology for HTN.
|
Essential/Idiopathic (unknown)
|
|
Diet management of HTN secondary to Renal Parenchymal disease.
|
Salt and fluid restriction
|
|
Goal BP in patient with proteinuria (renal disease)?
|
<130/80
|
|
African American with hypertension. This cheap medication class is particularly effective in this population.
|
Diuretics
|
|
How often to follow up a patient with controlled Hypertension to screen for end-organ damage.
|
q3-6 months
|
|
Sleep disorder that is associated with Hypertension.
|
OSA
|
|
This hypertensive medication can actually accelerate kidney damage if there is bilateral renal artery stenosis.
|
ACEI
|
|
OR-CHAPS mneumonic for causes of secondary hypertension.
|
OCP use
Renal Parenchymal Disease Cushings Hyperaldosteronism (Conn's) Aaortic Coarctation Pheochromocytoma S |
|
Antihypertensive med to use in UNILATERAL renal artery stenosis.
|
ACEI
|
|
OB/GYN med class that can cause secondary hypertension.
|
OCPs
|
|
Abnormality associated with Turner's syndrome that causes secondary hypertension.
|
Coarctation of the Aorta
|
|
How to diagnose a pheochromocytoma.
|
urinary metanephrines/catecholamine levels
|
|
What do you give a patient with pheochromocytoma BEFORE surgery?
|
both alpha and beta blockers
|
|
episodes of panic attack symptoms + episodic headaches + HTN; what tumor?
|
pheochromocytoma
|
|
What does a pheochromocytoma secrete?
|
epinephrine and norepinephrine
|
|
Conn's syndrome is caused by elevated secretion of what hormone?
|
aldosterone
|
|
Hyperaldosteronism (Conn's Syndrome) triad.
|
HTN, hypokalemia, metabolic alkalosis
|
|
What is Cushing's DISEASE?
|
Pituitary gland tumor over produces ACTH which causes Cushing's Syndrome.
|
|
Cushing Syndrome is most often cause by . . .
|
exogenous steroids
|
|
How to treat HTN caused by Cushing's Disease.
|
Surgery
|
|
Most common cause of renal artery stenosis in YOUNGER patients (under 25).
|
fibromuscular dysplasia
|
|
Usual cause of renal artery stenosis in OLDER pateints (over 50).
|
atherosclerosis
|
|
Diagnosis of Malignant Hypertension, a form of Hypertensive Emergency, requires what eye exam finding?
|
Papilledema.
|
|
4 organs most commonly damaged by Hypertensive Emergencies.
|
Brain, Eyes, Heart, Kidneys
|
|
Based on expert opinion, what is the initial goal mean arterial pressure reduction for Hypertensive Emergency.
|
25% reduction
|
|
What is the difference between Hypertensive Emergency and Hypertensive Urgency?
|
By definition, Emergency involves end organ damage.
|
|
What is the blood pressure which defines Hypertensive Urgency?
|
>180/110
|
|
Hypertensive Urgency vs. Emergency: use PO or IV meds?
|
Urgency: PO (e.g. clonidine); Emergency: IV (e.g. labetalol)
|
|
HTN patient with osteoporosis. What is the indicated medication?
|
Thiazide diuretics (not Loop)
|
|
HTN patient with BPH. What is an indicated medication?
|
Alpha-1 adrenergics (e.g. prazosin or terazosin)
|
|
Hypertensive patient is now pregnant (Chronic HTN). What is the indicated anti-hypertensive?
|
Methyldopa
|
|
What is the mechanism of the ACEI cough?
|
increased Bradykinin levels
|
|
Severe Pre-Ecclampsia. What is the indicated anti-hypertensive?
|
Hydralazine or Labetalol
|
|
Mechanism of the anti-hypertensive Hydralazine.
|
vasodilator - dilates arteries
|
|
Asthma patient with HTN. What medication is contra-indicated?
|
Beta Blockers
|
|
Most common cause of Pericarditis (50%).
|
Infection
|
|
CARDIAC RIND mnemonic for causes of Pericarditis.
|
Collegen vascular dx (Lupus)
Aortic dissection Radiation Drugs Infections ARF (uremia) Cardiac (MI) Rheumatic Fever Injury Neoplasms Dressler's syndrome |
|
PERICarditis mnemonic for signs of Pericarditis.
|
Pulsus paradoxus
ECG changes Rub Increased JVP Chest pain |
|
What is the classic description of chest pain with pericarditis?
|
pleuritic, relieved by sitting forward
|
|
Squeaky leather, grating, rasping sound on heart exam. Diagnosis?
|
Pericarditis (Friction Rub)
|
|
What is pulsus paradoxus?
|
Decreased systolic BP by 10 during inspiration (evidenced by diminished pulse strength on exam)
|
|
Beck's triad for Cardiac Tamponade.
|
JVD, HoTN, Distant heart sounds
|
|
The "water-bottle" sign (effusion) around the heart on Echocardiogram suggests what diagnosis?
|
Pericarditis
|
|
Theurapeutic Pericardiocentesis is also used diagnostically in these 2 etiologies of Pericarditis.
|
Neoplasm or Infectious causes
|
|
What etiology of pericarditis will need dialysis for treatment?
|
uremia 2/2 renal failure
|
|
What is symptomatic treatment for viral pericarditis?
|
ASA and NSAIDS
|
|
Why distant heart sounds in Cardiac Tamponade?
|
effusion muffles sounds
|
|
What is Kussmaul's sign commonly found in Cardiac Tamponade?
|
JVD during inspiration
|
|
Electrical alterans (QRS amplitude varies beat to beat) is pathognomonic for what?
|
Cardiac Tamponade
|
|
Besides urgent pericardiocentesis, how do you manage Cardiac Tamponade?
|
Aggressive IVF
|
|
What is the most common cause of valve diseases all together?
|
mechanical degeneration
|
|
When to replace valve in patient with Aortic Stenosis.
|
only if symptomatic (angina or syncope or SOB)
|
|
How to get a definitive diagnosis for a heart murmur.
|
Echocardiogram
|
|
Nifedipine or Amlodipine or ACEI for patient waiting for valve replacement: what valve disease?
|
Aortic Regurgitation (Insufficiency)
|
|
CREAM mnemonic for causes of aortic regurgitation (insufficiency).
|
Congenital
Rheumatic Fever Endocarditis Aortic Dissection Marfans |
|
Rheumatic Fever continues to be the most common cause of this valve disease despite decrease in incidence.
|
Mitral Valve Stenosis.
|
|
New Mitral Valve Regurgitation should prompt work up for what?
|
MI
|
|
Besides Mitral Stenosis, Mitral Regurgitation is often caused by this disease.
|
Rheumatic Fever
|
|
Treatment for Mitral valve disease is usually for symptoms caused by this abnormality.
|
arrhythmia
|
|
Definitive treatment for Mitral Stenosis in severe cases.
|
Valve replacement
|
|
Abdominal Aortic Aneurism (AAA) is associated with this pathology.
|
Atherosclerosis
|
|
more than 90% of Aortic Aneurisms are located where?
|
Abdomen (below renal arteries)
|
|
Pulsatile abdominal mass on exam. Diagnosis?
|
AAA
|
|
One time screening for men over 65 y/o who have ever smoked (w/ abdominal U/S) for this disease.
|
AAA
|
|
Ruptured Aortic Aneurism pain radiates where?
|
to back
|
|
Aortic Dissection is associated with this disease.
|
Hypertension
|
|
What size of AAA warrants surgical repair?
|
>5.5 cm
|
|
Follow AAA q6-12 months with serial Abdominal U/S if they are less than this size.
|
<5.5cm
|
|
When to screen males who have never smoked or females for AAA?
|
never
|
|
Most efficacious lifestyle change in preventing AAA rupture.
|
stop smoking
|
|
Sudden, tearing/ripping anterior chest pain radiating to interscapular back. Diagnosis?
|
ascending Aortic Dissection
|
|
Descending Aortic Dissection managment.
|
control BP and heart rate
|
|
Ascending Aorta Dissection treatment
|
emergent surgery
|
|
Consider this complication of Aortic Dissection if Hypotensive.
|
Pericardial Tamponade.
|
|
Virchows triad for DVT
|
Venous Stasis
Endothelial damage Hypercoagulable states |
|
Unilateral, deep leg pain and swelling. Diagnosis?
|
DVT
|
|
When to order D-Dimer.
|
When symptoms are indicative but patient risk factors are low for DVT or PE.
|
|
Anticoagulation for patient with DVT.
|
Heparin bridge to Warfarin
|
|
High risk DVT patient has contraindication to anticoagulation. Tx?
|
IVC filter
|
|
Prophylaxis for immobile hospital patient to prevent DVT/PE.
|
Enoxaparin
|
|
Pregnant woman with DVT. Treatment?
|
Enoxaparin
|
|
Patient with Aortic Dissection will have what variation in pulse and BP.
|
Asymmetric readings
|
|
Aortic Dissection can cause what heart murmur?
|
Aortic Regurgitation (Insufficiency)
|
|
Atherosclerotic plaque occluding blood supply to extremities. Diagnosis?
|
Peripheral Artery Disease (PAD)
|
|
Define intermittent claudication in PAD.
|
leg pain with walking and relieved by rest
|
|
Blue toe syndrome secondary to cholesterol atheroembolism is a known complication of what procedure?
|
CABG
|
|
With chronic severe PAD, what happens to the distal muscles?
|
from atrophy to gangrene/necrosis
|
|
1st step in evaluation of PAD severity.
|
Ankle-Brachial Index of Blood Pressure (ABI)
|
|
Diagnostic of choice when suspecting stenosis/occlusion from PAD.
|
Doppler U/S
|
|
What is the cut-off by Doppler U/S of ankle flow compared to brachial flow
|
ankle <90% of brachial = abnormal
|
|
Why avoid Beta Blockers in PAD?
|
Beta peripheral vasoconstriction
|
|
Medical therapy for PAD (other than Aspirin).
|
Cilostazol
|
|
Diabetics with PAD are especially prone to this complication.
|
ulcers
|
|
Surgery to consider before amputation of severe PAD.
|
Bypass
|
|
Treatment of PAD if medical treatment fails.
|
Angioplasty or Stent
|
|
Most common cause of lymphedema in the U.S.
|
surgery (e.g. mastectomy)
|
|
Most common cause of lymphedema in underdeveloped countries.
|
Filariasis parasites (e.g. Wucheria Bancrofti)
|
|
Congenital abnormalities in Milroy Disease causes this (usually lower extremity) abnormality bilaterally. Presents in childhood.
|
Lymphedema.
|
|
1st line treatment option for lymphedema secondary to surgery.
|
Pressure garments (Ted-Hose)
|
|
Monitor for this complication of chronic lymphedema.
|
cellulitis
|
|
Why does cardiac syncope need to be worked up even if the patient is currently assymptomatic.
|
1 year sudden cardiac death rate is 40%
|
|
Patient complains he passed out, reports he knew it was coming, and says he was confused afterward. Diagnosis?
|
Seizure
|
|
Most common cause of syncope.
|
Vasovagal (aka neurocardiogenic)
|
|
1st test to order when patient comes to ER reporting syncopal episode.
|
ECG
|
|
Syncope attributed to exertion on patient history. Next 2 orders in work-up (after ECG)?
|
Echo and Exercise Stress Test
|
|
Patient c/o syncope, now asymptomatic; no risk factors of heart disease. What test to order if this recurs?
|
tilt table
|
|
What is the cut-off age for automatic admit for work up after syncopal episode?
|
>60 y/o
|
|
Patient with syncopal episode has history of heart disease. What 2 tests to order?
|
Echo and Exercise tolerance test
|
|
Suspected cardiac source of syncope, but then got a negative work up. When do you consider Holter (ambulatory ECG)?
|
At 2nd syncopal episode, order holter.
|
|
Murmurs on heart exam in patient with history of syncope. Next 2 orders in work-up (besides ECG)?
|
Echo and Exercise Stress Test
|
|
DRIP-ABCDEFG-L mnemonic in CXR analysis.
|
Dumb stuff: right person? AP or PA? foreign bodies?
Rotation Inspiration (7-8 ribs) Penetration Airway (midline?) Bone Cardiac Silhouette Diaphragm Effusions (costophrenic angle) Free air (look under the heart) Gotta get to the Lungs Last: compare to previous CXRs |