T3 - Step 2 - Medicine

Front 1

what's better in MI - thrombolytics or angioplasty/stent? time limit?

Back 1

angioplasty/stent are better.
note that you only use thrombolytics if you can't do angioplasty, you have 12 hours to do it, and you only do it for STEMI (not N-STEMI/unstable angina).
if hospital doesn't have cath, transfer if takes <2 hours: if more, do the fibrinolysis.

Front 2

what's 1st degree heart block? 2nd degree?

Back 2

1st degree = PR interval >0.2 seconds.
2nd degree: type 1 = winkybock = PR gets wider until a QRS drops out.
mobitz type 2 = regularly dropped beat without prolonging PR. This OFTEN BECOMES COMPLETE BLOCK. so you'll see a repeated P wave without a QRS.

Front 3

when do you put in a pacer?

Back 3

complete heart block, symptomatic bradycardia (or rates <40). random other stuff (asystolic pauses >3 sec).

Front 4

what are the signs of WPW?

Back 4

wolf parkinson white will have short PR interval and a delta wave.

Front 5

someone with afib - when do you give them warfarin?

Back 5

CHADS 3 or greater, or prior stroke/TIA. CHF, HTN, Age >75, diabetes, stroke/tia. if 2 or below, use ASA.

note that rate control better than rhythm if >65 years due to side effects of anti-arrhythmatics. use B-block/verapamil/diltiazem for rate, amiodarone for rhythm.

Front 6

V-tach: what kinds are there? what are the EKG intervals to know?

Back 6

sustained = >30 seconds. non-sustained = >3 beats, <30 seconds. Also monomorphic vs. polymorphic (one kind of this = torsades).
QRS > 0.12 sec wide, >100bpm = vtach.

Front 7

wide complex QRS's and fast rhythm: what are the two big conditions that might cause this and you have to separate?

Back 7

true vtach from supraventricular tachycardia with abbarent conduction (like WPW) - the treatments are different.
Look for a P wave before each QRS - it might be really close in WPW, but should be there.

Front 8

treatment of vtach? acutely vs. chronically?

Back 8

if stable with a pulse, DC cardioversion. If unstable/no pulse, unsynchronized defibrillation.

chronically, can try ablation (if healthy) or ICD (heart disease, EF <35%).

Front 9

what drugs have been shown to lower mortality in CHF?

Back 9

B-blockers, Ace inhibitors, spironolactone/epilerinone, and in blacks, hydralazine/nitrates.

digoxin can prevent hospitalizations.

EF<30% can live longer with ICD.

diuretics are palliative only.

Front 10

someone with afib - when do you give them warfarin?

Back 10

CHADS 3 or greater, or prior stroke/TIA. CHF, HTN, Age >75, diabetes, stroke/tia. if 2 or below, use ASA.

note that rate control better than rhythm if >65 years due to side effects of anti-arrhythmatics. use B-block/verapamil/diltiazem for rate, amiodarone for rhythm.

Front 11

what does digitalis excess look like on EKG? what can you do about it?

Back 11

typically caused by hypOkalemia/renal insufficiency, causes atrial tachycardia with variable block (regular QRS complexes, variable # of P's for each QRS).

d/c digoxin, can give binding antibodies.

Front 12

when do you do stress EKG? when do you do stress perfusion scan/echo? when do you do dobutamine perfusion/echo?

Back 12

stress EKG in normal person you think might have CAD.

do perfusion scan/echo with normal exercise if they have WPW or baseline EKG abnormalities (ST depression especially) or if taking DIGOXIN (causes ST depression), also LVH (false positives)

Do dobutamine test if can't exercise, LBBB (causes false positives on perfusion scan) or electronically paced.

Front 13

what do you see on EKG in NSTEMI?

Back 13

NEVER a Q wave, usually ST depression, sometimes T wave inversion.

Front 14

when do you start spironolactone in heart failure?

Back 14

nyha class 3/4 (SOB with ADL's/rest), EF <35, need creatinine <2.5, and potassium <5.0.

otherwise, don't give it.

Front 15

mitral regurg/prolapse: how do valsalva/squatting change the sound?

Back 15

all about moving the click/murmur closer or further from S2.

Valsalva = eliminate preload = move snap closer to S1.

Squat = up preload = snap closer to S2.

Front 16

what's the typical presentation of a ventricular aneurysm?

Back 16

a month after the MI having signs of CHF, with new onset murmur (often mitral regurg).
Random thing = OFTEN PERSISTENT ST elevations, which should have gone away. This is NOT MI.

Front 17

cold aglutenins show up as being positive on what test? what infection is commonly seen with these?

Back 17

mycoplasma pneumonia. also, direct cooms positive for C3.

remember that these cause roulleaux, not spherocytes (warm causes that, with increased MCHC).

Front 18

liver dysfunction - what do you see in RBC's

Back 18

Echinocytes are like acanthocytes, but have LOTS of projections, and tend to be a little macrocytic (100-110).

Front 19

chest pain in a sickler - what might be wrong and how do you tell the difference?

what kind of strokes do sicklers get (bleed/clot?)

Back 19

acute chest = diffuse infiltrates, pneumonia = usually local infiltrate.
fat embolism common - often have other organs involved.
PE common.
MI common.

kids get thrombotic stroke, adults get bleeding stroke.

Front 20

what non-pain medicines are good to keep sicklers on?

Back 20

hydroxyurea = ups HbF, increases survival.

Ace inhibitors: renal disease common, start when proteinuria starts (like DM).

Pneumoccal, H. flu, Flu shots.

Front 21

what's the worry with HIT? what do you do about it?

Back 21

NOT BLEEDING - platelet counts rarely get below 60k. EMBOLISM is risk - PE, portal vein thrombosis, etc.

Need to start OTHER ANTICOAGULANT - lepirudin/agatroban (direct thrombin inhibitor).

Front 22

what's the weird tip-off that someone might have lupus anticoagulant?

Back 22

prlonged PTT with THROMBOSIS.

Front 23

what study do you have to do with AML patients and why?

Back 23

cytogenics - the 15:17 translocation is promyelocytic AML and requires treatment with retionic acid (vitamin A).

otherwise treatment is chemo, maybe bone marrow transplantation.

Front 24

how do you separate MGUS from MM?.

Back 24

MM = >10% plasma cells, or pesence of a plasmacytoma, and >3.5g/dl of IgG. MGUS is under this.

Note that "smouldering" = NO anemia, which is present in most MM.

remember ROULEAUX from all the Ig's.