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154 Cards in this Set
- Front
- Back
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A patient comes in with chest pain…Best 1st test =
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EKG
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A patient comes in with chest pain…If 2mm ST elevation or new LBBB (wide, flat QRS), that means
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STEMI
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If STEMI, when do you see ST elevation?
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Immediately
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If STEMI, how long do inverted T waves last?
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6hrs- years
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If STEMI, how long do inverted Q waves last?
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Forever
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What does a pathologic Q wave look like?
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What vessel is affected and what do you see on EKG for Anterior Infarct?
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LAD, V1-V4 |
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What vessel is affected and what do you see on EKG for Lateral Infarct?
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Circumflex, I, avL, V4-V6
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What vessel is affected and what do you see on EKG for Inferior Infarct?
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RCA, II, III and aVF
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What vessel is affected and what do you see on EKG for Posterior Infarct?
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V1, V2, Large R wave and upright T wave in V1 & V2
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What vessel is affected and what do you see on EKG for Right Ventricular Infarct?
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RCA, V4 on R-sided EKG is 100% specific
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What do you see on EKG if the Left Main Coronary is occluded?
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aVR** + usually ST DEPRESSION in I, II, V4-V6
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Draw Picture of Leads and areas affected by blockage of specific arteries.
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If patient comes in with chest pain and ST elevations, what do you do?
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Emergency repurfusion: go to cath lab or thrombolytics if no contraindications ***check this to make sure it is right
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If the patient has a right ventricular infarct, what symptoms might you see?
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hypotension, tachycardia, clear lungs, JVD, and NO pulsus paradoxus
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How do you treat Right ventricular Infarct?
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DON’T give nitro. Tx w/ vigorous fluid resuscitation ** check this to see if there is more to this treatment
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In a patient with chest pain, after the EKG, what is the next best test?
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Cardiac Enzymes q8hrs x 3
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What are the rise, peak and normalizations times of the cardiac enzymes?
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Myoglobin Rises 1st, Peaks in 2hrs, nl by 24
CKMB Rise 4-8hrs, Peaks 24 hrs, nl by 72hs Troponin I Rise 3-5hrs, Peaks 24-48hrs, nl by 7-10days |
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If someone comes in with chest pain, and MI is suspected/confirmed, how do you treat them?
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1 - Immediately - MONA-B Morphine, Oxygen, Nitrates, Aspirin, Beta Blocker
2 - Do coronary angiography within 48 hours to determine the need for intervention. 3 - PCI is standard. 4 - Do CABG if Left Main Disease, 3 vessel disease, 2 vessel Disease + DM, >70% occlusion, pain despite maximum medical tx, or post-infarction angina |
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Someone has an MI, what do you discharge them on?
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“A BASS”
ACE Inhibitor IF CHF or LV dysfx Beta Blocker Aspirin (+ clopidogrel for 9-12 months if stent placed) Statin Short acting Nitrate or “BANAS” Beta Blocker Aspirin (+ clopidogrel for 9-12 months if stent placed) Nitrate Aspirin (+ clopidogrel for 9-12 months if stent placed) Statin |
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What is the 1st test to workup for Angina?
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Exercise EKG: Avoid Beta Blockers and CCB before
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When can you not do an EKG stress test (other than patient’s physical condition)? What do you do intstead?
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If the patient has an old LBBB or Baseline ST elevation or is on Digoxin.
Do Exercise ECHO instead |
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What if the patient cannot physically exercise?
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do chemical stress test w/ dobutamine or adenosine.
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What is MUGA? What do you avoid before the test?
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(Multi Gated Acquisition Scan) aka Radionuclide Scan. Shows perfusion of areas of the heart. Avoid caffeine or theophylline before.
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What makes the Stress Test “Positive”. What do you do if it is positive?
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Chest pain is reproduced, ST depression, or hypotension.
Now do Coronary Angiography |
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Draw a flow diagram of the workup of Chest Pain
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What is the most common cauase of Death Post-MI?
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Arryhtmias, specifically V-Fib
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Post-MI complications: New systolic murmur 5-7 days s/p?
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Papillary muscle rupture
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Post-MI complications: Acute severe hypotension?
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Ventricular free wall rupture
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Post-MI complications: “step up” in O2 conc from RA RV?
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Ventricular septal rupture
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Post-MI complications: Persistent ST elevation ~1mo later + systolic MR murmur?
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Ventricular wall aneurysm
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Post-MI complications: “Cannon A-waves”?
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AV-dissociation. Either V-fib or 3rd degree heart block
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Post-MI complications: 5-10wks later pleuritic CP, low grade temp? How do you treat it?
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Dressler’s syndrome. (probably) autoimmune pericarditis. Tx w/ NSAIDs and aspirin.
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A young, healthy patient comes in with chest pain…
• If worse w/ inspiration, better w/ leaning forwards, friction rub & diffuse ST elevation |
pericarditis
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A young, healthy patient comes in with chest pain…If worse w/ palpation
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costochondriasis
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A young, healthy patient comes in with chest pain… If vague w/ hx of viral infxn and murmur
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myocarditis
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A young, healthy patient comes in with chest pain…If occurs at rest, worse at night, few CAD risk factors and migraine headaches, w/ transient ST elevation during episodes? How do you diagnose it? How do you treat it?
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Prinzmetal’s angina
– Dx w/ ergonovine stim test. Tx w/ CCB or nitrates |
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“Progressive, prolongation of
the PR interval followed by a dropped beat” |
Mobitz Type I, 2nd Degree AV Block
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Cannon-a waves on
physical exam. “regular P-P interval and regular R-R interval” |
3rd Degree AV Block
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“varrying PR interval with 3 or
more morphologically distinct P waves in the same lead”. Seen in an old person w/ chronic lung dz in pending respiratory failure |
Multifocal Atrial Tachycardia - d/t multiple sites of competing atrial activity
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“Three or more consecutive beats w/ QRS <120ms @ a rate of >120bpm”
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Atrial Tachycardia??
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“Short PR interval followed by QRS >120ms with a slurred initial deflection
representing early ventricular activation via the bundle of Kent”. |
WPW - abnormal accessory electrical conduction pathway (bundle of kent) stimulates ventricles to contract prematurely
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“Regular rhythm with a ventricular rate of 125-150 bpm and atrial rate
of 250-300 bpm” |
Atrial Flutter
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“prolonged QT interval leading to
undulating rotation of the QRS complex around the EKG baseline” In a pt w/ low Mg and low K. Li or TCA OD |
Torsades de Pointe
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“Regular rhythm w/ a
rate btwn 150-220bpm.” Sudden onset of palpitations/dizziness. |
Paraxysmal Supraventricular Tachycardia
there are three types: 1 - AV nodal Reentry 2 - Atrioventricular Reentrant Tachycardia 3 - Ectopic Atrial Tachycardia |
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Renal failure patient/crush injury/burn victim w/ “peaked T-waves, widened QRS, short QT
and prolonged PR.” |
Hyperkalemia
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“Alternate beat variation in direction, amplitude and duration of the QRS complex” in a
patient w/ pulsus paradoxus, hypotension, distant heart sounds, JVD |
Electrical Alternans - Cardiac Tamponade or severe pericardial effusion - basically d/t the heart wobbling around in the fluid
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“undulating baseline, no p waves appreciated., irregular R-R interval in a patient with hyperthyroid or an old patient with SOB/Dizziness/Palpitations with CHF or Valve Disease
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AFib
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SEM cresc/decresc, louder w/
squatting, softer w/ valsalva. + parvus et tardus |
Aortic Stenosis
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SEM louder w/ valsalva, softer
w/ squatting or handgrip. |
HOCM
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Late systolic murmur w/ click
louder w/ valsalva and handgrip, softer w/ squatting |
Mitral Valve Prolapse
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Holosystolic murmur radiates
to axilla w/ LAE |
Mitral regurge
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Holosystolic murmur w/ late
diastolic rumble in kiddos |
VSD
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Continuous machine like
murmur |
PDA
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Wide fixed and split S2-
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ASD
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Rumbling diastolic murmur
with an opening snap, LAE and A-fib |
Mitral Stenosis
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Blowing diastolic murmur with
widened pulse pressure and eponym parade. |
Aortic Regurge
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A patient comes in with shortness of
breath… • If you suspect PE (history of cancer, surgery or lots of butt sitting) what do you do? |
Heparin!!!
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A patient comes in with shortness of
breath… Give O2 if |
O2 sats < 90
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A patient comes in with shortness of
breath… If signs/sxs of pneumonia ? |
Get Chest XRay
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A patient comes in with shortness of
breath… If murmur present or history of CHF get what test? |
echo to check
ejection fraction |
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A patient comes in with shortness of
breath… For acute pulmonary edema give what? |
nitrates, lasix and
morphine |
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A patient comes in with shortness of
breath… If young w/ sxs of CHF w/ prior hx of viral infx consider? |
myocarditis (Coxsackie B).
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A patient comes in with shortness of
breath… If pt is young and no cardiomegaly on CXR consider? |
primary pHTN
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Draw the diagram of the right heart cath:
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What is the EF in Systolic CHF?
What is the condition of the heart muscle? What are the causes? Which of the causes is reversible? |
Systolic- decreased EF (<55%)
– Ischemic, dilated • Viral, ETOH, cocaine, Chagas, Idiopathic • Alcoholic dilated cardiomyopathy is reversible if you stop the booze. |
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What is the EF in Diastolic CHF?
What is the condition of the heart muscle? What are the causes? Which of the causes is reversible? |
• Diastolic- normal EF, heart can’t fill
– HTN, amyloidosis, hemachromatosis • Hemachromatosis restrictive cardiomyopathy is reversible w/ phlebotomy. |
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How do you treat CHF and which ones improve survival?
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ASDF B or SAD Boy Friend
ACE-I: Improves survival by preventing remodeling of the heart by aldosterone Spironolactone: Improves survival in NYHA class III and IV Digoxin: Decreases Sx and hospitalizations NOT survival Furosemide: Improves Sx (SOB, Crackles, Edema B-Blocker: (metoprolol, carvedilol) Improves Survival by Preventing remodeling by epi/norepi |
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Pulmonology NEXT
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next
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“Opacification, consolidation,
air bronchograms” |
Pneumonia
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What does air bronchograms mean
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air filled bronchi are made visible by opacification of surrounding alveoli that are filled with something other than air
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“hyperlucent lung fields
with flattened diaphragms” |
COPD
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“hyperlucent lung fields
with flattened diaphragms” |
COPD
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“heart > 50% AP
diameter, cephalization, Kerly B lines & interstitial edema” |
CHF
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What are Kerly B lines?
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Thin, linear opacities caused by fibrosis or hemosiderin deposition that is caused by recurrent pulmonary edema
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What does cephalization mean?
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recruitment of upper lung vessels to carry blood
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Cavity containing fluid air level
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abcess
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“Upper lobe cavitation, consolidation
+/- hilar adenopathy” |
TB
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For a pleural effusion...
how much fluid do you have to see? On what type of image? And what do you do next? |
>1cm of fluid on
Lateral decubitus X-ray Do a thoracentesis |
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If pleural effusino is transudative, what is the likely etiology?
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CHF, Nephrotic, Cirrhotic
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If pleural effusion is low in glucose what is the likely etiology?
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Rheumatoid arthritis
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If the pleural fluid is high in lymphocytes what is the likely etiology?
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TB
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If the pleural effusion is bloody what is the likely etiology?
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Malignancy or PE
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If the pleural effusion is exudative, what is the likely etiology?
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Parapneumonic (complicated/uncomplicated/empyema), cancer, etc.
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What is a complicated parapneumonic exudate?
What do you do for it? |
+ gram stain or culture, pH<7.2, and glucose <60
Insert chest tube for drainage |
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What is Light's Criteria?
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Pleural effusion is transudative if:
LDH<200 LDH Effusion/Serum <0.6 Protein Effusion/Serum <0.5 |
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on CXR:
Thickened peritracheal stripe and splayed carina bifurcation |
- Left atrial enlargement
- Mediastinal lymphadenopathy (cancer) ??? |
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Sx of PE
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pleuritic chest pain, hemoptysis, tachypnea
Decr pO2, tachycardia. |
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Random signs of PE
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right heart strain on EKG, sinus tach,
decr vascular markings on CXR, wedge infarct, ABG w/ low CO2 and O2. |
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What does right heart strain look like?
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ST depression and T wave inversion in V1-V3 and inferior lead (II, especially III, aVL)
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If PE is suspected, do what ist?
Then do what? Then what? |
give heparin 1st!
Then work up w/ V/Q scan, then spiral CT. Pulmonary angiography is gold standard. |
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How do you treat confirmed PE?
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--Tx w/ heparin warfarin overlap.
--Use thrombolytics if severe but NOT if s/p surgery or hemorrhagic stroke. --Surgical thrombectomy if life threatening. --IVC filter if contraindications to chronic coagulation. |
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What is the Pathophysiology of ARDS?
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inflammation --> impaired
gas xchange, inflam mediator release, hypoxemia |
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What causes ARDS?
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Sepsis, gastric aspiration, trauma, low perfusion,
pancreatitis. |
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How do you diagnose ARDS?
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1.) PaO2/FiO2 < 200 (<300 means acute lung injury)
2.) Bilateral alveolar infiltrates on CXR 3.) PCWP is <18 (means pulmonary edema is non cardiogenic) |
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How do you treat ARDS?
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mechanical ventilation w/ PEEP (according to ARDS.net protocol)
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What happens to the following values in obstructive vs Restrictive lung disease?
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What is DLCO?
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It is decreased in any condition that affects the effective alveolar surface area
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COPD
Criteria for diagnosis? |
Productive cough >3mo for >2 consecutive yrs
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COPD
Treatment? |
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COPD
• Indications to start O2? |
PaO2 <55 or SpO2<88%. If cor pulmonale, <59
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COPD
Criteria for exacerbation? |
Change in sputum, increasing dyspnea
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COPD
Treatment for exacerbation? |
O2 to 90%, albuterol/ipratropium nebs, PO or IV
corticosteroids, FQ or macrolide ABX, |
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COPD
Best prognostic indicator? |
FEV1
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Shown to improve
mortality? |
1.) Quitting smoking (can decr rate of FEV1 decline
2.) Continuous O2 therapy >18hrs/day |
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Why is our goal for SpO2
94-95% instead of 100%? |
COPDers are chronic CO2 retainers. Hypoxia is
the only drive for respiration. |
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Your COPD patient comes with a 6
week history of clubbing. What is the other name for it? What is likely causing it? |
Hypertrophic Osteoarthropathy
Lung Malignancy |
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Describe the stages of asthma and their treatments
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Mild Intermittent: If pt has sxs twice a week and PFTs are normal
Albuterol only Mild Persistent: If pt has sxs 4x a week, night cough 2x a month and PFTs are normal Albuterol + Inhaled steroids Moderate Persistent: If pt has sxs daily, night cough 2x a week and FEV1 is 60-80%? Albuterol + Inhaled Steroids + long acting beta ag (salmeterol) Severe Persistent: If pt has sxs daily, night cough 4x a week and FEV1 is <60%? Albuterol + inhaled CS + Salmeterol + montelukast (if obes/smoker/ASA sensitive) + Oral Steroids |
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How to treat an asthma exacerbation
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tx w/ inhaled albuterol and PO/IV
steroids. Watch peak flow rates and blood gas. PCO2 should be low. Normalizing PCO2 means impending respiratory failure --> INTUBATE. |
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What is a weird complication of asthma
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Allergic Brochopulmonary Aspergillus
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1cm nodues in upper lobes w/
eggshell calcifications. |
Silicosis. Get yearly TB test!.
Give INH for 9mo if >10mm |
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Reticulonodular process in
lower lobes w/ pleural plaques. |
Asbestosis. Most common cancer is
broncogenic carcinoma, but incr risk for mesothelioma |
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Patchy lower lobe infiltrates,
thermophilic actinomyces. |
Hypersensitivity Pneumonitis =
“farmer’s lung” |
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Hilar lymphadenopathy, ↑ACE
erythema nodosum. – Hypercalcemia? – Important referral? – Dx/Treatment? |
Sarcoidosis.
hypercalc: 2/2 ↑ macrophages making vitD referral: Ophthalmology uveitis conjunctivitis in 25% Dx by biopsy. Tx w/ steroids |
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So you found a pulmonary nodule…
1st step |
look for an old CXR to compare!
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Characteristics of benign pulmonary nodules:
How to treat? |
- Popcorn calcification = hamartoma (most common)
– Concentric calcification = old granuloma – Pt < 40, <3cm, well circumscribed • Tx w/ CXR or CT scans q2mo to look for growth |
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Characteristics of malignant nodules:
What to do next? |
– If pt has risk factors (smoker, old), If >3cm, if eccentric
calcification • Do open lung bx and remove the nodule |
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A patient presents with weight loss, cough,
dyspnea, hemoptysis, repeated pnia or lung collapse. MC cancer in non-smokers? |
Adenocarcinoma. Occurs in scars of old pnia
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Location and mets of adenocarcinoma
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Peripheral cancer. Mets to liver, bone, brain and adrenals
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Characteristics of effusion of lung adenocarcinoma
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Exudative with high hyaluronidase
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Patient with kidney stones,
constipation and malaise low PTH + central lung mass? What cancer? What are important lab values? |
Squamous cell carcinoma.
Paraneoplastic syndrome 2/2 secretion of PTH-rP. Low PO4, High Ca |
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Patient with shoulder pain, ptosis,
constricted pupil, and facial edema? |
Superior Sulcus Syndrome from Small
cell carcinoma. Also a central cancer. |
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Patient with ptosis better after 1
minute of upward gaze? |
Lambert Eaton Syndrome from small
cell carcinoma. Ab to pre-syn Ca chan |
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Old smoker presenting w/ Na = 125,
moist mucus membranes, no JVD? |
SIADH from small cell carcinoma.
Produces Euvolemic hyponatremia. Fluid restrict +/- 3% saline in <112 |
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CXR showing peripheral cavitation and
CT showing distant mets? |
Large Cell Carcinoma
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IBD
Involves terminal ileum? What does it mimic? What deficiency can it cause? |
Crohn’s. Mimics appendicitis. Fe deficiency.
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IBD
Continuous involving rectum? |
UC. Rarely ileal backwash but never higher
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IBD
Incr risk for Primary Sclerosing Cholangitis? |
UC. PSC leads to higher risk of cholangioCA
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IBD
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Fistulae likely?
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IBD
Granulomas on biopsy? |
Crohn’s.
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IBD
Transmural inflammation? |
Crohn’s.
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IBD
Cured by colectomy? |
UC.
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IBD
Smokers have lower risk? |
UC. Smokers have higher risk for Crohn’s.
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IBD
Highest risk of colon cancer? |
UC. Another reason for colectomy.
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IBD
Associated w/ p-ANCA? |
UC.
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IBD
treatment? |
Treatment = ASA, sulfasalzine to maintain remission. Corticosteroids to induce
remission. For CD, give metranidazole for ANY ulcer or abscess. Azathioprine, 6MP and methotrexate for severe dz. |
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IBD Complication
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Toxic Megacolon in Crohn's
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IBD
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String Sign in Crohn's
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IBD Complication
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Pyoderma Gangrenosum
UC |
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IBD Complication
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Erythema Nodosum
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AST>ALT (2x) + high GGT
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Alcoholic Hepatitis
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ALT>AST & in the 1000s
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Viral Hepatitis
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AST and ALT in the 1000s after
surgery or hemorrhage |
Ischemic Hepatitis (“shock liver”)
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Elevated D-bili
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Obstructive (stone/cancer) or Dubin’s Johnsons, Rotor
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Elevated I-bili
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Hemolysis or Gilbert’s, Crigler Najjar
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Elevated alk phos and GGT
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Bile duct obstruction, if IBD --> PSC
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Elevated alk phos, normal
GGT, normal Ca |
Paget’s disease (incr hat size, hearing loss,
HA. Tx w/ bisphosphonates. |
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Antimitochondrial Ab
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Primary Biliary Cirrhosis – tx w/ bile resins
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ANA + antismooth muscle Ab
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Autoimmune Hepatitis – tx w/ ‘roids
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High Fe, low ferritin, low Fe
binding capacity |
High Fe, low ferritin, low Fe
binding capacity |
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Low ceruloplasmin, high
urinary Cu |
Wilson’s- hepatitis, psychiatric sxs
(BG), corneal deposits |
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What is Dubin Johnson?
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Auto-recessive - increased direct bilirubin, normal AST and ALT, Asymptomatic, Black Liver, Normal Corproporphyrin in Urine
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What is Rotor Syndrome?
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Same as Dubin but no black liver, and Increased Corproporphyrin in Urine
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What is Gilbert's
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Genetic deficiency of glucuronyl transferase. usually asymptomatic, but can jaundice when sick or stressed
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