Cardio/Endo

Question 1

6 predictors of surgical cardiac complications

Answer 1

Ischemic heart disease, congestive heart failure, cerebrovascular disease, a high-risk operation, preoperative treatment with insulin, and preoperative serum creatinine greater than 2.0 mg/dL

Question 2

What cardiac conditions would you want to avoid elective surgeries

Answer 2

Unstable angina

Question 3

Noninvasive stress testing before noncardiac operations is indicated in patients with:

Answer 3

Active cardiac conditions (eg, unstable angina, recent MI, significant arrhythmias, or severe valvular disease)

Patients who require vascular operations and have clinical risk factors and poor functional capacity

Question 4

Coronary revascularization before noncardiac operations in patients with:

Answer 4

Significant left main coronary artery stenosis
Stable angina with three-vessel coronary disease
Stable angina with two-vessel disease
Significant proximal left anterior descending coronary artery stenosis with either an ejection fraction <50% or ischemia on noninvasive testing
High-risk unstable angina or non–ST-segment elevation MI, or acute ST-elevation MI

Question 5

The P’s of arterial emboli

Answer 5

P ain, P allor, P ulselessness, P aresthesia, P aralysis, P oikilothermia

Question 6

common causes of thrombus formation

Answer 6

Atrial fibrillation and mitral stenosis

Question 7

Gold standard dx for Arterial embolism/thrombosis

Answer 7

Angiography is considered the gold standard for diagnosis

Question 8

Tx of Acute arterial occlusion

Answer 8

Acute arterial occlusion: Treat with IV heparin if not limb threatening then call the vascular surgeon for angioplasty, graft or endarterectomy

Question 9

PAD is defined as

Answer 9

PAD is defined as an ABI < 0.9. The ABI Confirms the Diagnosis of PAD:

Question 10

Dx of PAD vs PVD

Answer 10

Angiography is considered the gold standard for diagnosing PAD/PVD

Question 11

Tx of PVD/PAD

Answer 11

Platelet inhibitors: Cilostazol, Aspirin, Clopidogrel

• Treat lipids - Statins
• Revascularization with PTA, bypass grafts, stenting
  
  • Exercise - walking to the point of claudication

Question 12

Which drug is contraindicated in isolated PAD – it will worsen claudication!

Answer 12

βblockers

Question 13

Which cardiac conditions are associated with dyspnea on exertion

Answer 13

Arrhythmia: Atrial fibrillation, inappropriate sinus tachycardia,sick sinus syndrome/bradycardia

• Hx: Palpitations, syncope
• PE: Irregular rhythm, pauses
• DX: ECG, event recorder, Holter monitor, stress testing

Myocardial: Cardiomyopathies, coronary ischemia

• Hx: Dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, chest pain or tightness, prior coronary artery disease or atrial fibrillation
• PE: Edema, JVD, S3, displaced cardiac apical impulse, hepatojugular reflex, murmur, crackles, wheezing, tachycardia, S4
• Dx: ECG, brain natriuretic peptide, echocardiography, stress testing, coronary angiography

Restrictive: Constrictive pericarditis, pericardial effusion/tamponade

• Hx: chest pain, dyspnea
• PE: Paradoxical pulse (exaggerated variation in blood pressure with respiration).
• Dx: EKG showing low voltage QRS along with electric alternans (see media section). Echocardiogram with increased pericardial fluid. Radiograph: Water bottle heart

Valvular: Aortic insufficiency/stenosis, congenital heart disease, mitral valve insufficiency/stenosis

• Hx: Dyspnea on exertion
• PE: Murmur, JVD
• Dx: Echocardiography

Question 14

Structural cardio pulmonary causes for syncope

Answer 14

• Aortic Stenosis - angina, syncope, and CHF - 3 -years life expectancy if left untreated (if experiencing syncope)
• Cardiomyopathy: HOCM - (young athlete with a positive family history has sudden death or syncopal episode)
• Pulmonary hypertension
• Acute MI

Question 15

sudden “ripping” or “tearing” CP radiating to back

Answer 15

Aotic dissection

Question 16

rare disease that can also be functional but should be considered on the differential of any adrenal mass, especially tumors larger than 4 cm

Answer 16

Adrenal cortical cancer

Question 17

Functional adrenal tumors

Answer 17

• Functional tumors include pheochromocytomas, aldosteronoma, and cortisol-producing adenomas. In patients with a previous or present history of malignancy, adrenal metastasis should be considered in the differential

Question 18

Workup for adrenal carcinoma includes:

Answer 18

• Plasma fractionated metanephrines or 24-hour urine metanephrines—must rule out pheochromocytoma for any adrenal mass
• Serum potassium and aldosterone and plasma renin activity
• 24-hour urinary-free cortisol or dexamethasone suppression test
• DHEA-S—high levels can be associated with ACC; virilization is the clinical manifestation of androgen overproduction
• CT scan - size > 4 cm
• MRI

Question 19

Why is laproscopic adrenalectomy not recommended?

Answer 19

• Laparoscopic adrenalectomy is NOT recommended for ACC given higher local recurrence rates due to positive or close margins

Question 20

Lab workup for fatigue

Answer 20

• Complete blood count - anemia
• Erythrocyte sedimentation rate - inflammatory state
• Chemistry panel - liver disease, renal failure, protein malnutrition
• Thyroid function tests - hypothyroidism
• Human immunodeficiency virus antibodies - if not previously tested
• Pregnancy test, if indicated

Question 21

Labs for hypothyroid

Answer 21

• Labs: TSH- elevated in primary disease. Low T4 (↑ TSH and ↓ Free T4)

Question 22

Labs for hashimotos

Answer 22

• Hashimoto’s: Antithyroid peroxidase, antithyroglobulin antibodies

Question 23

PALPABLE neck tumor and hypercalcemia

Answer 23

Parathyroid cancer → Hyperparathyroidism

Question 24

Female with heat intolerance, palpitations, sweating, weight loss, tremor, anxiety, tachycardia

Answer 24

Hyperthyroid

Question 25

Best test for hyperthyroid workup

Answer 25

• TSH (best test): Decreased in primary disease (↓ TSH and ↑ Free T4), elevated in secondary disease (↑ TSH and ↑ Free T4)
• Thyroid radioactive iodine uptake:
  • Graves: Diffusely high uptake
  • Toxic multinodular: Discrete areas of high uptake

Question 26

Tx of hypethyroid

Answer 26

• Beta-blockers (symptomatic), methimazole/propylthiouracil, radioactive iodine, thyroidectomy
• Thyroid storm- prompt beta blockers, hydrocortisone, methimazole/propylthiouracil, iodine
• Thyroidectomy- most likely complication is recurrent laryngeal nerve (hoarseness)

Question 27

What 2 adrenal conditions are palpations seen in?

Answer 27

Hyperthyroidism (see above) -heat intolerance, palpitations, sweating, weight loss, tremor, anxiety, tachycardia

Pheochromocytoma - recurrent headaches, HTN, sweating, palpitations

Question 28

Hypertension, diaphoresis (episodic), and palpitations

Answer 28

Pheochromocytoma

Question 29

Dx of pheochromocytoma

Answer 29

• 24-hour catecholamines including metabolites (metanephrine and vanillylmandelic acid)
  
  • MRI or CT of the abdomen to visualize tumor

Question 30

MC type of thyroid cancer

Answer 30

Most often papillary carcinoma (80%) - think papillary is “popular”

Question 31

Dx of thyroid cancer

Answer 31

• Ultrasound is the best initial screen followed by a thyroid uptake scan. Usually normal thyroid function.
• Microcalcifications, hypoechogenicity, a solid cold nodule, irregular nodule margins, chaotic intranodular vasculature, and a nodule that is more tall than wide.
• Fine needle biopsy for definitive diagnosis (all lesions >1 cm should be biopsied)
• TSH, calcium level, CXR

Question 32

Tx of thyroid cancer

Answer 32

Treatment: Surgical resection

• Surgical resection with chemotherapy and external beam radiation reserved for anaplastic thyroid cancer.

Question 33

Diagnostic test of choice for thyroid nodule

Answer 33

The diagnostic test of choice for thyroid nodule is Fine Needle Aspiration (FNA)

Question 34

Thyroid nodule that is hot indicates?

Answer 34

• U/S—solid or cystic nodule
• Fine Needle Aspirate (FNA) -> cytology 123 I scintiscan (hot or cold nodule)
  
  • Hot—Increased 123 I uptake = functioning/ hyperfunctioning nodule (non-cancerous)
  • Cold—Decreased 123 I uptake = nonfunctioning nodule (cancerous)

Hot = Not cancer

Cold = Cancer

Question 35

3 cardinal features of Parkinson’s disease

Answer 35

Rest tremor, cogwheel rigidity, and bradykinesia

Question 36

What is the classic tremor associated with PD?

Answer 36

A pill-rolling 4- to 6-Hz tremor seen at rest; usually begins asymmetrically. This is the most specific clinical sign of PD.

Question 37

TRAP symptoms of Parkinson’s disease

Answer 37

• Tremor
  
  • Resting tremor that is often asymmetric (disappears with voluntary movement)
  • Disappears with voluntary movement
  • Frequently emerges in a hand while walking and may present as pill-rolling
  • May also present in jaw, chin, lips, tongue
• Rigidity: cogwheel (catching and releasing) or lead pipe (continuously rigid) - rigidity is also responsible for the stooped posture and an almost expressionless face (masked facies) that some individuals with Parkinson’s might have
• Akinesia (absence of movement)/bradykinesia (slowness of movement)/hypokinesia (lessened movement) - examples of this are having the legs freeze up when trying to walk and also walking with a shuffling gait, or small steps
• Postural instability - a late feature of the disease which causes problems with balance and can lead to falls

Question 38

Tx of Parkinsons disease

Answer 38

• < 65 Dopamine agonists: bromocriptine, pramipexole, ropinirole. Directly stimulates dopamine receptors. Less side effects than Levodopa. Used in younger patients to delay the use of Levodopa.
• > 65 Sinemet (levodopa/carbidopa)