Bellevue Wards Flashcards
(107 cards)
1
Q
3 sets of criteria for LVH on EKG
A
- R in V1 or V2 + S in V5 or V6 > 35 mm
- Cornell criteria: R in aVL + S in V3
> 20 in F, > 28 in M - R in aVL > 11
2
Q
Describe the mechanism of DIC
A
DIC: some procoagulant exposure causes tons of coagulation and therefore consumption of coag factors and platelets => thrombocytopenia and prolonged PT and PTT
Abnormal activation of coagulation and fibrinolysis w/in the vasculature
3
Q
Most common cause of ascites w/ SAAG score
A
SAAG score
4
Q
Does cirrhosis cause high or low ascitic protein content and why?
A
In cirrhosis the liver sinusoids are fibrosed => proteins only extravagate out the capillary fenestrations (very small) => low protein content (
5
Q
4-fold initial medical tx for MI
A
MONA
- morphine
- oxygen
- nitrates: except NOT in hypotensive pts (don’t want to vasodilated hypotensive pt)
- aspirin
6
Q
What does an S3 indicate?
A
High LV filling pressures
-typically a dilated LV w/ high EDV
7
Q
Tx for acute PE
A
First line tx = Lovenox (low MW heparin)
8
Q
What is the delta gap?
(a) What does it tell you
A
Delta gap is the change in bicarb (normal - pt’s) - change in anion gap (normal - pts)
-basically comparing if the pt’s increase in bicarb is equitable to the anion gap
(a) If elevated, tells you that there is another form of acidosis going on. EX: a non-anion gap met. acidosis on top of the anion gap met acidosis
9
Q
What is cardiac syndrome X?
A
Microvascular angina, angina w/ normal coronary arteries
-thought to be due to occlusion of the tiny vessels that perfuse the heart that get occluded during systole
Basically angina (w/ evidence of ischemic changes on stress test) w/ a normal cath -b/c thought is that the vessels that are occluded are too small to see on catch
10
Q
Bicarb on BMP vs. ABG
A
Want the bicarb from the BMP
Bicarb on BMP is measured, while bicarb on ABG is calculated
11
Q
Octreotide- what is it?
(a) Indication
A
Octreotide = somastostatin analog causing vasoconstriction of the splanchnic arterioles to decrease blood to the gut => decrease blood load to the veins
(a) Used in acute tx of varices
- also used in tx of tumors
12
Q
Define AIDS
A
AIDS = either:
- HIV w/ CD4 count under 200
- HIV + OI (opportunistic infection)
13
Q
What is Budd Chiari?
A
Thrombi (blood clot) in the hepatic vein causes obstruction => portal HTN
14
Q
2 EKG findings of PE
A
- sinus tachycardia
2. S1Q3T3 = prominent S-wave in I, Q wave present in 3, T-wave inversions in V1-V3
15
Q
Two test besides cath to evaluate for ischemic cardiomyopathy
A
- CT Angiography
- Cardiac MRI
-used when the risk for ischemia is low, b/c if ischemia risk is high you just go for the more invasive procedure (cath) b/c it also can involve treatment (stent)
16
Q
Which cardiac marker to track for re-infarction
A
Track CK-MB for re-infarction, troponin remains elevated for 5-14 (typically 7) days after initial infarct
17
Q
HUS vs. TTP
A
HUS- “ATR”- has the middle of FAT RN
- anemia (hemolytic)
- thrombocytopenia
- renal failure
TTP mneumonia = FAT RN, HUS plus fever and neurologic status change Fever Anemia (hemolytic) Thrombocytopenia Renal failure Neurologic status change
18
Q
What test is good for PE when
(a) Pretest probability is high
(b) Pretest probability is low
A
PE diagnostic test
(a) High pretest probability: CT pulmonary angiogrpahy
(b) D-dimer when pretest probability is low, sensitive but not specific test => good to rule it out
19
Q
Duration of ischemia to get infarction
A
In just 20 minutes ischemia can cause infarction (tissue death)
20
Q
What is a protein gap?
(a) ULN
A
Protein gap = total protein = albumin
(a) Concerning over 5
Indicates other proteins in the blood: potentially pointing towards multiple myeloma
21
Q
What does an S4 indicate?
A
Atria contracting against high EDP, so a stiff ventricle
22
Q
R/o diagnoses for CP
A
Pneumothorax, MI, PE, aortic dissection, esophageal perforation (Boerhaave syndrome)
23
Q
Explain why fainting in more common in VT vs. AFib
A
Both have the same HR- but you faint from VT but not AFib- b/c VT the conduction is not coming down His bundles/specialized conduction system => loss of ventricular systolic coordination so systolic contraction is less effective
24
Q
Medication used for hepatic encephalopathy in addition to lactulose
A
Rifaximin = synthetic abx that stays in the GI tract (very poor oral bioavailability)
Kills the bacteria in the gut that produce N-containing products
25
AP vs. PA film (CXR) for cardiac silhouette
Cardiac silhouette appears larger on AP film (b/c heart is farther from the detector) => hard to judge cardiomegaly on AP film
Prefer PA film if looking just at cardiomegaly on a CXR
26
What is Flatbush diabetes?
DKA prone type 2 diabetes
27
Bromocryptine
Bromocriptine = dopamine agonist used for pitutiary tumors, Parkinson's disease, hyperprolactinemia, and neuroleptic malignant syndrome
28
2 indications that AKI can be chalked up to pre-renal
1. bland sediment on UA
- no evidence of intrarenal disease (coarse granular, WBC, RBC casts)
2. BUN:creatinine ratio over 20
29
Dantrolene
Dantrolene = muscle relaxant for malignant hyperthermia (rare life-threatining d/o triggered by general anesthesia)
Also can be used in neuroleptic malignant syndrome (adverse rxn to antipsychotic)
30
Describe the mechanism of vasovagal syncope
Acute increase in sympathetic tone (due to stressor) sensed by baroreceptor causes compensatory parasympathetic response => decrease in peripheral resistance => venous pooling (vasodilation)
31
What is lovenox? Indication?
Lovenox = low molecular weight heparin
Indication = DVT w/ or w/o PE
32
Advantages and disadvantages of drug eluding stent
Drug eluding stent: releases tacrolimus to prevent epithelialization of the stent
(+): decreased risk of re-stent stenosis
(-): need anticoag (ASA, Clopidogrel) for life
So need to be on life-long anticoagulation to avoid risk of re-stent thrombosis, low risk re-stent stenosis
33
Tx for type A vs. type B aortic dissection
Type A- typically requires surgery + medical therapy
Type B (involving descending aorta only) can be managed w/ medical therapy alone- BP control, acutely w/ labetolol
34
Relationship btwn creatinine and GFR
As creatinine doubles, GRF halves
35
Why is VTach so dangerous?
It's not the tachycardia...your heart goes that fast when you run! But b/c the atria and ventricles are out of sync => diastole/filling is impaired
VT: signal not going down the His Bundle => not going down the specialized conduction system => loss of ventricular systolic coordination so systolic contraction is much less effective
36
Type A vs. type B aortic dissection
Classified by location:
type A involves the ascending aorta and/or aortic arch
Type B does NOT involve the ascending aorta, instead is descending aorta or arch distal to the subclavian artery
37
Differentiate type I and type II NSTEMI
Type I = plaque rupture
Type II = demand ischemic
STEMI is by definition type I (due to plaque rupture)
38
2 causes of non anion gap metabolic acidosis
RTA (renal tubular acidosis)- when kidneys aren't excreting H+
Diarrhea- just pooping out tons of bicarb
39
Describe DKA in the context of imbalance of 2 types of hormones
DKA: imbalance of catabolic hormones (NE, epi, cortisol) and glucagon, compared to anabolic hormone insulin
=> DKA is a overwhelming catabolic state
Stress hormones cause breakdown to provide precursors => in catabolic state you're chewing up fatty acids and spitting out tons of ketones
40
When is FENa calculation in oliguria not useful? What do you use instead?
When pt is on Lasix, FENa is useless b/c your lasix is forcing Na+ excretion (so not indicative of kidney fxn)
Instead use FeUrea
FeUrea under .35 indicates prerenal pathology
41
When and how to correct Na+ value for hyperglycemia
For every 100 g of glucose over 100g, Na+ falsely drops by 1.6
So a glucose of 500 can falsely decrease measured serum Na+ by 4(1.6) = 6.4
42
Troponins
(a) If not positive how long after CP starts can you r/o MI
(b) When does it peak?
Troponins
(a) If not positive (aka not over 0.06) by 8 hrs after CP, you've r/o MI
(b) Peaks in about 12-24 hrs after myocardial injury
43
What does protein in the ascitic fluid indicate?
High protein (> 2.5) in ascitic fluid indicates process above the liver
Ex: right HF, Budd Chiari
-hence why high protein ascites is sometimes called 'cardiac ascites'
Obstruction is before the liver b/c the proteins are going thru (and getting out thru) the capillary fenestrations AND the liver sinusoids, so small proteins can get thru and into the ascitic fluid
44
What does it mean when you're delta-delta is higher or lower than the change in anion gap?
If bicarb is higher than change in anion gap, then bicarb is further compensating for ANOTHER acidosis on top of the present anion-gap metabolic acidosis
=> a non-anion gap acidosis is simulataneously present (ex: RTA, diarrhea)
If bicarb is lower than change in anion gap, there is a simultaneous alkalosis RIGHT
45
Distinguish the implications of a tall vs. a wide P-wave
Tall P-wave indicates RA enlargement (P wave over .25 m)
Wide P-wave indicates LA enlargement
46
What TIMI score is considered the cuttoff?
For unstable angina and NSTEMI: typically a TIMI score of 5 or above indicates revascularization
b/c TIMI score of 5 indicates 7.5-10% risk of recurrent MI
47
3 steps to determine the quality of an Xray
First say the type of film: 'AP film portable'
1. Penetration- best electrical intensity/penetration when there is a large difference in color btwn the bones and air
2. Pt's rotation- look at the clavicles
ex: rotated left anterior
3. Inspiratory effort- count ribs (hint: count posteriorly): 8-10 is good effort
48
Give a scenario when the pt has pre-renal azotemia but the FeNA isn't under 20
Pt on Lasix- aka you're making them pee out sodium so despite the kidney hypoperfusion (pre-renal azotemia) they're not holding on to salt
Instead- use FeUrea under .35 to indicate pre-renal azotemia in pts on diuretics
49
Differentiate spasticity and rigidity
(a) Velocity dependent
(b) Location of lesion
(c) Associated syndromes
Spasticity = velocity dependent (elicited by fast movements)
(b) Lesions of UMN, pyramidal tracts
(c) stroke, tumors, blunt trauma
Rigidity = velocity independent, does not vary w/ speed of movement of involved muscle groups
(b) extrapyramidal
(c) Parkinsons, NMS
50
Most common valvular diseased caused by acute rheumatic fever
Mitral stenosis
51
What is a paradoxical split S2?
(a) What does it indicate?
Paradoxical split S2- when P2 comes before A2
| Meaning the RV is done contracting before the LV, indicating a LBBB
52
Biggest risk for cholesterol emboli
Recent cardiac cath or vascular procedure- direct mechanical disruption of atherosclerotic aortic plaques
53
Differentiate bicarb from BMP and ABG
HCO3 from BMP is measured, while HCO3 in ABG is calculated
=> you want the HCO3 from the BMP (more directly accurate)
54
Amantidine
Weak NMDA (glutamate receptor) antagonist => increases dopmaine release and blocks dopamine reuptake
Used in Parkinson's (often in conjunction w/ L-DOPA)
55
Define ACS and it's 3 parts (and exactly how they are different)
ACS: spectrum from unstable angina, NSTEMI, STEMI
Anginal CP in some pattern that is different than normal- increased in intensity, newly at rest etc
Considered NSTEM (over anginal CP) when troponin is positive
56
Why is the goal O2 sat not 100% in a pt w/ chronic COPD
B/c you need the hypoxic-induced pulmonary constriction (natural compensation by the lungs) to maintain preferential shunting of blood flow to the ventilated areas of the lung parenchyma
Preserve V/Q match by keeping goal O2 sat 88-92%
57
What cause of ascites does SBP rule out?
A pt w/ ascites due to right heart failure (high protein, high SAAG score) CANNOT develop SBP (spontaneous bacterial peritonitis) b/c there are immunoglobulins in the ascitic fluid
Igs can get thru b/c the blockage is proximal to the liver, so high pressure in the liver allows extravasation thru the liver sinusoids (pretty big proteins like Igs can get thru)
58
Explain the concept of delta-delta in anion gap metabolic acidosis
Delta-delta helps you distinguish if there is another process going on ON TOP of the present anion-gap metabolic acidosis
Delta- delta = change in the bicarb, so normal bicarb - measured bicarb
If Pt's bicarb difference = change in anion gap (normal - pts), then entire picture is accounted for by the anion-gap metabolic acidosis
59
Describe why HOCM murmurs get ____ with squatting
HOCM murmurs get softer w/ squatting
Increased afterload increases the volume in the LV => moving the septum and lateral wall farther apart and decreasing LVOT obstruction => murmur gets softer
60
45 yo M presents w/ chronic diarrhea and 15 lb wt loss over the past year
- high fecal fat content
- abnormal oral D-xylose test (low urinary excretion), unimproved on rifaximin
Dx?
Which (and why not the wrong answers)
- Pancreatic insufficiency
- celiac disease
- bacterial overgrowth
- terminal ileal disease
Celiac disease- common cause of malabsorption (that's what the oral D-xylose test proves) w/ fatty stool and chronic diarrhea/wt loss
-Unimproved on rifaximin (abx) r/o traveller's diarrhea and bacterial overgrowth
D-xylose test = pt drinks solution of d-xylose, then urinary excretion of D-xylose is measured. Is an indication of small intestinal absorption of sugar
=> normal in pancreatic insufficiency
=> normal in Crohn's disease where the distal ileum is diseased (not the proximal small bowel where D-xylose is absorbed)
61
QT vs. QTc interval
(a) Formula for QTc
(b) When pt is tachy is the QT longer or shorter than the QTc
QT interval = beginning of Q-wave to end of T wave
QTc interval = QT interval corrected for HR
(a) QTc = QT / (square root (R-R interval))
(b) When pt is tachy the RR interval gets shorter (denominator goes down) so QTc gets longer
62
Go to medical treatment for aortic dissection
IV beta-blockers to decrease wall stress on the aorta to try to prevent propagation of the dissection
Medical therapy can be used alone in type B (just distal aorta involved), but surgery usually indicated when ascending arch is involved
63
When a pt is in DKA- why do you continue insulin even if pt is hypoglycemic?
(counterintuitive to have pt on both D5 NS and insulin ggt?)
Insulin is needed to balance the catabolic hormones- need to stop the production of ketones
DKA as imbalance btwn catabolic (stress hormones, glucagon) and anabolic hormones (insulin) => need insulin to stop ketone production and close the anion gap
64
How does pulmonary HTN change S2 splitting?
Pulmonary HTN increases the pressure at which the pulmonic valve closes => less split and increasing sound of P2 (when A2 is usually much louder)
65
How to r/o Budd Chiara
Get liver ultrasound w/ hepatic vein patency
Specifically ask for hepatic vein patency (aka if they're open or thrombosed) and the tech will do it w/ Doppler
66
55 yo F presents w/ pain, itching, and red streaks on left arm
-similar episode on chest 2 weeks that self-resolved
+heartburn and mild upper abdominal pain x months
-heavy smoking hx
-no murmurs, CTAB
-tender, erythematous, palpable cord-like lesions on the left arm and upper chest
(a) Dx
(b) Next step in management
(a) Trousseau's syndrome (or Trousseau sign of malignancy) = episodes of vessel inflammation due to blood clots (thrombophlebitis) commonly recurring or appearing in different locations over time (thrombophlebitis migrans)
(b) CT abdomen- Trousseau's syndrome is usually associated w/ occult visceral malignancy: most commonly pancreatic, also stomach lung or prostate carcinoma
- thought that tumor likely releases substance that reacts w/ platelets to form platelet-rich microthrombi
67
How to clinically differentiate benign ascitic fluid and SBP
Usually can't, 2/3 of the cases are asymptomatic
-only 1/3 of the cases have either elevated white count or fever
=>HAVE to do paracentesis on ascites pt to r/o SBP
68
Most common bugs causing myocarditis
Myocarditis is often viral, think coxsackie, echovirus, parvovirus, HIV, Hep B
69
Euthyroid sick syndrome vs. subclinical hypothyroidism
Euthyroid sick syndrome = low T3 (and non-elevated TSH) in the setting of acute illness
-on recovery from underlying non-thyroidal illness pts TSH will rise and T3 levels will recover
Subclinical hypothyroidism = elevated TSH w/ normal T4, T3 normal to a bit low. Thyroid hormones must be measured outside the setting of any acute illness (thyroid function testing is unreliable in pts w/ acute illness)
70
HUS vs. TTP
HUS = ATR
- anemia (hemolytic)
- thrombocytopenia
- renal failure
TTP = 'FAT-RN'
-three above + fever and neurologic status change
71
Advantages and disadvantages of bare metal stent
Bare metal stent
(+): doesn't require anticoagulation, so better for ppl who won't be compliant w/ meds
(-): body epithelializes along the foreign object, narrowing the lumen and increasing risk of restent stenosis
So risk of re-stent stenosis, low risk re-stent thrombosis
72
ACL tear
(a) Physical exam findings
(b) Findings on joint aspiration
ACL tear: acute popping sensation at time of injury
(a) Anterior laxity of tibia relative to femur (as seen on anterior drawer test)
(b) Grossly bloody joint fluid due to rapid onset of hemarthrosis (not seen in MCL tear)
73
Clinical features to distinguish pericarditis and myocarditis
Pericarditis presents w/ position CP
Myocarditis presents w/ acute HF
74
Hint on echo that cardiomyopathy is ischemic vs. nonischemic
Ischemic cardiomyopathy would show an isolated wall abnormality on echo
When wall abnormalities are diffuse (ex: akinesia of some walls w/ hypokinesias of the rest etc) it indicates a more diffuse, nonischemic process, is going on
75
4 types of intrarenal pathology that can cause AKI, and what you see on UA
Intrarenal AKI
1. ATN- coarse granular/brown muddy casts (these are dead tubular cells)
2. AIN- WBC casts (b/c it's inflammatory)
3. vascular-small vessel disease- see RBC and RBC casts
4. Glomerulonephritis- depen
76
What is a TIMI score used for?
TIMI score tells you the risk of mortality in an unstable or NSTEMI pts, then another TIMI score is for STEMI pts
So basically tells you how sick an ACS pt is- helps determine if they need cath or not
77
Criteria for nosocomial infection
Have been in the hospital anytime for at least 48 hours in the past 90 days = considered nosocomal infection
-has to be 48 continuous hours int he past 3 mo.
78
Differentiate hemophilia A and B
Hemophilia A is more common, both are X-linked recessive
```
A = deficiency in factor VIII
B = deficiency in factor IX
```
79
What can you tell from paracentesis?
Paracentesis gives you ascites fluid and then based on the SAAG (serum ascites albumin gradient) score you can narrow down dx
80
Differentiate mechanism of drug-induced AKI
(a) Bactrum
(b) NSAIDs
(c) Acyclvoir
(d) ASA
(e) Gentamycin
(f) Cefetaxime
(g) PenG
Bactrum, Acyclovir, and aminoglycosides (gentamycin) cause AKI via ATN- tubular damage
NSAIDs/ASA, cephalosporines, and beta-lactams cause AKI via AIN (acute interstitial nephritis)- which is an inflammatory response of the interstitial space btwn nephron tubules
81
Would portal vein thombosis have low or high ascitic protein content and why?
Portal vein thrombosis- specific finding is low protein in ascitic fluid (
82
What is tachy-brady syndrome?
Pattern of alternating slow and fast heart rhythms
-type of sick sinus syndrome (SA nodal dysfunction) accompanied by AV nodal conduction disturbances by atrial tachyarrhtyhmia on top of the sick sinus syndrome
83
What is a SAAG score?
(a) How does it help your ddx
SAAG score = serum ascites albumin gradient
SAAG > 1.1 (serum albumin much higher than ascites albumin) indicates portal-HTN related process
-comparable to transudative process
SAAG
84
Differentiate the problem in cardiogenic vs. distributive shock
Cardiogenic shock- the problem is low stroke volume
Distributive shock- the problem is low SVR
85
TIPS procedure
(a) Mechanism
(b) 2 indications
(c) 1 contraindication
TIPS = transjugular intrahepatic portosystemic shunt
(a) Connect portal vein to hepatic vein
- basically bypass liver to decrease the portal HTN backload
(b) Refractory bleeding varices and refractory ascites
(c) Contraindication = history of encephalopathy
86
Typical presentation of toxoplasmosis
(a) Imaging finding
Signs of increased ICP (ex: headache)
(a) multiple ring enhancing lesions on CT
87
Would HF have a wide or narrow pulse pressure? Why?
Narrow pulse pressure seen in heart failure
Low stroke volume decreases SBP, and high SVR increases DBP
88
Locate the focus
(a) Afib
(b) Aflutter
Focus
(a) Afib = where the pulmonary veins enter the left atrium
(b) Aflutter = isthmus of the right atrium, halfway thru where the IVC enters and the tricuspid valve
89
What score is used to rank ppl on the liver transplant list? What are the criteria of this score?
MELD score (model of end stage liver disease)
1. INR
2. total bili
3. creatinine: worst prognostic factor b/c associated w/ hepatorenal syndrome
90
Describe why HOCM murmurs get louder w/ Valsalva maneuver
Valsalva decreases preload and increases intrathoracic pressure, therefore decreasing venous return and decreasing the volume in the LV
Decreased volume in the LV moves the septum and lateral wall closer together, worsening the LVOT obstruction => murmur gets louder
91
How to calculate normal anion gap
Normal anion gap = 3 x albumin
92
Benztropine
Benztropine (Cogenitin) = anticholinergic used to treat Parkinson's and dystonia
93
What is the Well's score used for?
Well's score calculates pretest probability of PE
94
Which part of S2 is louder and why?
A2 is much louder than P2 b/c aortic valve is closing at much higher pressure than pulmonic valve
Recall: typically aortic closes first
95
Name some other things that can cause troponin elevation besides MI
- HF (wall stretch)
- AFib
- PE, pulm HTN, COPD exacerbation
- CKD
- Sepsis
96
What makes ejection fraction not an exact measurement of LV function
Atrial node dysfunction
EF = (DV-EDV) / DV
If there's aortic stenosis, your LV may be pushing just fine by EF is low since can't get thru stenotic aortic valve
97
Besides abx and draining, what do you give to treat SBP?
Give albumin to maintain intravascular volume and renal perfusion
-need to prevent hepatorenal syndrome (carries very high mortality)
98
Explain why pts in DKA have fruity breath
B/c acetone is a ketone and gives a fruity smell
99
38 yo HIV (+) F presents w/ 7 days of fatigue and HA that worsened today
- no confusion or personality changes
- oral thrush, supple neck, no neurological deficits
- bilateral papilledema, normal MRI of the brain
Dx
Cryptococcal meningoencephalitis = invasive fungal infection typically seen w/ CD4 counts under 100.
100
Indications for negative-pressure wound therapy
Negative-pressure wound therapy = vacuum-assisted wound closure, used on healthy, granulating wounds to accelerate healing process (not on infected or necrotic wounds)
101
Effect of small vessel hyalinosis in the brain
Small vessel hyalinosis (hardening of vessel wall due to hyaline deposition) + atherosclerotic microemboli = deep lacunar strokes
-25% of ischemic strokes are lacunar strokes, small (not seen on imaging)
102
Definition (exact criteria) of
(a) STEMI
(b) NSTEMI
Diagnostic criteria
(a) STEMI = ST elevations > 1 mm in 2+ contiguous leads
(b) NSETMI = ST depressions (>.5 mm) in 2+ continuous leads
103
Give two examples of non-anion gap metabolic acidosis
(a) What other electrolyte abnormlaity is present?
(a) All non-anion gap metabolic acidoses are hyperchloremic aciodses, Cl- balances the decreased HCO3-
104
What is subclavian steel syndrome?
Sydrome caused by retrograde flow of blood in the vertebral artery or internal thoracic artery due to proximal stenosis or occlusion of the subclavian
Aka stenosis of the subclavian artery proximal to the branching off of the vertebral artery
Clinically presents w/ presyncope (feel like going to pass out) and syncope
105
Which is more sensitive- EKG or nuclear stress test
Nuclear is much more sensitive than EKG- EKG you'd need a large area of ischemia to see changes
106
Ground glass opacities
Characteristic finding of PCP pneumonia- indicating diffuse parenchymal infiltrate
Is a CT (NOT CXR) finding
107
Speckled pattern on echo
Indicates amyloidosis (restrictive cardiomyopathy)
