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Cardio Flashcards

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1
Q

Patient on warfarin and high dose aspirin for three weeks presents with abdominal pain and bloody bowel movements. He feels dizzy.

BP 79/53
HR 110

  1. Diagnosis?
  2. Pathophys?
  3. Treatment?
A
  1. Acute upper GI bleed
  2. Aspirin impairs mucosal lining of stomach and warfarin decreases clotting. GI bleed is significant to make the patient hemodynamically unstable.
  3. IV fluids, RBC, and Vasopressors through central line. Place line lateral to pulse of Common Carotid artery.
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2
Q

Patient has chest pain only with activity. History of CAD, smoking, and surgery to repair AAA. Father died of stroke. He is prescribed Metoprolol.

  1. Diagnosis?
  2. Physiology change with medication?
A
  1. Stable Angina with progressively worsening CAD.
  2. Beta blocker that decreases HR. Decreased HR allows for increased diastolic filling, increasing EDV and preload. This increases SV to maintain CO. CO slightly decreases, decreasing MAP.
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3
Q

Patient has history of HTN, Hyperlipidemia, and DM. Medication was prescribed that did not lower LDL.

  1. First medication?
  2. What is prescribed next?
  3. MoA?
  4. ADR?
A
  1. Statin (gold standard)
  2. Fibrates (Gemofibrozil)
  3. upregulates lipoprotein lipase that hydrolyzes triglycerides and VLDL and decreases their levels.
  4. Inhibit 7a-hydroxylase and decreases bile acids leading to formation of gallstones.
    - alos myositis, renal impairment
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4
Q

Patient is being treated for HTN with Captopril. History of DM. He presents with dry cough.

  1. Why cough?
  2. What should be prescribed?
  3. MoA?
  4. ADR?
A
  1. ACEi increase Bradykinin which vasodilates, causing cough and angioedema
  2. Losartan. ARBs (1st line for DM who are intolerant to ACEi). They do not increase bradykinin.
  3. Ang II receptor blocker which decreases Ald and Ang II. Decreases Na reabsorption and vascular constriction.
  4. Hyperkalemia
    Decreased GFR
    Teratogen
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5
Q

54 year old man presents with acute chest pain, N/V, SOB, and sweating profusely. History of HTN and recent cocaine use. HR 101 bpm.

  1. Diagnosis?
  2. What treatment is contraindicated?
  3. Treatment?
A
  1. MI
  2. NS beta blockers b/c effects of cocaine on alpha receptors would go unopposed. NE at Alpha 1 would cause increased vascular smooth muscle contraction and increased HTN and ischemia.
3. Aspirin
Anticoagulants
Beta blockers (if no cocaine use)
ACEi
Fibrinolytics
Reperfusion therapy
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6
Q

Young boy dies suddenly while playing basketball. He had no significant medical history. Pathology shows enlarged heart.

  1. Diagnosis?
  2. Pathophys?
A
  1. Hypertrophic obstructive cardiomyopathy
  2. autosomal dominant mutation in sarcomere beta myosin heavy chain that enlarges the ventricles of the heart, impairing diastolic filling.
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7
Q

Old woman with history of 2 MI’s and CHF presents with fatigue and exertional dyspnea. PE shows JVD, pulmonary crackles, peripheral edema, and orthopnea. She stopped Furosemide 1 week ago. An S3 heart sound is heard at the apex of the heart in a lateral decubitus position.

  1. Diagnosis?
  2. Pathophys?
  3. What increases intensity of murmur?
A
  1. Decompensated heart failure from medicine noncompliance.
  2. S3 indicates a ventricular volume overload associated with systolic heart failure or Mitral/Aortic regurgitation. During diastole, ventricular filling suddenly stops as ventricle wall reaches its limit.
  3. Maneuvers that increase VR such as squatting, leg raising, and volume expansion.
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8
Q

Patient who had an MI 7 days prior presents with hypotension, bilateral rales, syncope, and a new holosystolic murmur radiating to the axilla.

  1. Diagnosis?
  2. Pathophys?
  3. Why give Nitroprusside?
A
  1. Cardiogenic shock secondary to acute mitral regurgitation
  2. Regurgitation due to papillary muscle rupture which is a complication of MI. Blood flows back causing pulmonary edema. Low CO causes syncope.
  3. Vasodilator that decreases after load to increase CO
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9
Q

Patient has high TG, but normal LDL and HDL.

  1. What medication do you prescribe?
  2. MoA?
A
  1. Fibrate (Gemfibrozil)

2. Increases expression of PPAR which increases Lipoprotein lipase. Increases clearance of TG.

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10
Q

Patient with hypercholesterolemia has chest pain when walking a few blocks, but goes away after rest.

  1. Diagnosis?
  2. Pathophys?
  3. What do you prescribe for her attacks?
A
  1. Stable Angina
  2. Patient has atheromatous plaque in coronary vessels that decreases blood flow to myocardium. Exercise increases myocardial demands.
  3. Sublingual Nitroglycerin
  4. Nitric oxide causes vasodilation of vascular SM by cGMP. Low doses affect veins to decrease preload which decreases myocardial demand. High doses affect arterioles to decrease after load but it causes reflex tachycardia.
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11
Q

Man presents to ER with SOB, “heart beating out of his chest,” with a history of CAD and HTN. Heartbeat is irregularly irregular. No troponins.

  1. Diagnosis?
  2. What jugular venous pulse tracing is abnormal?
A
  1. AFib

2. a wave is affected which corresponds to atrial systole

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12
Q

Old man presents with chest pain on inspiration and when supine. He had an MI two days ago. He was not treated with reperfusion or fibrinolytic. Faint rubbing noise is head over left side of chest. Troponin is positive and CK-MB is not detectable. EKG shows ST elevations across all leads and Q waves in V3-V6.

  1. Diagnosis?
  2. Pathophys?
  3. Other complications post MI?
A
  1. Early infarct pericarditis is a complication post MI
  2. Necrotic myocardium from transmural MI causes inflammation to spread to pericardium if not treated with reperfusion. Exacerbated by supine posture. Shows diffuse ST elevations.
  3. Pericardial effusions are more common post MI. Myocardial wall ruptures at 4-7 days post MI when macrophages invade to clean dead debris.
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13
Q

Dressler Syndrome?

A

Pericarditis weeks after an MI. Initial injury exposes cardiac antigens to body’s immune system. Immune complexes deposit onto pericardium, pleura, and lungs.

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14
Q

Man presents with palpitations, tachycardia, and ECG shows narrow QRS complex.

  1. Diagnosis?
  2. Pathophys?
  3. Treatment? MoA?
A
  1. Supraventricular Tachycardia
  2. abnormally fast rhythm from above ventricles that arises from AV node reentry
  3. Adenosine (IV) which slows conduction velocity and increases refractory period at AV node.
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15
Q

Young man with crushing chest pain that radiates to his back. He is thin and till with a pectus excavatum. CXR shows widened mediastinum.

  1. Diagnosis?
  2. Pathophys?
A
  1. Aortic Dissection
  2. Marfan Syndrome with an autosomal dominant mutation in fibrillin gene causes cystic medial necrosis in the tunica media of the aortic root causing an aneurysm
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16
Q

Why is the risk of MI decreased in premenopausal women?

A

Estrogen exerts cardioprotective effects by modulating inflammation of atherosclerosis

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17
Q
  1. Hydrochlorothizide MoA?
  2. Why calcium sparing?
  3. ADR?
A
  1. Inhibits reabsorption of Na and Cl at DCT by blocking Na/Cl symporter.
  2. Increase Na/Ca antiporter on basolateral membrane which increases Ca in the ISF
  3. Hyperglycemia (careful with DM)
    Hyperlipidemia
    Hyperuricemia
    Hypercalcemia
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18
Q

Immigrant patient with frequent episodes of pharyngitis presents with dyspnea, hemoptysis, pulmonary crackles, and diastolic murmur with an opening snap.

  1. Diagnosis?
  2. Pathophys?
  3. Significance of pharyngitis?
A
  1. Mitral Stenosis
  2. Higher LAP causes increased pressure in order to overcome the narrowed valve. It snaps open during diastole.
  3. Mitral stenosis can be caused by Rheumatic fever from Strep throat which causes an immune attack on the valve.
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19
Q

Patient presents with productive cough, fever, shaking chills, hypotension, and tachycardia. BP 90/60. Elevated WBC.

  1. Diagnosis?
  2. Cardiac output and SVR?
A
  1. Septic shock
  2. Cardiac output is high due to increased isotropy and decreased after load. SVR is low due to decreased BP and the release of inflammatory mediators that cause vasodilation.
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20
Q

What are the fetal vessels that connect placenta to fetus?

A

Two umbilical arteries that carry deoxygenated blood to the placenta

One umbilical vein that carries oxygenated blood from placenta to fetus

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21
Q

Patient had syncope while gardening at home. The patient is unresponsive and presents with warm skin.

BP 80/30
HR 120
Temp 102.4
WBC 21,000
Lactate 4.5
  1. Diagnosis?
  2. Pathophys?
  3. Treatment?
A
  1. Septic Shock
  2. Inflammatory mediators cause blood vessels to dilate and increase capillary permeability leading to hypotension
  3. IVF and NE to stimulate sympathetic alpha 1 receptors to cause vasoconstriction which increases preload and BP
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22
Q

Man presents with fatigue, SOB, palpitations, and irregularly irregular heartbeat. History of HTN.

  1. Diagnosis?
  2. Treatment to increase inotropy?
  3. Change in CO?
A
  1. AFib
  2. Digoxin which inhibits Na/K ATPase in the myocardium which increases intracellular calcium to increase force of contraction. It also decreases conduction at AV node and depresses SA node.
  3. Increases cardiac output and decreased EDV
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23
Q

Patient who is IVDA presents with fatigue, fever, dyspnea, a new pansystolic murmur heard over left 3rd/4th ICS, and painless macules on palms and soles.

  1. Diagnosis?
A
  1. Infective Endocarditis with Staph Aureus
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24
Q

Infective Endocarditis manifestations?

A

Fever

Roth Spots (retinal hemorrhages)

Osler nodes (tender nodules on pads fingers/toes)

New murmur

Janeway Lesions (nontender macules on palms/soles)

Anemia

Nailbed hemorrhage

Emboli

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25
Patient had an acute STEMI. Now is in VFib. 1. Treatment?
1. Epinephrine followed by Amiodarone ``` 2. Pulmonary fibrosis Hypotension Thyroid dysfunction hepatotoxic corneal deposits Bradyarrhythmia Torsades de pointes ```
26
ADR of yellow green vision?
Digoxin
27
Malar rash ADR?
Procainamide induced lupus
28
ADR of increased post-MI mortality?
Class IC - Flecainide - Encainide
29
Pathophys of Atherosclerosis?
1. Damage to endothelial cells 2. Macrophages enter the intima and phagocytose LDL to become foam cells 3. Cytokines and GFs trigger migration of SM cells 4. SM produce collagen which forms fibrous cap
30
Boy has harsh or blowing murmur heard at left sternal border. 1. Diagnosis?
1. Small VSD - smaller size means harsher sound - most common congenital cardiac anomaly - Left to right shunt
31
Fixed split S2 sound?
ASD
32
Holosystolic blowing murmur that radiates to axilla?
Mitral Regurgitation
33
Common cause of mitral regurgitation?
Rheumatic fever
34
Patient with continuous machine like murmur and lower extremity cyanosis?
Patent ductus arteriosus - 6th aortic arch - treat with Indomethacin
35
Holosystolic blowing murmur at left sternal border?
Tricuspid regurgitation
36
Patient with a history of MVP presents with fever, papules on palms of hands, and white spots on the retinas surrounded by hemorrhages. She has been feeling under the weather for 2 weeks. 1. Diagnosis?
1. Subacute endocarditis from strep viridans - Gram+ cocci in chains - also associated with dental procedures
37
Cause of neonatal meningitis?
Strep agalactiae
38
Patient with rheumatic fever and acute GN?
Strep pyogenes
39
Patient with history of colon cancer presents with fever and new heart murmur. Diagnosis?
Strep bovis
40
Patient has refractory HTN after being on multiple medications. 1. New medication? 2. MoA? 3. ADR?
1. Clonidine 2. Alpha 2 agonist that decreases sympathetics in CNS which leads to decreases in SVR, HR, and BP. 3. Severe rebound HTN
41
Treatment for septic shock?
1. IVF 2. NE - alpha 1 > alpha 2 > Beta 1
42
Patient has chest pain that improves with leaning forward and worsens with inspiration. Diffuse ST elevations on ECG. History of viral illness. Scratchy leathery sound is heard on auscultation. 1. Diagnosis? 2. Pathophys?
1. Pericarditis from Coxsackie virus B +ssRNA naked icosahedral picornavirus virus 2. Fluid in pericardium puts pressure on the heart making it difficult to contract. Leaning forward moves fluid away from heart. Coxsackie virus is one of the most common causes. Pericarditis usually follows upper RTI.
43
Boy is delivered healthy. One hour later he is pale and has cold extremities. Does not improve with supplemental O2. Echocardio shows Aorta anterior to pulmonary artery. No VSD or ASD. 1. Diagnosis? 2. Pathophys? 3. Treatment? 4. What not to treat with?
1. Transposition of Great Arteries 2. Aorta connects to RV taking deoxygenated blood to system. Incompatible with life. The baby must have a patent ductus arteriosus that sends some O2 through aorta. 3. PGE will keep the PDA open until surgery 4. Indomethacin is used to close PDA
44
Patient presents with dizziness and lightheadedness when getting up. They are on amitriptyline (TCA) and amlodipine. 1. Diagnosis?
1. Orthostatic hypotension as ADR of medication | 2. Amlodipine is calcium channel blocker
45
1st aortic arch?
maxillary artery
46
2nd aortic arch?
stapedial and hyoid arteries
47
3rd aortic arch?
carotid arteries
48
4th aortic arch?
distal aortic arch and subclavian
49
6th aortic arch?
proximal left pulmonary arteries and distal ductus arteriosus
50
Patient presents with chest pain, SOB, diaphoresis, and ST elevations on ECG. He goes into cardiac arrest and dies. 1. Diagnosis? 2. Pathophys? 3. Treatment?
1. Sudden cardiac death from VFib as a complication of MI 2. ischemic myocardium produces abnormal reentry circuits that lead to VFib 3. CPR, Epi, Amiodarone, Defibrillation
51
Complications post-MI?
Arrhythmia within minutes (VFib) Papillary muscle rupture 2-7 days Interventricular septal rupture 3-5 days LV free wall rupture 3-14 days LV failure late sequelae
52
Motorcyclists falls and hits head and goes unconscious. He is alert when EMT gets there and then quickly deteriorates upon arrival to ER. BP 158/80 and HR 38 with irregular breathing. 1. Diagnosis? 2. Pathophys? 3. Other signs?
1. Epidural hematoma 2. Fracture of temporal bone lacerates middle meningeal artery. Patients have lucid interval and then neuro deteriorates as ICP increases. 3. ICP pushes ipsilateral uncus to herniate through tentorial incisure and compress ipsilateral Oculomotor nerve III causing down and out gaze with pupil dilation.
53
Crescent shaped brain lesion that crosses suture lines on noncontrast CT?
Subdural hematoma from tearing of cortical bridging veins | -gradual onset
54
CSF from lumbar puncture has yellow hue?
Blood from subarachnoid hemorrhage
55
Patient involved in MVA has severe chest pain that radiates to back. CXR shows widened mediastinum. 1. Diagnosis? 2. Pathophys?
1. Aortic Isthmus rupture just distal to Left subclavian artery 2. Rapid deceleration causes shearing force that tears aorta causing profuse bleeding. Isthmus is immobile as it is attached to the pulmonary artery by the ligamentum arteriosum
56
Patient suffers MI and undergoes reperfusion treatment. What will you see first on Histo biopsy?
Contraction bands adjacent to areas of myocyte necrosis. Due to hyper contraction of sarcomeres from rapid calcium influx. Reperfusion increases ROS and phospholipase which increase lipid membrane calcium permeability and release of intracellular calcium stores
57
Patient from China is positive for HBsAg. History of abdominal pain, fever, and rash. Angiogram shows bead like aneurysms. 1. Diagnosis? 2. Pathophys? 3. What else is affected? 4. What is spared?
1. PAN as complication of Chronic HBV 2. Transmural inflammation of medium sized vessels with fibrinoid necrosis with different stages of inflammation 3. Affects all visceral organs, heart, and kidneys 4. Does not affect pulmonary arteries
58
Man presents with fatigue, weight gain, lightheadedness and palpitations. ECG shows Delta waves. TSH is high and Thyroxine is low. 1. Diagnosis? 2. Pathophys? 3. What is causing weight gain?
1. Wolff parkinson white syndrome 2. Bundle of kent bypasses AV node depolarizing ventricles early 3. Amiodarone is used to treat this condition can cause hypothyroidism or hyperthyroidism. Pulmonary fibrosis, hepatotoxicity, and neuro effects. - always get LFTs, PFTs, and thyroid function tests
59
Man presents with severe chest pain radiating to back. History of HTN and Smoking. BP right arm is 160/80. BP left arm is 90/75. Troponins are normal.
Thoracic Aortic Dissection
60
Treatment for smoking cessation?
1. Bupropion - NE and Dopamine reuptake inhibitor 2. Varenicline - nicotine receptor partial agonist - decrease nicotine dependence
61
Old man has exertion chest pain and dyspnea that relieves with rest. A crescendo-decrescendo murmur is heard over right sternal border. His pulses are weak. He has experienced syncope in the past. 1. Diagnosis? 2. Pathophys?
1. Aortic stenosis 2. age related calcification of the valve - in young person its caused by bicuspid valve - in immigrants its caused by rheumatic fever
62
Patient has SOB, chest pain, diaphoresis, and ECG showing ST elevations in II, III, and aVF. 1. Diagnosis? 2. Histo?
1. Inferior MI 2. Coagulative necrosis - also seen in kidneys when Renal Artery is occluded
63
Man who had a severe MI 5 days prior presents with BP 72/35 and JVD. 1. Diagnosis?
1. Cardiac Tamponade due to rupture of free ventricular wall
64
Woman with unilateral frontotemporal headache, low grade fever, and weight loss. She has an afferent pupillary defect and chalky white fundus on same side as headache. 1. Diagnosis? 2. Pathophys? 3. Treatment?
1. Giant Cell Arteritis (Temporal) 2. degeneration of internal elastic lamina with granulomatous inflammation of the Temporal Artery 3. Corticosteroids
65
Child with MI. 1. Diagnosis? 2. Treatment?
1. Kawasaki | 2. Aspirin and IVIG
66
Young male smoker presents with pain in fingers during exercise and the beginning of ulcers on the digits. 1. Diagnosis? 2. Pathophys? 3. Treatment?
1. Thromboangiitis Obliterans (Buerger's) 2. Autoimmune 3. Stop smoking
67
Patient with history of HBV presents with fatigue, fever, abdominal pain, and muscle pain. Serum BUN and Creatinine are high. 1. Diagnosis? 2. Pathophys? 3. Treatment?
1. Polyarteritis Nodosa 2. Transmural inflammation and fibrinoid necrosis with different stages of inflammation with beads on a string appearance 3. Corticosteroids or cyclophosphamide
68
Child has opaque rings on lower irises, xanthomas on eyelids, and high serum LDL. 1. Diagnosis? 2. Pathophys?
1. Familial Hypercholesterolemia | 2. Autosomal dominant causes defect in LDL receptor so more LDL stays in circulation
69
Labs show elevated LDL, VLDL, and total cholesterol. Diagnosis?
Apolipoprotein E deficiency
70
Labs show increased chylomicron. Diagnosis?
Lipoprotein lipase deficiency
71
Man with history of heart problems is put on medication. Months later he presents with weight loss, tremors, and is seen wearing light clothing in freezing weather. 1. Diagnosis? 2. Pathophys?
1. Hyperthyroidism due to Amiodarone toxicity | 2. Class III drugs block slow K channels and prolongs the effective refractory period
72
Patient who recently had a dentist appointment presents with fever, painless raised lesions on pads of fingers, and erythromatous lesions on palms and soles. A new heart murmur is heard. 1. Diagnosis? 2. Pathophys?
1. Subacute Endocarditis from Viridans strep (Gram+ catalase -, alpha hemolytic cocci, optochin resistant) 2. Normal flora of the mouth seed the bloodstream after dental procedures
73
Gram+ cocci, catalase negative, beta hemolytic, bacitracin sensitive?
Strep pyogenes
74
Gram+ cocci, catalase negative, beta hemolytic, bacitracin resistant?
Strep agalactiae
75
Gram+ Catalase+ Coagulase+ cocci?
Staph Aureus
76
3 year old boy has fever longer than 5 days, conjunctivitis, mucosal erythema, and cervical lymphadenopathy. 1. Diagnosis? 2. Potential complications?
1. Kawasaki's | 2. Acute necrotizing vasculitis of medium sized vessels that could lead to coronary artery aneurysms and MI in children
77
Patient had a febrile illness 4-6 weeks ago and now presents with hematuria, proteinuria, and HTN. 1. Diagnosis? 2. Pathophys?
1. Poststrep GN | 2. immune complex deposition at glomerular BM
78
Young patient presents with weakness, hypotonia, and normal blood glucose. Systolic murmur is heard at left sternal border. Muscle biopsy is PAS+. 1. Diagnosis? 2. Pathophys?
1. Pompe Disease 2. Deficiency in lysosomal acid alpha glucosidase that causes accumulation of glycogen in heart, liver, and muscle with organomegaly and muscle weakness.
79
Young patient has stunted growth, hepatomegaly, normal blood lactate, and mild hypoglycemia. 1. Diagnosis? 2. Pathophys?
1. Cori Disease | 2. Deficiency in Debranching enzyme alpha 1,6 glucosidase causes mild accumulation of glycogen in heart, liver, muscle.
80
Patient has sever fasting hypoglycemia, hepatomegaly, and increased blood lactate. 1. Diagnosis? 2. Pathophys?
1. Von Gierke | 2. G6 phosphatase deficiency causes lack of glucose from G6P in GNG, glycogen accumulates in liver
81
Infant with cataracts?
Galactosemia from Galactose-1-phosphate uridyltransferase deficiency
82
Patient with painful muscle cramps and myoglobinuria with strenuous exercise, but then gets a second wind. Flat lactate curve. Normal blood glucose 1. Diagnosis? 2. Pathophys?
1. McArdle's | 2. Deficiency in skeletal muscle glycogen phosphorylase causes increased glycogen in muscle
83
Child presents with short stature, webbed neck, flat shield chest, and finger lymphedema. 1. Diagnosis? 2. Pathophys? 3. Heart complications?
1. Turner Syndrome 2. Loss of one X chromosome in female fetus 3. Coarctation of the aorta which narrows the descending aorta just distal to left subclavian artery and opposite the ductus arteriosus - left arm may be smaller than right - horseshoe kidney - bicuspid aortic valve
84
Adult with HTN in upper extremities and weak pulses in lower?
Postductal coarctation of aorta
85
Meds that reduce mortality in CHF?
``` ACEi ARBs Aldosterone antagonists Beta blockers Hydralazine with Nitrates ```
86
Pregnant patient with rash, joint pain, and red eyes. Her baby is born with microcephaly. Diagnosis?
Zika virus
87
Man from Peru has SOB, biventricular dilatations, difficulty swallowing, and endomyocardial biopsy with protozoan parasites.
1. Chagas Disease 2. Myocarditis from Trypanosoma cruzi transmitted by reduviid bug - it localizes in heart and myenteric plexus leading to myocarditis and GI dysmotility
88
Patient has worsening dyspnea, nocturnal dyspnea, bibasilar crackles, JVD, and B/L lower extremity edema. 1. Diagnosis? 2. How does the body compensate?
1. CHF 2. Increased SNS Increased HR Increased Vasoconstriction Increased RAAS Increased ADH Increased ECF volume
89
Heart conditions common to Marfan's?
MVP Cystic Medial Necrosis Aortic Dissection
90
Treatment of AFib and flutter?
Non-dihydropyridines - Diltiazem - Verapamil Block calcium channels at AV node to slow action potential conduction. This will decrease the rate at which impulses from ectopic foci are transmitted through AV node.
91
Why would a smoker with DM have a thick LV?
Increased after load on the heart from Systemic HTN
92
Patient has a history of stable angina, HTN, and DM. He presents with acute chest pain, diaphoresis, SOB, and N/V. Troponins are elevated. 1. Diagnosis? 2. Pathophys?
1. Acute MI | 2. History of atherosclerosis caused buildup of plaque in coronary arteries that ruptured and occluded the vessel.
93
Elderly man with history of HTN presents with increased urinary frequency, nocturia with incomplete voiding, and enlarged prostate. 1. Diagnosis? 2. Treatment? 3. ADR?
1. Benign prostatic hyperplasia 2. Prazosin is selective alpha 1 receptor antagonist used to treat HTN and BPH. It blocks vasoconstriction. 3. Orthostatic hypotension, syncope, headache
94
Treatment for patient with HTN and renal disease?
Clonidine | -alpha 2 agonist that decreases NE
95
Treatment for shock and acute heart failure?
Dobutamine | -Beta 1 agonist to stimulate heart
96
Treatment of nonsurgical pheochromocytoma?
Phenoxybenzamine | -irreversible nonselective alpha antagonist to prevent catecholamines
97
Patient diagnosed with CHF is taking medication. They present with fatigue, N/V, blurry vision, and bradycardia. 1. What medication are they on? 2. MoA? 3. What do you not prescribe on top of it?
1. Digoxin 2. Block cardiac Na/K ATPase to increase calcium inside cell and increase contractility. Leads to hypokalemia. 3. Do not prescribe Furosemide which exacerbates hypokalemia and increases Digoxin toxicity
98
Patient is in VFib post-MI. Treatment?
``` Lidocaine or Mexiletine -class 1b Na channel blockers and that decreases AP duration ```
99
Patient is on chemo for breast cancer. She presents with fatigue, dyspnea, JVD, lung crackles, and pitting edema. CXR shows enlarged cardiac silhouette. 1. What medication is she on? 2. MoA? 3. ADR?
1. Doxorubicin or Daunorubicin 2. DNA intercalator that binds DNA and disrupts nucleic acid synthesis 3. Dilated Cardiomyopthy Bone marrow suppression Red urine
100
Woman in labor receives epidural. 10 minutes later she complains of palpitations and dizziness. 1. Diagnosis? 2. Pathophys?
1. Person pierced vessel with epidural containing Bupivicaine 2. Blocks Na channels and prevents depolarization causing arrhythmias and hypotension 2nd degree heart block (Mobitz type II)
101
Patient presents with substernal chest pain that radiates to left arm, diaphoresis, and SOB with a history of stable angina. 1. Diagnosis? 2. Next step in workup?
1. Acute MI | 2. ECG to show ST elevations
102
ECG shows ST elevations in leads II, III, aVF. 1. Diagnosis?
Inferior MI in Right Coronary Artery
103
ST elevations in leads I, aVL, and V5-V6. Diagnosis?
Left Circumflex Artery MI on posterolateral wall
104
ST elevations in V1-V6. Diagnosis?
Anterior MI in LAD
105
Patient with dyspnea, orthopnea, and B/L lung crackles. Murmur is holosystolic blowing that decreases with inspiration. S3 heard. No JVD. She has swollen joints and face rash. 1. Diagnosis? 2. Pathophys?
1. SLE causing Libman sacks endocarditis 2. Verrucous vegetations on mitral valve causing Mitral regurgitation. Note: Right side murmurs increase with inspiration.
106
Patient is tall with dislocated lens and scoliosis. Decrescendo diastolic murmur heard. 1. Diagnosis? 2. Pathophys?
1. Aortic regurgitation 2. Autosomal dominant FBN1 mutation on chromo 15 causes defective fibrillin around elastin that can lead to aortic dissection or MVP.
107
Patient has systolic ejection murmur on right sternal border, weak peripheral pulses, and delayed carotid rise. Normal ejection fraction and CO. 1. Diagnosis? 2. Pathophys?
1. Compensated Aortic Stenosis 2. AV valve is narrowed causing heart to increase pressure to overcome the valve. Only after load increases. LV will hypertrophy. When heart becomes decompensated, LV loses compliance and causes CHF.
108
Effects of Nadolol?
NS Beta blocker: - blocks beta 1 causing decreased HR, contractility and renin - blocks beta 2 of vessels in skeletal muscle which blocks vasodilation and increases resistance
109
Middle aged man with HBV, weight loss, melena, and skin nodules. Labs show increased serum Cr and BUN and decreased albumin. ANCA negative. Increased ESR and CRP. Angiogram shows multiple micro aneurysms in renal vasculature. 1. Diagnosis? 2. Pathophys? 3. Treatment?
1. PAN 2. Type III hypersensitivity reaction causing immune complexes (Ag-Ab) to bind complement and activate neutrophils. Causes transmural inflammation of arterial wall and fibrinoid necrosis. 3. Corticosteroids or Cyclophosphamide
110
Young patient has tachycardia. ECG shows HR 150 bpm, narrow QRS, and P wave obscured by T wave. 1. Diagnosis? 2. Treatment? 3. MoA?
1. Paroxysmal Supraventricular Tachy (PSVT) 2. Adenosine 3. increases K conductance out of cell and decreases calcium current into cell at AV node which hyper polarizes it. 15 second duration.
111
Girl had sore throat 1 month ago now presents with migratory polyarthritis, erythema marginatum. Myocardial biopsy shows interstitial granulomas (Aschoff nodules). 1. Diagnosis? 2. Pathophys?
1. Acute Rheumatic Fever 2. Group A strep. - early: holosystolic murmur from MR - late: mid diastolic snap with low pitched murmur at apex from MS
112
Effect of NE? Uses?
1. Alpha 1: vasoconstriction - increases preload - causes reflex bradycardia greater than Beta 1 HR effect Beta 1: increase HR 2. 1st line treatment of shock
113
3 year old asian girl has 7 day fever, conjunctival injection, desquamating skin, edematous hands and feet, and strawberry tongue. 1. Diagnosis? 2. Pathophys? 3. Treatment?
1. Kawasaki 2. acute necrotizing vasculitis of small vessels. Tunica media becomes inflamed and necrotic. Laminae can split causing coronary aneurysms. 3. IVIG and Aspirin
114
Emergency medical treatment and labor act (EMTALA)?
person who presents to ER should be treated regardless of insurance
115
Patient with history of HTN and CHF presents with muscle weakness. ECG shows prolonged PR and peaked T waves. He cannot remember names of medications. 1. Diagnosis? 2. Pathophys?
1. Hyperkalemia induced by spironolactone (K sparing) 2. aldosterone antagonist that inhibits Na-K exchange at collecting tubule, increasing blood K. Increased ECF K cause increased velocity of repolarization. Inactivates Na channels, decreasing slope 0 and membrane excitability.
116
Pregnant woman has hypotension when lying supine. 1. Diagnosis? 2. Treatment?
1. IVC compression | 2. lie on side
117
Patient with palpable purpura on extremities, fatigue, muscle pain, weight loss, red brown sputum, and dark stools. P-ANCA+. No granulomas. 1. Diagnosis? 2. Pathophys? 3. Treatment?
1. Microscopic polyangitis 2. small artery vasculitis in caucasians. Activation of p-ANCA leads to inflammation and necrosis characterized by paucity of immune deposits. 3. Cyclophosphamide or corticosteroids
118
Patient who thinks he is having heart attack presents with intermittent chest pain worse in supine position. Labs shows normal troponins. Normal ECG. No SOB. 1. Diagnosis? 2. Pathophys? 3. Treatment?
1. GERD 2. decreased LES tone causes reflux after meal that can mimic MI. 3. PPI
119
MoA of Verapamil?
calcium channel blocker of pacemaker cells in heart at phase O upstroke that decreases action potential
120
Use of esmolol?
short acting beta blocker used in HTN emergency and to see if patient can tolerate longer acting beta blocker
121
Patient with history of HTN and DM presents with palpitations and SOB with exercise. Holosystolic murmur at apex. 1. Diagnosis? 2. Pathophys?
1. MR | 2. during systole, blood leaks back into LA and lungs, increasing LAP and causing SOB.
122
Patient with history of COPD presents with chest pain that radiates to shoulder and jaw. ECG shows ST elevations in II, III, aVF. Troponins are elevated. 1. Diagnosis? 2. Treatment? 3. MoA?
1. STEMI 2. Metoprolol Aspirin Stent 3. B1 selective blocker to decrease sympathetic to heart to slow HR. Don't use NS beta blocker b/c of history of COPD
123
Patient is lightheaded and fatigued with history of MI and chronic HTN. ECG shows independent P and QRS waves. He is on verapamil. 1. Diagnosis? 2. Pathophys?
1. 3rd degree AV block 2. verapamil decreases calcium conduction during phase 0, delaying depolarization of node which causes uncoordinated firing of AV and SA nodes. Contraindicated in CHF with reduced EF (HFrEF)
124
Immigrant woman with history of CHF exacerbated by pregnancy. Late diastolic murmur increases with leg raise and no change with hand grip. Diminished S1. Dysphagia. 1. Diagnosis? 2. Pathophys?
1. Mitral Stenosis 2. RHD is common cause of MS in immigrants. Murmur decreases in intensity and S1 diminishes as valve narrows. Aschoff bodies with lymphocytes, plasma cells, and activated macrophages (Anitschkow cells) Dysphagia due to LA dilation and compression of Left recurrent laryngeal n.
125
Patient with dizziness, cinchonism, syncope, and history of Quinidine. HR 210 bpm. ECG shows long QT interval and QRS that appeared to be pointing up, are now pointing down. 1. Diagnosis? 2. Pathophys? 3. Other causes? 4. Treatment?
1. Torsades de pointes 2. Quinidine (Class 1A) blocks Na channel and increases AP duration, ERP, and QT interval leading to TdP. ``` 3. Macrolides Haloperidol TCAs Odansetron HypoMg HypoCa ``` 4. IV Mg sulfate
126
Patient with squeezing chest pain after exercise that resolved on the way to the hospital. He just finished a burger before exercise. History of hyperlipidemia, HTN, and GERD. Normal Troponins and ECG. 1. Diagnosis? 2. Pathophys? 3. Treatment?
1. Stable Angina from Coronary ATS - squeezing pain - not GERD due to onset and not burning sensation 2. HTN and lipids leads to endothelial injury which increases vessel permeability, leukocyte adhesion, LDL accumulation and SM proliferation and migration forming a plaque. Increased cardiac demand causes ischemia due to decreased blood flow. 3. Beta blockers Nitrates Ca channel blockers
127
Patient presents with muscle pain, muscle weakness, and blood in urine (no RBC). History of Diabetic nephropathy, HTN, and dysplipidemia. Elevated creatine kinase. He is on medications for hyperlipidemia. 1. Diagnosis? 2. Pathophys? 3. Treatment?
1. Rhabdomyolysis from Gemfibrozil with Statin 2. Fibrates inhibit CYP3A4 metabolism and liver glucuronidation which increases blood concentration of statins causing acute myopathy and kidney injury (myoglobinuria) 3. Take statin with Ezetimibe to avoid complications
128
Young woman with chest pain on exertion, palpitations, mild fever, and new systolic murmur heard at apex. History of upper respiratory illness. Elevated cardiac enzymes. Biopsy shows lymphocytes and necrosis. Diagnosis?
Acute Viral Myocarditis from Coxsackie B
129
MoA of Sacubitril?
- inhibits neprilysin which leads to increased bradykinin and vasodilation - prevents degradation of ANP and BNP to decrease blood volume and BP - use with Valsartan to inhibit RAAS and sympathetics for treatment of HFrEF
130
Amiodarone 1. MoA? 2. ADR?
1. class III: K channel blocker that prolongs repolarization and increases AP duration, ERP, and QT. 2. Chronic ISF pneumonitis Pulmonary fibrosis Hepatoxicity Blue skin (happen) Heart block Hypothyroid (mimics T4 so blocks conversion of T4 to T3)
131
Patient with orthopnea, rales, hepatomegaly, edema and history of alcohol abuse. PMI is displaced laterally and CXR shows balloon shaped heart. 1. Diagnosis? 2. Causes?
1. Dilated Cardiomyopathy caused by alcohol 2. Alcohol Beriberi Coxsackie B Cocaine Chagas Doxorubicin
132
1st line treatment for patients with DM type II?
lifestyle modification - exercise increases translocation of GLUT4 to cell surface which increases insulin sensitivity - 150 mins of mod aerobics per week
133
Autosomal dominant inheritance with variable phenotypes?
incomplete penetrance
134
2 week old with cyanosis that worsens with crying and feeding. Harsh systolic murmur at left upper sternal border. CXR shows boot shaped heart.
1. Tetralogy of Fallot 2. Most common cause of childhood cyanosis. Right to left shunt sends deoxygenated blood to system. Associated with Digeorge syndrome. - Pulm stenosis (important for prognosis) - RV hypertrophy (boot shaped heart on CXR) - overriding Aorta - VSD
135
Patient with left sided sharp chest pain with inhalation that does not radiate. Does not relieve with leaning forward and laying on back. Positive ANA, antihistone ab, but negative anti-dsDNA ab. CXR shows left pleural effusion. He is on class 1 antiarrhythmic. Diagnosis?
SLE with Serositis induced by Procainamide
136
Young girl with muscle twitches in extremities and dark frothy urine. History of mild febrile illness 4 weeks ago. 1. Diagnosis? 2. Pathophys?
1. Post strep glomerulonephritis (beta hemolytic s. pyogenes) 2. S. pyogenes can cause nephritic syndrome and acute RF if untreated. can cause sydenham chorea which are uncontrollable movements. Type II hypersensitivity reaction resulting in M protein cross reaction with host antigens
137
Immigrant woman with history of recurrent childhood fevers presents with new heart murmur, SOB, and ankle swelling. While lifting heavy object, she collapses and dies. 1. Diagnosis? 2. Pathophys? 3. Treatment?
1. Rheumatic fever 2. group A beta hemolytic strep pharyngeal infection infects mitral valve leading to early MR and late MS. Aschoff bodies and anitschkow cells on biopsy. Type II hypersens reaction 3. penicillin
138
Patient with history of MVP has new murmur, with low grade fever, malaise, weight loss, tender lesions on fingers, and painless lesions on palms after having dental procedure. 1. Diagnosis? 2. Pathophys?
1. Subacute endocarditis | 2. Viridans strep, gram+ optochin resistant, alpha hemolytic cocci in chains usually attack valves with previous damage
139
Patient has heart problems and DM. which drug if given would mask hypoglycemia from DM medication?
Beta blocker -low blood sugar increases release of glucagon, NE, and cortisol which cause tachycardia, shaking, sweating. Beta blocker decreases sympathetics and HR which could mask hypoglycemia.
140
Digoxin 1. MoA? 2. Effects? 3. ADR?
1. inhibits Na/K ATPase which inhibits Na/Ca exchanger which increases Ca inside to increase contractility. Stimulates Vagus N. to decrease HR 2. Increase contractility decreased end systolic volume increases EF Decreases HR 3. yellow vision hypokalemia increases toxicity causes hyperkalemia
141
1st line treatment for HTN in pregnancy?
Hydralazine -potent arteriole vasodilator that causes reflex tachycardia Labetalol -beta blocker to prevent reflex
142
20 year old Woman with intellectual disability, marfanoid habitus, and lens subluxation presents with chest pain, SOB, and ST elevations in V1-V4. History of MI at younger age. Labs shows deficiency in enzyme that uses Vitamin B6 as cofactor. 1. Diagnosis? 2. Pathophy? 3. Treatment?
1. Acute MI from Homocystinuria 2. Cystathione synthase deficiency, decreased affinity for B6, or methionine synthase deficiency cause excess homocysteine 3. restrict methionine, and increase cysteine, B6, B12, folate
143
Patient works at factory and has history of CVD. Every Monday he has headache, dizziness, and palpitations. 1. Diagnosis? 2. Pathophys?
1. Monday disease from Nitrates 2. prolonged nitrate exposure causes reflex tachycardia, dizziness, hypotension, flushing, and headache when reexposed on monday after being away from nitrates all weekend. Due to loss of tolerance. Could cause coronary ischemia on saturday after abrupt cessation of exposure
144
Evolution of MI? Complications?
Day 1: Neutrophils, Free radicals -arrhythmia (sudden death few hours after MI) 1-3: coagulative necrosis with more neutrophils -pericarditis 3-14: macrophages - papillary muscle rupture - IV septal rupture 14+: scar complete - Dressler syndrome - mural thrombus
145
IVDA presents with fever, chest pain, dry cough, systolic murmur over lower left sternal border. 1. Diagnosis? 2. Pathophys?
1. Endocarditis of Tricuspid Valve 2. Staph aureus, catalase+, coagulase+, beta hemolytic gram+ cocci is most common organism in IVDA that seeds tricuspid valve. Can cause pulmonary emboli causing cough.
146
Pressures as cardiac cath goes through heart?
RA: 0-5 mmHg RV: 5-25 mmHg Pulmonary A: 10-25 mmHg Wedge (LA): 4-12 mmHg LV: 10-130 mmHg Aorta 90-130 mmHg
147
Write prescription for lisinopril?
lisinopril 10mg daily - no decimals - no QD (daily) - write out name
148
Young girl has arrhythmia diagnosed at birth. ECG shows delta waves. 1. Diagnosis? 2. Pathophys?
1. Wolff parkinson white syndrome 2. fast accessory path through bundle of kent from atria to ventricles bypasses AV node causing early depolarization of ventricles leading to SVT
149
Patient with sudden ab pain, elevated lipase and TG. History of DM. 1. Diagnosis? 2. Treatment and MoA?
1. Acute Pancreatitis from HyperTG 2. Fibrates activate PPAR to increase lipoprotein lipase to breakdown TG and increase HDL. reduces CAD in Type II diabetes.
150
Young man with syncope on exertion. S4 gallop at apex. Mild systolic murmur that decreases when squats and increases with valsalva. 1. Diagnosis? 2. Pathophys? 3. Treatment?
1. Hypertrophic cardiomyopathy 2. cause of sudden death in young athletes. S4 gallop due to stiffness of ventricle. Systolic murmur due to septal hypertrophy. Valsalva decreases preload which increases murmur. Squatting increases preload to decrease murmur. Diastolic dysfunction. 3. Stop athletics Beta blocker Non-dihydropyridine Ca blocker (verapamil)
151
Old man with history of CAD, HTN presents with sudden abdominal pain that radiates to his back. High HR. Low BP in extremities. Pulsatile mass found. 1. Diagnosis? 2. Pathophys? 3. Treatment?
1. AAA 2. dilation of aorta due to weakness of wall. 3. emergency surgery
152
Patient returned from long flight and presents with stroke in left parietal lobe and wide patent carotid arteries. Midsystolic murmur with wide split and fixed S2. 1. Diagnosis? 2. Pathophys? 3. Physiology vs pathophys?
1. ASD 2. paradoxical embolus passes from right side to left side into middle cerebral artery. normally left to right shunt but reverses with coughs, bearing down for BM, or valsalva. 3. Normal: - inspiration increases preload, delaying pulmonic valve -expiration decreases preload, earlier closure of pulmonic valve ASD: -bloods passes from LA to RA every beat, decreasing pulmonic variation causing wide fixed S2
153
Patient with history of smoking, HTN, and DM presents with loss of consciousness when he tilts his head back.
1. Vertebral A. atherosclerosis 2. vertebral arteries branch off subclavian arteries and travel through transverse foramina and combine in skull as Basilar A. Subclavian steal: - demand for blood in upper extremity causes blood to blow down vertebral to subclavian causing syncope - caused by cervical rib or Takayasu
154
Patient with COPD, HTN, stable angina, and PVD is given Hydralazine. 1. MoA? 2. ADR? 3. Other drugs to administer?
1. increases cGMP causing SM relaxation and arteriole vasodilation reducing after load on heart. use for severe HTN. 2. body compensates for low BP with reflex tachycardia. This creates demand on heart and ischemia leading to angina 3. Beta blocker to offset reflex tachycardia Diuretic to prevent edema
155
Tall slender patient with FMH of aortic dissection presents with mid systolic click with crescendo decrescendo murmur at apex. 1. Diagnosis? 2. Maneuvers to increase intensity of murmur?
1. MVP from Marfans 2. valsalva and standing up decrease VR causing less volume in LV, increasing intensity and duration of murmur and earlier mid systolic click
156
Patient with pulmonary edema from CHF exacerbation. 1. 1st line treatment? 2. MoA?
1. Furosemide 2. inhibit Na/K/Cl of thick ascending to void fluid and stimulates PGE leading to vasodilation 1st line to treat acute CHF and pulm edema
157
Patient with CHF is on drug that causes accumulation of Na and Ca intracellularly. 1. What drug? 2. MoA? 3. ADR?
1. Digoxin 2. Inhibits Na/K ATPase causing Na to accumulate inside cell which indirectly inhibits Na/Ca exchanger causing Ca to accumulate in the cell. 3. yellow vision hyperkalemia AV block (stimulates Vagus N.)
158
Patient presents with chest pain and ST elevations. 1. Drug that relieves chest pain? 2. MoA?
1. Nitroglycerin (SL) 2. increase cGMP leading to SM relaxation dilating veins that decreases preload and VR which reduces O2 demand on myocardium Coronary arteries already fully dilated from local factors like Adenosine
159
Patient with acute onset chest pain that radiates to his back and hoarse voice. History of painless genital lesion that resolved its own. 1. Diagnosis? 2. Pathophys?
1. Thoracic aortic dissection 2. tertiary syphilis causes vasculitis in vasa vasorum that weakens wall of aorta. Decreased perfusion to tunica media leading to breakdown of elastic lamina leading to aneurysm and insufficiency. Hoarse voice: compressing recurrent laryngeal N.
160
Patient with history of osteoarthritis is taking Celecoxib presents with STEMI. Pathophys?
COX 2 inhibitor blocks PGI2 (vasodilator) leading to vasoconstriction. No effect on TXA2 leading to platelet aggregation and vasoconstriction causing MI
161
Patient who wants to become pregnant has a history of HTN, transient sharp chest pain at rest, and migraine attacks. On Captopril and HCTZ. 1. Diagnosis? 2. Recommendations? 3. Safe in pregnancy? 4. Treatment?
1. Variant Angina 2. Discontinue Captopril (ACEi) and ARBs due to birth defects. Decreased RAAS leads to decreased kidney development, fetal oliguria leading to Potters sequence 3. Safe: - HCTZ - Amlodipine - Methyldopa (gestational HTN) - Labetalol - Hydralazine (not for variant) 4. add Amlodipine for variant angina and HTN and discontinue Captopril
162
Niacin deficiency symptoms?
Dermatitis Diarrhea Glossitis (swollen tongue)
163
Patient with history of MVP who recently had dental procedure presents with painless monocular vision loss, fever, new murmur. Eye exam shows hemorrhagic cotton wool spots. 1. Diagnosis? 2. Pathophys?
1. Endocarditis (Strep viridans) 2. septic emboli occludes central retinal artery causing painless monocular vision loss History of MVP predisposes to IE
164
Patient with red yellow papules on arm and very high TG level. 1. Diagnosis? 2. Treatment? 3. MoA? 4. ADR?
1. Hyper TG xanthomas 2. Fibrates 3. upregulate LPL to decrease TG 4. increase PPAR that decreases 7a-hydroxylase leading to decreased bile acid synthesis leading to cholesterol stones
165
Patient with FMH of MI at young age, B/L corneal lesions, and achilles tendon xanthomas. Elevated HDL. 1. Diagnosis? 2. Pathophys? 3. Treatment? 4. MoA? 5. ADR?
1. Familial Hypercholesterolemia (IIa) 2. defective LDL receptors or Apo B100 leading to accelerated atherosclerosis 3. Ezetimibe (+ statin) 4. Mibe: inhibits absorption of cholesterol at brush border of SI by blocking NPC1L1 leading to delivery to liver and increased LDL clearance Statin: HMG CoA reductase inhibitor to reduce LDL 5. Statins: hepatotoxic
166
Patient with history of intellectual disability, seizures, and worsening SOB. Face has severe acne (angiofibromas). Head CT shows hamartomas in brain. 1. Diagnosis? 2. Heart pathophys?
1. Tuberous Sclerosis 2. TSC mutation (AD) leading to increased giant cell astrocytomas can lead to rhabdomyomas in ventricular wall causing outflow obstruction
167
Patient presents with bradycardia due to beta blocker overdose. 1. Treatment? 2. MoA?
1. Glucagon 2. targets Gs transmembrane protein to activate adenylate cyclase and increase levels of cAMP which raises HR and increases contractility

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