effect of valsalva early strain(2)
decrease venous return
decrease all murmurs except HCM and MVP
effect of valsalva late release(2)
increase venous return
increase right sided murmurs
effect of standing(2)
decrease venous return
similar to the strain phase of valsalva
effect of squatting(3)
increase venous return
increase afterload by kinkingof femoral arteries
increase reverse flow
effect of handgrip(3)
increase afterload
increase blood pressure
increase reverse flow across valve
murmurs getting louder with valsalva(2)
HCM
MVP
why during valsalva murmur get louder in MVP (2)
decrease left ventricular volume
increase of leaflet prolapse
why during valsalva murmur get louder in HCM (2)
decrease left ventricular volume
increase gradient
effect of standing resembles what other effect
valsalva
murmurs that get louder with squatting(3)
aortic regurgitation
mitrel regurgitation
VSD
murmurs that get softer with squatting(2)
HCM
MVP
why murmurs get softer with squatting in HCM (4)
more blood less murmur
increase preload
decrease gradient across outflow obstruction
decrease obstruction and decrease afterload
why murmurs get softer with squatting in MVP(2)
increase left ventricular size
decrease mitral valve leaflets prolapse
murmurs getting louder with handgrip(3)
aortic regurgitation
mital regurgitation
VSD
murmurs getting softer with handgrip(3)
HCM
increase gradient across outflow obstruction
decrease flow
auscultation in mitral valve prolapse(2)
single or multiple non ejection clicks
plus
mid to late systolic of mitral regurgitation
CHF with ejection fraction a 55 dx
diastolic dysfunction
number 1 cause of diastolic dysfunction
HTA
rx of diastolic dysfunction(2)
diuretics
antihypertensives
physiopatho in diastolic dysfunction
impaired ventricular filling due to poor myocardial relaxation or diminished ventricular compliances
cause of AFIB in diastolic dysfunction(3)
left ventricular dilation
leads to left atrial dilation
which in turn causes atrial fibrillation
HTA in the setting of bilateral nontender masses
autosomal dominant polycystic kidney disease
HTA in the setting of bilateral nontender masses best test to do
abdomen ultrasonogram
clue for autosomal dominant polycystic kidney disease(5)
HTA Hematuria proteinuria palpable renal masses progressive renal insufficiency
flank pain in autosomal polycystic kidney disease cause(3)
renal calculi
cyst rupture or hemmorrage
upper urinary tract infection
the early common finding in autosomal polycystic kidney disease
HTA
extra renal manif of autosomal polykidney disease(5)
cerebral aneurisms hepatic and pancreatic cysts cardiac valve disorder colonic diverticulosis ventral and inguinal hernias
management of APKD(3)
follow blood pressure and renal function
aggressive control of cardiovascular risks factors
ACE inhibitor for HTA
end stage renal diasease in APKD(2)
dyalisis
renal transplant
patient with HTA is seen in consultation in history , he exercices regularly an eats low salt diet .but he drinks 3-4 glasses of wine every day and 6-8 beers on week end .he quits smoking 3 years ago next step in management of HTA in this patient
counsel for reduction of alcohol
quid of excessive alcohol intake
> 2 drinks a day
quid of binge drinking
> 5 drinks in a row
lifestyle modification in HTA(6)
low salt diet diet rich in fruit and vegetables low fat dairy products regular aerobic exercices lose weight limit alcohol intake
patient with TA 160/85 while supine and 135/70 while standing dx
orthostatic hypotension
EKG for AFIB(3)
narrow qrs complex
no organised P waves
irregularly irregular rythm
stable patient with afib Management
Rate control
medication used for rate control
Betablocker
calcium blocker like Diltiazem
use of digoxin for rate control in AFIB(2)
AFIB due to heart failure
patient unable to tolerate B blocker or Calcium channel blocker
indication of cardiversion in Patient with AFIB(4)
less than 48 h
patient with hypotension
pulmonary edema
ischemic heart disease
what to do before beginning cardioversion in AFIB more than 48 h(2)
anticoagulation 3-4 weeks
plus
rate control
best test to see if AFIB is complicated with heart thrombus
TEE
patient with chest pain sus elevation of ST segment and ventricular premature beats administration of lidocaine will cause what in this patient
increase the risk in asystole
advantage and drawback of lidocaine in acute coronary syndrome(2)
decrease risk of VFIB
increase the risk of asystole
patient with history of rhinitis and eczema in childhood is coming for chest pain .ekg shows st segment depression .he is placed on aspirin bblocker etc.2 days later he develops respiratory distress with wheezing and prolonged expiratory.cause of that
medication side effect Bblocker and Aspirin
causes of acute dyspnee in hospitalized patients(7)
arrythmia bronchoconstriction CHF/hypervolemia infection/pneumonia asppiration pleural effusion PE anxiety
patient with cardiac disease or (electrolytes abnormalities) develops dizziness tachycardia(or braadycardia) during hospitalisation dx
arrythmia
patient with history of asthma ,is placed on aspirin and Bblocker develops wheezing and pprolonged expiratory phase during hospilaisation Cause of that
bronchoconstriction
patient with cardiac disease develops crakles high jugular venous pressure>8 cm h2o lower extremity edema cause of that
CHF
accidentaly patient has received 2000 cc de liquide develops dyspnea,develops crackles DX
hypervolemia
characteristics clinique of pleural effusion in tyhe context of acute dyspnee (2)
decreased breath sounds
dullness to percussion
clue for anxiety in the setting of acute dyspnea in hospitalised patient(4)
tachycardia
tachypnee
normal lung exam
normal oxygenation
EG in anterolateral MI
st segment elevation in 1 avl,v1-v3
what can happen in anterolateral MI(2)
muscle ischemia or rupture—>
mitral regurgitation
MI causing typically mitral regurge and why(2)
posteroseptal MI
a cause of solitary blood supply of of the post medial papillary muscle
consequence of lmitral regurge in anterolateral MI or post septal MI(4)
increase left atrial pressure
but no changes in left atrium size
in left ventricular sizes
and no changes in left ventricular ejection fraction
patient with chest pain during exercice but normal baseline resting EKG ,next step
exercice EKG
why patient with SLE are at risk for acute coronary syndrome(2)
most of the they are reiceiving prednisone
prednisone and Lupus cause acelarated coronary atherosclerosis
syncope during exercice(3)
aortic stenosis
HOC
VTAC
murmur in aortic stenosis(3)
2 nd intercostal space
radiation in caritids
crescendo-decrescendo
disease with pulsus parvus and tardus
aortic stenosis
quid of pulsus parvus and tardus
aotic stenosis
other finding in aortic stenosis
weak S2
S4
three possible symptoms in AS(3)
syncope during exercice
exertionnal angina
dyspnea
definitive dx of AS
echocardiogram
rx of symptomatic AS
valve replacement
patient with chest pain with normal QRS complex 80msec(n
first degree heart block
clue for first degree heart block(2)
prolonged PR interval
P wave always follows QRS unlikely other heart block
rx of first degree heart block with normal QRS duration
abservation
First degree AV block with prolonged QRS
electrophysiologic testing to determine the nature of the delay of conduction below the AV node
patient with history of respiratory infection one week ago develops Ta =100/60 distended neck veins and heart sounds distant dx
pericardial effusion
xray in pericardial effusion
enlarged cardiac silhouette
ekg clue for pericardial effusion
electrical alternans
quid of electrical alternans
qrs complexes whose amplitude vary from beat to beat on ekg
definitive dx in pericardial effusion
echocardiogram
quid hypertensive urgency(2)
severe HTA > ou egal 180/120
no symptoms ,no end organ damage
two divisions for hypertensive emergency(2)
malignant HTA
Hypertensiive encephalopathy
clue for malignant HTA(2)
severe HTA
plus
papilledema and retinal hemorrage
clue for hypertensive encephalopathy(2)
severe HTA
plus
cerebral edema and non localizing neurologic symptoms and signs
symptom in cerabral edema(4)
headache
nausea
vomiting
plus non localizing neurologic symptoms
quid of non localizing neurologic symptom(4)
restlessness
confusion
seizures
coma
organ atteint in malignat HTA(2)
rein
eye
rein problem in malignant HTA
nephrosclerosis
quid of manif of nephrosclerosis(3)
acute renal failure
hematuria
proteinuria
auscultation finding in aptient with aortic stenosis
systolic murmur ejection radiating to the apex and carotid arteries
teens and early twenties with AS cause
bicuspid valve
elderly with AS cause
Calcification of the trileaflet valve
muscle pain in patient taking statin
statin induced myopathy
mechanism of action of statin
inhibition of intracellular synthesis pathway
action of station intracellularly(3)
inhibit HMG co A reductase enzyme
prevent conversion of HMG co A to mevalonic acid
increase the number of cell membrane LDL receptors
why statin can induce myopathy
by decreasing co enzyme synthesis Q 10
role of Q10 coenzyme
involve in muscle cell energy
clue supraventricular tachycardia on EKG(4)
narrow QRS complex
tachycardia
no regular P waves as they are buried within QRS complex
retrograde P wave can occur
dx and management of supraventricular tachycardia(2)
adenosine
or vagal maneuvers
action of adenosine(3)
slows the sinus rate
increases AV nodal conduction delay
can cause a transient block in AV node conduction
role of adenosine in supraventricular tachycardia(2)
can help to identify P waves to clarify dx of atrial flutter or atrial tachycardia
terminate paroxysmal supraventricular tachycardia by interrupting the AV nodal reentry circuit
quid of vagal maneuvers(3)
carotid sinus massage
valsalva
eyeball pressure
patient smoker complain of cramping pain in his right thigh after walking 2 blocks ,the pain goes away once he stops and rests for several minutes
PAD
best initial management in PAD intermittent claudication
exercice therapy
indication of cilostazole in PAD
persistent symptom despite adequate supervised exercice therapy
indication of surgery in PAD
persistent symptom despite adequate supervised exercice therapy and cylostazole
HTA basic testing(4)
urinalysis for occult hematuria and urine protein creatinine ratio
chemistry panel
lipid profile
baseline ECG
when to search for secondary HTA(4)
severe or malignant HTA
resistant HTA requiring > ou egal a 3 drugs
sudden blood pressure rise in patient with previosly controled HTA
age of onset
patient with HTA ,hypokaliemia and hyperglycemia and weight gain dx
adrenal cortical disease
cushing disease
cause of cushing syndrome(4)
adrenal cortical hyperplasia
acth producing pituitary adenoma (cushing disease)
ectopic ACTH production
exogenous steroids
clue for cushing(7)
poximal muscle weaness central adiposity thinning of the skin psychiatreic problem hypokaliemia hypertension hyperglycemia
psychiatric problem in cushing(3)
sleep disturbances
depression
psychosis
quid of preload measurement(2)
right atrial pressure
pulmonary capillary wedge pressure
normal right atrial pressure
mean 4 mm of HG
normal pulmonary wedge pressure
mean of 9 mm de HG
quid of cardiac index
pump function measurement
normal cardiac index
2.8-4.2 l/mn/m2
quid of systemic vascular resistance
measure afterload
normal systemic vascular resistance
1150l/mn/m2
normal mixed venous oxygen saturation
60%-80%
the only parameter increase in Hypovolemic schock
everything is low except systemic vascular resistance
the only two parameters decrease in cardiogenic shock
everything is high except cardiac pump function
mixed venous oxygen saturation
the only shock syndrome with low vascular resistance and increased mixed venous oxygen saturation
septic shock
patient with hypotension, normal Pulmonary wedge pressure and increased mixed venous saturation
septic shock
hwat’s the underlying basic pathophysiology in septic shock
decrease systemic vascular resistance due to overall peripheral vasodilation
swanz ganz catether in septic shock(4)
low pulmonary wedge pressure
low systemic vascular resistance
increased cardiac output
high mixed venous oxygen saturation
origin of formation of AFIB focii
pulmonary veins
quid for atrial flutter origin
reentrant circuit that rotates around the tricuspid annulus
quid for paroxysmal supraventricular tachycardia origin
reentry circuit most commonly oinvolved the AV node or via accessory bypass tract
patient on digoxin and furosemide present with wide complex tachycardia what to check
serum electrolytes
effect of furosemide(2)
low K
low MG++
effects of low K and low Mg++
ventricular tachycardia
risk factor for digoxin toxicity
low K
consequence of digoxin toxicity
ventricular tachycardia
side effect of thiazide (5)
hyperglycemia increased LDL cholesterol and plasma triglycerides hyponatremia hypokaliemia hypercalcemia
hypergluc in thiazide(4)
G= glycemia
L=lipidemia
U=uricemia
C=Calcemia
in swanx ganz catheter clue for cardiogenic shock(2)
reduced cardiac index
elevated pulmonary wedge pressure
how ‘s systemic vascular resistance in cardiogenic shock
high to maintain adequate perfusion of tissue
the most contributory factor in CHF edema
increased renal sodium retention
cause of increased renal sodium retention in CHF(2)
low renal perfusion—-> stimulation of renin aldosterone system—>hypoperfusion renal secondary to cardiac output
renal arteries are constricted
patient with palpitations HR 160 suddenly with no history of haert problem.Symptoms improves when immersing face in cold water dx
paroxysmal supraventricular tachycardia
the cold therapy work s by affecting what
atrioventricular node conductivity
cause of supraventricular tachycardia
accessory conduction pathways
why you can have hepatomegaly,ascites, increased JVP in constrictive pericarditis
decreeased diastolic filling leafing to cardiac output impairment
common cause of constrictive pericarditis(4)
radiation therapy
viral pericarditis
cardiac surgery
idiopathic
kussmaul sign
failure of JVP to decrease during inspiration
other name of constrictive pericarditis
inelastic pericardium
dx of constrictive pericarditis(3)
calcified pericardium in xray
thickened pericardium on CT or MRI scanning
cardiac catheterisation
rx of constrictive percarditis(2)
diuretics
or
pericardiectomy
after anterior wall MI patient develops pleuritic chest pain improving when sitting and leaning forward.EKG shows diffuse ST segment elevation dx
acute pericarditis
laps de temps pour developper acute pericarditis post MI
within the first several days
EKG for acute pericarditis(2)
diffuse ST segment elevation
PR depressions
quid of lone AFIB
presence of paroxysmal persistent or permanent AFIb with no evidence of cardiopulmonary or structural heart disease
rx of lone AFIB
nothing
paroxysmal AFIB
reccurrent > a 2 episodes that terminate spontaneously in
persistent AFIB
episodes lasting more than 7 days
longstanding persistent AFIB
pesistent for more than 1 year duration
permanent AFIB
persistent with no further plans for ryhtm controls
CHADS 2 score 0(2)
no anticoagulation
aspirin preferred
CHADS 2 score 1 (2)
anticoagulation preferred
or
aspirin
CHADS 2 score 2-6
anticoagulation
cause of restrictive cardiomyopathy(4)
sarcoidosis
amyloidosis
hemochromatosis
fibrosis endomyocardial
clue for restrictive cardiomyopathy in echo
symmetrical thickening of the left ventricular walls and slightly reduced systolic function
the only reversible cause of restrictive cardiomyopathy
hemochromatosis
echo with interventricular septum thickness
hypertrophic cardiomyopathy
primary rx of hemochromatosis
phlebotomy
quid of the anti-ischemic nitrate action
systemic vasodilation rather than coronary dilation
systemic venodilation lowers (ventricular)preload and left ventricular end diastolic volume reducing wall stress and myocardial oxygen demand
dilation of capacitance vessels
action of nitrate
reduced left ventricular volume
supraventricular tachycardia in patient hemodynamically unstable management
DC cardioversion
anterior wall myocardial infarction with pulmonary edema what medication to give and why
furosemide
furosemide causes venodilation which further decreases the preload
anterior wall myocardial infarction with pulmonary edema what medication u cant give and why
betablocker
can worsen acute heart failure
other medication can be used in pulmonary edema caused by anterior wall myocardial infarction and why
Morphine
decrease prload and anxiolytic
patient with syncope with history of respiratotry infection 2 weeks ago EKG shows electrical alternans best next step in this patient
percardicenthesis
quid of electrical alternans
une onde qrs longue suivie d’une courte
EKG of pericardial effusion(3)
electrical alternans
sinus tachycardia
low QRS voltage in large pericardial effusion
quid of sinus tachycardia with electrical alternans
large pericardial effusion
problem in HIC(2)
abnormal mitral leaflet motion= systolic anterior motion of the mitral valve septal hypertrophy
cause of systolic dysfunction
MI
…
catetherisation during systolic heart failure(3)
CI decreased
left ventricular end diastolic volume increased
total peripheral resistance increased
how ‘s the left ventricular end diastolic heart failure
normal
patient with tachysystolic AFIB what to do to improve the left ventricular function in those patients
control the rate and the rythm
why tachysystolic AFIB causes significant left ventricular dialtion and depressed EF(4)
tachycardia
neurohumoral activation
absence of atrial kick
atrial ventricular desynchronisation
importance of atrial kick
it accounts for 25% of LV end diastolic volume
tachysystolic AFIB (3)
irregular irregualr rythm
tachycardia
no P waves ion EKG
cardiac problem in hemochromatosis(3)
cardiac conduction abnormalities
dialted cardiomyopathy
heart failure
the greatest risk factor for printzmetal angina
smoking
young female with nocturnal chest pain lasting 15-20 mn .EKG shows St segment elevation in lead 1 avl,v4-v6 during the episode rx
diltiazem
or
nitrate
why to not give bblocker or aspirin in printz metal angina
cause vasoconstriction
other name of printz metal
variant angina
after long trip to central asia female using OCP develops hemoptysis and pleuritic chest paincause of these symptoms
pulmonary infarction
number one cause of pleuritic chest pain
PE
gold standard Dx in PE
helical CT
patient with chest pain palpitations is seen in emergency .Physical exam reveals HTA ,dilated pupils ,small amount of blood at the external nares St segment elevation in V1-V4.explanation of the symptoms
drugs induced vasospasm
cocaine abuse
why you cant give bblocker to patietn in cocaine abuse
unopposed alpha agonist will worsen vasospasm in cocaine abuse
cause of St segment elevation(4)
MI
Cocaine abuse
acute pericarditis
printzmetal
clue for aortic regurge
wide pulse pressure
manif of wide pulse pressure in reality
water hammer pulse
=pounding heartbeat
way for the patient hear better the pounding heart(2)
lying supine and
lying on the left
most common cause of aortic dilation in The US(2)
aortic root dialtion
bicuspid aortic valve
the greater non pharmocologic rx with greatest impact on HTA and why(2)
weight loss
reduce HTA of 5-20 per 10 kg loss
the second non pharmocologic rx with greatest impact on HTA and why(2)
DASH diet
reduce HTA 8-14 mm de hG
thethird non pharmocologic rx with greatest impact on HTA and why(2)
exercice
reduce HTA 4-9 mm de hg
the 4 e non pharmocologic rx with greatest impact on HTA and why(2)
dietary sodium
reduce HTA 2-8 mm de hg
the 5 e non pharmocologic rx with greatest impact on HTA and why(2)
alcohol intake
reduce HTA 2-4 mm de hg
quid of DASH diet(2)
Diet rich in fruits and vegetables
and low saturated fat and total fat
time to work out in HTA(2)
30 min /day
5-6 days /semaine
dietary sodium restriction in HTA
alcohol intake restriction in HTA(2)
2 drinks /day in men
1 drink /day in women
first line rx for newly dx hypertension satge 1
lifestyle modification
patient with pedal edema ascite emigrating from china to come in the US.chest xray reveals decreased heart sound and an accentuated sound directly after the second heart sound in ear;y diastole .chest xray shows ring calcification around the heart and jugular venous pressure tracings show prominent x and y descents cause of the patient symptoms and Dx
tuberculosis
constrictive pericarditis
clinical presentation of constrictive pericarditis(4)
fatigue and dyspnee on exertion
peripheral edema and ascites
high jugular venous pressure
pericardial knock
dx findings in constrictive pericarditis(2)
X and Y descents during jugular venous pulse tracing
imagind shows pericardial thickening and calcification
pericardial knock
early heart sound after S2
heart dysfunction in constrictive pericarditis
diastolic
endemic areas for TB(3)
africa
india
china
EKG for Mobitz type 1(wenkeback)
PR interval growing slowly progressively leading up to a dropped beat
problem in mobitz one
impaired AV node conduction
sudden tearing chest pain in aptient with chest xray showing widened mediastinum dx and medical condition causing that
dissection aortic
HTA
drugs increasing the riosk of bleeding when taking warfarin(9)
acetaminophen NSAIDS antibiotis/antifungal amiodarone canberry juice ginkgo biloba viit E omeprazole thyroid hormone selectice serotonin reuptake inhibitors
drugs decreasing the effect of warfarin(6)
rifampin carbamazepine oral contraceptives ginseng st jhon's wort green vegetables(spinach)
dose of acetaminophen to cause bleeding with warfarin ingestion
> 2 g /jour for 1 week
the most important factor for survival in out hospital sudden cardiac arrest
time to rythm analysis and defibrillation=elapse time to effective resuscitation
en d’autres mots:prompt effective resuscitation with adequate bystander CPR,prompt rythm analysis and defibrillation
number one cause of outhospital sudden cardiac arrest(2)
sustained VTAC
sustained VFIB
both cause by MI or ischemia
murmur in aortic dissection
diastolic murmur in left sternal border
3 clinical findings in aortic dissection with 2 you make the DX
tearing chest pain radiating in the back
variation in pulse or blood pressure between the right and the left arm
widened mediastinum
complication of dissection aortic
extend to pericardium=tamponnade
extend to coronary arteries=stroke
extend to carotid arteries=stroke
dissection aortic plus hemiplegia dx
stroke
incidence of aortic dissection when 2 clinical symptoms are present see question above
80 %
patient found with pulsatile mass above umbilicus creat 2.0 and TA:160/90 dx and best test to confirm the DX(2)
abdominal aneurism of aorta
abdominal ultrasound
quid of BNP
release by dilated ventricle
value for BNP to Dx CHF(4)
> 100 pg /ml
specificity 76
sensitivity 90
predictive value 83
importance of BNP
helps to differentiate dyspnea of cardiac origin with any other origin
cause of right Heart failure in COPD
pulmonary artery systolic pressure
sequence of event causing right heart failure in COPD
hypoxemia causes constriction of the pulmonary artery and with time pulmonary hypertension—> will lead to right ventricular hypertrophy and right ventricular failure
does right ventricular failure cause pulmonary edema
it s not a common cause of pulmonary edema
management of STEMI(6)
oxygen nitrates antiplatelet therapy anticoagulation bblockers prompt reperfusion with PCI
antiplatelet therapy used in STEMI
platelet P2y12 receptor inhibitor
anticoagulation used in STEMI
bivalirudin is preferred over heparin
ideal first rx for STEMI
prompt reperfusion with PCI
clue for benign essential tremor(3)
tremor worst with activity
improves with with alcohol
family inheritance autososmal dominant
HTA plus benign esential tremor Rx
propranolol
the most effective non pharmacological rx of HTA
weight loss
clue for venous insufficiency(4)
pedal edema
medial ankle ulcer
dilated and tortuous superficial veins
normal physical exam
initial rx of venous insufficiency(3)
leg elevation
exercice
compression stockings
method to hear aortic regurgitation murmur(4)
diastolic murmur
best heard along the left sternal border at the third and fourth interspaces
best heart when you apply firm pressure with the diaphragm of the sthetoscope while patient is sitting up leaning forward and holding the breath in full expiration
cause of aortic regurge in developed countries in young adults
bicuspid aortic valve
cause of aortic regurge in developing countries in young adults
rheumatic heart disease
common cause of aortic regurgitation involving the aortic valve leaflet(8)
rheumatic heart disease endocarditis bicuspid aortic valve trauma myxomatous degeneration ankylosing spondylitis acromegaly medications
common cause of aortic regurgitation involving trhe ascending aorta or aortic root disease (8)
hta aortitis syphilitic ankylosing spondylitis dissection aortic ehlers danlos IBD reactve arthritis Marfan syndrome
Medication to hold for 48 h prior to cardiac testing(3)
Bblocker
calcium blocker
nitrates
medication to hold 48 h prior to vasodilator stress test
dipyridamole
medication to hold 12 h prior to vasodilator stress test
caffeine containing food or drinks
medication you can continue prior to to cardiac stress testing(5)
ACE inhibitor ARBs digoxin statins diuretics
gold standard Dx of CAD
coronary angiography
indication of amiodarone(3)
ventricular arythmias
rythm control in AFIB
left ventricular systolic dysfuction
toxicity of amiodarone(7)
hypo or hyper thyroidism hepatotoxicity bradycardia heart block pneumonitis neurologic symptoms visual disturbances
visual probelm associated with amiodarone(2)
corneal microdeposits
optic neuropathy
heart problem with amiodarone(2)
Qt prolongation
risk de torsades de pointes
dermatologic problem associated with amiodarone
blue gray skin discoloration
neurologic problem associated with amiodarone
peripheral neuropathy
gastrointestinal and hepatic problem associated with amiodarone(2)
elevated transaminases
hepatitis
mark for IV drug user in USMLE
needle tracks on arms
IV drug user with fever andround lesions in lungs and sinus tachycardia.what accompanying finding is expected
systolic murmur that increases with inspiration
bug in infective endocarditris in IV drug user
staph aureus
what increases the risk of infective endocarditis in IV drug user
HIV infection
holosystolic murmur increasing with inspiration quid of that
tricuspid involvement
IE with round lung opacity
septic pulmonary emboli
what must be done in young patient with systemic HTA
evaluation for coarctation of aorta
assessment of coarctation of aorta in physical exam(3)
search for brachio femoral delay
upper extremity hypertension lower extremity hypotension
continuous cardiac murmur from large collaterals
acqiured cause of coarctation of aorta
maladue de takayasu
chest xray for aaortic coarctation
notching of the 3 th-8th ribs from enlarged intercostal arteries
confirmatory dx for aortic coarctation
echocardiography
rx of aortic coarctation(2)
balloon angioplasty
plus or minus
stent
complication of CABG
AFIB
AFIB in hemodynamically unstable patient rx
DC cardioversion
EKG of AFIB(3)
absent P waes
an irregularly irregylar rate
narrow QRS complex
clinical features for cocaine abuse(4)
sympathetic activity
chest pain
psychomotor agitation
seizures
sympathetic activity in cocaine abuse(3)
tachycardia
HTA
dilated pupils
why chest pain in cocaine abuse
coronary vasodilation
complication of cocaine abuse(3)
acute MI
aortic dissection
intracranial hemorrage
clue in USmle for cocaine abuse
nasal mucosa is atrophic
chest pain management in cocaine abuse(5)
benzodiazepines aspirin Nitrate and calcium blocker no Bblocker immediate cardiac catheterisation with reperfusion when indicated
why you ccant use fibrinolytics in the management of chest pain caused by cocaine abuse
increased risk of intracranial hemorrage
patient with infective endocarditis is started on vancomycin .Days later culture grows streptococcus mutans highly sensitive to PNC next step
switch antibiotics to IV ceftriaxone
rx of infective endocarditis caude by step mutans(3)
IV pNC
IV ceftriaxone
for 4 weeks
what intervention in STEMI will improve the long term prognosis of patient
restore coronary blood flow
inferior MI
2 ,3 avf
two primary options to restore coronary blood flow(2)
PTCA
fibrinolysis
when to do exercice EKG or pharmacologic stress testing in patient with chest pain
when you have intermediate risk of CAD
quid of intermediate risk of CAD(3)
atypical angina in men of all ages
atypical angina in women > ou egal 50
typical angina in women age 30-50
high risk for CAD(2)
typical angina in men > ou egal a 40 ans
typical angina in women age > ou egal a 60 ans
low risk for CAD(2)
atypical chest pain in women age
high risk for CAD CAT(2)
start Rx
coronary angiography if unstable angina
patient with ant.hypertension with hypotension tachycardia,distended neck veins pulsus paradoxus with teraing chest pain dx
pericardial tamponnade due to dissection aortique
USMLE pulsus paradoxus
respiratory variation in systolic blood pressure or
decrease > 10mm de hg drop in systolic pressureduring inspiration
why syncope and hypotension in tamponnade(4)
compression of cardiac chambers by fluid in pericardium
limit diastolic filling of trhe right sided chambers
decreases preload
reduces cardiac out put
young age under 70 patient with aortic stenosis cause
bicuspid aortic valve
elderly 70 patient with aortic stenosis cause
calcification of aorta
tearing cehst pain in thew context of hypotension with respiratory variation in systolic blood pressure hypotension ,distended jugular veins dx
dissection aortique
dissection aortic wuth Ta higher in right arm than the left arm why
extension of the dissection into the great vessels feeding the left arm
after myocardial infarction patient develops develops widened QRS complex with compensatory pause next step but patietn is asymptomatic
observation
PVC in symptomatic patient rx
Bblocker
when you cant use nitrates in in MI
right ventricular MI
when to suspect right ventricular MI
often accompany post MI
when to suspect right ventricular MI(5)
hypotension
with clear lung fields
high JVP
Kussmaul’s sign positif
Left ventricular infarct(2)
hypotension
pulmonary edema
correction of hypotension in right ventricular infarct(2)
administer normal saline bolus
don’t give nitro
patient developping dyspnea after stab wound to the right thigh 10 months ago .In EP,right leg is warmer and apperas flushed compared to his left leg cause of the patient symptom
increased cardiac preload
patient developping dyspnea after stab wound to the right thigh 10 months ago .In EP,right leg is warmer and apperas flushed compared to his left leg cause of the patient symptom dx
AV fistula
congenital cause of AV fistula(4)
PDA
angiomas
pulmonary AVF
CNS AVF
acquired cause of AVF(4)
trauma
iatrogenic ( femoral catheterisation)
atherosclerosis(aortocava fistula)
cancer
why heart failure in AVF
the circulation is unable to meet the oxygen demand of the peripheral tissues
patietn with dyspnes and elevate BNP what you expect to find in this patient
S3
meaning of S3 and elevated BNP
increased cardiac filling pressures
patinet with left sided chest pain improving with leaning forward and creat 5.1 dx and rx(2)
pericarditis
hemodyalisis
most common cause of pericarditis
viral infection
rx of viral pericarditis
NSAID
cause of pericarditis(5)
iatrogenic connective tissue disease cardiac uremic malignancy
iatrogenic cause of pericarditis(4)
surgery
trauma
radiation
drug related/chemo
connective tissue causing pericarditis(2)
RA
SLE
cardiac problem causing pericarditis
dressler syndrome
quid of dressler syndrome(2)
post MI infarction
usually 1 -6 weeks after MI
when you will have uremic pericarditis
whrn BUN> 60 mg/dl
CHADS 2 score(5)
C=CHF =1 pt H=hypertension=1 A=age . ou egal a 75=1 D=diabetes=1 S=prior stroke =2
CHF apres recent cold
dilated cardiomyopathy
finding on echo in dilated cardiomyopathy(2)
dilated ventricles with diffuse hypokinesia
low ejection fraction
viral myocarditis cause #1
coxsackievirus B
viral myocarditis other cause(4)
parvovirus B19
human herpes virus 6
adenovirus
enterovirus
tracing of arterial line and BP
compare pick lors de l’inspiration and pic in systolic presure to understand the graphics
quid of pulsus paradoxus
decrease of ten mm de hg of systolic pressure during inspiration
explanation of pulsus paradoxus
in inspiration the intrathoracic pressure is negative
incresase venous return to the right heart
interventricular septum shifs into the left ventricular cavity reducing the left ventricular and diastolic volume
d’ou decreasd systolic blood pressure in the case of tamponnade
other cause of pulsus paradoxus(2)
severe asthma
COPD
why isolated systolic hypertension in elderly
rigidity of the arterial wall
rx of isolated systolic hypertension in elderly
monotherapy with thiazide
or ACE inhibitor
or
long acting calcium channel blocker
heart problem in Marfan(3)
aortic dilation
regurge
aortic dissection
murmur in Marfan
early diastolic murmur
skeletal problem in Marfan(5)
arachnodactyly pectus deformity joint hypermobility increase arm to height ratio decrease upper to lower body segment ratio
ocular problem in marfan
ectopia lentis
why marfan patient tend to have spontaneous pneumothorax
rupture of apical blebs
skin finding in Marfan(2)
reccurrent or incisionnal hernia
skin striae
Marfan patient with acute chest pain
acute aortic dissection
syncope provoked by strong emotion
vasovagal syncope
inciting event of vasovagal syncope in patient
emotionnal stress(venipuncture) orthostatic stress(prolonged standing)
inciting event of vasovagal syncope in patient > 60 ans(3)
micturition
cough
defecation
dx of uncertain vasovagal syncope
upright tilt table testing
dx of vasovagal syncope
clinical
what medication should be given to all patient with MI within 24 hours
ACE inhibitor
why ACE inhibitor in post MI(2)
to prevent remodelling of the ventricle and
possible dilation of the ventricle leading to CHF
military recruit with body temperature > 40 during exercice with central nervous system dx
heat stroke
common symptom in heat stroke(3)
dehydration
hypotension
tachycardia
systemic effects of heat stroke(4)
seizures
acute respiratory distress syndrome
DIC
hepatic and renal failure
rx of heat stroke(4)
rapid cooling with ice water immersion
fluid resuscitation
electrolyte correction
management of end organ damage
antipyretic in heat stroke
any role
risk factors for heat stroke(6)
strenuous activity during hot and humid weather dehydration poor acclimatisation lack of physical fittness obesity medications
medication involved in heat stroke(4)
anticholinergics
antihistamines
phenothiazines
tricyclics
murmur on right sternal border increased with expiration
left side heart murmurs
symptom of aorti stenosis(3)
S=Syncope
A=angine
D=Dyspnea
indication of surgery in Aortic stenosis(3)
symptomatic patient
patients with severe AS undergoing CABG or other valvular surgery
asymptomatic patient with severe AS and poor LV systolic function=LV hypertrophy >15 mm
valve area
cause of anginal pain in aortic stenosis
increased myocardial oxygen demand
medication with decreased mortality following MI(4)
aspirin
B blockers
ACE inhibitor
lipid lowering statins
indication of clopidogrel in MI(3)
intolerance to aspirin
post US/NSTEMI
following PCI
duration of taking of aspirin and clopidogrel after UA/NSTEMI
12 months for clopidogrel
definitely for aspirin
role of clopidogrel and aspirin inn post PCI
prevent stent thrombosis
AFIB with cardiac arrest next step
chest compression
quid of pulseless electrical activity
the presence of organized rythm on cardiac monitoring without a measurable BP or palpable pulse in a cardiac arrest patient
wht to do in pulseless electrical activity(2)
chest compression
no defibrillator
nosynchronised cardioversion
AFIB with cardiac arrest Dx
pulseless electrical activity
reversible causes of asystole/pulselkess electrical activity 5H(5)
hypovolemia hypoxia hydrogen nions( acidosis) hypo or hyperkaliemia hypothermia
reversible causes of asystole/pulselkess electrical activity 5T(5)
tension pneumothorax tamponnade toxins thrombosis(pulmonary or coronary) trauma
elderly with diarrhea develops orthostatic hypotension,mucosal dryness, what’s the most sensitive indicator to see if elder is dehydrated
increase BUN/CREAT ratio
after MI patient develops leg Pain dx
occlusion of popliteal artery
5 P in occlusion artery
Pain pulselessness paresthesia poikilothermia pallor
tr of occlusion artery(2)
embolectomy
or
intra arterial fibrinolysis/mechanical embolectomy via interventionnal radiology
pleuritic chest pain normal cardiac exam, tenderness to palpation over the sternum
costochondritis
clue for pain from musculoskeletal origin
reproducible with palpation
papiltaion with AFIB in patient with lid lag retraction and tremor dx
graves disease
rx of hyperthyroidism related tachysystolic AFIB
propranol
patient with HTA is receiving a drug whicn enhances natriuresis,decreases serum angiotensin 2 concentration and decreases aldosterone production action of that drug
direct renin inhibitor
example of direct renin inhibitor
aliskiren
drugs affecting the renin angiotensin aldosterone axis(3)
ACE inhibitors
angiotensin receptor blockers
direct renin inhibitor
MI plus flash pulmonary edema management
furosemide
initial stabilisation of acute ST segment elevation MI(7)
02 if sao2
ST segment elevation plus unstable sinus bradycardia management
IV atropine
ST segment elevation plus persistent severe pain ,management
IV morphine
ST segment elevation plus persistent
pain,hypertension or heart failure ,management
IV nitroglycerine
when you cant use nitro in MI(3)
hypotension
right ventricular infarct
severe aortic stenosis
when you cant use b blockers in MI(2)
CHF
bradycardia
laps of time to perform percutaneous transluminal coronary angioplasty following MI
within 90 mn preferred
if PTCA within 120 mn not available in case of acute ST segment elevation next step
thrombolysis
patient is receiving a medication for palpitation ,he undergoes a stres test for chest pain durinfg the test his heart rate increases form 65 to 175 and qrs duration from 0,09 to 0.13 seconds .which medication was used for palpitation in thsis patient
flecainide
why during stress test if you are taking flecainide heart rate will increase and QRS complex prolonged
the medication has a use dependance prperty
more effective at higher heart rates because there is not as much time between heartbeats for the medication to dissociate from its receptor
action of flecainide
block sodium channel
indication of flecainide(2)
ventricular arythmias
supraventricular tavhycardia as AFIB
class of antiarrythmic involved in use dependence phenomenon
class 1c class iV
does class IV prolong QRS complex
no
patient with MI under rx 4 days later develops chest pain .the best marker to be useful in this patient
CK MB
the most specific and sensitive test for MI(2)
troponin T
return to normal in 10 days post MI
wy CKMB is the best test in reocclsuion following a previous recent one
it takes 1-2 days to become normal after MI
murmur in mitral regurge
holosystolic murmur
features for mitral regurgitation(4)
exertional dyspnea
fatigue
AFIB
heart failure signs
aortic stenosis in elderly cause
sclerocalcific changes
you perform myocardial perfusion scanning for a patient,it reveals uniform distribution at rest but inhomogenesity of the distribution after dipyridamole injection.waht effect of dipyridamole helps in making the dx of ischemic heart disease
coronary steal phenomenon
indication of myocardial perfusion scanning with dipyridamole
amputated patient
quid of coronary steal
redistribution of coronary blood flow to non diseases segments
whta other substance can be used in myocardial perfusion scanning
adenosine
risk of mitral stenosis
left atrial dilation
AFIB
cardiac emboli
consequence of pressure transmitted to pulmonary vasculature inmitral stenosis(3)
dyspnea
cough
hemoptysis
patient with right sided weakness cough hemoptyis dyspnes from cambogia dx
stroke caused by cardiac emboli inthe setting of mitral stenosis
quid of mallory weiss(2)
upper gastrointestinal mucosal tear
caused by forceful retching
quid of boerhave syndrome(3)
esophageal transmural tear
caused by forcefu retching
esophageal air and fluid leakage in nearby areas
chest xray in boerhave syndrome(3)
unilateral pleural effusion
with or without pneumothorax
subcutaneous or mediastinal emphysema
widened mediastinum
pleurl fluid analysis in boerhave syndrome(2)
high amylase > 2500 UI
food particles
dx of boerhave syndrome(*2)
CT
contrast esophagography with gastrographin
confirnatory dx in mallory weiss
endoscopy gastro digestive
risk factor for variant angina
smoking
EKG in variant angina
ST segment elevation
condition associated with printzmetal angina(2)
migraine
raynauds phenomenon
pain characteristic in prntzmetal
occurs at night
goes spontaneously after 15-20 mn
hypertension in the setting of hypercalcemia
parathyroid gland disease
secondary HTA caused by renal parenchymal disease(2)
elevated serum creat abnormal urinalysis (proteinuria,red blood cell casts)
secondary HTA caused by reno vacular disease(4)
severe HTA > ou egal 180/120 after 55
abdominal bruit
flash pulmonary edema
unexplained rise in creat
secondary HTA caused by primary aldosteronism(3)
hypokaliemia
slight hypernatremia
adrenal incidentaloma
secondary HTA caused by pheochromocytoma (3)
paroxysmal elevated BP with tachycardia
pounding headaches papiltations and diaphoresis
adrenal incidentaloma
secondary HTA caused by hypothyroidism(5)
constipation weight gain bradycardia cold intolerance dry skin
secondary HTA caused by primary hyperparathyroidism(3)
hypercalcemia
kidney stones
neuropsychiatric disease
secondary HTA caused by coarctation of aorta
differential HTA with brachio femoral pulse delay
xray findingds in pericardial effusion
water bottle cardiac silhouette
how ‘s the jugular venous pressure in viral pericarditis
could be normal
how ‘s the point of maximal impulse in viral pericarditis
non palpable
first test to do in a setting of syncope
EKG
syncope occuring during prolonged standing position distress or painful stimuli dx
vasovagal or neurally mediated syncope
syncope occuring during postural changes with changes in heart rate and blood pressure
orthostatic hypotension
syncope during exercice or with exertion(4)
aortic stenosis
HOC
anomalous coronary arteries
VTAC
syncope with sinus pauses on monitor prolonged PR interval or QRS duration(3)
sick sinus syndrome
bradyarythmiasd
av block
syncope with hypokaliemia or hypomg++ or any medication causing prolonged QT interval
torsades de pointes
acquired long QT syndrome
syncope with triggers ( swimming,during sleep sudden noice) family history of sudden daerth prolonged qt interval on ECG
congenital long Qt syndrome
ECG findings suggesting arrythmia as the cause of syncope(6)
innaproppriate sinus bradycardia sino atrial block sinus pauses AV block nonsustained VTAC short or long QTC interval
murmur in aortic regurge(2)
early diastolic murmur
left sternal border
bounding pulse or water hammer peripheral pulse
aortic regurgitation
aortic murmur in regurgitation localisation in valvular disease
diastolic murmur in left sternal border 3 e 4 e espace intercostal
aortic murmur in regurgitation localisation in aortic root disease
diastolic murmur in right sternal border
conduction abnormality in the setting of infective endocarditis
perivalvular abcess
risk in acute endocarditis involving the aortic valve in IV drug user
periannular extension of endocarditis
peripheral edema with normal physical exam in a patient taking calcium blocker cause of edema
dihydropyridine Ca channel antagonist
sudden death in young athlete
hypertrophic cardiomyopathy
risk factor for coroanry syndrome(3)
smoking
family history
estrogen therapy
patientin EB with chest pain and suspected coronary syndrome .what drug should be administered first
aspirin
why aspirin is so important in acute coronary syndrome(2)
reeudces risk of MI
decrease mortality overall
apical holosystolic murmur
mitral rergurgitation
apical mid late systolic murmur
mitral valve prolapse
apical mid late diastolic murmur
mitral stenosis
left sternal border systolic ejection murmur
Hypertrophic cardiomyopathy
left sternal border early diastolic murmur(2)3 e espace intercostal
aortic regurgitation
pulmonic regurgitation
quid of pulomonic area
2 espace intercostal G
systolic ejection murmur in pulmonic area
pulmonic stenosis
flow murmur
ASD
systolic ejection click in pulmonic area
pulmonic stenosis
quid aortic area
2 e espace intercostal droit
systolic ejection murmur in aortic area
aortic stenosis
holosystolic murmur in tricuspid area
tricuspid regurge
VCD
quid of tricuspid area
4 e espace intercostal in the left close to sternum
mid late diastolic murmur(2)
tricuspid stenosis
ASD
cause of mitral regurgitation in developed countries
mitral valve prolapse=myxomatous degeneration of the valve
complication of severe chronic Mitral regurgitation(3)
AFIB
left ventricular dysfunction
CHF
most common benign tumor in heart
Myxoma
Symptom for atrial myxoma(3)
systemic embolization
cardiovascular symptoms simulating mitral valve disease
constitutioonnal symptoms
most sensitive test to Dx atrial myxoma
transesophageal echocardiography
complication of myxoma
sudden death
murmur in myxoma
early diastolic sound=tumor flop
why constitutionnal symptoms in myxoma
overproduction of interleukin 6
anterior wall MI
V1- V6
hemodynamic hypotension compromises 3 a 7 jours after anterior MI(3)
paillary muscle rupture
left ventricle free wall rupture
interventricular septum rupture
hypotension with pansystolic murmur apical after anterior wall MI
acute mitral regurgitation caused by papillary muscle dysfunction
normal heart rate at rest
60-100
symptomatic sinus bradycardia(dizziness) rx
iV atropine
symptomatic sinus bradycardia unresponsive to atropine
permanent pace maker
cause of sinus bradycardia(4)
sick sinus syndrome
hypoglycemia
medication
exagerated vagal activity
medication involved in sinus bradicardia(3)
digitalis
B blocker
Calcium channel blocker
first line antianginal rx used in stabe chronic angina
B blocker
antianginal drug(3)
bblocker
calcium channel blocker
nitrates
action of BBlocker as antianginal drug
decrease myocardial contractility and heart
action of calcium channel blocker as antianginal drug
peripheral and coronary vasodilation
can you combine Bblocker and calcium blocker as antianginal
yes
in persisting angina
preventive rx in stable chronic angina(5)
aspirin statin smoking cessation regular exercices and weight loss control of BP and diabetes
when to use nitrate in stable chronic angina
when B blocker and calcium blocker are contindicated
medication which has not been shown to improve survival in patients with CHF(2)
digoxin
furosemide
medication which has been shown to improve survival in patients with CHF(5)
ace inhibitor ARB's bblocker aspirin spironolactone
S4 meaning
diastolic disfunction
why S4 in MI
ischemic damage may lead to diastolic dysfuction and stiffened ventricle
rx of dressler syndrome
NSAIDS
indication of corticosteroids in dressler syndrome(2)
refractory cases
contrindication of NSAIDS
why you should avoid anticoagulation if you suspect dressler syndrome
risk of hemorragic pericardial effusion
bad prognosis factor in heart failure
hyponatremia
why hyponatremia is a factro of bad prognosis in heart failure(2)
it indicates sever heart failure
high level of neurohumoral activation
cause of hypo or hyperkaliemia in CHF(2)
drugs induced
reflection of renin angiotensin aldosterone system activity
CHF with echo finding of concentric thickening of the ventricular walls ,normal ventricular chamber dimensions and diastolic dysfunction cause of that
amyloidosis
type of amyloidosis(2)
primary=AL
secondary=AA
cause of amyloidosis
any chronic inflammator conditions
some examples of chronic inflammatory disease(5)
inflammatory arthritis chronic infections IBD Malignancy vasculitis
CHF in amyloidosis
restrictive
dx of amyloidosis
tissue biopsy(abdominal fat pad biopsy)
inthe USMLE clue for syncope caused by arrythmia(4)
syncope without warning
presence of structural disease(post infarction)
frequent ectipic beats
thiazide is taking by teh patient
patient after MI develops cold leg next step and why(2)
echo cardiography
search for intraventricular thrombus
patietn presenting with left chestpain 5 days ago he was diagnosed for ant MI with complete occlsuion of LAD 2 miniutes later he is unresponsive with no pulse palpated and death(possible)dx
ventricular free wall rupture
mechanical complication of MI(4)
right ventricular failure
papillary muscle rupture
interventricular sseptum rupture
free wall rupture
artery involved in right ventricular failure
RCA
time course for right ventricular failure
acute
finding in right ventricular failure(2)
hypotension with clear lungs
kussmaul sign
echo finding in right ventricular failure
hypokinetic RV
artery involved in papillary mx rupture
RCA
time course for papillary mx rupture
acute and within 3 -5 days
finding in papillary mx rupture
acute severe pulmonary edema
new holosystolic murmur
echo finding in papillary mx rupture
severe mitral regurge with flail leaflet
artery involved in interventricular septum rupture or defect(2)
LAD for apical rupture
RCA for basal rupture
time course in interventricular septum rupture or defect
acute and within 3 -5 days
finding in interventricular septum rupture or defect(4)
shock
chest pain
new hollow systiolic murmur
biventricular failure
echo finding in interventricular septum rupture or defect(2)
left to right shunt level of ventricle
step up oxygen between right atrium and ventricle
artery involved in free wall rupture
LAD
time course in free wall rupture
within first 2 days - 2 weeks
finding in free wall rupture(3)
shock and chest pain
jugular venous distension
distant heart sounds
echo finding in free wall rupture
pericardial effucion with tamponnade
SMVT
sustained monomorphic ventricular tachycardia
cause of SMVT
post MI complication 6 a 48 h apres MI
EKG of SMVT
wide complex tachycardia with 2 fusion beats
rx of hemodynamic stable SMVT(3)
IV amiodarone
lidocaine
procainamide
rx of hemodynamic unstable SMVT
electrical cardioversion
heart and alcohol
dilated cardiomyopathy
measures most likely to reverse heart failure in alcoholic CHF
total abstinence from alcohol
mainstay of rx of alcoholic CHF
total abstinence from alcohol
what disease patient with intermittent claudication will have over the next 5 years
MI
major cause of mortality in patient with PAD
cardiovascular disease
probability of non fatal MI and stroke in patient with intermittent claudication
20% 5 year risk
probability of death to cardiovascular causes in patient with intermittent claudication
15 a 30 %
probability of critical limb ischemia with risk of limb amputation in patient with intermittent claudication
1 a 2 %
stanford classification of dissection aortic (2)
type A
B
rx of type A aortic dissection(2)
Labetalol
surgery
rx of type A aortic dissection
Labetalol
quid of type A aortic dissection
ascending aorta is involved
quid of type B aortic dissection
descending aorta
CT for aortic dissection
descending aorta with false and true lumen separated by an intimal flap
aortic mur murmur caused by aortic dissection
right sternal border compared to primary aortic valvular disease ,murmur is herad to the left
best test to Dx aortic dissection
TEE
CT with contrast
when to use CT with contrast in the Dx of aortic dissection
when renal function is normal
artery and lead in anterior MI(2)
LAD
v1 a V6
artery and lead in inferior MI(2)
RCA or left circumflex artery 9LCX)
ST elevation 2,3 avf
artery and lead in post MI(4)
RCA or left circumflex artery
ST depression in leads V1-V3
ST elevation in 1 and AVL(LCX)
ST depression in leads 1 and AVL (RCA)
artery and lead in lat MI(3)
LCX/diagonal
St elevation in leads 1 avl v5 v6
St depression in leads 2, 3 avf
right ventricular MI when it occurs
in inferior MI
artery in right ventricular MI(2)
RCA
St segment elevation in leads V4-V6R
MI plus hypotension plus clear lung
right ventricular failure
MI with sinus bradycardia
inferior MI
why inferior MI cangive bradycardia(2)
increased vagal tone
RCA supply blood to sinoatrial node
complication of RCA occlusion and why
AV block
RCA supply AV node through AV nodal artery
ST segment elevations in 2,3 avf and ST segment depression in V1 V2
inferior MI with posterior MI associated
hypotension AV block and bradycardia in the setting of MI
inferior MI
clue for MI inferior involving right heart(2)
ST segment elevation ,2,3 AVL
St segment depression in i and AVL
EKG in atrial premature beats
early P wave
risk factor for atrial premature beats(4)
tobacco
alcohol
caffeine
stress
symptomatic patient with atrial premature beats rx
B blocker
xray in thoracic aorta aneurism(3)
widened mediastinum
increased aortic knob
tracheal deviation
cause of ascending aorta aneurism(2)
cystic medial necrasis
connective tissue disorders
cause of descending aorta aneurism
atherosclerosis
enlarged aorta in xray
aneurism
patient with low grade fevers exertionnal dyspnea
fingerttip pain and dark and cloudy urine.In physical exam proximal and distal interphalangeal joints are swollen
infective endocarditis
quid of osler nodes
painful fingertip
dark and cloudy urine(2)
proteinuria
hematuria
swollen interphalangeal joints
arthritis
vascular phenomoenon in infective endocarditis(5)
systemic arterial emboli septic pulmonary infarcts mycotic aneurism conjonctival hemorrage janeway lesions
quid of Janeway lesions
macular erythematous nontender lesions on the palms and soles
systemic emboli manifestation(3)
focal neurologic deficits
renal infarcts
splenic infarcts
definitice dx or infective endocarditis
DUKE criteria
inheritance of hypertrophic cardiomyopathy
autosomal dominant
quid of masive pulmonary embolism(2)
PE complicated by hypotension
and acute right strain
sign of right heart strain in PE(2)
high JVP
RBBB
complication of right heart strain in PE(6)
right ventriculr dysfunction decreasde to the left side of the heart decreased cardiac output left heart pump failure bradycardia cardiogenic shock
fibrinolysis in PE in the setting of post op
can’t be given within the past 10 days of surgery
CHF with normal TA or elevated TA(3)
supplement o2
IV loops diuretics
consider IV vasodilators as nitroglycerin or nitroprusside
CHF plus sign de shock(3)
supplement o2
IV loops diuretics
IV vasopressors as norepinephrine
side effect of digoxin(5)
nausea vomiting diarrhea vision changes arythmias
patient is taking digoxin develops diarrhea what to do
measure digoxin levels
patient taking an anti arrythmic in teh setting of VTAC develops fibrose pulmonaire .what drug was used to rx the patient
amiodarone
patient with diatolic and continuous murmur at left sternal border next step
echocardiography
rule for diastolic and continuous murmur as well as loud systolic murmurs next step
investigate with transthoracic echodopler
midsystolic murmur grade 1-2 /6 in young patient next step(2)
nothing
benign
medication reducing overall mortality in CHF(4)
ACE inhibitor
b blocker
ARBs
spironolactone
complication of niacin(2)
pruritis
flushing
how to explain niacin complication
prostaglandin related vasodilation
rx of niacin induced pruritis and flushing
low dose of aspirin
patient with medical history of wolt parkinson white develops palpitations and AFIB rx
procainamide
rx of AFIB normally
AV nodal blockers
quid AV nodal blocker(4)
b blocker
calcium channel blocker
digoxin
adenosine
middle aged or older male loses consciuousness immediately after urination or during coughing fits
situationnal syncope
cause of situationnal syncope
autonomic dysregulation
beck triad in tamponnade(3)
hypotension
muffled heart sound
distended neck veins
hypotension in tamponnade(3)
shift of interventricular septum toward the left ventricular cavity
reduces left ventricular preload
stroke volume and cardiac output
clue for GERD(3)
retrosternal burning sensation after eating and with lying down
hoarseness
chronic cough
initial rx of GERD(2)
proton pump inhibitor
H2 receptor antagonist
quid of resistant HTA
persistent HTA persistent despite using > ou egal a 3 antihypertensive agents
what to do in front of all resistant HTA
check secondary HTA
when to suspect renovascular HTA in case of secondary HTA(6)
severe HTA with recurrent flash pulmonary edema
severe HTA with diffuse atherosclerosis
onset of severe HTA after 55
HTA with asymetric kidney size or small atrophic kidney unilateral
presence of abdominal bruit
elevation of serun creat > 30 % from baseline after starting ACE inhibitor or ARbs
clue for renovascular HTA
continuous abdominal bruit
young patient with CHF first dx