CF cases 1 Flashcards
(182 cards)
1
Q
What is the most common cause of mitral stenosis?
A
Rheumatic heart disease
2
Q
What is the common presentation of mitral stenosis?
A
Young woman, often in pregnancy, with shortness of breath, hemoptysis, and a diastolic murmur
3
Q
What is the most common presentation of mitral valve prolapse?
A
Pain, palpitations, panic attack. More common in women. Different symptoms from mitral stenosis.
4
Q
Which murmur gets better with increased blood flow?
A
Mitral valve prolapse
5
Q
What does the murmur of MS sound like?
A
Opening diastolic snap with late diastolic decrescendo murmur (often called a rumble). Louder S1
6
Q
Which action would worsen the murmur of MS?
A
Anything that increases venous return to the heart (Ex: leg raising)
7
Q
What is the pathophysiology in hemoptysis in MS?
A
Increased pulmonary vein pressure causes small vessel rupture in the lungs, leading to hemoptysis
8
Q
What is the pathophysiology in dysphagia in MS?
A
Dilation of the left atrium presses against the esophagus, which lies immediately behind the left atrium.
9
Q
What is Kussmaul’s Sign?
A
Increase in JVP on inhalation
10
Q
What is Kussmaul’s Sign indicative of?
A
Defective filling of the right ventricle, such as in constrictive pericarditis
11
Q
What is pulsus paradoxus?
A
Drop in > 10mmHg in blood pressure during inhalation. Often, radial pulse is no longer palpable during inhalation
12
Q
How does the murmur of MS change as disease worsens?
A
Opening snap occurs earlier (closer to S2) and the duration of the rumble is longer.
13
Q
What is the treatment of choice in stable V-tach?
A
Amiodarone
14
Q
What is the treatment of choice in unstable V-tach?
A
Cardioversion
15
Q
Which EKG finding is associated with MS?
A
Atrial fibrillation
16
Q
What is the most accurate test in MS? What is the best first test?
A
Most accurate is cardiac cath and direct measurement of the mitral valve opening. Best first test is transesophageal echocardiography.
17
Q
How is cardiomegaly defined on CXR?
A
> 1/2 transthoracic diameter
18
Q
What is the most accurate test for pleural effusion?
A
Thoracentesis
19
Q
What are the medical treatments of choice in aortic dissection?
A
Labetalol (to decrease pulse and pressure) and nitroprusside (to decrease afterload)
20
Q
What is the most accurate test for aortic dissection?
A
Angiogram
21
Q
What is the best initial therapy for mitral stenosis?
A
Diuretic such as furosemide
22
Q
What are the roles of digoxin, beta blockers, and Ca channel blockers in A-fib?
A
Slowing heart rate to allow for more time for ventricular filling
23
Q
What is the treatment for mitral stenosis refractory to diuretics/salt restriction?
A
Manual balloon valvuloplasty
24
Q
What is the definitive treatment for aortic stenosis?
A
Aortic valve replacement
25
What is the pathophysiology for hoarseness in mitral stenosis?
Compression of recurrent laryngeal nerve by a dilated left atrium
26
What patients should be screened for diabetes?
Asymptomatic obese patients with BP > 135/80
27
Which patients should be screened with abdominal ultrasound?
Males 65-75 years of age who have a history of smoking (to rule out abdominal aortic aneurysm)
28
When should patients be screened with colonoscopy?
Starting at age 50 at least once every 10 years.
29
What is the most appropriate screening test for diabetes?
2 fasting glucose measurements of >126 OR 1 random glucose over 200 OR abnormal glucose tolerance test. HA1C is NOT part of diagnostic screening.
30
What is the underlying pathophysiology of Type II DM?
Insufficient number of insulin receptors. Obesity is a risk factor b/c adipocytes and resting muscle MUST have insulin for glucose to enter
31
What is the mechanism of miglitol?
Inhibits breakdown of disaccharides and polysaccharides by alpha glucosidases so that glucose absorption in the small intestine is decreased
32
What is the best first treatment option in patients with hyperglycemia?
Diet and exercise. First pharm treatment is metformin b/c it doesnt cause hypoglycemia or weight gain
33
Why are sulfonylureas not first line drugs in diabetes?
They can cause weight gain and hypoglycemia (due to increased insulin release --> lower glucose and greater glucose uptake by adipocytes)
34
What is the mechanism of metformin?
1. Decreased hepatic gluconeogenesis and 2. increased insulin sensitivity
35
What is the only commonly used drug of the biguanide class?
Metformin
36
What is the mechanism of pioglitazone?
PPAR-gamma agonist. Increases transcription of insulin sensitive genes. Increases insulin sensitivity
37
What is the adverse effect of metformin use?
Lactic acidosis (in patients renal insufficiency)
38
Which diabetes drug is associated with diarrhea and flatus?
Miglitol. It induces a lactose-intolerance-like state
39
Which diabetes drugs are associated with exacerbation of heart failure?
Glitazones (pioglitazone, rosiglitazone)
40
Which diabetes drugs are associated with SIADH?
Sulfonylureas
41
Which hypertensive drugs are first line in diabetics?
ACE inhibitors or angiotensin receptor blockers (NOT beta blockers or diuretics) due to renal protective effect (dilation of efferent arteriole)
42
What is the target BP in a diabetic patient or a patient with renal insufficiency?
Less than 130/80
43
What is the target for LDL in diabetic patients or patients with coronary artery disease?
<100.
44
What is the best next step in management in a diabetic patient with elevated LDL?
A statin drug such a simvastatin. Statins are preferred because they lower the mortality more than other options. If LDL >100, diet/exercise alone are not considered sufficient
45
Which cholesterol control agent is contraindicated in diabetes?
Niacin, because it can actually raise blood glucose
46
What is the most common adverse effect of statin therapy?
Increased LFTs. This is much more common than myositis. Thus, LFTs should be routinely checked. CPK doesn't have to be routinely checked.
47
How long into the past does HA1c predict glucose levels?
Past 3 months, because of the lifespan of RBCs
48
What is the routine management of renal function in a diabetic with normal BUN/creatinine?
Microalbumin level (NOT dipstick b/c it is not sensitive enough). Microalbuminuria is LESS protein than trace urine on urinalysis.
49
What drug should be started in a diabetic with microalbuminuria?
ACE inhibitor or angiotensin receptor blocker (for renal protective effect)
50
What histological finding is unique to diabetic nephropathy?
Kimmelsteil-Wilson nodules
51
Which populations are at greatest risk for focal segmental glomerulonephropathy?
HIV and IV drug use
52
What is the normal cup to disk ratio on fundoscopic exam?
0.3
53
What is the fundoscopic finding in diabetic retinopathy?
Neovascularization into the optic disc
54
What is the treatment for diabetic retinopathy?
Laser photocoagulation
55
What is the fundoscopic finding in glaucoma?
Increased cup to disc ration
56
What is the fundoscopic finding in central retinal artery occlusion?
Pale retina due to lack of blood flow
57
What is the fundoscopic finding in hypertensive retinopathy?
AV nicking, cotton wool spots, and copper wiring
58
What is the test of choice to detect diabetes in a pregnant woman?
Oral glucose tolerance test. Blood glucose levels > 200 several hours after drinking the sugar solution is a positive result
59
What is the underlying cause of diabetic foot ulcers?
Neuropathy leading to decreased sensation --> injuries are not realized --> infection --> ulcers
60
What is the underlying cause of decreased gastric motility and bloating in diabetics?
Autonomic neuropathy --> no perception of stretch in GI --> decreased GI motility --> gastroparesis
61
What is the best treatment for diabetic gastroparesis?
Metoclopramide or erythromycin
62
What is the mechanism of metoclopramide?
D2 receptor antagonist --> antiemesis and increased gastric motility
63
What is the most likely diagnosis in a diabetic in DKA with black lesion on the roof of the mouth?
Mucormycosis infection (fungus). This is a medical emergency
64
What is the treatment of choice for mucormycosis?
Amphotericin B
65
What is the most common side effect of amphotericin B?
Type I renal tubular acidosis
66
What is a side effect of ketoconazole in men?
Gynecomastia - antiandrogenic effect
67
What is the most important treatment of mucormycosis aside from amphotericin B?
Surgical debridement
68
What is glargine?
Glargine (Lantus) is long acting insulin. Provides stable overall insulin levels
69
What is aspart?
Insulin aspart (NovoLog) is a rapid acting insulin given prior to mealtime
70
What is seen on CT in malignant otitis externa?
Collapsed mastoid air cells
71
What is the most common organism responsible for malignant otitis externa?
Pseudomonas
72
Why can infection trigger DKA?
Infection causes insulin resistance and also increase of cortisol, which decreases uptake of glucose by tissue
73
Why is Kussmaul's breathing seen in DKA?
Compensation for metabolic acidosis. Deep, rapid breaths blow off more CO2
74
What is the best initial therapy in DKA?
Normal saline bolus and IV insulin
75
What EKG finding will be seen in DKA?
Peaked T waves indicative of hyperkalemia (due to exchange of H+/K+ in cells in an attempt to correct the acidosis)
76
What is the treatment for hyperkalemia?
Calcium chloride or calcium gluconate
77
What happens to serum sodium levels when glucose levels increase?
Increase of 100 mg/dL in glucose causes a 1.6mEq/L decrease in Na+
78
What is the mechanism of hypotension in DKA?
Osmotic diuresis
79
What is the first test to order for a patient with purpura or petechiae and epistaxis?
Platelet count
80
When is a bleeding time the best study?
When a patient has platelet type bleeding but a normal platelet count
81
Which test is used to assess functionality of vonWillebrand factor?
Ristocetin. It acts as an artificial endothelial membrane that platelets should bind to.
82
When is a Ristocetin cofactor assay the best study?
Platelet type bleeding with normal platelet count and normal quantitative vWF
83
What is the primary difference between platelet type bleeding and coagulation factor type bleeding?
Platelet type bleeding is generally more superficial and presents as petechiae, purpura, bleeding gums, epistaxis
84
What is the difference between petechiae and purpura?
Size. Purpura is just larger petechiae.
85
Which drugs can be associated with thrombocytopenia?
Penicillin, sulfa drugs, allopurinol, quinidine, lamotrigine, and rifampin
86
What is the presentation of ITP?
Isolated thrombocytopenia in a healthy person with a normal spleen
87
What is the best next step in a patient with suspected ITP?
Initiate treatment with prednisone (NOT order diagnostic tests. Do this after treatment is initiated)
88
Which disease is associated with Auer rods?
Acute myeloid leukemia
89
What is seen in increased numbers on a peripheral smear of an ITP patient?
Megakaryocytes
90
What is the best next step in a patient treated with prednisone for ITP and now presenting with GI bleeding?
IVIG (plasmapheresis does NOT work)
91
When is IVIG necessary in ITP?
Brain or bowel bleeds constitute life threatening bleeding and require IVIG therapy
92
What is the role of platelet transfusion in ITP?
None. ITP is a platelet destruction problem, not a production problem. Transfused platelets will be destroyed.
93
What is the inheritance pattern of vonWillebrand disease?
X-linked recessive
94
What is the typical presentation of vonWillebrand's disease?
Patient with platelet type bleeding and normal platelet count but increased bleeding time and aPTT (due to decreased Factor VIII)
95
Which drug can possibly precipitate vonWillebrand's disease?
Aspirin
96
What is the best initial test in suspected vonWillebrand's disease?
Bleeding time
97
What is Factor VIII antigen?
Factor VIII antigen = vWF
98
What are the two ways one can have vonWillebrand's disease?
Quantitative decrease in vWF or functional quality decrease in vWF
99
What is the role of desmopressin in vonWillebrand's disease?
Increases release of subendothelial stores of Factor VIII and vWF
100
What is the best initial therapy in vonWillebrand's disease?
Desmopressin. If this doesn't work, give Factor VIII replacement
101
What is the typical presentation of hemophilia?
Boy with delayed hemarthrosis. Hemophilia A is far more common than Hemophilia B
102
What is the best initial test in suspected Hemophilia?
aPTT. If aPTT prolonged, follow it up with a mixing study
103
What does a mixing study accomplish?
Distinguish between a factor deficiency (aPTT corrected with mixing) and an antibody inhibitor (aPTT doesn't correct with mixing)
104
What is the next test in a patient with prolonged aPTT that is corrected with mixing study?
Factor VIII level. Factor VIII deficiency is far more common than factor IX deficiency
105
What is the best treatment for hemophilia A?
Recombinant Factor VIII replacement
106
What is a treatment for very mild hemophilia A?
Desmopressin
107
What type of bleeding is caused by DIC?
Both platelet type and coagulation factor type bleeding.
108
Which tests are the most accurate in diagnosing DIC?
D-dimer or fibrin split products
109
What is the best treatment for DIC?
Replace platelets and fresh frozen plasma. Heparin is NOT an option because the patient is already bleeding.
110
What is acquired storage pool disorder?
Uremia induced platelet dysfunction. Uremia prevents platelets from degranulating --> no aggregation
111
What is Glanzmann's thrombasthenia?
Genetic condition in which defective GpIIb/IIIa prevents platelet to platelet adhesion, increasing bleeding time. Presents like vonWillebrand disease with normal vWF levels.
112
What is Bernard-Soulier syndrome?
AR deficiency in the Gp1b glycoprotein receptor on the surface of the platelets. Presents like vonWillebrand disease with normal vWF levels.
113
What is the best treatment for uremic induced platelet dysfunction?
DDAVP - releases more Factor VIII and vWF
114
What is the presentation of heparin induced thrombocytopenia?
Dropping platelet counts after starting a patient on heparin
115
What is the next step in a patient with HIT who must continue to be anticoagulated?
Switch to a direct thrombin inhibitor such as argatroban and hirudin
116
What is the best test in suspected heparin induced thrombocytopenia?
Platelet factor 4 antibodies
117
What is the clinical triad of HUS?
Hemolytic anemia, acute renal failure, and thrombocytopenia.
118
What is the pathophysiology of HUS?
Shiga-like toxins inactivate ADAMTS13, resulting in formation of microthrombi and consumption of platelets. Narrowed blood vessels cause shearing of RBCs and ischemia to end organs (particularly kidney)
119
What is the difference between TTP and HUS?
Very similar pathophysiology and presentation. TTP often presents with fever and neurologic symptoms
120
Which organism is most associated with HUS aside from E. coli O157:H7
Shigella
121
What is the role of ADAMTS13?
Dissolves vWF so that small primary platelet clots that aren't crosslinked with fibrin get broken up
122
What happens to aPTT and PT in HUS?
Normal
123
What does haptoglobin do?
Scavenges free hemoglobin (from hemolysis) and binds to it in order to recycle it.
124
What happens to haptoglobin levels in hemolysis?
Decreased b/c they get bound to free hemoglobin
125
What happens to LDH levels in hemolysis?
RBC have lots of LDH so hemolysis raises the serum LDH levels
126
What is the best treatment for TTP/HUS?
Plasmapheresis or fresh frozen plasma (replaces the ADAMTS13). Do NOT give antibiotics or platelets
127
Which drugs can cause HUS?
Clopidogrel and ticlopidine. The reason is unclear
128
What is the next best step in a patient presenting with pulmonary edema?
Oxygen and preload reduction (furosemide)
129
What are the steps in management of suspected pleural effusion?
Decubitus CXR's (fluid should move around) then thoracentesis
130
What are the expected findings of a CXR in pulmonary edema?
Congestion of the pulmonary vessels, especially at the top of the lung (cephalization of flow)
131
When should an arrhythmia be cardioverted?
If there is hemodynamic instability (chest pain, shortness of breath, hypotension, confusion)
132
What is the definitive treatment for WPW syndrome?
Radiocatheter ablation
133
What should be done if an arrhythmia is deemed the cause of pulmonary edema?
Emergent cardioversion
134
What is seen on Swan Ganz catheter in CHF?
Increased wedge pressure and decreased cardiac output
135
What is the best preload reducing agent in acute pulmonary edema?
Furosemide
136
What is the mechanism by which morphine helps in acute pulmonary edema?
Vasodilation of pulmonary veins decreases hydrostatic pressure in the lung
137
What is nesiritide?
A synthetic ANP. Not shown to have any benefit over nitrates.
138
Which test can be used to rule out CHF?
BNP. If levels are low, CHF can be ruled out. However, elevated BNP is fairly nonspecific and can be a result of numerous causes
139
What is the most accurate test to determine ejection fraction?
MUGA (nuclear ventriculography)
140
What are the types of drugs shown to decrease mortality in CHF?
ACE inhibitors, beta blockers, and spironolactone
141
What can be used in the treatment of acute pulmonary edema that does not improve with oxygen, furosemide, nitrates, and morphine?
Dobutamine IV.
142
What is the mechanism of dobutamine in pulmonary edema?
Increases inotropy of the heart and decreases afterload (some vasodilation)
143
How do beta blockers affect the RAAS?
Decreased renin release in the nephron
144
What happens to mortality benefit of beta blockers with decreasing ejection fraction?
Increased mortality benefit of beta blockers with decreased ejection fraction. The sicker the heart the more benefit beta blockers have
145
What is the most common cause of death in CHF?
Ischemic ventricular arrhythmias
146
What is the main mechanism of mortality benefit in beta blockers?
Decreased heart rate allows for decreased O2 consumption as well as increased coronary filling time --> decreases risk for ischemic arrhythmia
147
What are the indications for biventricular pacemaker?
Decreased EF as well as wide QRS
148
What is the most dangerous lesion in a pregnant woman?
Eisenmenger's shunt
149
Which type of restrictive cardiomyopathy is associated with speckled septum on echo?
Amyloid
150
What is the difference in management between ischemic dilated cardiomyopathy and drug-related dilated cardiomyopathy?
CABG and aspirin will not help. All other mortality reducing drugs (beta blocker, ACE-I, spironolactone) are still indicated
151
What will worsen the murmur of HOCM?
Anything that decreases LV blood volume such as standing or valsalva
152
What will improve the murmur of HOCM?
Anything that increases LV blood volume such as squatting (increased preload) or hand grip (increased afterload)
153
Where is the murmur of HOCM best heard?
At the lower left sternal border (the same place you would hear tricuspid stenosis)
154
What is the treatment with best mortality reduction in a HOCM patient who has had syncopal episodes?
Implantable cardiac defibrillator or catheter septoplasty. Metoprolol should also be used but is not the immediate best option if there is a history of syncope
155
What is the best option for a patient on ACE-I with a dry cough?
Switch the ACE-I to an angiotensin receptor blocker
156
What therapy should be used for a patient who cannot tolerate ACE-I or ARBs?
Hydralazine (arterial vasodilation) and nitrates (dilates coronaries)
157
What is a frequent side effect of nitrates?
Throbbing headache (migraines).
158
When are triptans contraindicated for headache?
Patients with history of MI or CHF
159
What can therapeutic digoxin present as on EKG?
ST depression - often difficult to distinguish from ischemia
160
What is the most common risk factor for coronary artery disease?
Hypertension
161
What is the worst risk factor for CAD?
Diabetes. In fact, diabetics are at equal risk for MI's as those with coronary artery disease
162
The presence of what symptoms excludes coronary artery disease?
Chest wall tenderness (95% sensitivity), changes with position, or changes with respiration
163
What is always the next best step in a patient with any type of chest pain?
EKG, even if you are sure it will be normal
164
What is the upper limit of a normal PR interval?
0.2 seconds
165
What is a pathologic Q wave?
Greater than 1 box wide and 1 box deep and at least 1/4 of total QRS height
166
What is the next step in a patient with on and off chest pain who has ST depression at baseline?
Stress echo (detects abnormal wall motion) or stress thallium
167
What is the next best step in a patient with on and off chest pain but normal EKG?
Stress test and EKG
168
What is the next best step in a patient with chest pain if a stress test shows ischemia?
Give aspirin and beta blockers. Diagnostic tests such as angiograms should be done after giving aspirin
169
What is the most likely etiology of chest pain in a young, menstruating female with no risk factors for CAD?
Prinzmetal's angina (vasospasm)
170
What does ergonovine do?
Causes vasospasm of the coronary arteries. Can be used to test for Prinzmetal's angina
171
What is the upper limit of a normal QRS complex?
0.12 seconds (3 small boxes)
172
What is the best next step in a patient with chest pain and an EKG showing STEMI?
Give chewable aspirin (morphine, nitrates, and oxygen do NOT lower mortality)
173
What is the parasite responsible for Chagas disease?
Trypanosoma cruzi. It is spread by the bite of the Reduviid bug.
174
What can Chagas disease do to the heart?
Cause dilated cardiomyopathy
175
What should the target LDL be for a patient with diabetes AND coronary disease?
Under 70
176
Which cardiac enzyme will go up first in a patient with acute STEMI?
Myoglobin (goes up in 1 hour). CK-MB and troponins goes up starting at 4-6 hours.
177
What is the next best step in a patient with acute STEMI after aspirin is given?
Angioplasty
178
What is the strongest indication for thrombolytics?
ST elevation or new LBBB within 12 hours of onset of chest pain (assuming angioplasty is not available). NOT indicated in ST depression
179
What is the best test to diagnose WPW syndrome?
Electrophysiology study
180
What is the most likely cause of erectile dysfunction post-MI?
Anxiety (usually NOT a drug reaction). If it must be due to a medication, think beta blockers
181
What is the best next step for a patient with chest pain and an EKG with ST depression?
Aspirin followed by either catheterization or low molecular weight heparin. Heparin prevents the clot that would progress to STEMI.
182
What drugs are used in conjunction with aspirin in NSTEMI's when catheterization is indicated?
Clopidogrel or tirofiban (block platelet activation). They decrease risk of re-stenosis of the coronary artery
