EM EOR Topic List_Cardio_Pulm Flashcards
1
Q
CXR findings indicative of acute bronchitis
A
thickening of bronchial walls in lower lobes
2
Q
auscultation findings of acute bronchitis
A
wheezing and rhonchi
3
Q
acute bronchitis patients complain of productive cough for _________
A
greater than 5 days
4
Q
what is the treatment regimen for acute bronchitis?
A
symptomatic management
5
Q
S/S of acute PE (six)
A
dyspnea, cough, pleuritic chest pain, tachypnea, tachycardia, JVD, decreased breath sounds
6
Q
> = 5 mm induration to PPD skin test is considered POSITIVE for TB for the following people:
A
HIV positive
organ transplant
recent contact w/ TB pt
nodular/fibrotic changes on CXR
7
Q
> = 10 mm induration to PPD skin test is considered POSITIVE for TB for the following people:
A
recent arrivals (< 5 yrs) from high-prevalence countries
IV drug users
resident/employee of high-risk congregate settings
children < 4 yrs
8
Q
> = 15 mm induration to PPD skin test is considered POSITIVE for TB for the following people:
A
person with no known risk factors for TB
9
Q
define ACUTE BACTERIAL ENDOCARDITIS and name MC organism
A
infection of normal valves with a virulent organism
S. aureus
10
Q
define SUBACUTE BACTERIAL ENDOCARDITIS and name MC organism
A
indolent (causing little or no pain) infection of abnormal valves with less virulent organisms
S. viridans
11
Q
what criteria are used to diagnose infective endocarditis and how does it work?
A
Duke’s Criteria
2 major or
1 major + 3 minor or
5 minor
12
Q
list two main common clinical manifestations for infective endocarditis
A
persistent fever most common (part of generalized constitutional symptoms)
new onset of a murmur (or worsening of an existing murmur)
13
Q
list five classic signs of infective endocarditis
A
Osler's nodes Janeway lesions Roth spots (on retina) splinter hemorrhages clubbing
14
Q
(SmartyPance)
what is the empiric treatment for infective endocarditis?
A
IV vanc
or
ampicillin/sulbactam PLUS aminoglycoside
(aminoglycosides include gentamicin, tobramycin)
15
Q
(SmartyPance)
what arrhythmia is most commonly seen in patients with COPD? describe it
A
multifocal atrial tachycardia (MAT)
irregularly irregular w/ varying PR interval, various P wave morphologies (3 or more foci)
16
Q
(SmartyPance)
define paroxysmal AFib
A
episodes of AF that terminate spontaneously w/in 7 days (most last <24 hrs)
17
Q
(SmartyPance)
define persistent AF
A
episodes of AF that last more than 7 days and may require either pharm or electrical intervention to terminate
18
Q
(SmartyPance)
define permanent AF
A
AF that has persisted for more than 1 yr, either because cardioversion has failed or not been attempted
19
Q
(SmartyPance)
list some risk factors for AFib
A
endocrine disorders ETOH and drug use advancing age men more than women in all age groups white persons more than black persons
20
Q
(SmartyPance)
Most cases of AF are _____
A
asymptomatic (90%)
21
Q
(SmartyPance)
two main characteristics of AFib
A
irregularly irregular
tachy (110-140 bpm)
22
Q
(SmartyPance)
what are first line agents for rate control in
AF? what caution should be exercied?
A
beta blockers and CCB (can be IV or oral)
caution should be exercised in patients with REACTIVE AIRWAY DISEASE with beta blockers
23
Q
(SmartyPance)
Open heart surgery may lead to what arrhythmia?
A
atrial flutter
atrial flutter may be a sequela of open heart surgery. After cardiac surgery, atrial flutter may be reentrant as a result of natural barriers, atrial incisions, and scar.
24
Q
(SmartyPance)
what are typical symptoms of atrial flutter?
A
palpitations
presyncope
fatigue or poor exercise tolerance
mild dyspnea
25
(SmartyPance)
| what is the main difference in treatment between atrial fibrillation and atrial flutter?
most cases of atrial flutter can be cured with RFA
26
(SmartyPance)
| what is the most rapid way to lower the INR for a pt on warfarin who is vomiting blood?
fresh frozen plasma
27
(SmartyPance)
| AFib definition/description
irregular heart rate that at high rate may cause
palpitations
fatigue
SOB
P waves are chaotic
28
(SmartyPance)
| AFib - - what is happening to the heart when this occurs?
It occurs when upper chambers of heartbeat out of rhythm;
| there are multiple atria foci
29
(SmartyPance)
| what is atrial flutter? what does it look like on EKG?
atria w/ SINGLE foci
multiple P waves before QRS (sawtooth pattern)
30
(SmartyPance)
| what is paroxysmal supreventricular tachycardia?
regular
| fast (160-220 bpm) rate that begins and ends suddenly, originating in atria
31
(SmartyPance)
| what is Beck's triad? What condition does this term apply to?
THREE D's
Distant heart sounds
Distended jugular veins
Decreased arterial pressure
this applies to cardiac tamponade
32
(SmartyPance)
| one remarkable PE finding of AAA
pulsatile abdominal mass
33
(SmartyPance)
| distinct presenting symptom of aortic dissection
sudden onset TEARING chest pain, BETWEEN SCAPULAS
34
(SmartyPance)
| CXR widened mediastinum indicates
aortic dissection
35
(SmartyPance)
| what are the P's of arterial emboli?
```
Pain
Pallor
Pulselessness
Paresthesia
Paralysis
Poikilothermia (inability to regulate core body temp)
```
36
(SmartyPance)
| what are two most common causes of thrombus formation?
AFib
| mitral stenosis
37
(SmartyPance)
| what is gold standard for dx for arterial embolism/thrombosis?
angiography
38
(SmartyPance)
| initial treatment of acute arterial occlusion
IV heparin
39
(SmartyPance)
| what is second treatment move for acute arterial occlusion after IV heparin, if not limb-threatening?
call VASCULAR SURGEON for angioplasty, graft, or endarterectomy
40
(SmartyPance)
| what kind of murmur is heard with aortic stenosis?
harsh systolic ejection
crescendo-decrescendo murmur
at RUSB
w/ radiation to neck and apex
best heard by leaning forward with EXPIRATION
41
(SmartyPance)
what does this mean:
harsh systolic ejection
crescendo-decrescendo murmur
at RUSB
w/ radiation to neck and apex
best heard by leaning forward with EXPIRATION
aortic stenosis
42
(SmartyPance)
| what kind of murmur is heard with aortic regurgitation?
soft, early diastolic blowing murmur
along L sternal border
w/ patient sitting leaning forward after EXHALING
43
(SmartyPance)
what does this mean:
soft, early diastolic blowing murmur
along L sternal border
w/ patient sitting leaning forward after EXHALING
aortic regurgitation (aka diastolic murmur)
44
(SmartyPance)
| what kind of murmur is heard with mitral stenosis?
diastolic decrescendo low pitched rumbling murmur
w/ opening snap best heard at apex (mitral area)
w/ pt in lateral decubitus position
45
(SmartyPance)
what does this mean:
diastolic low pitched decrescendo rumbling murmur
w/ opening snap best heard at apex (mitral area)
w/ pt in lateral decubitus position
mitral stenosis
46
(SmartyPance)
| what kind of murmur is heard with mitral regurgitation?
holosystolic high-pitched blowing murmur
at apex (mitral area)
that radiates to axilla with a split S2
47
(SmartyPance)
what does this mean:
holosystolic high-pitched blowing murmur
at apex (mitral area)
that radiates to axilla with a split S2
mitral regurgitation
48
(PPP)
| most common valve involved in infective endocarditis
mitral valve
(M>A>T>P)
IV DRUG USERS: tricuspid valve is most commonly infected, rather than mitral
49
(PPP)
| whats the difference between acute and subacute bac endocarditis?
acute: normal valves, virulent organism (prob S. aureus)
subacute: abnormal valves, less virulent organism (prob S. viridans)
50
(PPP)
| what happens if you suspect infective endocarditis and get back negative blood cultures?
test for HACEK organisms!
gram negative organisms that are hard to culture
```
Haemophilus aphrophilus
Actinobacillus
Cardiobacterium hominis
Eikenella corrodens
Kingella kingae
```
51
(PPP)
| what are the clinical manifestations of infective endocarditis? (two big ones, and a group of four)
```
PERSISTENT FEVER (MC)
NEW ONSET OF MURMUR (or worsening of existing murmur)
```
also -
Osler nodes, Janeway lesions, splinter hemorrhages, Rosh spots
52
(PPP)
| four diagnostic studies for suspected infective endocarditis
EKG
echo (TEE vs TTE)
blood cultures (before abx given)
labs: CBC, ESR/rheumatoid factor
53
(PPP)
| how is native valve infective endocarditis treated (empirically), and for how long?
anti-staph PENICILLIN + CEFTRIAXONE (or GENTAMICIN)
penicillin allergy? suspect MRSA? get out vanc instead of penicillin
treat for 4-6 weeks
54
(PPP)
| two most common causes of LEFT-sided HF?
CAD
HTN
55
(PPP)
the most common cause of RIGHT-sided HF?
what are two others?
most common cause of R-sided failure is LEFT-sided failure!
also -
pulmonary disease (COPD, pulm HTN)
&
mitral stenosis
56
(PPP)
| what is another name for systolic HF?
HFrEF
| REDUCED ejection fraction
57
(PPP)
| what is the more common form of HF?
systolic HF, aka HFrEF
58
(PPP)
| what is another name for diastolic HF?
HFpEF
| PRESERVED ejection fraction
59
(PPP)
| what murmur finding is indicative of diastolic HF (aka HFpEF)?
S4
60
(PPP)
| what murmur finding is indicative of systolic HF (aka HFrEF)?
S3
61
(PPP)
| two key characteristics of pt presentation for HF?
exertional dyspnea (SOB) --> SOB with rest
orthopnea (late sign)
62
(PPP)
| one key sign of either type of HF
edema
| think of signs of fluid --> rales/crackles, edema, JVD, ascites
63
(PPP)
| four characteristics of systolic heart failure (HFrEF)
decreased ejection fraction
thin ventricular walls
dilated LV chamber
S3
64
(PPP)
| four characteristics of diastolic heart failure (HFpEF)
preserved ejection fraction
THICK ventricular walls
small LV chamber
S4
65
(PPP)
| three tests for HF, whether regular or congestive
echo
CXR
BNP
66
(PPP)
| what does echo tell us for the testing of HF?
ejection fraction, ventricular fxn
67
(PPP)
| what do CXR and BNP tell us for testing of HF?
CXR - Kerly B lines, maybe bat wings, pulm edema appearance
BNP > 100 = CHF is likely
68
(PPP)
| what is the most common cause of pleural effusions?
CHF (90% of all transudates)
69
(PPP)
| what are the single most effective meds for mortality benefit in HFrEF?
ACE INHIBITORS
| can add BBlockers
70
(PPP)
| basics of long-term management of HF
ACEI & diuretic for symptoms
ACEI>beta blockers
beta blockers usually added after ACEI or ARB, if additional treatment needed
71
(PPP)
| how do we treat SVT (or PSVT)? (four categories)
STABLE (narrow, regular): vagal maneuver, adenosine (first line med mgmt), CCB (Diltiazem), BBlockers (metoprolol), digoxin
STABLE (wide): antiarrhythmics (amiodarone), procainamide for WPW
UNSTABLE: cardiovert
DEFINITIVE: RFA
72
(PPP)
| how does VTach present on EKG?
prolonged QT
regular, wide complex tach w/ no P waves
73
(PPP)
| how do we treat VTach (four categories)?
STABLE: antiarrhythmics (amiodarone, lidocaine, procainamide)
UNSTABLE w/ PULSE: cardioversion (synchronized)
PULSELESS: defib/CPR
TORSADES: IV Mg+
74
(PPP)
| best way to assess asthma exacerbation in acute asthma exacerbation
peak expiratory flow rate
| can assess before and after treatment
75
(PPP)
| what is the discharge criteria after treating an acute asthma exacerbation?
70% of peak expiratory flow rate (PEFR)
76
(PPP)
| what are three short acting beta agonists used as first line trtmt for acute asthma exacerbation?
albuterol
terbutaline
epinephrine
77
(PPP)
| what is an anticholinergic (antimuscarinic) used for relief of acute asthma exacerbation?
ipratropium
78
(PPP)
| what are three corticosteroids used for relief of acute asthma exacerbation?
prednisone
methylprednisolone
prednisolone
79
(PPP)
| How is acute bronchiolitis diagnosed?
clinically -
| RSV causes it
80
(PPP)
| how is acute bronchilitis treated?
supportive measures
- humidified O2
- IV fluid
- antipyretics
81
(PPP)
| how is pleural effusion diagnosed?
CXR (initial test of choice)
- blunting of costophrenic angles (meniscus sign)
- lat decubitus films are best
Diagnostic gold std = THORACENTESIS
(Light's Criteria)
82
(PPP)
| how is pleural effusion managed?
TREAT UNDERLYING DISEASE
thoracentesis (don't remove >1.5L)
chest tube fluid drain if empyema
pleurodesis
83
(PPP)
| how is acute bronchitis diagnosed?
clinically -
- >5 days cough
- may have hemoptysis
- may have wheezing and ronchi
may get CXR
84
(PPP)
| how is acute bronchitis managed?
```
symptomatically
- fluids
- antitussives
- antipyretics
- analgesics
(don't need abx)
```
85
(PPP)
| how is acute epiglottitis diagnosed?
definitive diagnosis = LARYNGOSCOPY
86
(PPP)
| buzz words for CXR sign for acute epiglottitis
THUMB OR THUMBPRINT sign
87
(PPP)
| how is acute epiglotitis treated?
PROTECT THE AIRWAY
(OR --> intubation)
dexamethasone for airway edema
ABX --> ceftriaxone or cefotaxime
may add penicillin, ampicillin, or anti-staph Vanc
88
(PPP)
| what is important to take care of with acute epiglottitis patients?
treat the family/close contacts with Rifampin
get everybody Hib vaccinated
89
(SmartyPance)
| how is viral pneumonia diagnosed?
CXR --> bilteral interstitial infiltrates
rapid antigen testing swab
cold agglutinin titer negative
90
(SmartyPance)
| how is viral pneumonia treated?
if influenza is origin, and symptoms <48 hrs, treat w/ oseltaimvir (Tamiflu)
treat symptoms w/ beta 2 agonists (albuterol), fluids, rest
91
(SmartyPance)
| how is bacterial pneumonia diagnosed?
CXR --> patchy, segmental lobar, multilobar consolidation
blood cultures x2
sputum gram stain
92
(SmartyPance)
| how is bacterial pneumonia treated?
OP:
doxy
macrolides (clarithromycin, azithromycin)
IP:
ceftriaxone + azithromycin/resp FQs (levofloxacin, moxifloxacin, gemifloxacin)
93
(SmartyPance)
| how is PJP diagnosed? (five items)
CXR --> diffuse interstitial or bilteral perihilar infiltrates
Broncheoalveolar lavage PCR
Labs (increased LDH)
HIV test
Low O2 despite supplemental O2
94
(SmartyPance, PPP)
| how is PJP treated?
TMP-SMX (Bactrim) x 21 days
if HIV positive, add prednisone
95
(PPP)
| how is ARDS diagnosed?
three components:
1) severe hypoxemia refractory to O2
2) CXR: bilteral diffuse pulm infiltrates
3) absence of cardiogenic pulm edema (CHF)
96
(PPP)
| how is ARDS treated?
VENTILATION: mechanical or noninvasive
TREAT UNDERLYING CAUSE
97
(PPP)
| talk about CXR for ARDs
bilateral diffuse pulmonary infiltrates
similar to CHF, BUT,
ARDS classically spares the costophrenic angles
98
(PPP)
| how is pneumothorax diagnosed?
CXR
- expiratory upright view
- ->decreased peripheral markings (i.e. collapsed lung tissue)
- ->companion lines
99
(PPP)
| how is pneumothorax managed (size, severity)?
small - observation + supplemental O2
large - needle or catheter aspiration or chest tube or catheter thoracostomy
stable - chest tube or catheter thoracostmy + admit
tension - needle aspiration followed by chest tube thoracostomy
100
(PPP)
| how is asthma diagnosed (ER)?
peak expiratory flow rate
101
(PPP)
| how is asthma treated ("rescued")?
```
beta 2 agonists, short acting
- albuterol, terbutaline, epi
anticholinergics
- ipratropium
corticodsteroids
- prednisone, metylprednisolone, prednisolone
```
102
(PPP)
| what is most common cause of croup?
parainfluenza virus type I
103
(PPP)
| how is croup diagnosed?
clinically (once epiglottitis and FBO are r/o)
could do a CXR and look for STEEPLE SIGN (rarely done)
104
(PPP)
| how is croup managed?
mild? supportive care. Dexamethasone provides significant relief
moderate? dexamethasone PO or IM + supportive treatment. nebulized epi
severe? dexamethasone + nebulized epi + admit
105
(PPP)
| how are pulmonary emboli diagnosed?
CT ANGIOGRAPHY (best initial test to confirm presence of PE)
tachypnea (MC sign)
sudden onset of triad: dyspnea (MC), pleuritic chest pain, hemoptysis/cough
106
(PPP)
| how are pulmonary emboli treated?
STABLE:
anticoagulation (1st line therapy)
- heparin bridge + coumadin or a NOAC (Dabigatran, Apixaban, Rivaroxaban, Edocaban)
IVC filter
UNSTABLE
thrombolysis
thrombectomy or embolectomy
107
(PPP)
| what is most definitive diagnostic test for FBO aspiration?
rigid bronchoscopy
| you may try CXR or CT chest
108
(PPP)
| how do you treat/fix FBO aspiration?
get out the object
removal of foreign object via rigid bronchoscopy
109
(SmartyPance)
| how do you diagnose respiratory syncytial virus?
diagnosed with NASAL WASHING,
RSV antigen test
CXR can show diffuse infiltrates
110
(SmartyPance)
| how is RSV treated?
supportive measures include albuterol via neb, antipyretics, humidifed O2, wait 5-7 days
if tachypneic w/ feeding difficulties, visible retractions, or O2 desat <95% --> admit
111
(SmartyPance)
| what are the three most common causes of hemoptysis?
bronchitis (50%)
tumor mass (20%)
TB (8%)
112
(SmartyPance)
| what do we do to diagnose a pt who presents with hemoptysis?
examine the expectorate
cytology (lung cancer?)
fiberoptic bronchoscopy for CA
rigid bronchoscopy for massive bleeding cases
high-res CT
113
(SmartyPance)
| what do you do with a pt who presents with hemoptysis, esp massive hemoptysis?
massive? get aggressive, consult pulmonologist early
protect airway!!
114
(PPP)
| how is flu diagnosed?
rapid influenza nasal swab
or
viral culture
115
(PPP)
| how is flu treated?
mild? supportive, rest, acetaminophen or salicylates
high risk pts? antivirals (oseltamivir w/in 48 hrs of symptom onset)
116
(SmartyPance)
| how is small cell lung cancer diagnosed?
?? incidental finding of nodules on CXR??
then biopsy...
117
(SmartyPance)
| how is small cell lung cancer treated?
SCLC accounts for 15% of cases, 99% smokers.
very aggressive, doesn't respond to surgery, these pts get chemo
118
(SmartyPance)
| how is NON-small cell lung cancer diagnosed?
?? incidental finding of pulm nodules on CXR??
...then biopsy...?
119
(SmartyPance)
| how is NON-small cell lung cancer treated?
NSCLC = 85% of cases
stages 1-2 --> surgery
stage 3 --> chemo, then surgery
stage 4 --> palliative care
120
(PPP)
| what infectious pathogen causes whooping cough?
aka pertussis
| Bordatella pertussis
a gram negative coccobacillus
121
(PPP)
| how do we diagnose pertussis (whooping cough)?
clinically -
-but-
order both throat culture and PCR
lymphocytosis common
122
(PPP)
| how do we treat pertussis (whooping cough)?
supportive treatment
- O2
- nebulizers
- mechanical vent as needed
abx to decrease contagiousness
- macrolides (azithromycin, erythromycin)
123
(PPP)
| how is tuberculosis diagnosed?
CXR (often initial test)
- reactivation --> apical fibrocavitary disease MC
- primary --> middle/lower lobe consolidation
- miliary --> 2-4 mm millet-seed-like nodular lesions
124
(PPP)
| how is tuberculosis treated?
RIPE = Rifampin, Isoniazid, Pyrazinamide, Ethambutol
RIPE for 2 months
RI for 4 months after that
125
(PPP)
| what is the treatment of cardiac tamponade?
immediate PERIDCARDIOCENTESIS to remove the pressure
| volume resuscitation and pressor support if needed
126
what is the primary cause of ARDS?
sepsis
| from the "mid-term exam"
127
(RR)
| what is the first line vasopressor or inotropic agent of choice for cardiogenic shock?
NOREPINEPHRINE
although norepi acts primarily on the vasculature to increase vascular tone, it is still the first recommended agent for cardiogenic shock
128
(RR)
| most common valve affected by IV drug use in terms of infectious endocarditis
```
tricuspid valve
(it's the first valve the pathogens meet after they are introduced via nonsterile injection techniques)
```
129
(RR)
| how does acid-base physiology present for COPD exacerbation?
ACUTE-ON-CHRONIC HYPERCAPNIA
ACUTE RISE IN PaCO2 ON TOP OF A CHRONIC RESPIRATORY ACIDOSIS WITH METABOLIC COMPENSATION
130
(RR)
| in pure chronic hypercapnia, what happens to the pH, bicarb, PaCO2?
pH will be only slightly acidic (often falling in normal range due to compensation)
THE BICARB WILL INCREASE BY 1 FOR EACH 10 MM Hg OF PaCO2
131
(RR)
| two features of acute respiratory failure in terms of respiratory acidosis
```
PaCO2 is elevated (>45 mmHg)
accompanying acidemia (pH < 7.35)
```
132
(RR) Respiratory Acidosis
| what are three features of chronic resp acidosis (such as COPD or obesity hypoventilation syndrome)?
1 - PaCO2 is elevatd (>45 mm Hg)
2 - normal or near-normal pH (pH ~ 7.4, renal compensation)
3 - elevated serum bicarb (>30 mEq/L)
133
(RR) Resp Acidosis
| what are two physiologic compensations for resp acidosis?
1 - CELLULAR BUFFERING
(occurs over minutes to hours, 1mEq/L for each 10 mm Hg increase in PaCO2)
2 - RENAL COMPENSATION
(occurs over 3-5 days, 3-5 mEq/L for each 10 mmHg increase in PaCO2, excretion of carbonic acid, bicarb reabsorption)
134
(RR)
| what does the FROM JANE acronym stand for, in terms of infectious endocarditis?
Fever
Roth spots (in the eye)
Osler nodes (hands)
Murmur
JANEway lesions
Anemia
Nail bed hemorrhage
Emboli
135
(RR)
| how is the diagnosis made for a patient presenting with aortic dissection symptoms?
CT ANGIOGRAPHY OF AORTA IS PREFERRED IMAGING MODALITY
| diagnosis is made via imaging studies, CT angiography is the preferred modality
136
(RR)
| what is the treatment for proximal aortic dissections?
medical and surgical management:
AGGRESSIVE BLOOD PRESSURE CONTROL with BB such as ESMOLOL
(if bp is not controlled, then add vasodilators such as nicardipine or NITROPRUSSIDE)
137
(RR)
"why is lowering the heart rate, not only the blood pressure, also an important step in the management of aortic dissection?"
"lowering the heart rate in aortic dissection decreases the potential propagation of the dissection flap by decreasing the shearing forces"
138
```
(RR)
a pt is found to have a low pitched rumbling diastolic apical murmur. Which of the following is the most frequent presenting complaint associated with this murmur?
a) chest pain
b) dyspnea with exertion
c) hemoptysis
d) palpitations
```
B) DYSPNEA WITH EXERTION
139
(RR)
| Mitral stenosis is characterized by what?
```
LEFT VENTRICULAR INFLOW OBSTRUCTION
resulting in
LOW PITCHED
RUMBLING
DIASTOLIC
APICAL MURMUR
```
140
(RR)
| what is the most common cause of mitral stenosis worldwide?
rheumatic heart disease
141
(RR)
| what is the most common presenting complaint for mitral stenosis, found in up to 70% of patients?
DYSPNEA WITH EXERTION
142
(RR)
| "How does mitral stenosis result in hoarseness?"
"Left atrial enlargement can cause compression of the recurrent laryngeal nerve resulting in hoarseness."
143
(RR)
| What does mitral stenosis sound like upon auscultation?
LOUD S1 (although intensity diminishes as disease progresses)
OPENING SNAP
LOW-PITCHED
RUMBLING DIASTOLIC APICAL
murmur
144
```
(RR)
LOUD S1 (although intensity diminishes as disease progresses) OPENING SNAP LOW-PITCHED RUMBLING DIASTOLIC APICAL murmur
```
MITRAL STENOSIS
145
(RR)
| how do you distinguish tricuspid regurgitation from mitral regurgitation?
by the Carvallo Sign - a pansystolic murmur becomes LOUDER DURING INSPIRATION
this feature makes it tricuspid regurgitation
146
(RR)
| what is a common cause of tricuspid regurgitation?
```
FUNCTIONAL OVERLOAD (such as pulmonary hypertension, RV dilation), or
STRUCTURAL LEAFLET ABNORMALITIES (endocarditis, Ebstein anomaly)
```
147
(RR)
| what valve is most often effected by IV drug use?
TRICUSPID REGURGITATION
"Tricuspid regurgitation can result from seeding of the tricuspid valve w/ bac as seen in endocarditis, creating vegetations that render the valve leaflets incompetent. This is usually due to intravenous drug use..."
148
(RR)
| "what is the most common cause of right heart failure?"
"left heart failure"
149
(RR)
| what are physical exam findings for tricuspid regurgitation?
JVD
BLOWING HOLOSYSTOLIC MURMUR best heard at the LEFT STERNAL BORDER that becomes LOUDER WITH INSPIRATION
150
(RR)
| what is the one most common cause for tricuspid regurgitation?
RV DILATION
"most commonly caused by RV dilation"
151
(RR)
| what are three physical exam findings that suggest CHF?
PRESENCE OF A THIRD HEART SOUND OR S3 GALLOP
HEPATOJUGULAR REFLUX
JUGULAR VENOUS DISTENTION
152
(RR) BUZZWORDS
| S3 gallop
CHF
"Jugular venous distention is seen in congestive heart failure, but has a lower likelihood ratio than an S3 gallop."
153
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(RR)
"You are concerned with hearing a new diastolic, rumbling murmur in one of your pts. This murmur is best heard with the bell of the left sternal border at the fourth intercostal space and is louder during inspiration. Which of the following is the most likely diagnosis?
a) aortic regurgitation
b) aortic stenosis
c) tricuspid regurgitation
d) tricuspid stenosis"
```
D) TRICUSPID STENOSIS
154
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| how do you describe tricuspid stenosis sounds?
DIASTOLIC RUMBLE
LOUDER THAN MITRAL STENOSIS DURING INSPIRATION
(this is a rare murmur)
155
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| "Tricuspid stenosis rarely occurs......
...alone, and almost always occurs with mitral stenosis..."
156
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| "what is rheumatic heart disease (also known as rheumatic fever)?"
"An antibody-cross reactivity inflammatory disease which follows Streptococcus pyogenes infection and causes heart (myocarditis), joint, skin and brain inflammation, most commonly occurring in 6-15 year olds."
157
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(RR)
"In normal hearts, which of the following heart valves is composed of two cusps?
a) aortic
b) mitral
c) pulmonic
d) tricuspid"
```
B) MITRAL
158
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| "Third degree, or complete, heart block is characterized by....
...absent conduction of all atrial impulses and complete electrical AV dissociation."
159
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| what are the hallmark findings of third degree AV heart block?
"REGULAR PP INTERVALS UNRELATED TO REGULAR R-R INTERVALS with P WAVES THAT APPEAR TO MARCH THROUGH THE QRS-T COMPLEXES."
160
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| what is HBsAg? What does it tell us about hepatitis infection?
Hepatitis B surface Antigen
"When a patient has immunity due to vaccination, the HBsAg will be NEGATIVE since they are not acutely or chronically infection"
161
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| what is HBc? What does it indicate for hepatitis infection?
Hepatitis B core antibody
"The anti-HBc will be negative as they have not had a previous or an active infection"
162
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| what is HBs? What does it mean for hepatitis infection?
Hepatitis B surface antibody
"the anti HBs will be positive if a person was immunized against the virus by a vaccination"
163
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| What combination of hepatitis B serologic markers is indicative of hep B immunity secondary to vaccination?
HBsAg negative
anti-HBc negative
anti-HBs positive
164
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| "What does the HBeAg serologic marker for hepatitis B indicate?"
"Replication and infectivity. Its presence represents high levels of DNA in the serum and higher rates of transmission."
165
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| "A first degree AV block is characterized by ___________
"a long PR interval (>200 ms)"
166
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| "A prolonged PR interval is a sign of _____
...A DELAYED CONDUCTION AT THE AV NODE BEFORE VENTRICULAR DEPOLARIZATION"
167
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| "What is the best management of first degree atrioventricular block?"
"No treatment is necessary"
168
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| for first degree heart block, what will the PR interval be?
>0.20 s (200 msec)
169
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| Where is the aortic valve best appreciated?
THE RIGHT SECOND INTERCOSTAL SPACE JUST LATERAL TO THE STERNUM
170
(SmartyPance)
| "compare the timing of aortic valve murmurs"
AR MS --> diastolic murmurs
(Aortic Regurg Mitral Stenosis)
AS & MR --> systolic murmurs
(Aortic Stenosis Mitral Regurg)
171
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| what does aortic stenosis show on physical exam?
CRESCENDO-DECRESCENDO systolic murmur that
RADIATES TO THE CAROTIDS
PARADOXICALLY SPLIT S2, S4 GALLOP
172
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| "what is the most common sequela of mitral stenosis?"
"atrial fibrillation"
"increased atrial irritability and hypercoagulability associated with pregnancy combined with increased left atrial pressure, increase the risk of atrial fibrillation and left atrial thrombus formation"
173
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| what is a common historical finding of rheumatic fever?
GAS infection
174
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| "what ECG finding has the highest likelihood ratio for the diagnosis of heart failure?"
"ATRIAL FIBRILLATION"
175
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| acute decompensated heart failure - what is a key lab finding, i.e. what lab will be increased?
BNP will be increased
176
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| what is a type A aortic dissection?
it involves the ASCENDING AORTA
and it is a SURGICAL EMERGENCY
177
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| what is a Stanford Type B aortic dissection?
involves only DESCENDING AORTA
178
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| what are five components to managing aortic dissection?
1 - reduce bp to lowest tolerable level
2 - reduce HR <60bpm
3 - intravenous beta blockers (esmolol, labetalol, propanol)
4 - nitroprusside (only after HR s controlled)
5 - pain control
179
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| "Why is lowering the heart rate, not only the bp, also an important step in the management of aortic dissection?"
"lowering the heart rate in aortic dissection decreases the potential propagation of the dissection flap by decreasing the shearing forces."
180
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| what does CXR show in an aortic dissection?
a widened mediastinum
181
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| what is the most common type of cardiomyopathy?
dilated cardiomyopathy
| PE will show a S3 gallop
182
(SmartyPance)
| define angina
CHEST PAIN OR DISCOMFORT, heaviness, pressure, squeezing, tightness that is INCREASED WITH EXERTION OR EMOTION
183
(SmartyPance)
| define stable angina
PREDICTABLE
| RELIEVED BY REST AND/OR NITRO
184
(SmartyPance)
| what is the treatment for stable angina?
BB
nitro
(if severe --> angioplasty and bypass)
185
(SmartyPance)
| what is the treatment for unstable angina?
pain control w/ nitro and morphine
IV access, O2
ASA, clopidogrel, BB (first line)
LMWH
(MONA --> morphine, oxygen, nitro, ASA)
admit to cardiac unit
186
(SmartyPance)
| what is Prinzmetal variant angina?
CORONARY ARTERY VASOSPASMS causing transient ST SEGMENT ELEVATIONS, NOT ASSOCIATED WITH A CLOT
187
(PPP 53)
| how do we treat Prinzmetal variant angina?
once dx is made,
CCB (1st line)
nitro (2nd line)
avoid BB
188
(RR)
According to The Coronary Vasomotion Disorders International Study group, what are the three main criteria for diagnosis of Prinzmetal angina?
1 - nitrate-responsive anginal episodes either at rest, with diurnal characteristics, or precipitated by hyperventilation,
2 - transient ischemic EKG changes during the pain
3 - proof of transient coronary artery spasm
189
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| when are Prinzmetal angina attacks most common?
at night and at rest
190
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| how do you distinguish between L and R BBB?
WiLLiaM MaRRoW in V1 and V6
W in V1 and M in V6 = LBBB
M in V1 and W in V6 = RBBB
191
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| new LBBB + chest pain = ______ until proven otherwise
MI
new LBBB + chest pain = MI until proven otherwise
192
(RR)
| "What are causes of left bundle branch block?"
"Myocardial ischemia,
myocardial infarction or myocarditis,
but most often is caused by DEGENERATION OF THE CONDUCTION SYSTEM with age."
193
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A 65 y/o asymptomatic man is noted to have a murmur on cardiac auscultation. What findings are suggestive of chronic mitral regurgitation?
a HOLOSYSTOLIC MURMUR WITH RADIATION TO THE AXILLA
194
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| mitral regurg has what two forms?
acute and chronic
195
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| what causes acute mitral regurg?
sudden rupture of chord tendineae or acute papillary muscle dysfunction from cardiac ischemia
(this is an emergency!)
196
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| what is chronic mitral regurg?
gradual loss of competence of mitral valve
| more common than acute
197
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| what are the characteristics of chronic mitral valve regurgitation?
holosystolic murmur at the apex which radiates to the axilla
198
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| how do we make diagnosis of mitral valve regurg?
echocardiogram
199
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| how do we treat acute mitral valve regurg?
nitroprusside
dobutamine
intra-aortic balloon pump
emergency surgery
200
(RR)
| how do we treat chronic mitral valve regurg?
anticoagulation
CHF Rx
valve repair or replacement
201
(RR)
| where are aortic valve murmurs best auscultated?
right
2nd intercostal space, just lateral to the sternum
202
(RR)
| where are pulmonic valve murmurs best auscultated?
on the LEFT
2nd intercostal space, just lateral to the sternum
203
(RR)
| where are tricuspid valve murmurs best auscultated?
on the LEFT
4th-5th intercostal space over LEFT sternal border
204
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| where are mitral valve murmurs best auscultated?
LEFT
5th intercostal space, midclavicular line (APEX)
205
(RR)
"a 32-year old man presents to the emergency department with palpitations and occasional non-exertional chest pain. Physical exam reveals a tall, thin man with pectus excavatum. A late systolic murmur with a midsystolic click is heard on auscultation. Which of the following maneuvers will result in movement of the click later into systole?
a) inspiration
b) squatting
c) standing
d) Valsalva"
"B) SQUATTING"
"maneuvers that increase preload, such as squatting, or afterload, such as hand grip, move the click later in systole"
206
(RR)
| what kinds of maneuvers move the midsystolic click of mitral valve prolapse EARLIER into systole?
MANEUVERS THAT DECREASE PRELOAD, SUCH AS VALSALVA AND STANDING
"The midsystolic click is moved earlier in systole by maneuvers that decrease preload, such as Valsalva and standing."
207
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| what kinds of maneuvers move the midsystolic click of mitral valve prolapse LATER into systole?
MANEUVERS THAT INCREASE PRELOAD
"Maneuvers that increase preload, such as squatting, or afterload, such as hand grip, move the click LATER in systole."
208
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| what causes mitral valve prolapse?
myxomatous degeneration of the valve
("most common cause of primary valvular disease in industrial countries")
(I'm not sure what myxomatous means...something to do with the Greek word for mucus?)
209
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| what happens to the pulse pressure with aortic regurgitation?
WIDE PULSE PRESSURE
"Aortic regurgitation occurs when valve leaflets fail to close fully, causing blood to flow from the aorta back into the left ventricle during diastole. Increasing stroke volume followed by a rapid pressure drop during diastole results in a WIDE PULSE PRESSURE."
210
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| what are s/s of atypical pneumonia?
(aka "walking pneumonia")
no signs of lobar consolidation
presence of extrapulmonary symptoms
pt "looks better" than clinical picture
211
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| what is the treatment for atypical pneumonia?
tetracyclines (doxy, tetracycline)
macrolides (azithromycin, clarithomycin)
FQ's
212
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| how do pts present for atypical pneumonia?
gradual onset of dry cough, dyspnea, extrapulmonary symptoms such as HA, myalgias, fatigue, GI disturbance
213
(RR)
| medications of choice for hypertensive emergency (mod to severe HTN w/ evidence of end-organ damage)?
nicardipine and labetalol
214
(RR)
match the drug of choice for the following hypertensive emergencies:
acute MI - ?
aortic dissection - ?
eclampsia - ?
acute MI - nitro
aortic dissection - esmolol
eclampsia - mag sulfate, hydralazine
215
(RR)
| what are the goals of Hypertensive Emergency treatment?
"gradually reduce MAP by ~10-20% in the first hour and by a further 5-15% over the next 23 hours"
216
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| define MAT
irregular rhythm resulting from at least three different atrial foci
therefore, the EKG shows three different P wave morphologies
rate is about 100-180
217
(RR)
| treatment for MAT
supportive care directed toward underlying cause
218
(RR)
| "what is considered safe time period for cardioversion in new-onset atrial fibrillation or atrial flutter?"
"48 hours"
219
(RR)
| what kind of murmur is associated with hypertrophic obstructive cardiomyopathy?
holosystolic murmur heard best at APEX and LLSB that radiates to the suprasternal notch and DECREASES WITH MANEUVERS THAT INCREASE CARDIAC PRELOAD SUCH AS SQUATTING
220
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| what are the EKG findings usually associated with hypertrophic obstructive cardiomyopathy?
tall R and S waves associated with LVH, and
| deep, DAGGER-LIKE Q WAVES IN INFERIOR AND LATERAL LEADS
221
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| treatment of pertussis?
azithromycin (macrolide)
| although TMP-SMX may be used in macrolide-intolerant patients
222
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| if a patient has pertussis, and a glucose 6-phosphate dehydrogenase deficiency, what treatment should be chosen?
azithromycin
| TMP-SMX is contraindicated in pts with glucose 6-phosphate dehydrogenase deficiency b/c it causes hemolysis
223
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| EKG findings suggestive of PE
S wave in Lead I
Q wave in Lead III
flipped T wave in Lead III
this is called the "S1-Q3-T3 pattern"
224
(RR)
| what is the treatment for unstable pulmonary embolism? stable pulmonary embolism?
Hemodynamically unstable pts are treated with THROMBOLYSIS.
Stable pts are treated with HEPARIN.
225
(RR) BUZZWORDS
| Hamptonhump
CXR abnormality of "pleural-based wedge infarct" indicating
| PE
226
(RR) BUZZWORDS
| Westermarksign
CXR abnormality of "vascular cutoff sign" indicating
| PE
227
(RR)
| EKG findings of Wolff-Parkinson-White
shortened PR interval with a slurring of the QR or R segment of the QRS segment known as the "DELTA WAVE"
228
(RR)
| what are the only two appropriate treatments of WPW reentrant tachycardia
procainamide and cardioversion
229
(RR)
| "what is the most common location for a AAA?"
"below the level of the RENAL ARTERIES (infrarenal)"
230
(RR)
| how do we diagnose AAA?
U/S
231
(RR)
| risk factors for AAA
male sex
older patients
smoking
HTN
232
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(RR)
"which of the following pt hx elements is most indicative of cardiac syncope?
a) absence of a postdrome
b) postevent confusion
c) prodrome with dizziness and nausea
d) provocation with prolonged standing"
```
A) ABSENCE OF A POSTDROME
233
(RR)
| true cardiac etiologies typically have no _______
harbingers or postepisode symptomatology
234
(RR)
| "patients with what medical conditions have a high likelihood of dysrhythmia as a cause of syncope?"
"structural heart disease (e.g. cardiomyopathy, aortic stenosis) and heart failure"
235
(RR)
"A 71-year-old woman presents with exertional dyspnea. A murmur is heard on cardiac auscultation. She reports a hx of acute rheumatic fever as a child. Which of the following murmurs suggests a diagnosis of mitral stenosis?
a) continuous, machine-like murmur
b) harsh systolic murmur radiating to carotids
c) high-pitched apical holosystolic murmur
d) mid-diastolic rumbling murmur"
D) MID-DIASTOLIC RUMBLING MURMUR
| mitral stenosis is a diastolic murmur! and I guess it rumbles...
236
(RR) BUZZWORDS
| waterbottle shape of cardiac outline
cardiac tamponade/pericardial effusion
237
(RR)
| what happens to the EKG if pericardial effusion progresses to cardiac tamponade?
electrical alternans -
| - - > alternating high and low QRS complex amplitudes between beats
238
(RR)
| "What is Beck's triad?"
"hypotension with a narrowed pulse pressure,
JVD,
distant heart sounds,
all symptoms associated with acute cardiac tamponade"
239
(RR)
| what are three most common causes of pleural effusion in developed countries?
pneumonia
malignancy
CHF
240
(RR)
| what LDH values suggest EXUDATIVE pleural effusion?
pleural fluid LDH twice that of serum LDH
241
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| two adverse effects of ethambutol
optic neuritis
| red-green color blindness
242
(RR)
| which TB drug requires supplementation with a certain vitamin...and what is the vitamin?
ISONIAZID
Pyridoxine (Vit B6)
243
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| "what are the options for outpt anticoagulation for atrial fibrillation?"
"warfarin or
| new oral anticoagulant drugs (e.g. dabigatran, rivaroxaban, apixaban)"
244
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| AAA's are frequently misdiagnosed b/c they present with symptoms consistent with _____
RENAL COLIC
"the combination of back and abdominal pain should prompt the consideration of AAA in all patients"
245
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| what is the AAA triad?
abdominal pain
hypotension
pulsatile abdominal mass
246
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| how long is a prolonged PR interval?
>.20 seconds (or >200 msec)
247
(RR)
| what are two characteristics of First Degree Heart Block?
rhythm will be regular
PR interval will be >0.20 seconds (or >200 msec)
248
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| what can abnormal EKG changes, including sinus tach, widened QRS intervals, regional ST segment elevations indicate?
myocarditis
249
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| what does physical exam show for myocarditis?
tachycardia disproportionate to fever or discomfort
250
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| what are "grouped beats" of the heart and what does it indicate?
"clustering of QRS complexes separated by a pause from a dropped beat. This is known as grouped beating and is characteristic of SECOND-DEGREE MOBITZ TYPE I AV BLOCK"
It's prolongation of PR intervals until a beat is dropped (aka Wenckebach).
251
(RR)
in a stable SVT patient, after vagal maneuvers and a single dose of adenosine 6 mg have been attempted and fail, it is most appropriate to give what?
adenosine 12 mg IV
252
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| in a pt w/ SVT w/ abrupt onset of tachycardia who becomes unstable, what do we do?
synchronized cardioversion
| "Synchronized cardioversion as low as 50 to 100 joules may be effective"
253
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| in the setting of chest pain and elevated ST segments in V4R and V5R, what medicine is contraindicated?
NITROGLYCERIN
this is a right ventricular infarction, and pts are dependent upon preload to maintain cardiac output, so give them fluids and NO NITRO
254
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| what is the cause of the steeple sign seen on PA chest xray in croup pts?
SUPRAGLOTTIC NARROWING
255
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| treatment of acute pericarditis
NSAIDs and discharge home
add colchicine to reduce risk of recurrent pericarditis
(this may present with diffuse ST segment elevation and PR segment depression)
256
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| first-line antihypertensive med for hypertensive encephalopathy
nicardipine
(nicardipine and labetalol are meds of choice...nicardipine is a DHP CCB that is given as continuous infusion; labetalol is combined beta- and alpha-adrenergic blocker w/ rapid onset of action, so it can be given as bolus or continuous infusion)
257
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| most common group of pts who develop aortic dissection
those over 50 yrs of age w/ hx of chronic HTN
"CHRONIC HTN IS MOST COMMON AND MOST IMPORTANT PREDISPOSING RF"
