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Flashcards in firecracker 11/28 Deck (132):
1

RHF

right ventricle cannot pump blood into lungs
blood accumulates in systemic venous system

2

most common cause of RHF

left heart failure
also:
pulmonary HTN, L2R shunt, Tricuspid valve regurg

3

most common cause of RHF if no LSHF

COPD

4

cor pulmonale

rhf due to chornically elevated pulmonary artery pressures

5

RSHF symptoms

HSM
peripheral edema
jugular venous distension

6

hepatomegaly in RSHF

venous congestion of hepatic veins of liver
can cause portal htn

7

hepato-jugular reflux

pressing on RUQ elcitis distension of right jugular vein

8

peripheral edema cause

increase in venous hydrostatic pressure

9

jugular venous distension

increased venous pressure in superior venous cava
>4cm abnormal

10

severe pulmonary hypertension ECG

P pulmonale
peaked P waves >2.5 in inferior leads II, III, avf
right axis deviation
right ventricular hypertrophy

11

treatment for cor pulmonale

adequate oxygenation
correct respiratory acidosis
treat underlying infections
decrease work of breathing using positive pressure or bronchodilators

12

HIT

immune mediated reaction after exposure to heparin products
paradoxically pro-thrombotic state

13

pathophysiology of HIT

auto-antibodies to platelet factor 4:heparin complex
Ab cross react with platelets
peripheral activation (thrombosis)
and destruction (thrombocytopenia)

14

HIT risk factors

unfractionated (vs LMWH)
higher doses
female
recent surgery

15

timing of hit

5-10 days after exposure
early onset within 24 hrs if exposed to heparin in past 3 months

16

thrombocytopenia in HIT

drop in platelet count >50%

17

thrombosis in HIT

venous>arterial
skin necrosis at injection sites
limb gangrene
organ ischemia or infarction

18

4 T score of HIT

thrombocytopenia
timing
thrombosis
oTher causes not present

19

HIT diagnosis

immunoassay test anti-PF4 antibodies
serotonin release assay

20

management of HIT

stop heparin
start direct thrombin inhibitor (argatroban or bivalirudin)
fondaparinux

21

HIT - pts with renal dysfunction

argratroban

22

HIT - pts with hepatic dysfunction

fondaparinux

23

gout

deposition of monosodium urate crystals in joints

24

primary gout

hyperuricemia due to nucleic acid metabolism disorders or underexcretion of uric acid

25

secoundary gout

diseases with high metabolic turnover (leukemia, psorasis)

26

gout age groupd

men, 40-60

27

overproduction of uric acid

obesity, cancer, hemoglobinopathies

28

underexcretion of uric acid

renal disease
diuretic use

29

podagra

first metatarsophalangeal joint

30

gout diagnosis

needle shaped negatively birefringent crystals
not uric acid

31

tophi

x ray imaging that shows bony erosions and soft tissue crystal deposition

32

gout treatment

nsaids, colchicine, corticosteroids

33

chronic gout treatment

allopurinol (decrease UA production)
probenecid (inhibit renal UA reabsorption)

34

pleural effusion

collection of fluid between parietal and visceral pleura

35

causes of exudative pleural effusions

lung infections, tb
cancer
pulmonary embolism
impaired pleural lymphatic drainage

36

transudative

increased hydrosatatic pressure or decreased serum oncotic pressure

37

exudate

increased vessel permeability

38

causes of transudative pleural effusion

CHF
nephrosis, cirrhosis
injuries to pleural lining

39

injuries to pleural lining

central venous catheter misplacement

40

pulmonary emobolism - type of pleural effusion

trans or exud

41

chylous effusions

iatrogenic (surgery)
traumatic
malignant

42

pleural effusion symptoms

dyspnea
pleuritic chest pain
worsens with time
associated symptoms (night sweats, wt loss, swelling)

43

pleural effusion physical exam

decreased breath sounds
dullness to percrussion
decreased fremitus

44

pleural effusion cxr

blunting of costophrenic angle
transudative - bilateral, exudative - unilateral

45

lateral decubitus cxr

most sensitive

46

light's criteria

pleural prot/serum >.5
pleural ldh/serum ldh >.6
pleural ldh greater than 2/3 of normal serum ldh

47

treatment of parapneumonic effusions (around a pneumonia)

antibiotics if uncomplicated
chest tube drainage if complicated

48

ischemic atn most common cause

pre renal failure
- decreased effective circulating load/preload
- decreased cardiac output
- nsaids

49

DKA potassium levels

low total body levels
normal/high on labs

50

common cause of nephrotoxic ATN

aminoglycosides, amph b, cisplatinum
heavy metals, contrast, gram negative sepsis, myoglobinuria

51

meds for pts with coronary interventions

clopidogrel
gb11a/111b inhibitor

52

decreased effective circulating blood volume

hypovolemia
systemic vasodilation/septic shock
cirrhosis

53

chylous pleural effusion

iatrogenic (surgery)
traumatic
malignant

54

CXR RSHF

right ventricular enelargement
pulmonary artery dilatation

55

delta gap

AG - 12
/
24 - HCO3

56

ATN - ischemic and nephrotoxic have in common...

disturbances in renal blood flow
tubular injury

57

RSHF echo

tricuspid regurg
paradoxical displacement of IV septum into LV during systole

58

agents that cause CAP

streptococcus pnemoniae
haemophilus influenzae
klebsiella pneumonia
pseudomonas aeruginosa
staphylococcus aureus

59

most common cause of pneumonia

streptococcus pneumoniae

60

risk factors for streptococcus pneumoniae

smoking
copd
immunocompromised

61

H influenzae risk factors

sickle cell dz
copd, smoking
immunocomprimised
alcoholism, diabetes

62

klebsiella risk factors

alcoholics, strokes, elderly, decreased LOC

63

pseudomonas risk factors

structural lung dz: bronchiectasis, cystic fibrosis, copd
hosp or nursing home residents
pts who have received broad spectrum antibiotics or high dose steroid therapy

64

s. aureus risk factors

recent flu or viral illness
skin colonization or staph infection
laryngeal cancer
immunosuppressoin

65

pseudomonas treatment

piperacillin/tazobactam
cefepime
imipenem
meropenem + fluroquinolone

66

symptoms for pneumonia

increased tactile fremtius
dullness to percussion
pleural friction rub

67

atelectasis is

decrease in lung volume secondary to partial collapse of lung tissue

68

atelectasis caused by

operations, impaired inspiratory ability, lack of cough reflex, obstructions/tumors, foreign body in children

69

resorption atelectasis

airway obstructed by foreign object, tumor or thick mucus plug
devoid of lung sounds

70

compression atelectasis

space occupying lesion in pleural caivty (air or fluid) increases pressure

71

atelectasis symptoms

dyspnea, fever
pleuritic chest pain
tachycardia, hypoxia

72

atelectasis physical exam

dullness to percuss
decreased breath sounds
crackles on ausuclation

73

atelectasis CXR

raised diaphram in lower lobe atelectasis
tracheal deviation towards atelectasis in upper lobes
fluffly infiltrates

74

atelectasis treatment

incentive spirometry
deep breathing
ambulation
(bronchoscopy)

75

atelectasis complications

damange to lung parenchyma
pneumonia
resp failure

76

maintaining body ph

bicarbonate buffer in ECF
proteins and phosphates in ICF

77

phosphate regulation

PTH decreases
insulin lowers
vit D increases

78

signs of pulmonary emoblism - later

resp alkalosis with hypoxia, hypocarbia
loud p2
right heart failure

79

unstable angina

1) chest pain at rest >10 min
2) severe and new onset
3) cresendo pattern

80

most common cause of UA/NSTEMI

rupture of coronary artery plaque --> down stream occlusion

81

unstable angina cause

incomplete stenosis or presence of well-perfused collaterals

82

st depression

subendocardial ischemia

83

NSTEMI vs UA

elevations in cardiac enzymes in NSTEMI

84

pts w/ UA/NSTEMI admit

- telemetry
- serial cardiac enzymes
- possible coronary angiography if indicated

85

Thrombolysis Infarction Risk score

>/= 3 consider LMWH, angiography
Severe angina, coronary artery stensosi >50%, age >65, aspirin use within past 7 days, three or more Risk factors for cad, enzymes elevated, ST segment changes

86

cardiac stress test

- diagnose ischemic heart disease

87

cardiac stress test, how test is performed

exercise --> increase cardiac oxygen demand
dobutamine -- cardiac INOTROPE

88

stress test with adenosine or dipyridamole

coronary vasodilators
stenotic vessels will dilate less
blood flow through stenotic vessels will be decreased and those tissues will get less oxygen --> "cardiac steal"

89

pre test probability of coronary artery disease

age
sex
typical/definitive AP vs atypical probably AP
nonagnial chest pain

90

high probability patients

more likely to have false negative

91

diagnostic testing for CAD warranted in

pts with symptoms of CAD
asymptomatic pts with high pre test CAD probability
pts with newly diagnosed heart failure

92

asymptomatic pts who should undergo stress testing

>20% 10-year CAD risk
exercise ECG

93

symptomatic pts with low or intermediate pre-test probability

if able to exercise and have interpretable ECG --> undergo stress exercise testing

94

test of choice for symptomatic pts unable to exericse or uninterpretable ECG

stress radionuclide imaging or echo

95

stress cardiac mri

symptomatic high pre test

96

symptomatic pt with high pre test probability should receive

stress radionucleide imaging, stress echo, stress MRI, or coronary angiography
not exercise ecg

97

newly diagnosed CHF pts

evaluated similarity to symptomatic with high pre test probability

98

exercise stress test that diagnose coronary artery stenosis show

greater than 2mm ST segment depression
greather than 10mmhg drop in systolic blood pressure

99

drugs that should be held before exercise stress test

beta blockers, non-dihydropyridine calicum channel blockers
certain antiarrhthm - amiodaraone, sotalol
digoxin, nitrates

100

exercise stress testing contraindicated in

unstable patients
patients who cannot exercise
patients with uninterpreable EKGs

101

nuclear stress testing

thallium
accumulates in well-perfused heart tissue
approriate in pts with baseline EKG abnormalities

102

coronary angiography

most sensitive and specific for CAD
allows immediate intervention (stent placement)

103

A fib

signal from SA node is overwhelmed by disorganized signals from other areas
myocytes contracting at different times

104

most important risk factor for A fibrillation

mitral valve stenosis

105

A fib incidence increases with

age

106

atrial rate vs ventricular rate

500bpm vs 120-180

107

A fib symptoms

palpitations
exercise intolerance
venous statsis --> SOB, edema

108

A fib EKG/PE

>100 bmp
irregularly regular rhythm with ventricular rate >100 bmp
absence of p waves
narrow QRS complexes

109

lab tests for A fib

renal function
electrolytes
TSH
CBC

110

complications of a fib arise from

reduced CO
increased cardiac oxygen demand
thromboembolism

111

A fib - blood remains

in atrium, may lead to clot --> emoblic event --> stroke

112

increased cardiac oxygen demand

can lead to MI

113

reduced cardiac output can lead to

CHF symptoms like pulmonary or lower leg edema

114

treatment of a fib - ventricular rate

beta blocker, calcium channel blocker

115

chemical cardioversion of a fib

class IC (propafenone, flecainide)
class III (ibutilide, dofetilide > amiodarone, sotalol)

116

electric cardioversion in afib

delivery of DC synchronized with QRS complex

117

CHADS

CHF, HTN, Age > 75 (2 pts)
DM
Previous stroke or TIA (2)

118

VASC

vascular dz
age >65 but less than 75
sex cateogry - female

119

anticoagulation with a fib

warfarin
dabigatran

120

warfarin causes prolongation of

PT/INR, aPTT

121

a fib rate control

class II (BB)
class IV (CCBs)

122

ventricular rate ontrol

slows conduction from fibrilating atria to ventricles
pts >65

123

rhythm control

propafenone, dofetilide, amiodarone
alter cardiac potential

124

CHADSVASC of 1

aspirin

125

CHADSVASC of 2

anticoagulation

126

TTP and HUS characterized by

microangiopathic hemolytic anemia
+
thrombocytopenia

127

TTP vs HUS

neuro symptoms - TTP
renal symptoms - HUS

128

TTP/HUS pentad

F - fever
A - micoangiopathic anemia
T - thrombocytopenia
R - acute kidney injury
N - neuro abnormalities (AMS)

129

MAHA

non-immune hemolysis
RBC fragmentation = schitocytes

130

TTP/HUS associated symptoms

bloody diarrhea ( e coli 0157h7)
pregnancy
meds - mitomycin C, cyclosporine, gemcitabine

131

lab studies for TTP/HUS

schistocytes
elevated LDH
decreased haptoglobin
<10% ADAMTS13

132

TTP/HUS treatment

plasma exchange
normalize platelet count, LDH level