Flashcards in Firecracker/Qbank Deck Number Three Deck (242):
transudative or exudative fluid in pericardial sac
SLE, viral, autoimmune, RA, uremia
underlying uremia, MI, acute rheumatic fever, or radiation injury
tubercular pericarditis in endemic regions
sudden onset of chest pain
worse with inspiration
better with leaning forward
pericarditis, pain can radiate to
pericarditis - PE
distant heart sounds
large pericardial effusion compression LLlobe, bronchial breath sounds at left inferior scapular angle
pericarditis - ECG
global st segment elevation
low voltage and elctrical alterans
pericarditis - c xray
can have enlarged cardiac silhouette with >200 cc
purulent pericarditis treatmetn
drainage via subxiphoid pericardial windowing/pericariectomy
location of MR murmur
nitroglycerin mechanism of action
dilation of capacitance vessels
decrease ventricular preload
drugs to hold prior to stress testing
BB, CCB, nitrates
test for suspected aortic dissection
cardiac sound that can be heard during acute phase of ACS
EKG - post mi
PVC (wide qrs)
coronary artery disease
narrowing of arteries
mismatch in myocardial oxygen supply and demand
CAD modifiable risk factors
tobacco, HTN, sedentary lifestyle, obesity, DM
CAD nonmodifiable risk factors
family hx (less than 55 in men, less than 65 in women)
initial lesion of takayasu arteritis
proximal 2/3 of left subclavian artery
takayasu early symptoms
constituation - fatigue, wt loss
articular - juvenile idiopathic arthritis
dermatologic - similar to erythema nodosum/pyoderma gangrenosum
cardiac ausculatation of takayasu
diastolic murmur of AR
takayasu lab findings
elevated inflamm markers
MTX, AZA, DMARDs
side effects of diuretics?
myocarditis PE findings
S3 or S4 heart sound as signs of ventricular dysfunction
If severely dilated, murmurs of either tricuspid or mitral insufficiency may be present
Pericardial friction rub may be present with myopericarditis.
Edema of the extremities, dull breath sounds at the bases of the lung, and increased JVP may all be present as signs of heart failure due to dilated cardiomyopathy and ventricular dysfunction.
myocarditis chest xray
cardiomegaly with or without marked pulmonary vascular markings and edema.
side effect of IFN
symptoms associated with viral myocarditis
heart failure and dilated cardiomyopathy with fatigue, dyspnea, and decreased exercise capacity being the first signs and symptoms.
drugs that can cause myocarditis
What sequelae are associated with stage 2 of lyme disease?
Cardiac involvement (most commonly myocarditis and AV block)
causes of a hemothorax
backflow of blood into LA from LV during systole
MR caused by disease that dilate LV
aortic stenosis, aortic regurg
drugs that can cause MR
radiates to the axilla
MR EKG findings
notched P waves
also seen in mitral stenosis
other heart sounds with MR
- widely split S2
aortic valve closing before pulmonic valve
medical management of symptomatic MR patients - goal
medical management of MR - how to reduce afterload
nitrates (also reduce preload)
blood into LV from aorta during diastole
acute AR cause
damage to valve - endocarditis, rheumatic fever
aortic dissection, trauma
chronic AR cause
dilation of aortic root: CTD, symphilis, aging
acute AR symptoms
chronic AR symptoms
can be asymptomatic until they can no longer compensate and get LSHF
AR exacerabted by
- high salt diet
enhanced by leaning forward
AR 2/2 valvular insuff
left sternal border at the third or fourth interspace
AR 2/2 aortic root diltation
right sternal border or the apex
low-pitched mid- to late-diastolic rumble best heard at the apex observed in severe regurgitation which results from turbulence of the anterograde stream from the left atrium competing with retrograde flow across the insufficient aortic valve.
ST depression at rest/exercise
chronic AR heart sound
goal of AR medical management
treatment for acute decompensated AR
surgery for replacement
IV afterload reduction - nitroprusside + inotropes (dobutamine)
medical management for which AR pts
chronic, asymptomatic, EF >50%
vasodilators, low salt diet, diuretics, CCB
late presentation of aortic coarctation
Aortic coarctation - blood pressures
HTN in UE
hypotension in LE
Aortic coarctation - ECG
acute limb ischemia treatment
IV heparin + embolectomy
syncope due to bradycardia, look for
prolonged PR or QRS
low dose ASA
HCM mitral valve
systolic antermior motion
most common liver mets
porcelin gallbladder - risk for
NAFLD most likely due to
acute bleeding in liver failure treatment
amebic liver mass treatment
fulminant hep failure - def
hep encephalophy within 8 weeks
chronic constrictive pericarditis
chronic inflamm process involing pericardial space --> consolidation, scarring
dysfunction w/ constrictive pericarditis
constrictive pericarditis - clinical picture
symptoms of decrease CO and increase systemic venous pressure
- fatigue, hypotension, reflex tachy
- JVD, HSM, ascites, edema
constrictive pericarditis can be mistaken for
constrictive pericarditis PE
early diastolic knock, friction rub
neck vein distention with inspiration
constrictive pericarditis CT
thicken pericardium >2mm
confirmation of constrictive pericarditis
rapid early diastolic filling
prominent y descent on RAP tracing
constrictive pericarditis with calcifcation of pericardial space
accompanied by early diastolic knock
untreated chronic constrictive pericarditis
rise in systemic pressue
constrictive pericarditis treatment
surgical removal of pericardium
causes of constrictive pericarditis
black / dark pigmented liver
blood contains large amounts of proteins insoluble at cold temps
associated with Hep C, MM
heb B virus type
antigen associated with hep b infectivity
Surface antigen, indicates active infection or carrier state (HBsAg: virus is preSent)
Antibody against core antigen. Critical for diagnosis during the window phase, when HBsAg is absent but HBsAb isn't detectable yet. Doesn't confer immunity.
Core antigen. Presence indicates transmissibility (HBeAg=rEplication)
Antibody against HBeAg, indicates low transmissibility
chronic Hep B infection
greater than 6 months
inactive Hep B carriers
Prior HBV infection
anti-HBs (IgG) and anti-HBc (IgG)
+ anti-HBs AB
treatment of Hep B in unvaccinated pts
immedate Hep B vaccine + Hep B IG following expsoure
chronic active Hep B treatment
gastrinoma stomach biopsy
multiple stomach ulcers + thickened gastric folds
diagnosis of gastrinoma
fasting gastrin level >1000
if less than 1000, do secretin stimulation test
vit d def lab values
decrease Ca + Phosphate
disseminated gonogoocal infection triad
painless skin lesions
increased homocysteine treatment
pyridoxine and folate
increased homocystine predisposes to
massive PE echo findings
acute RV dilation and ventricular hypokinesis
vasovagal maneuvers in SVT - mechanism
increase vagal tone
decrease conductivity thru AV node
systemic scleroderma antibody
2nd amyloidosis treatment and prophylaxis
2ndry amyloidosis causes
inflamm arthritis, IBD, chronic infections, malignancy, vasculitis
complications of untreated gonorrhea in females
diagnosis of gonorrhea
gram stain of urethra discharge
resp acidosis defined as
ph <7.37 with increase in pco2
cause of resp acidosis
- CNS depression
- neuromuscular failure
- decreased resp system compliance (restrictive lung dz)
- increased airway resistance (obstrutive lung dz)
- increased dead space
resp acidosis treatment symptoms
bicarb given in pure resp acidosis?
hco3 + H -> co2 + h2o
causes of resp alkalosis
- cns stimulation
resp alk general values
compensate with decreased hco3 reabsorp
increased pH can cause
resp alkalosis on ventilators
decrease their settings
- calcification of valve leafets with age
- 7th decade
aortic stenosis presenting at an early age
congenital bicuspid aortic valves
symptoms of aortic stensosis
classic syncope, angina, dyspnea
aortic stenosis can lead to what heart pathology
aortic stenosis murmur
2ICS at RSB
aortic stenosis murmur radiates to
aortic stenosis murmur decreases with
aortic stenosis - other heart sounds
weak pulse (pulsus parvus et tardus)
aortic stenosis CXR
aortic stenosis echo
increased pressure gradient (best assessed with cath)
aortic stenosis ECG
cardiac insuff in aortic stenosis
leds to ischemic heart disease, heart failure
medical management of aortic stenosis
control HTN - diuretic, ACEI
avoid vigorous activity
avoid venodilators (nitrates)
negative inotropes (CCB/BB)
aortic valve replacement
only treatment for aortic stenosis
- asymptomatic underoing cabg
- sever with systolic failure
located anteriomedial below knee
anklyosing spondylitis extra-articular finding
murmur in marfan's patients
AR --> diastolic
hypercalcemia >14 treatment
NS + calcitonin
loops only if volume overload
if chronic problem - bisphosphonates
Familial Hypocalciuric Hypercalecmia
high normal PTH
high, asymptomatic calcium
low urine calcium
viral causes of thrombocytopenia
EBV, HepC, HIV
dysphagia to solids and liquids
anti-tissue transglutaminase ab
foul smelling sputum
uncomplicated cystitis treatment
tmp smx x 3
fosfomycin x 1
complicated cystitis treatment
pyelonephritis treatment outpatient
pyelonephritis treatment inpatient
IV fluro or ceftriaxone
UTI during pregnancy, treatment
pityriasis rosea, most common in
older children + young adults
what is pityriasis rosea
acute inflamm skin dz
papular lesions on trunk, proximal areas of extremities
What typically precedes a pityriasis rosea eruption?
single round lesions
how is pityriasis rosea treated?
Recent studies have also found antiviral treatment with acyclovir to be effective in accelerating improvement.
How can pityriasis rosea be differentiated from tinea corporis?
negative potassium scrape (not fungus)
What is the typical presentation of pityriasis rosea?
pruritic, oval erythematous papules that are covered by white scale. T
less than 150,000
less than 10,000 spontaneous bleeding
less than 50,000 surgical bleeding
broad categories of thrombocytepenia due to
diagnosis of thrombocytopenia
peripheral smear to r/o pseudothrombocytopenia
TB, positive with 5+ induring
meningitis prophylaxis 2-50 yr
vanc + 3 degree cephalopsorin
meningitis prophylaxis greater than 50 yr
vanc + 3 degree cephalosporin + ampicllin
meningitis prophylaxis immunosuppresion
vanc + amp + cefepime
cryptococcal meningitis treatment
amphotericine + flucytosine
UTI - pyruia
CMV, HSV, candida
CMV colitis in AIDs pts
owl's eyes - inclusion bodys
HIV needle stick
draw serologies and start 3 drug regimen
aspergillus -- invasive
bilateral lung infiltrates
pulmonary nodule with halo sign
adverse effect of fluroquinolones
oseltamivir use within
48 hrs of symptoms
food poisoning from rice
central and southern US (ohio and miss river valleys)
nonspecific: joint pains, chest pain, etc
Nocardia - type of organism
gram positive, acid fast
tmp-smx for long duration
increased capillary permeability
lung symptoms + pain in arm
COPD air trapping during
pulmonary fibrosis, A-A gradient
increased alevolar-arterial gradient
most common cause of inherited hypercoagulability
factor V leiden
hodgkin's lymphoma treated when less than 30, at risk for
What are examples of disease states that can cause an increased A-a gradient?
R to L vascular shunts
What can cause a falsely normal A-a gradient?
definitive diagnosis of Histoplasma
tissue biopsy of lung
lymph nodes that demonstrate granulomas
splenic and liver calcifications
On microscopy, how does Histoplasma capsulatum appear at varying temperatures
mold at ambient temps
yeast at body temps
Where are Histoplasma capsulatum cells found on microscopy?
facultative intracellular yeast (2 - 4 microns in diameter) found inside macrophages.
populations predisposed to diseeminated histo
infants or immunocompromised
two general manifestations of histo?
pulmonary infection or disseminated
What causes erythema nodosum
delayed hypersensitivity reaction to antigens
What is erythema nodosum?
inflammation of subcutaneous fat that results in painful erythematous nodules, usually in a pretibial location.
What is the single most frequent condition associated with the development of erythema nodosum?
What is the typical presentation of erythema nodosum?
the typical presentation of erythema nodosum involves painful erythematous nodules, usually on the anterior portion of the tibia with possible malaise, fatigue, and polyarthralgia.
Amongst whom is erythema nodosum most common?
women ages 15-40
What laboratory findings are associated with erythema nodosum?
antistreptolysin o ab
Rx treatment of erythema nodosum
What are two causes of failure of muscle relaxation in achalasia?
dysfunction of NO synthase producing neurons
denervation of esophageal muscle
diagnosis of achlasia
What is the cause of achalasia?
failure of LES to relax
What three things does manometry demonstrate in achalasia?
↓ Relaxation of lower esophageal sphincter (LES) after swallowing
↑ Resting tone of LES
esophagomyotomy, botulinum toxin injections, nitrates and calcium channel blockers.
Patients with achalasia have an increased risk of what condition?
esophageal squamous cell carcinoma
What is seen on barium swallow in a patient with achalasia?
Classic “Bird’s beak” appearance at the lower esophageal sphincter (LES)
Proximal esophageal dilation
What are some causes of “secondary” achalasia?
What complication can result from balloon dilation treatment in a patient with achalasia?
What are three ways to biochemically reduce LES tone in patients with achalasia?
What is the presentation of diffuse esophageal spasm?
chest pain and dysphagia
precipitants: rapid eating, extreme food temps, heart burn, stress
What is diffuse esophageal spasm?
abnormal (non-peristaltic) contractions of esophagus
What is seen on manometry in diffuse esophageal spasm?
uncoordinated, nonperistaltic contractions
diffuse esophageal spasm treatment
CCB, Nitrates, TCAs
esophageal spasm imaging
OSA - increased hematocrit
hypoxemia --> increased EPO from kidneys
spherocytes w/o central pallor + positive coombs test
autoimmune hemolytic anemia
Hairy Cell Leukemia
positive tartrate resistance acid phosphatase
diarrhea for >2 weeks
inflammed synovium from RA/OA/cartilage tears
ABG on CHF pt in resp distress
treatment of cocaine related chest pain
benzos, aspirin, nitroglycerin, CCB
do not give BB
cyst with eggshell calcifications
associated with echinococcus granulosis (dogs!)
itching after hot bath
uremic coagulopathy due to
BT is prolonged
treat with DDAVP
What interventional studies may be used in the evaluation of hematuria?
cytoscopy - bladder cancer
retrograde pyelogram - ureteral malignancy
kidney biopsy - GN or vasuculitis
What imaging studies may be used in the evaluation of hematuria?
xray - kidney stone
ultrasound - renal masses
CT - renal malignancy
What do you suspect with painful hematuria? Painless hematuria?
painless - bladder cancer, renal cell carcinoma
pain - kidney stone, renal infarction, cystitis/kidney infection
ultrasound in hematuria
cystic vs solid masses
In general, what is the cause of hematuria?
whole RBCs leak into urine
If a patient has grossly bloody-appearing urine but a urine dipstick negative for blood, what does this mean?
substances from food/beets
no follow up needed
What is the treatment for myoglobinuria secondary to rhabdomyolysis?
Start IV normal saline to help preserve kidney function, and correct electrolyte abnormalities
What is the role of abdominal x-ray in the evaluation of hematuria?
What are some specific causes of hematuria?
malignancy (bladder and renal cell carcinoma), infection, stones, glomerulonephritis, vasculitis, and trauma.
What is the main focus of the treatment of hematuria?
What does a urine dipstick positive for blood tell you? What is the next step?
could also be from hemoglobinuria or myoglobinuria
need urine microscopy to detect RBC
What is the treatment for hemoglobinuria secondary to intravascular hemolysis?
start intravenous saline to preserve kidney function and correct electrolyte abnormalities (eg, hyperkalemia) if present.
What is the difference between gross hematuria and microscopic hematuria?
gross - urine is pink/red
micro - >3 RBC
What would you expect to find on urine microscopy in all cases of true hematuria?
greater than 3 rbcs
tests for hemoglobinuria