Internal Medicine Flashcards
(95 cards)
1
Q
1st test for chest pain
2nd test for chest pain
A
EKG
Cardiac enzymes
2
Q
EKG findings for STEMI
A
- ST elevation (2mm)
- New LBBB (long, flattened QRS)
3
Q
Order of EKG findings for STEMI (in time)
A
- ST elevation (immediate)
- T wave inversion (6 hrs - years)
- Q waves (forever)
4
Q
Treatment of STEMI
A
Emergency reperfusion
- Cath lab (stent), OR... - Thrombolytics (no contraindications, early enough)
5
Q
Window for thrombolytics
Contraindications to thrombolytics
A
6 hours
- Bleeding
- Hemorrhagic stroke (ever)
- Ischemic stroke (recent)
- Closed head trauma (recent)
- Surgery
6
Q
Hypotension Tachycardia JVD Lungs clear No pulsus paradoxus
Tx? What not?
A
R ventricular infarction (cardiogenic shock)
FLUIDS, not nitro (preload)
7
Q
Normal EKG, elevated cardiac enzymes
A
NSTEMI
8
Q
Order of enzyme rises (w/ timeframes)
A
- Myoglobin (peak 2hrs, nml 24hrs)
- CKMB (peak 24hrs, nml 72hrs)
- Troponin (peak 24-48hrs, nml 7-10 days)
9
Q
Best cardiac maker for 2nd MI
Why?
A
Myoglobin
Falls in 24 hrs, will rise again if 2nd MI occurs
10
Q
NSTEMI - Tx
A
- MON(A/C) + beta blocker
- Coronary angio (w/in 48 hrs)
- PCI w/ stent OR CABG
11
Q
When is CABG preferred over PCI/stent?
A
- L main dz
- 3 vessel dz
- > 70% occlusion
- Pain after max medical tx
- Post-infarct angina
12
Q
D/C meds after MI
A
- Aspirin (+ clopidogrel if stent)
- Beta blocker
- ACEI (if CHF or LVD)
- Statin
- Nitrates
13
Q
MI-like chest pain, normal EKG, normal enzymes
Workup?
A
Unstable angina
STRESS TEST:
- Exercise stress EKG (D/C beta blockers and CCBs)
- Exercise stress echo if can’t do the EKG
- Chemical stress test (dobut./adenosine) if can’t exercise
- MUGA scan (radionuclide angio) (no caffeine/theoph)
14
Q
Positive stress test signs?
What next?
A
- Pain reproduced
- ST depression
- Hypotension
Coronary angio
15
Q
Reasons a stress EKG would be too hard?
A
- Old LBBB
- Baseline ST elevation
- On Digoxin
16
Q
New systolic murmur 5-7 days after MI?
A
Papillary rupture –> regurg
17
Q
MI –> murmur, hypotension, very sick
A
Free wall rupture
18
Q
Step up O2 concentration from RA to RV?
A
Septal rupture
19
Q
MI –> 1mo later persistent ST elevation + MR murmur
A
Ventricular aneurysm
20
Q
Cannon A-waves - what are they?
Meaning?
A
Huge JVP pulses w/ heart beat
Right A-V dissociation (3rd degree block OR V-fib)
21
Q
MI –> 5-10 wks later pleuritic CP + low fever
Tx?
A
Dressler syndrome (autoimmune pericarditis)
Aspirin + NSAIDs
22
Q
Diffuse ST elevation
Other signs you’ll see?
A
Pericarditis
Worse w/ inspiration, better leaning forward, friction rub
23
Q
Vague chest pain, murmur, hx of viral infection
A
Myocarditis
24
Q
Prinzmetals - Dx?
Tx?
A
Ergonovine stimulation test
CCB or Nitrates
25
Varying PR intervals
3+ different P-wave forms in same lead
Meaning?
MAT
Bad pneumonia or chronic lung dz --> pending resp. failure
26
V-Tach (stable) - tx?
Unstable - tx?
Lidocaine or Amiodarone
Defibrillation
27
WPW - tx?
Contraindicated drugs?
Procainamide
A-V conduction blockers (BB, digoxin, Verap/Diltiazem)`
28
A-flutter (stable) - tx?
Unstable?
BB, digoxin
Defibrillation
29
Torsades - predisposing things?
- Hypokalemia
- Hypomagnesium
- TCA overdose
30
Sudden onset and offset of palpitations and dizziness, very fast HR (150-220)
1st tx?
Or?
SVT
Carotid massage
Adenosine
31
Widened QRS, Prolonged PQ, Short QT
Other finding?
Hyperkalemia
Peaked T-waves
32
Pulsus paradoxus - what is it?
Seen in what?
Large (>10) drop in SBP on inspiration
Cardiac tamponade, pericarditis, croup, severe obstructive lung dz, chronic obstructive sleep apnea
33
A. fib - causes
Symptoms?
Tx?
- Hyperthyroidism / Synthroid OD
- Mitral valve dz / CHF
SOB, palpitations, dizziness
RATE control (beta blocker or digoxin)
34
Diastolic murmurs
Systolic murmurs
ARMS PITS
Other 4
35
Systolic ejection murmur, louder w/ squatting, softer w/ valsalva, parvus et tardus
Treatment?
Aortic stenosis
Valve replacement
36
Systolic ejection murmur, louder w/ valsalva, softer w/ squatting or handgrip
Hypertrophic obstructive cardiomyopathy
37
What does valsalva do?
Decreases pre-load
38
Late systolic murmur w/ click, louder w/ valsalva, softer w/ squatting and handgrip
MVP
39
Holosystolic murmur w/ radiation to axilla
Mitral regurg
40
Holosystolic murmur w/ late diastolic rumble
VSD
41
Wide fixed and split S2
ASD
42
Rumbling diastolic murmur w/ opening snap
Mitral stenosis
43
Blowing diastolic murmur w/ widened pulse pressure
Aortic regurgitation
44
Suspect PE...1st thing to do?
What else?
HEPARIN
Check O2 sat (give O2 if under 90%)
45
Suspect pneumonia...1st thing to do?
CXR
46
If murmur or CHF history...1st thing to do? Why?
Echo - get ejection fraction
47
Acute pulmonary edema...treatment?
Nitrates, lasix, morphine
48
Young, CHF symptoms w/ prior viral illness...Dx?
Myocarditis (Coxsackie B)
49
Young, SOB but no cardiomegaly on CXR...Dx?
How to Dx for sure? How?
Pulmonary HTN
R heart cath - PCWP normal (high in CHF)
50
What does PCWP symbolize?
L atrial pressure
51
Sign of systolic CHF
Causes?
Reversible one?
EF under 55% (ischemic, dilated heart)
Viral, EtOH, Cocaine, Chagas, Idiopathic
Alcoholic - STOP DRINKING
52
Sign of diastolic CHF
Causes?
Reversible one?
Normal EF (heart can't fill)
HTN, amyloidosis, hemochromatosis
Hemochromatosis (phlebotomy)
53
CHF - treatments
Which ones increase survival?
1. ACEI - survival (less aldosterone remodeling)
2. Beta-blocker (metoprolol, carvedilol) - survival (less catecholamine remodeling)
3. Spironolactone - survival (NYHA class 3 or 4)
4. Furosemide - SYMPTOM improval (SOB, crackles, edema)
5. Digoxin - decreased SYMPTOMS
54
Lobar consolidation, air bronchograms
Pneumonia
55
Hyper-lucent lungs, flat diaphragms
COPD
56
Cardiomegaly, Kerley B lines, interstitial edema
CHF
57
Cavity w/ air-fluid level
Abscess (anaerobes, staph)
58
Upper lobe cavitation and consolidation, hilar LAD
TB
59
Thickened peritracheal stripe, splayed carina bifurcation
1. LAE (Mitral stenosis)
| 2. Mediastinal CA
60
> 1cm of fluid at costophrenic recess when lat. decub.
Tx?
Pleural effusion
Thoracentesis
61
Transudative pleural effusion - causes?
CHF, nephrotic, cirrhotic
62
Transudative w/ low glucose
Why?
Rheumatoid arthritis
Lots of inflammatory cells --> eat up glucose
63
Transudative w/ high lymphocytes
TB
64
Transudative w/ blood
PE or cancer
65
Exudative effusion - causes?
Parapneumonic, cancer
66
Effusion w/ low glucose, low pH, and/or positive for bugs
Treatment?
Pneumonia
Chest tube drainage
67
******How to distinguish transudative vs. exudative
LIGHT'S CRITERIA (all 3 = transudative)
1. LDH < 200
2. LDH eff/serum < 0.6
3. Protein eff/serum < 0.5
68
Risk factors for PE
Surgery, stasis, nephrotic syndrome, cancer
69
Symptoms of PE
```
Pleuritic chest pain
Hemoptysis
Tachycardia
Tachypnea
Decreased pO2
```
70
Lab/imaging signs of PE
```
Sinus tachycardia
R heart strain on EKG
Decreased vascular markings
Wedge infarct
Low O2 and CO2 on ABG
```
71
PE...Dx and Tx steps
1. HEPARIN (w/ warfarin bridge)
2. V/Q scan OR spiral CT
3. Pulmonary angiography (gold standard, if necessary)
4. Thrombolytics if severe (unless contraindicated)
5. Surgical thrombectomy (IF IMMEDIATELY LIFE THREATENING)
6. IVC Filter (if can't take chronic blood thinners)
72
B/l fluffy infiltrates on CXR
Pathophysiology
***Causes?
ARDS
Inflammation at alveolar walls --> impaired gas exchange, inflammatory mediator release, hypoxemia
Sepsis (LPS), aspiration, trauma, pancreatitis, low perfusion
73
***3 Dx criteria for ARDS
1. PaO2 / FiO2 < 200
2. Bilateral infiltrates on CXR
3. PWCP < 18 (NOT cardiogenic infiltrates)
74
Treatment for ARDS
O2 w/ PEEP
75
Obstructive or restrictive...
Low FEV1/FVC ratio
Obstructive
76
Obstructive or restrictive...
High TLC and RV
Obstructive
77
Obstructive or restrictive...
Low TLC and RV
Restrictive
78
What disease...
Improves w/ bronchodilator (at least 12%)
ASTHMA
79
What diseases...
Reduced DLCO (and why?)
Emphysema - alveolar destruction
| Interstitial lung disease (sarcoid, silicosis, asbestos) - fibrosis/thickening
80
Causes of restrictive lung disease
```
ILD (sarcoid, silicosis, asbestos)
Obesity
MG/ALS
Phrenic nerve paralysis
Scoliosis
```
81
Criteria for COPD diagnosis
Productive cough for > 3 mo for > 2 consecutive years
82
COPD - treatment options
1. Ipratropium/Tiotropium (anticholinergic, antimuscarinic)
2. Beta-2 agonists (albuterol, terbutaline, salmeterol, etc.)
3. Theophylline (PDE inhibitor - inhibits LTs and TNF-a)
83
When to start oxygen?
PaO2 < 55
| O2 sat < 88%
84
COPD exacerbation - treatment?
O2 to sat of 90%
SABA/Ipratropium
Steroids
Abx (FQ or macrolide)
85
Best prognostic indicator for COPD
FEV1
86
How to improve mortality in COPD
- Quit smoking
| - Continuous O2 >18 hrs/day
87
COPD - important vaccinations?
Pneumococcus w/ 5 yr boosters
| Influenza annually
88
NEW clubbing in a COPDer...MC cause?
Test?
Lung malignancy
CXR
89
Asthma...
Sxs 2x per wk, normal PFTs
Albuterol
90
Asthma...
Sxs 4x per wk, night cough 2x per mo, normal PFTs
Albuterol + inhaled CS
91
Asthma...
Daily sxs, night cough 2x per wk, FEV1 60-80% --
Albuterol, inhaled CS, LABA
92
Asthma...
Daily sxs, night cough, FEV1 < 60%
Albuterol, inhaled CS, montelukast and oral steroids
93
Asthma exacerbation
If CO2 starts to normalize?
Albuterol + PO/IV steroids
INTUBATE
94
Small nodules in upper lobes, eggshell calcifications
What next?
Silicosis
TB test
95
Reticulonodular process in lower lobes w pleural plaques
Increased risk?
Asbestosis
Bronchogenic carcinoma OR mesothelioma
