Internal Medicine Flashcards
(159 cards)
1
Q
The best “initial” diagnostic test for for ischemic type pain is ?
Note : If the case is very very typical of chest pain or ischemic type pain
A
EKG
2
Q
If in ischemic type pain ( chest pain ) they give you to choose between EKG and treatment with aspirin , nitrates , oxygen and morphing , wha would you choose first ?
A
Treatment first
3
Q
Answer :
Who Binds to calcium to activate actin/ myosin interaction
A
Troponin C
4
Q
Binds to tropomyosin
A
Troponin T
5
Q
Blocks or inhibits actin / myosin interaction
A
Troponin i
6
Q
In ischemic attack, which enzymes rise at 3-6 hours after the start of the chest pain ?
A
1- CK- MB ( stays elevated 1-2 days )
2- Troponin ( stays elevated 1-2 weeks )
7
Q
Best enzyme to diagnose re-infarction is ?
A
CK-MB ( stays elevated only for 1-2 days )
8
Q
The most “accurate “ test for ischemic type pain is ?
A
CK-MB and troponin
9
Q
Which enzyme rise first in ischemic attack ?
A
Myoglobin ( 1-4 hours after the chest pain starts )
10
Q
The “stress “ test used in obese and big- breast patients with CAD is ?
A
Sestamibi nuclear stress test ( this radioisotope penetrates best the tissue )
11
Q
The 3 “stress test” used for patients who can not exercise to a target heart rate of > 85 % of maximum are ??
A
1- Dypiridamol or 2- adenosine thallium or 3- dobutamine echo
Note : patients with 1- COPD 2- Amputation 3- Deconditioning 4- weakness / previous stroke 5- lower extremity ulcer 6- dementia 7- obesity
12
Q
Note : patients with the following conditions will benefit from the 3 “stress test “ called 1- COPD 2- Amputation 3- Deconditioning 4- weakness / previous stroke 5- lower extremity ulcer 6- dementia 7- obesity
A
1- Dypiridamol or 2- adenosine thallium or 3- dobutamine echo
13
Q
If the stress test is unreadable for ischemia, what type of stress test (2) would you use ?
A
Exercise thallium stress test or stress echocardiography
Patients with:
1- left bundle branch block
2- digoxin use
3- pacemaker in place
4- left ventricular hypertrophy
5- any baseline abnormality of ST segment of the EKG
14
Q
Patients with the following conditions will benefit from the “ stress tests “ called ?? ( 2 )
1- left bundle branch block
2- digoxin use
3- pacemaker in place
4- left ventricular hypertrophy
5- any baseline abnormality of ST segment of the EKG
A
Exercise thallium stress test or stress echocardiography ( used when EKG is unreadable )
15
Q
Best initial test for evaluating valve function or ventricular wall motion is ?
A
Echocardiogram
16
Q
Most accurate method to evaluate ejection fraction is ?
A
Nuclear ventriculogram
17
Q
If angiogram has already been done in a patient with positive CAD and still with symptoms, the next best step is ?
A
CABG ( coronary artery bypass graft )
18
Q
The isotope that is used I stress tests when the EKG is unreadable is called ( blank ) ? And the mechanism of action is through ……..?
A
Thallium ( isotope ) . The mechanism of action is through:
Na/K/ ATPase of normal myocardium that picks the isotope when the tissue is alive ( because thallium looks like potassium )
19
Q
Answer : Can you have an ACS with a normal EKG ?
A
Yes , because acute coronary syndrome is NOT based on enzyme levels , or angiography or stress test results or even EKG …… it is based on history of chest pain with features suggestive of ischemic disease
20
Q
Mention the 3 medications added to anyone getting an angioplasty and stent ( they inhibit ADP activation of platelets )
A
1- Clopidogrel
2- Ticagrelor
3- Prasugrel ( causes more bleeding that is why is given only when angioplasty is done ) . The other 2 can be given with aspirin for patients with acute myocardial infarction
21
Q
Mention (from the drugs inhibiting ADP activation of platelets ) which is the only one given during angioplasty ??
A
Prasugrel ( causes more bleeding that is why is given only when angioplasty is done ) . The other 2 can be given with aspirin for patients with acute myocardial infarction ( they are clopidogrel and ticagrelor )
22
Q
Mention : P2Y12 Antagonists that block the aggregation of platelets by inhibiting ADP activation of the P2Y 12 receptor
A
Ticagrelor
Clopidogrel
Prasugrel
The last 2 are in thienopyridine class
23
Q
What treatment has the single greatest efficacy in lowering mortality in STEMI when thrombolytics are contraindicated ??
A
“Urgent “ angioplasty or PCI
24
Q
Chest pain for < 12 hours and ST segment elevation in 2 or more leads or a new LBBB . What is the next step in management ????
A
Thombolytics ( should be given within 30 minutes of patient arrival in ED with pain
25
Mention who can :
| Activate plasminogen into plasmin so plasmin can chop up fresh or newly formed fibrin strands into D-dimers
Thrombolytics ( that is why clots elevate D- dimers )
| Note : when fibrin clots are stabilized by factor XIII then plasmin will not cleave fibrin anymore
26
What groups ( 2 ) of medication should be given to anyone with ACS , but they only lower mortality when there is “ left ventricular dysfunction “ or systolic dysfunction “ ( ejection fraction is low )
ACE inhibitors and ARBs ( angiotensin receptor blockers )
27
What is the most common cause of death in CHF and MI ?
| What medication group lower mortality if given ( no need to give “urgent” as aspirin ) to the ischemic patient ??
1- “ventricular “ arrhythmia
| 2- Beta blockers because they are both anti- ischemic and anti- arrhythmic
28
The Platelet inhibitor ( or antagonist ) that is associated with neutropenia is called ??
Ticlopidine
29
When is pacemaker the answer for acute MI ? ( mention the 5 main causes )
```
1- Complete heart block ( 3rd degree)
2- Mobitz ll second degree AV- block
3- BIFASCICULAR BLOCK
4- New LBBB
5- Symptomatic bradycardia
```
30
When is lidocaine or amiodarone the answer for acute MI ?
Ventricular tachycardia or ventricular fibrillation
31
Mention the 2 main diagnostic tests for cardiogenic shock
Echocardiogram and Swan- Ganz ( right heart ) catheter
32
Mention the 2 best options of treatment is a patient with cardiogenic shock
ACE inhibitors and urgent revascularization
33
Best diagnostic test in a patient with valve rupture
Echocardiogram
34
Mention the Best 3 treatment choices “before surgery” in a patient with valve rupture
ACE inhibitors,
Nitroprusside
Intra-aortic balloon pump
35
Best diagnostic tests ( 2 ) in a patient with septal rupture
1-Echo and
2- right heart catheter ( or Swan- Ganz ) catheter ( shows a step up in saturation from the right atrium to the right ventricle)
36
Best treatment choices ( 2 ) in a patient with a septal rupture “before URGENT surgery “
ACE inhibitors
| Nitroprusside
37
Best diagnostic test for myocardial wall rupture
Echocardiogram
38
Best treatment choice (2 ) in a patient with myocardial wall rupture . Mention the 2 consecutive way of action
Pericardiocentesis and urgent cardiac repair
39
Best treatment choice in a patient with right ventricular infarction
Fluid loading ( first diagnose with EKG showing right ventricular leads )
40
For how long is the waiting “to have sex “ after a myocardial infarction ?
2-6 weeks
41
Mention the 3 best treatment choices that “Lower mortality in NSTEMI “
1-Heparin ( Better is low molecular weight )
2- GP llb / llla inhibitors ( eptifibatide , tirofiban , abciximab )
3- angioplasty/ PCI
42
Mention the 3 drugs belonging to the group : GP llb / llla inhibitors
GP llb / llla inhibitors ( eptifibatide , tirofiban , abciximab )
43
The single greatest benefit from : GP llb / llla inhibitors in a patient with ACS , comes with their association with :
Angioplasty and stent placement
44
What medication potentiates the effect of antithrombin which is in charge of the inhibition of almost every step of the clotting cascade ?
Heparin ( prevents new clots from forming ) . Does not work in patients with “ antithrombin “ deficiency
45
If chest pain persist after adding nitrates in a patient with ACS , you most add ??
Ranolazine ( anti-angina medication added if other can’t control pain )
or ivabradine
46
The 4 indications for CABG are ??
1- three coronary vessels with > 70 % stenosis
2- left main coronary artery stenosis > 50-70 percent
3- two vessels in a diabetic patient
4- 2 or 3 vessels with low ejection fraction
47
Indications for CABG are (4 ) ?
- 3 coronary vessels with > 70 % stenosis
- left main coronary artery stenosis > 50-70 %
- 2 vessels in a diabetic
- 2 or 3 vessels with low ejection fraction
48
Goal of therapy with statins in CAD is an LDL less than ??
> 70 ( statins are used for any CAD or equivalent like diabetes with LDL > 100 )
49
Use statins is the 10 year risk of CAD is > of ????
> 7.5 %
50
The 4 CAD equivalents are ??
- Diabetes
- PAD
- Aortic disease
- Carotid disease
51
The most common adverse effects of statins therapy is ??
Liver toxicity
52
Mention 2 PCSK9 inhibitors ?
This drugs inhibit PCSK9 which blocks the clearance of LDL by the liver from the blood. This drugs can bring down enormous amounts of LDL in familial hypercholesterolemia . Are injectable . Are the answer when statins are used at maximum doses and still LDL is not controlled
Evolocumab and alirocumab
53
Every patient with CAD and stroke should be on ?
Statins
54
Most patient with diabetes should be on ??
Statins
55
Patients with > than 10% ten-year risk of CAD or > 7.5% as well should be on ??
Statins
56
The 4 pilars of treatment in a patient with pulmonary edema are ?
Oxygen , furosemide , nitrates and morphine
57
The sound on S3 gallop is ?
Splash
58
The sound on a S4 gallop is ??
Bang !
59
Mention the 4 Pilars in tests in a patient with pulmonary edema .
This tests are indicated at the same time that treatment with nitrates -morphine- oxygen and furosemide ( in CCS)
- CXR
- EKG
- Oximeter / consider also ABG
- Echocardiogram
60
What agent ( drug group ) is given in pulmonary edema when preload reduction fails to suppress the SOB ? ( that is when clock is moved forward for 30-60 minutes and still there is SOB )
Positive inotropes ( dobutamine , milrinone , inamrinone )
61
Mention 3 drugs used for sustained ventricular tachycardia that is hemodynamically stable ....
Amiodarone , procainamide and
| Lidocaine
62
Mention a synthetic version of atrial natriuretic peptide used in acute pulmonary edema as part of preload reduction
Nesiritide
63
A normal ( blank ) level excludes CHF . Fill the blank
BNP ( is indicated when the diagnosis is not clear ..... can distinguish from pulmonary embolism, pneumonia , asthma and CHF )
64
# Fill the blank by using “ decrease “ and increase “ in the following patient with : pulmonary edema “””that has a right heart catheter placed “””
- cardiac output
- systemic vascular resistance
- wedge pressure
- right atrial pressure
- decreased
- increased
- increased
- increased
65
# Fill the blank by using “ decrease “ and increase “ in the following patient with : hypovolemic shock “ “””that has a right heart catheter placed “””
- cardiac output
- systemic vascular resistance
- wedge pressure
- right atrial pressure
- decreased
- increased
- decreased
- decreased
66
# Fill the blank by using “ decrease “ and increase “ in the following patient with : septic shock “””that has a right heart catheter placed “””
- cardiac output
- systemic vascular resistance
- wedge pressure
- right atrial pressure
- increased
- decreased
- decreased
- decreased
67
# Fill the blank by using “ decrease “ and increase “ in the following patient with : pulmonary hypertension “””that has a right heart catheter placed “””
- cardiac output
- systemic vascular resistance
- wedge pressure
- right atrial pressure
- decreased
- increased
- decreased
- increased
68
Wedge pressure is the same as ....?
Left atrial pressure ( increased with left ventricular failure)
69
All patients after stabilized from acute pulmonary edema should have a ( blank ) to check for systolic with low ejection fraction or diastolic dysfunction with normal ejection fraction
Fill the blank
Echocardiogram
70
The beta blockers with evidence of lowering mortality are ( 3 )
Metoprolol
Carvedilol
Bisoprolol
71
In CHF with systolic dysfunction, when ACE inhibitors or ARBs can’t be used then we must use the combination of .....?
Hydralazine and nitrates
72
In CHF , the diuretic ( blank ) lowers mortality only in advance symptomatic disease
Fill the blank
Spironolactone ( any patient originally presenting with pulmonary edema should spironolactone )
73
The diuretic ( blank ) causes gynecomastia and erectile dysfunction in men so you must switch to ( blank )
Spironolactone..... switch to eplerenone ( mineralocorticoid antagonist that lowers mortality....without androgenic side effects of spironolactone )
74
In CHF with systolic dysfunction after using : ACE inhibitors, beta blockers , diuretics , digoxin and mineralocorticoids inhibitors ; the patient is still dysgenic ....... what drug would you use now ??
Mention 1 drug and 1 combination of drugs
1- drug ( Ivabradine ) . Used if Pulse > 70 or beta blockers can’t be used in systolic dysfunction . Is a SA nodal inhibitor of “ funny channels “ that slows the HR
2- combination ( Sacubitril / Valsartan ). Used instead of ACE inhibitors. Sacubitril is only added to an ARBs as for example : valsartan
75
Mention the 6 groups of medication or combinations used in CHF with systolic dysfunction
```
1- ACE inhibitors or ARBs
2- Metoprolol , carvedilol or bisoprolol
3- spironolactone or esplerenone
4- Diuretics
5- Digoxin
6- Hydralazine / Nitrates
```
76
Mention the 2 groups of medication used in CHF with diastolic dysfunction
- metoprolol, carvedilol and bisoprolol
| - diuretic
77
A patient with CHF that feels good but has a EF of 23% in “ the last 6 months “ may benefit from ...?
Implantable cardioverter / defibrillators ( indicated in dilated cardiomyopathy because the most common cause of death in CHF patients is sudden death from arrhythmia. Those with EF below 35 “”that persist “” are candidates for implantable defibrillators
78
If a patient with CHF is still SOB and has a wide QRS ( > 120 ) you must resynchronize him with a ......?
Biventricular pacemaker ( used in a those with severe CHF because in them lowers mortality) . To use when EF < 35 and QRS > 120 . This is called : “ Cardiac resynchronization therapy “”
79
Wide QRS means the ventricles are not beating together so there is inefficient forward flow ..... so you must use ( like in a patient with CHF ) a ???????
Biventricular pacemaker . The effect is instant
80
The most common causes of valvular heart disease in young patients are ?? ( 4)
Mitral valve prolapse
HOCM
Mitral stenosis
Bicuspid aortic valve
81
Must common valvular disease in a patient with :
| Turner’s syndrome and Coartation of the aorta is ??
Bicuspid aortic valve
82
A young female with palpitations and atypical chest pain NOT with exertion probably has ?
Mitral valve prolapse
83
In CCS in a patient with valvular disease , what exams would you check on the physical exam ?? ( 3 )
Cardiovascular
Chest
Extremities
84
Mention the 4 most common causes of systolic murmurs
Aortic stenosis
Mitral regurgitation
Mitral valve prolapse
HOCM
85
Mention the 2 most common causes of diastolic murmurs
Aortic regurgitation
| Mitral stenosis
86
Fill the blank
| All right- sided murmurs increase in intensity when you order the patient to perform ( blank ) ?
Inhalation
87
Fill the blank
| All left- sided murmurs increase in intensity when you order the patient to perform ( blank ) ?
Exhalation
88
In the 4 groups of maneuvers for valvular diseases the ones (2) that increase the venous return and so increase the “murmurs “ in the following entities is called ????
- aortic and mitral STENOSIS
- aortic and mitral REGURGITATION
- VSD
Note: The exemption to the rule are 2 conditions called ( blank and blank ) ????
- Maneuvers : squatting and leg raising
- HOCM and mitral valve prolapse ( decrease the murmur because ventricles receive much blood and this conditions improve when ventricles are ingurgitated with blood )
89
In the 4 groups of maneuvers for valvular diseases the ones (2) that decrease the venous return and so decrease the “murmurs “ in the following entities is called ????
- aortic and mitral STENOSIS
- aortic and mitral REGURGITATION
- VSD
Note: The exemption to the rule are 2 conditions called ( blank and blank ) ????
- standing and Valsalva maneuvers
- HOCM and Mitral valve prolapse ( increase the murmur because ventricles receive less blood and this entities get worse when ventricles are thinner or not full with blood )
90
In the 4 groups of maneuvers for valvular diseases the “one “ that increases afterload and behaves as the OPPOSITE from ACE inhibitors worsening the murmur of conditions that would get better with ACE inhibitors ( like MR , AR and VSD ) is called ( blank ) ??
This maneuver only makes improvement in the 2 conditions called ( blank and blank ) ??
Handgrip maneuver ( only improves the murmur of HOCM and MVP because allows the ventricles be more filled out with blood and so this makes these conditions better and their murmurs softens )
91
In the 4 groups of maneuvers for valvular diseases the “one “ that decreases afterload and behaves like ACE inhibitors improving the murmur of conditions that would get better with ACE inhibitors ( like MR , AR and VSD ) is called ( blank ) ??
This maneuver only worsens two conditions called ?
Amyl nitrate ( is the opposite from handgrip maneuver ) . This maneuver worsens the murmur in HOCM and MVP because ventricles are less fill out with blood and so this worsens these specific conditions
92
What does handgrip do to the murmur of aortic stenosis ??
Softens or louder the murmur ??
Softens the murmur because prevents the blood from leaving the ventricles . Is like covering up a trumpet so the air won’t go out . This happens because the gradient goes down with the increased afterload ( gradient between the left ventricle and the aorta ) , so less gradient less murmur and viceversa
93
What does Amyl nitrate do to the murmur of aortic stenosis ??
Softens or louder the murmur ??
Harden the murmur because decreases afterload because is a vasodilator and by doing this increase the gradient between the left ventricle and the aorta so the murmur is louder
94
The effect of handgrip and Amyl nitrate in “ mitral stenosis “ is ??
None .... or negligible
95
The best initial diagnostic test for valvular lesions on single best answer questions is ?
Echocardiogram ( order TTE first in CCS, then order TEE second if still no diagnosis )
Note : on CCS cases you should also add
EKG , and CXR ( looking for hypertrophy due to the valvular lesion )
96
The most accurate diagnostic test for valvular lesions is ?
Left heart catheterization
97
In “CCS “ cases in valvular lesions, besides the TTE , TEE and left heart catheterization , what other 2 tests you must order ??
EKG and CXR
98
What is the best choice of treatment for regurgitant valvular lesions ?
Vasodilators such as ACE inhibitors, ARBs and nifedipine ( because they cause afterload reduction )
Note : when vasodilation is not enough then use surgery
99
Stenotic valvular lesions are best treated with ....( blank ) but in some cases like mitral stenosis a patient should undergo ( blank , blank ) even if the patient is pregnant
```
Anatomic repair ( surgery )
Balloon valvuloplasty ( even if the patient is pregnant )
```
100
answer yes or no the following question :
In valvular lesions where “valsalva and standing maneuvers “ improve the murmur :
“ diuretics are or aren’t indicated “
Are indicated ( yes ) . This lesions are :
1- Aortic stenosis
2- Aortic regurgitation
3- Mitral stenosis
4- Mitral regurgitation
5- VSD
Note : in mitral stenosis balloon valvuloplasty is better than diuretics ...... and in aortic stenosis valvular replacement is better than diuretics
Note : valsalva maneuvers decrease venous return so murmur softens ( less blood less murmur )
101
In the following lesions mention “yes or no “ if diuretics are or aren’t indicated
```
1- Aortic stenosis
2- Aortic regurgitation
3- Mitral stenosis
4- Mitral regurgitation
5- VSD
```
Yes ( these lesion’s murmur gets better with valsalva and standing maneuver so in this lesions diuretics are indicated )
See page # 47 of master the boards
102
Mention “yes or no” if in the following lesions diuretics are or aren’t indicated :
HOCM and MVP
No indicated because this lesions get better when the ventricles are more full of blood so if you use diuretics........ you know baby
103
In valvular lesions where Amyl nitrate is indicated mention “yes or no “ if you consider ACE inhibitors could be used
Yes because Amyl nitrate is a vasodilator as ACE inhibitors so ..... they make better valvular lesions like :
1- AR 2- MR 3- VSD
104
Mention “yes or no “
In the following valvular lesions is ok to use ACE inhibitors and ARBs ??
1- AR 2- MR 3- VSD
Yes because they are vasodilators which improve regurgitant lesions
105
What does “ leg raising - squatting and Amyl nitrate “ do to the murmur of AORTIC STENOSIS ???
“ Softens or make it louder and worse “????
Make it louder and worse because with Aortic stenosis something very interesting happens and that is : the bigger the gradient between the left ventricle and the aorta the louder and worse is the murmur so this maneuver put more blood into the left ventricle and the aorta he murmur is louder .... and Amyl nitrate is a vasodilator so makes it easy to the left ventricle push blood forward so this increases the gradient and the murmur is heard louder
106
What does Amyl nitrate do to the murmur of aortic stenosis ??
“ makes it better or softer or makes it louder or worse “
Explain !!
Louder or worse because :
Make it louder and worse because with Aortic stenosis something very interesting happens and that is : the bigger the gradient between the left ventricle and the aorta the louder and worse is the murmur so Amyl nitrate is a vasodilator so makes it easy to the left ventricle push blood forward so this increases the gradient and the murmur is heard louder
107
What does “ handgrip maneuver “ do to the murmur of aortic stenosis ??
“ makes it better or softer or makes it louder or worse “
Explain !!
Better or softer because : with Aortic stenosis something very interesting happens and that is : the bigger the gradient between the left ventricle and the aorta the louder and worse is the murmur so with handgrip the afterload is bigger and the gradient between the left ventricle and the aorta is less or smaller .... the left ventricle needs to push harder against the aorta and the murmur is softer
108
What does valsalva and standing maneuvers do to the murmur of aortic stenosis ??
“ softens or make it louder and worse “??
Softens because these maneuvers decrease the venous return and less blood passes through the Left ventricle al this makes the murmur softer . That is why diuretics are used in aortic stenosis before surgery is performed
109
Aortic stenosis is considered mild when the gradient is less than ( blank mm Hg ) , is moderate when the gradient is between ( blank and blank mm Hg ) , and is severe when the gradient is more than ( blank mm Hg )
Fill the blank
Mild ( < 30 mm Hg )
Moderate ( 30 - 70 mmHg )
Severe ( > 70 mm Hg )
110
The main advantage of using Bioprosthetic valve replacement over mechanic valves is ....?
They don’t need anticoagulation with warfarin ( bioprosthetic ) . Is true that they last less time ( only 10 years ) and mechanical last 15 -20 years but anticoagulation sometimes brings a lot of complications
111
Cystic medical necrosis can cause a valvular condition called ??
Aortic regurgitation . Other rarer causes are :
| Marfan’s syndrome , ankylosis spondylitis syphilis and reactive arthritis
112
Diastolic decrescendo murmur heard best at the left eternal border refers to .....?
Aortic regurgitation
113
Corrigan’s pulse also known as water hammer pulse belongs to the valvular disease called ??
Aortic regurgitation
114
Capillary pulsations in the finger nails known as Quincke pulse belongs to a valvular disease called ?
Aortic regurgitation
115
Musset’s sign ( head bobbing with each pulse ) belongs to a valvular condition called ?
Aortic regurgitation
116
Duroziez ‘s sign ( murmur heard over femoral artery ) belongs to a valvular disease called ?
Aortic regurgitation
117
Hill sign ( blood pressure gradient much higher in the lower extremities ) belongs to a valvular disease called ?
Aortic regurgitation
118
The 3 groups of medication that are the best initial therapy for Aortic regurgitation are ??
ACE inhibitors
ARBs
Nifedipine
Note : for CCS you should add a loop diuretic such as furosemide
119
Surgery is the answer in Aortic regurgitation when ejection fraction drops below ( blank % ) or the left ventricular end systolic diameter goes above ( blank mm ) even if patients are asymptomatic
Fill the blank !!
< 55 % ejection fraction
| > 55 mm of the left ventricular end systolic diameter
120
Diastolic rumble after an opening snap ( can be described as an extra sound in diastole ) ; refers to ??
Mitral stenosis
121
As the mitral stenosis worsens , the opening snap moves ( blank ) to ( blank )
(Closer) to (S2 ) because mitral opens when LA pressure > LV pressure so as MS worsens = higher LA pressure and the valve is pushed to open earlier
Note : the murmur increases with leg raising , squatting and expiration
122
On CXR is seen “straightening of the left heart border and elevation of the left mainstem bronchus “ . This refers to the valvular disease called ??
Mitral stenosis
123
Answer which are :
1- the main initial therapy and the
2- most effective therapy for mistral stenosis
1- diuretics
| 2- Balloon valvuloplasty
124
Aortic stenosis is due to ( blank ) of the valve , and mitral stenosis is due to ( blank ) of the valve . That is why balloon is used in mitral stenosis and no in aortic stenosis
( calcification )
( Fibrosis )
Note : that is why mitral stenosis can be stretched by balloon because fibrosis can be stretched opposite to calcification which is better treated by removing or replacing the valve
125
Th murmur from mitral regurgitation ( blank ) in intensity with leg raising , squatting and handgrip . This murmur ( blank ) in intensity with valsalva and Amyl nitrate
( increases)
| decreases
126
The best initial therapy for mitral regurgitation is with 3 groups of drugs called ?
```
ACE inhibitors
ARBs
Nifedipine ( anticalcics )
Because they are vasodilators
Note : for CCS cases you should add furosemide
```
127
In mitral regurgitation you should add surgery as treatment when ejection fraction is below (blank ) percent or left ventricular end systolic diameter goes above ( blank ) mm
Below 60 %
Above 40 mm
Note : repair is preferred to replacement
128
Fill the blank related to the criteria for surgery in:
1- aortic regurgitation :
-ejection fraction less than ( blank %)
- left ventricular end systolic diameter above ( blank mm )
2- Mitral regurgitation :
-ejection fraction less than ( blank %)
- left ventricular end systolic diameter above ( blank mm )
1- < 55 % and LVESD > 55 mm
| 2- < 60 % and LVESD > 40 mm
129
What happens ( louder or smaller ) with the murmur of VSD with : squatting , exhalation and leg raise ??
Louder ( worsen ) . More blood more murmur . Exhalation worsen the murmur because is a systolic murmur and those worsen with exhalation
130
ASD is a hole in the heart that is associated with ( blank blank ) of the S2
Fill the blank !
Fixed splitting
131
ASD should be repaired when the shunt ratio exceeds ( blank ) to ( blank ) . Fill the blank with numbers !!
1.5 to 1
132
The best initial test in Dilated cardiomyopathy is ( blank ) also known as ( blank ) . It is used to determine ejection fraction and look for wall motion activity . The most accurate test is ( blank ) which is the most accurate method to determine ejection fraction . Fill the blank !!
- Echocardiography
| - MUGA or nuclear ventriculography
133
Ischemia , alcohol , adriamycin , radiation and Chagas’ disease are causes of ( blank ) ??
Dilated cardiomyopathy
134
The treatment for : Dilated cardiomyopathy is with 4 groups of drugs which are ??
Other medications used are digoxin and Ivabradine . The last one is used if after the use of ( blank blank ) if the heart rate is > 70 / min
1-ACE inhibitors
2-ARBs
3-Beta blockers
4-Spironolactone
After the use of : Beta blockers use
Ivabradine ( a sodium funny channel blocker ) if heart rate is > 70
135
( blank ) is a test for Hypertrophic cardiomyopathy where you can see that the ejection fraction is normal
Echocardiography
136
The mainstay of therapy for Hypertrophic cardiomyopathy is with ( blank blank and blank) . ACE inhibitors can be use but their benefit is not as clear
Fill the blank !!
Beta blockers and diuretics
137
There is a unique sign belonging to 2 heart conditions called : Restrictive Cardiomyopathy and Constrictive pericarditis . This sign happens due to an increase in jugular venous pressure on inhalation . This sign is called ??
Kussmaul’s sign
138
In Restrictive Cardiomyopathy ( blank ) is the mainstay of diagnosis and ( blank blank ) is the single most accurate diagnostic test of the ETIOLOGY
Fill the blank !!
Echocardiography ( mainstay )
| Endomyocardial biopsy
139
In Restrictive Cardiomyopathy, cardiac catheterization shows ??
... and EKG shows ??
Rapid x and y descents
| EKG shows low voltage
140
In Restrictive Cardiomyopathy, the bet treatments is with ( blank ) and correcting the underlying cause . Fill the blank !
Diuretics
141
A sudden systolic dysfunction in a postmenopausal woman with sudden psychological stress that looks like a myocardial infarction with ventricular dysfunction refers to a rare disease called ??
Takotsubo Cardiomyopathy
Treatment is with : ACE inhibitors, diuretics and beta blockers. If the patient doesn’t die he/she will recover in a few weeks
142
Takotsubo Cardiomyopathy is treated with 3 groups of drugs which are ??
```
Treatment is with :
ACE inhibitors,
diuretics and
beta blockers.
Note : If the patient doesn’t die he/she will recover in a few weeks
```
143
Pleuritic, positional , sharp and brief chest pain refers to ??
```
Pericardial disease : has positive “ friction rub” and NEGATIVE :
1- pulsus paradoxus
2- Kussmaul sign
3- tenderness or edema
4- blood pressure
5- jugular venous distention
```
144
Best initial test for pericardial disease is ??
EKG ( ST elevation everywhere and PR depression in lead II is pathognomonic )
145
Management ( treatment ) of pericardial disease is with ( blank ) combined with ( blank ) ??
NSAIDs combined with colchicine
Note : advance the clock 1-2 days and have the patient visit the office ... if still in pain give prednisone orally and advance the clock 1-2 days more to see result
146
Patient presents with :
| SOB , hypotension and jugular venous distention ( with clear lungs ) ..... the patient has ??
Pericardial tamponade
Note : unique features are
1- Pulsus paradoxus
2- electrical alternans
147
Note : unique features are
1- Pulsus paradoxus
2- electrical alternans
This refers to ??
Pericardial tamponade
148
What does inhalation do on venous return ?
Increases
149
The most accurate diagnostic test for Pericardial Tamponade is ??
Echocardiography ( the earliest finding is diastolic collapse of the right atrium and right ventricle )
150
When and Echocardiography is done the earliest finding is diastolic collapse of the right atrium and right ventricle . This refers to the emergent condition called ??
Cardiac Tamponade
151
EKG will show : low voltage and electrical alternans ...... this refers to ??
Cardiac tamponade
152
Right heart catheterization will show “equalization “ of all the pressure in the heart during diastole ...... is his refers to ?
Cardiac tamponade
153
The wedge pressure will be the same as the right atrial pressure and pulmonary artery diastolic pressure ..... this refers to ?
Cardiac tamponade
154
Answer the following regarding Cardiac tamponade :
The best initial therapy is ( blank )
The most effective long-term therapy is ( blank )
The most dangerous therapy is ( blank )
Pericardiocentesis
Pericardial window placement
Diuretics ( dangerous )
155
A patient presents with SOB, and signs of chronic Right heart failure ( edema , jugular venous distention, heptosplenomegaly and ascites ) and also with :
-Kussmaul sign
- Pericadial knock
This patient has ?????????????
Constrictive pericarditis
156
Extra diastolic sound from the heart hitting a calcified , thickened pericardium refers to the sign called ( blank ) ..... this is related to the disease called ( blank ) ?
Pericardial knock .... related to Constrictive pericarditis
157
According to Constrictive pericarditis mention the 3 groups of testing that you will order and what do you expect to find
CXR ( shows calcification )
EKG ( shows low voltage )
CT and MRI ( shows thickening of the pericardium )
158
Mention the :
1- best initial therapy and
2- most effective therapy
For Constrictive Pericarditis
1- Diuretics
| 2- Surgical removal of the pericardium ( ex : pericardial stripping )
159
According to the following heart conditions , mention for which of them the therapy with “diuretics “ is “ The most dangerous therapy “ and “ The best initial therapy “
1- Pericardial Tamponade
2- Constrictive Pericarditis
1- Pericardial Tamponade ( NEVER give diuretics )
2- Constrictive Pericarditis ( Diuretics are best initial therapy ) .... most effective therapy is surgical removal of the pericardium ( that is : Pericardial stripping )
