LOs Flashcards
(105 cards)
1
Q
What are the top 5 symptoms that correlate with edema?
A
- Leg swelling
- Dyspnea
- Orthopnea
- Paroxysmal Nocturnal Dyspnea
- Weight gain
2
Q
what is edema?
A
abnormally large amounts of fluid in intracellular spaces that can be localized (d/t venous obstruction or lymphatic obstruction) or generalized, d/t systemic causes.
3
Q
What is edema called in the
- - peritoneal cavity
- - pleural cavity
- - pericardial sac
A
- Ascites
- Hydrothorax
- Hydropericardium
4
Q
Non-pitting edema is due to?
A
- 1. Metabolic disease (myxedema)
- 2. Lymphatic system disease
- 3. Warm weather
5
Q
type of imaging for edema
A
1. CXR- PA and lateral
2. EKG
3. Echo
6
Q
if out of country and patient has lymphedema, what should come to mind as the cause?
A
Filarial infection
7
Q
What is a fever?
A
- rise in body temperature in response to endogenous cytokines
- Above 100.0 F (38.3 C)
8
Q
involuntary muscle contractions that occur as a result of a sudden lowering of body temperature below a persons set point
A
chills
9
Q
- Describe hyperthermia and its distinction from fever while relating common entities that are associated with its occurrence.
A
-
Hyperthermia → elevated body temperature inability of body to dissipate heat in response to environmental heat
- Anything over 105.8 (41 C) is hyperthermia
10
Q
What is a fever of unknown origin
A
- fever that lasts 3 weeks or longer with temperatures above 100.9, with no clear dx, even though there has been 1 week of clinical investigation
11
Q
How does a fever occur?
A
- Lipopolysaccharide (endotoxin) of gram (-) rods, ciruses and other fungi, etx
-
Endogenous pyrogens (EP) binds to receptors in hypothalamus.
- IL1
- TNF: like IL1, but does not activate lymphocytes
- Interferon-a
- Increase in PGE2, monoamines, cations and cAMP
12
Q
- 4 common causes of fever
A
- Infection
- Autoimmune disease
- CNS disease
- Malignancy
13
Q
less common causes of fever
A
- CVD
- GI Disease
- Misc.
14
Q
most common causes of hyperthermia
A
- Heat Stroke
- Neuroleptic Malignant Syndrome
- Malignant Hyperthermia
15
Q
Describe the cource of fever in younger adults vs over 65 pts
A
-
younger adults: benign and self-limited.
- Challenge: ID meniningitis or sepsis
-
older than 65/those with chronic disease and fever: high risk for bad things.
- 70-90% are hospitalized
- Infection is the MCC in adults
16
Q
in older people, what body systems are 80% of the target, which cause fever?
A
- Respiratory tract
- Urinary tract
- Skinn and soft tissue
17
Q
what alarm systems are assx with a fever?
and what could they imply
A
-
High fever (above 105.8)
- CNS infection, NMS, heat stroke
-
Rash
- Meningitis, bacteremia with shock
-
Changes in mental status
- Meningitis, encephalitis
-
Dizziness or lightheadedness
- Bacterial infection with shock, adrenal insuff, PE
-
Recent chemo
- nocosomial infection w neutropenia
-
SOB or Chest Pain
- PE, pneumonia and empyema
18
Q
- Thermometer with the most variability: ______
- Subjective report of a fever is usually ______.
- In patients with a fever, the best predictors of bacteremia are what?
- Prescence of _________ increases the probability of bacteremia.
- What is the GREATEST VALUE of fever patterns today?
- Persistance of a fever means what?
A
- tympanic fever
- accurate
- patients underlying conditions
- shaking chills
- they respond to antimicrobial agents
- superinfection, drug fever, abcess or noninfectious mimic of infectious disease (vasculitis, tumor)
19
Q
- MCC of nocosomial infections in hospitilzed pts
- MCC cause of FUO:
- Malignancies most assx with FUO:
- 36% of patients with ____ have fever at presentation
- 42% of patients with ____ have fever at presentation
- 42% of patients with ____ have fever, but develops LATER in the course of illness.
A
- bacterial: pneumo, catheter-related spesis, clostridium difficile diarrhea, wound infections, UTI
- TB and intra-abdominal abcess
- Hodkines and non-hodgkins lymphoma
- SLE
- Giant cell arteritis
- IBD
20
Q
-
Endocarditis + fever
- MCC
- Other causes
- Diagnose:
A
- Rheumatic Heart Disease
- Staph aureus, strep vridans
- Clinical eval is not enough
- Blood cultures***
- Transesophageal echo is the cornerstone
21
Q
what is used to dx Endocarditis?
A
Duke criteria
22
Q
if pt presents with HF, what is important to note?
A
- HF is caused by many things.
- thus, it is important to ID the UNDERLYING cause of HF.
23
Q
how to dx HF?
A
- 1. Natriuretic peptide levels
- 2. 2D echo with doppler
- 3. CXR
24
Q
S3 gallop means what?
S4?
A
- S3: systolic HF
- S4: diastolic HF
25
* **Myocarditis**
* ****Follows:
* Present with:
* Similar to \_\_\_\_, coming on a **few weeks after** a febrile illness.
* May have _________ when auscultated
* Diagnose
* Would cardiac enzymes be elevated?
* **URI**
* **CP** or **signs of HF**
* **PSGN**
* **Pericardial friction rub**
* **ECG**, would see **sinus tachycardia**
* **COULD** be
26
1. **Granulomatosis with polyangiitis** (also called \_\_\_\_\_\_)
1. \_\_\_\_-ANCA
2. Patient could have a \_\_\_\_\_\_
* **Wegners**
* **c-ANCA**
* **Cough**
27
what would have **P-ANCA?**
* **1. Microscopic polyangitis**
* **2. Polyarteritis nodosa**
28
1. **Pulmonary Embolism (fever)**
1. Elevated levels of \_\_\_\_\_
2. Sx:
* **D-dimer**
* **Appear anxious or ill**, **hypoxemia**, **tachypnea**
29
do we **hospitlize** patients with **FUO**?
* **only if clinical condition requires it,** _NOT_ for diagnosis.
* thus, does **NOT need a in-hospital eval**
30
**FUO** defintion
1. Fever **\> 101** on at least **2 occasions** for **3 or more weeks**
31
Infections cause 1/5 of causes of FUO in Western countries. Next in frequency are what?
* **Non-infectious inflammatory diseases (NIIDS)**
* collagen or rheumatic diseases
* vasculitis
* granulomatous disoders
* autoinflammatory syndromes neoplasma
32
* If we have a **FUO**, which DOES NOT ALWAYS MEAN INFECTION, how do we treat?
* What about if the patient is toxic or septic?
* Withhold ABX
* If patient is toxic or septic, empirical ABX.
33
1. **Tick-borne illness** that can cause fever?
* 1. **Rickettsial** (rocky mountain spotted fever)
* 2. **Lyme disease**
34
What tick-borne illness is common in **SW Missouri?**
treat is?
HME: **_Erlichiosis_**
-empirical ABX
35
MRC **Dyspnea** Scale
1. When you have **SOB**
* 1 → no trouble except for strenuous exercise
* 2 → hurrying walking up hill
* 3 → walking slower than most, stops after a mile or 15 minutes
* 4 → after 100 yards or a couple of minutes
* 5 → at rest, can’t leave the house
36
how do diagnose **COPD**?
**GOLD** and **MRC Dyspnea scale**
37
1. Describe the **6-minute walk test** and its utility in the diagnosis and management of patients with **dyspnea** and **dyspnea on exertion.**
* **6 minute walk test** is a part of diagnosing _COPD_ + _pulmonary HTN._
* determines function of the **right side of the \<3**
38
what is best at detecting **pulmonary HTN**/COPD?
how can we track progression of **PAH**?
* **6 minute walk test**
* **6 minute walk test + echo**
39
the **GOLD** **criteria** is used to diagnose \_\_\_\_\_
**_COPD_**
1. Mild (\>80)
1. **SABD prn**
2. Moderate (50-80)
1. **+ LABD + pulm rehab**
3. Severe (30-50)
1. **+ ICS if repeated exacerbations**
4. Very severe
1. \< 30
2. or \<50 + respiratory failure
3. **+ add long-term O2 therapy; surgery**
40
what do we see with **diffuse parenchymal lung disease** on CXR?
other findings?
* **diffuse bilateral reticular lung disease** in the **upper zones** of the lungs
* **dry crackles**, **parasternal S2**
41
treatment of **asthma** plan
1. **LABA** + **LAMA** (Long acting muscarinic antagonist)
* Salmeterol/formotorol + tiotropium
42
**_a1AT deficiency_**
* Which of the following do we give?
* ICS,
* O2
* LABA
***LABA***
## Footnote
* do not give O2 bc 6 minute walk test is NL
* no ICS
43
pt who is **hypoxic** will describe what symptom
**SOB**
44
**COPD** d/t **infection** is caused by
1. **Strep. pneumo**
2. **M. catarhallis**
3. **H. influenzae**
45
classic 4 signs of **sarcoidosis**
1. **erythema nodosa**
2. **fever**
3. **arthralgia**
4. **hilar adenopathy (CXR)**
46
Which DPLD has **HIGH ACE** levels
sarcoidosis
47
1. Identify patients at risk for the development of **pneumonia**.
1. **CURB-65** → identify **high risk patients** + predict **complicated course**
1. C → Confusion
2. U → BUN \> 19.6
3. R --\>RR \> 30
4. B → Systolic Blood Pressure LESS 90
5. 65 → \> 65 years old
2. **2 findings:** admit to hospital
3. **3 findings**: admit to ICU
48
if you give a patient therapy for **community-acquired pneumo**, but they **do not respond in 48-72 hours**, what should we suspect?
1. **Legionnarires**
2. **TB**
3. **Fungi**
4. **Viruses**
5. **Pneumocystitis**
49
1. Describe patients at risk for developing **active tuberculosis,** or harboring **latent tuberculosis.**
1. **_Active TB_**
1. Born in **areas endemic** to TB
2. Around people w/ it
3. **Medically underserved/low income populations**
4. **IV Drugs users**
2. **_Latent TB_** → Asymptomatic
1. **HIV/AIDS**
2. **Immunosuppression** in general
3. **Malnutrition**
50
Signs of **active** and **latent TB?**
* **Active**: hemoptysis and weight loss
* **Latent**: constitiuional sx and asymptomatic
51
In what conditions is **_tactile fremitis_**
INCREASED:
DECREASED:
* **Increased**: pneumonia
* **Decreased**: COPD and asthma
52
1. Plan a directed evaluation of a patient with **hypoxia** to determine the diagnosis and severity
of the disorder.
* **CXR: PA/lateral view**
* **EKG**
* **CMP/CBC**
* **Lactic acid, blood culture and sputum culture**
* **kidney fxtest**
53
1. vicious cycle in **_COPD_** pts that are **tired** and have **shoulder pain**
* Gave tramadol
* Cause pleurisy
* Took more and made it worse
* Hypoventilates =\> retain **CO2**
54
\_\_\_\_\_ patients retain CO2
\_\_\_\_\_\_ are CO2 responsive
* **Chronic bronchitis** (blue bloaters) **retain CO2**
* Pink puffers (emphysema) respond to CO2
55
What are signs of **infection**?
* **Increased band count**/ **increase neutrophil granulation/vacuolization** =\> **LEFT shift** =\> **INFECTION**
56
1. DDX for **Community-Acquired Pneumonia**
1. **Organizing Pneumonia**
1. Diffuse Parenchymal Lung Disease
2. **Lung Cancer**
3. **Eosinophilic Pneumonia**
4. **Hypersensitivity Pneumonitis**
57
top 4 causes of **persistant cough?**
* **1. post nasal drip**
* **2. Asthma**
* **3. GERD**
* **4. Pulmonary infection**
58
1. Non-pulmonary causes of cough
1. **GERD**
2. **PND**
3. **HF**
4. **Sinusitis**
59
**_Pulmonary infections_**
1. **Bronchiectasis** (produces lots of \_\_\_\_\_\_\_)
2. **Bronchitis** (common in \_\_\_\_\_\_)
3. **MAC** (MC in whom)
4. **Mycoplasma**: \_\_\_\_\_\_\_\_\_\_
5. **Clamydia**: \_\_\_\_\_\_\_\_\_
* mucus
* smokers
* older patients, especially with disease
* #1 atypical PNA; in military recruits
* #2 atypical PNA
60
* **+ bronchoprovication test** = \_\_\_\_\_\_\_\_\_\_
* **decreased intensity of breath sounds**= \_\_\_\_\_\_\_\_\_
* asthma
* COPD
61
which vasculitis of the **skin** and **legs** presents with a **cough + dyspnea**
and has shit ton of **_eosinphils_**?
**churg strauss**
62
how do we diagnosis **churg straus?**
**_fibrinoid necrotizing epitheloid_** + **_eosinophillic granulomas_**
63
Treatment of Churg-Straus?
How do we maintain therapy?
* **Corticoisteroids (prednisone)** +**cyclophosphamide** until remission then taper off.
* Exchange cyclophsophamide with **methotrexate**
64
what clinical CV findings do we see with **Sarcoidosis**?
* **1. Restrictive cardiomyopathy**
* **2. Cardiac dysrhythmias**
* **3. Conduction disturbances**
65
66
**_Restrictive lung disease_**
\_\_\_\_\_ lung volume.
\_\_\_\_\_\_\_ TLC or FVC
\_\_\_\_\_\_\_ FEV1/FVC ratio
* decreased
* alteration in lung parenchyma
* disease of pleura, chest wall or NM
* Decreased
* NL
67
**_Obstruction LD_**
* FEV1
* FVC
* FEV1/FVC ration
* TLC
* decreased
* NL
* decreased
* NL or increase
68
**_idiopathic pulmonary fibrosis_**
* Mutation:
* Presentation:
* Dx:
1. **Surfactant C** and **telomerase/MUC5B**
2. **Gradual onset (\>6) months**; **progressive dyspnea** is the most COM symp
1. basilar inspiritary crackles
2. clubbing
69
what do lung function tests show for **idiopathic pulmopnary fibrosis?**
how is it dx?
* **Decreased** diffusing capacity of the lungs for CO (**DLCO**)
* **GOLD STANDARD** + **lung biopsy**
70
What is **acute coronary syndrome-NSTEMI**
**NSTEMI (unstable angina)** that presents with substernal **crushing** chest pain that radiates to L arm for more 30 minutes and can be relieved with **nitro**.
71
What is the inital steps in management of **NSTEMI (ACS)?**
* 1. **O2** via nasal canula
* 2. **Pain relief with opiate analgenics and nitroglycerin**
* MONA: morphine, O2, nitratates and ASP
* 3. **Aspirin**
* 4. **ECG**
* 5. **Labs**: CKMB, tropinin, CMP to check renal fx
* High troponin: NSTE
* NL troponin: unstable angina
72
What are treatments for **NSTE-ACS?**
1. **Anticoagulation therapy:** IV heparin, Enoxaparin
2. **Class 1 Antiplatelet drugs** (have to do them over and over again for a year)
1. Aspirin
2. P2Y12 inhibitors
1. Clopidogrel and Ticagrelo
3. Glycoprotein 2a3b inhibitors for HIGH risk NSTE-ACS
1. Abciximab, tirofiban +eptifibitide
3. **Opiate analgesia** + **NG** ONLY IF THERE IS PAIN
4. **Bblockers**, **ACE inhibitors**, **statins**
73
What is a **class 3 drug** that you should **NOT** use for **NSTE-ACS?**
**Thrombolytics**
74
When do you give **PCI (percutaneous intervention)** to a patient with NSTE-ACS?
* **High-risk patient,** then send to cath lab
75
How do you treat a low-risk and high-risk patient differently with **NSTEMI-ACS?**
* **Low risk (NL troponin and - ST depression):** stress test
* **High risk (high troponin and + ST depression):** PCI and cath lab
76
What are high risk feautures of **NSTEMI-ACS?**
**Elevated troponin + ST depression**
77
How can we tell if patient with **ACS** is experiencing **unstable angina?**
* **NL levels of troponin** unstable angina
* **High levels of tropinin:** NSTEMI
78
\_\_\_\_\_\_\_ is dangerous in **NSTE-ACS.**
\_\_\_\_\_\_ is the MOST important thing in **STEMI**?
* **thrombolytic/fibrinolytic therapy**
* **reperfusion therapy**
79
80
\_\_\_\_ supplies in the inferior of heart:
what arteries supplies V1/2? (anterior part of the heart)
1 and aVL? (lateral part of the heart?
* **RCA**
* LAD
* LCX or diagnonal A from LAD
81
what is the progression of changes in cardiac enzymes in pt with **STEMI**?
1. Initial cardiac enzymes may be normal if early presentation.
2. Become + 4-6 hours later
3. Troponin may stay elevated for 5-7 days after STEM
82
How do you treat **STEMI**?
1. **Aspirin**
**2. PG2Y12 inhibitor (clopidrgel/ Ticagrelor)**
* If high risk: Gp2a/3b inhibitors
3. **Reperfusion therapy**: via coronary angiography & PCI or thrombolytics (if facility of Primary PCI is not available) d/t ST elevation,
* Only give thrombo is cannot do CA or PCI in a cath lab
* PCI: door to ballon is 90 minutes
* If no cath lab, but you can transfer pt to hospital in 120 minutes, **DO IT**
83
what are **absolute CI** for thrombolytics in **STEMI**?
* **1. Prev hemorrhagic stroke**
* **2. Other strokes**
* **3. Intracranial neoplasms**
* **4. recent head trauma**
* **5. Active internal bleeding** (not menstruation)
* **6. Suspected aortic dissection**
* **7. ANY bleeding**
84
#1 treatment for **STEMI**?
1. **SEND TO CATH LAB**
85
1. **Post MI complications (5)**
1. Post infarct ischemia
2. Arrhythmia
3. Right ventricular infarction
4. Mechanical complications
5. Myocardial dysfunction
86
**Post MI Ischemia** can occur when?
Tx?
* 1. After **thrombolytic** therapy for **STEMI**
* 2. **After medically treating a NSTEMI.**
Treat with vigorous medical therapy. If refractory, undergo early aniography and revascularization
87
What **arrythmias** can occur after a **MI**?
1. Sinus bradycardia (MCC in inferior MI)
2. Supraventricular tachycardia, including a-fib
3. Conduction disturbances
4. Ventricular arrhythmias
88
1. **AV node** supplied by \_\_\_\_\_\_\_
**RCA**
89
**Post-M**I, patient has
* 1st degree AV block
* 2nd degree AV block
* Complete AV block
describe them
* **1st degree AV block:** most common and no treatment
* **2nd degree AV block**: only treat if symptom
* **Complete AV block:** most common in an inferior MI.
* If occurs with an anterior MI =\> worse.
90
**complete AV block** is most common in an ____ MI and worse with an _____ MI? What is the treatment?
* **inferior**
* **anterior** = worse bc sign of BAD infarction
* Permenant pacing
91
What is the most comon conduction abnormality in the **first few hours** after MI and how is it treated?
**Ventricular arrythmia (VT/VF)**
* if hemodynamically signifiant: defibrillate
* Stable: antiarrhythmic meds + amiodrone
92
how do you treat **RV infarction,** which occurs in 1**/3 of all inferior MIs.**
**_IV fluids_**
* - AVOID VASODILATORS (NG)
* - DO NOT REDUCE PRELOAD
93
**Right ventricular infarcts (RV infarcts)** presents with what sx?
**1. Hypotension**
**2. Normal LV function**
**3. High JVP**
**4. Clear lungs**
94
How are **LV/RV infarcts** different?
* **RV infarcts**
* RV infarcts will have clear lungs
* Dx by: ST elevation in the right sided anterior leads
* **LV infarcts**
* LV infarcts do NOT have clear lungs
* Dx: ST elevation in the left sided anterior leads
95
**_NAME THAT SHOCK!_**
* **Systolic BP \< 90mmhg** and **diminished perfusion** (cold clammy extremities, decreased urine output, confusion), however the patient **does not respond to fluid resuctiation.**
**Cardiogenic shock**
96
**NAME THAT SHOCK**
should be considered for urgent _coronary angiography_, _revascularization_ and possible _placement of intra-aortic balloon pump._
**cardiogenic shock**
97
**_NAME THAT SHOCK_**
**Echocardiagram** should be taken and will show function of the **LV is moderately - severely reduced.**
**Cardiogenic shock**
98
**_NAME THAT SHOCK!_**
what type of shock has a 3**0 day mortality** of **40-80%**
99
• Essentials of Diagnosis in a patient with **shock** (4)
1. **Hypotension**
2. **Tachycardia**
3. **Oliguria**
4. **Altered mental status**
100
**_Name that shock_**
**Blood loss** or **dehydration** causes decreased intravascular volume. To **treat**, we **replete** the intravascular volume
**hypovolemic shock**
101
**_NAME THAT SHOCK!_**
Shock caused by [**cardiac tamponade**, **tension pneumothorax** and **massive PE]** that is treated by _treating underlying cause_
**Obstructive shock**
102
**_NAME THAT SHOCK_**
A category of shocks, where the most common in **septic shock!**
**distributive shock**
103
**_NAME THAT SHOCK!_**
Shock most commonly caused by gram (-/+) organism where hypotension does NOT respond to fluid. Systolic BP are \< 100mmHg, serum lactate levels are high (\> 2mmol/L) and requires vasopressors to keep MAP above 65mmHg.
**SEPTIC SHOCK**
104
**_NAME THAT SHOCK!_**
Type of shock treated by fluids + ABX + hope for the best!
**Septic shock**
105
