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Terms / Facts

 
 

!

Peptic ulcer Gastritis Malignancy

DDx: Abdominal pain of gastroduodenal origing

(3)

DDx: Abdominal pain of intestinal origin (6)

!

Appendicitis Obstruction Diverticulitis Gastroenteritis Mesenteric adenitis Strangulated hernia

DDx: Abdominal pain of hepatobiliary origin (3)

 

!

Acute cholecystitis Chronic cholecystitis Cholangitis

DDx: Abdominal pain of pancreatic origin (3)

 

!

Acute pancreatitis Chronic pancreatitis Malignancy

DDx: Abdominal pain of urinary tract origin (4)

!

Cystitis Acute retention of urine Acute pyelonephritis Ureteric colic

DDx: Abdominal pain of gynecological origin (6)

!

Rupture of extopic pregnancy Rupture/Torsion of ovarian cyst Salpingitis Endometriosis Mittelschmerz Severe dysmenorrhea

DDx: Abdominal pain of vascular origin (2)

!

Aortic aneurysm Mesenteric embolus

DDx: Abdominal pain of peritoneal origin

(2)

! Primary periotonitis Secondary peritonitis

DDx: Abdominal pain referred from other locations (3)

 

! Myocardial infarction Pericarditis Testicular torsion

DDx: Abdominal swelling in the RUQ (4)

 

!

Right kidney carcinoma Right colonic carcinoma Feces Diverticular mass

DDx: Abdominal swelling in the LUQ (6)

!

Splenomegaly Gastric carcinoma Left kidney carcinoma Feces Diverticular mass Pancreatic pseudocyst

DDx: Abdominal swelling in the epigastrium (5)

! Lipoma Epigastric hernia Carcinoma of the transverse colon Feces Diverticular mass

DDx: Abdominal swelling in the umbilical region (5)

 

! Paraumbilical/umbilical hernia Malignancy Carcinoma Feces Diverticular mass

DDx: Abdominal swelling in the RLQ (5)

!

Appendix mass/abscess Carcinoma of the cecum Carcinoma of the ascending colon Feces Crohn's disease

DDx: Abdominal swelling in the LLQ (3)

 

!

Carcinoma of the sigmoid colon Diverticular mass Feces

DDx: Abdominal swelling in the suprapubic region (4)

 

!

Acute/chronic bladder retention Pregnancy Fibroids Diverticular mass

DDx: Acute anorectal pain (4)

!

Fissure-in-ano Perianal hematoma Thrombosed

Terms / Facts

hemorrhoids Perianal abscess

DDx: Chronic anorectal pain

(3)

! Fistula-in-ano Anorectal malignancy Chronic perianal spesis

DDx: Arm

pain (5)

! Disc lesion Cervical spondylosis Myocardial ischemia Repetitive strain injury Carpal tunnel syndrome

DDx: Arm swellings (2)

!

Trauma Infection (cellulitis, lymphangitis)

DDx: Ascites

(5)

! Cirrhosis Cardiac failure Nephrotic syndrome Carcinomatosis Abdominal/pelvic tumor

DDx: Axillary swellings

(5)

! Acute abscess Sebaceous cyst Lipoma Lymphadenopathy Breast lump

DDx: Backache (congenital) (3)

!

Kyphoscoliosis Spina bifida Spndylolithesis

DDx: Backache of traumatic origin (4)

! Vertebral fractures Ligamentous injury Joint strain Muscle tears

DDx: Backache of inflammatory origin (2)

! Ankylosing spondylitis Rheumatologic disorder

DDx: Backache of neoplastic origin (2)

!

Metastases Primary tumors

DDx: Backache of degenerative origin (2)

!

Osteoarthritis Intervertebral disc lesions

DDx: Backache of metabolic origin (2)

!

Osteoporosis Osteomalacia

DDx: Backpain of gynecological origin

(2)

! Pelvic inflammatory disease Endometrosis

DDx: Backpain of renal origin (2)

!

Renal calculus Renal carcinoma

DDx: Breast lumps (discrete) (5)

! Breast carcinoma Fibroadenoma Cyst (cystic mastitis) Duct ectasia Sebaceous cyst

DDx: Breast lumps due to generalized swelling

(4)

! Pregnancy Lactation Puberty Mastitis

DDx: Breast

pain

! Non-/Cyclical mastalgia Duct ectasia Breast abscess Pregnancy Lactation

DDx: Chest

pain (5)

! Angina/Myocardial infarction GERD Pneumonia/Pneumothorax Chest wall injury Depression

How does one quickly calculate heart rate when rhythm is normal with an EKG?

! 300/ # large boxes between 2 QRS complexes

How does one calculate heart rate

!

Count the number ofo complexes that occur in

 

Terms / Facts

 

from an EKG if the rhythm is irregular?

a 6-second interval (30 boxes) and multiply by 10 to get a rate

!

What rule determines whether the rhythm is sinus on an EKG?

If p waves are present in all leads and upright in leads I and aVF, then the rhythm is sinus

 

!

Normal sinus

What kind of rhythm is indicated by an EKG where each QRS wave is preceded by a p wave?

 

rhythm

What EKG findings indicate a normal axis?

!

I and aVF are both upright and positive

What EKG findings indicate a left axis deviation?

! I is upright and aVF is upside down

 

What EKG findings indicate right axis deviation?

! I is upside down and aVF is upright

 

What EKG findings indicate extreme right axis deviation?

! I and aVF are both upside down or negative

What is the time range of a normal PR interval?

 

!

0.12 to 0.20 seconds

 
 

!

Wolff-Parkinson-White

 

What disease is a short PR interval associated with?

 

syndrome

 

What kind of EKG appearance characterizes Wolff-Parkinson-White syndrome?

!

Delta wave

What PR interval indicates a first-degree block?

 

!

PR > 0.2 seconds

 

What is the length of a normal QRS complex?

 

!

0.12 s

 

What R wave width on lead I indicates LVH?

 

!

R I > 15 mm

 

What R wave width on lead II indicates LVH?

 

!

> 20 mm

 

What R wave width on lead aVF indicates LVH?

 

!

> 20 mm

 

What R wave width on lead aVl indicates LVH?

 

!

> 11 mm

 

What R wave width on lead V5 indicates LVH?

 

!

> 26 mm

 

What R wave width on lead V6 indicates LVH?

 

!

> 26 mm

 

If the sum of the widths of R I and S III is > 25 mm, what cardiac pathology is indicated?

 

!

LVH

What EKG morphology indicates right atrial hypertrophy?

!

Tall or peaked p waves in limb or precordial leads

What EKG morphology indicates left atrial hypertrophy?

 

!

Broad or notched p waves in limb leads

 

Terms / Facts

 

The presence of a Q wave indicates what cardiac pathology?

 

!

Old infarction

What mechanical event does the QRS complex represent?

 

!

Ventricular contraction (initiation)

 

What electrical event does the QRS complex represent?

 

!

Ventricular depolarization

What electrical event does the ST segment represent?

 

!

Plateau phase of venricular repolarization

 

The horizontal segment of baseline that follows the QRS complex is known as the

! The horizontal segment of baseline that follows the QRS complex is known as the ST segment.

[

]

segment.

What electrical event does the T wave represent?

 

! The rapid phase of ventricular repolarization

 

What are the boundaries of the ST segment?

 

!

End of the S to the beginning of the T

What parts of the EKG represent ventricular systole?

 

!

Beginning of the QRS complex to the end of the T wave

What are the boundaries of the QT interval? What cardiac event does it represent?

 

!

Begininng of the Q to the end of the T; ventricular systole

What is a simple rule of thumb for determining whether a QT interval is normal?

 

!

A QT interval should be less than half of the R-to-R interval at normal rates

What ion is responsible for conduction in the AV node?

 

!

Ca2+

What is deflection with respect to an EKG?

!

The direction of a wave on an EKG

Positive deflections are [ EKG.

]

on the

! Positive deflections are upward on the EKG.

Negative deflections are [ EKG.

 

]

on the

!

Negative deflections are downward on the EKG.

What kind of electrical activity produces a positive deflection on an EKG?

! Movement of positive charges (depolarization) toward a positive skin electrode

How much time is represented by a small square on an EKG?

 

!

0.04 s

How many leads does a standard EKG have?

 

!

12 leads

In the aVR lead, what limb electrode is positive?

 

!

Right arm positive

In the aVL lead, what limb electrode is considered positive?

 

!

Left arm positive

In the aVF lead, what limb electrode is considered positive?

 

!

Foot (left)

 

Terms / Facts

 

What are the lateral leads?

 

!

Leads I and AVL

 

Why are leads AVL and I called the lateral leads?

!

These leads have a positive electrode positioned laterally at the left arm

What are the inferior leads? (3)

 

!

Leads II, III and AVF

 

Why are leads II, III and AVF called inferior leads?

!

They have positive electrodes positioned inferiorly on the left foot

What is the charge of the chest electrodes?

 

!

Positive

Through what part of the heart are the chest leads oriented?

 

!

AV node

What is the orientation of electrode V2?

 

!

Front to back of the patient

What is the deflection of V1 and V2 normally?

 

!

Negative

What is the deflection of V6 normally?

 

!

Positive

What part of the heart are the V3 and V4 leads oriented over?

 

!

Interventricular septum

What plane do the six limb leads lie in?

 

!

Frontal plane

What plane do the six chest leads lie in?

 

!

Horizontal plane

What is the normal heart rate range?

 

!

60-100 bpm

What is the heart's normal pacemaker?

 

!

SA node

What is the inherent rate of the AV junctional automaticity focus?

 

!

40-60 bpm

What is the inherent rate of the atrial automaticity focus?

 

!

60-80 bpm

What is coronary ischemia?

!

An imbalance between blood supply and oxygen demand, leading to inadequate perfusion.

When does stable angina occur?

 

!

Stable angina occurs when oxygen demand exceeds available blood supply.

What causes stable angina pectoris?

 

!

Due to fixed atherosclerotic lesions that narrow the major coronary arteries.

What are the possible clinical presentations of coronary artery disease? (5)

!

When thinking CAD, ASSUMe the following presentations: Asymptomatic Stable angina pectoris Sudden cardiac death Unstable angina pectoris Myocardial infarction e

What are the risk factors for stable angina pectoris? (8)

!

Don't get LASHeD by Stable Angina Pectoris Low HDL Age (m>45, w>55) Smoking Hyperlipidemia, Hypertension,

 

Terms / Facts

 
 

Homocysteine, History (family) Diabetes mellitus

 

What is the normal left ventricular ejection fraction (%)?

 

!

> 50%

What is the clinical presentation of stable angina pectoris? (3)

 

!

Crushing retrosternal chest pain Exertional dyspnea Radiation of pain to left side

Involvement of what coronary artery has the worst prognosis for stable angina pectoris? Why?

!

Left main coronary artery because it serves nearly 2/3 of the heart.

 

!

EF <

What ejection fraction is associated with increased mortality in stable angina pectoris?

50%

 

!

Confirmation of diagnosis of angina Evaluation of response to therapy in CAD Indentification of patients with CAD with high risk for acute coronary events

In what situations is stress ECG used?

 

(3)

What relieves stable angina pectoris? (2)

 

!

Rest Nitroglycerin

 

Are there normally any abnormalities on an ECG in a patient with stable angina pectoris?

 

!

Not usually, unless a prior cardiac pathology is present

 

!

Test that involves recording ECG before, during and after excerise on a treadmill.

What is a stress

ECG?

What condition must be met to make a stress ECG most sensitive?

 

!

Patient must be able to achieve 85% of maximum predicted heart rate for age.

How does excerise-induced ischemia present on a stress ECG in

!

ST-segment

depression

a

patient with stable angina pectoris?

 
 

!

Cardiac catheritization should be performed

What is the course of treatment for a patient with

a

positive stress test?

What is the preferred test for assessing stable angina

 

!

Stress echocardiography

pectoris?

 

What is the course of treatment for a patient with a positive stress echocardiograph?

 

!

Cardiac catherization should be performed.

What criteria make a stress test positive? (4)

!

Any of the following: ST segment depression Chest pain Hypotension Significant arrhythmias

Why is stress echocardiography preferred to stress ECG?

!

Stress echo is more sensitive, can assess LV size and function, and can diagnose vascular disease.

What procedure is almost always performed concurrently with cardiac catherization? Why?

 

!

Coronary angiography for visualization

What is the most accurate method of identifying the presence

!

Coronary

Terms / Facts

and severity of CAD?

arteriography

What stress test should be used if a patient cant' exercise?

! Pharmacologic stress test

What drugs are used in a pharmacologic stress test? (3)

! IV adenosine IV dipyramidole IV dobutamine

What is the mechanism by which IV adenosine and dipyramidole work in pharmacologic stress testing?

! Adenosine/dipyramidole are vasodilators; because diseased coronary arteries are already maximally dilated at rest to increase blood flow, they received relatively less blood flow when the entire coronary system is dilated pharmacologically.

Explain how myocardial perfusion scintigraphy works.

! Viable myocardial cells extract the radioisotope (thallium 201) during exercise; no radioisotope uptake means no blood flow to an area of the myocardium.

What is the mechanism by which dobutamine works in pharmacologic stress testing.

! Dobutamine → ↑ myocardial O2 demand → ↑ HR/BP/Contractility

What diagnostic tool is used to detect silent ischemia?

! Holter monitoring (ambulatory ECG)

By how much is the risk of coronary heart disease reduced with smoking cessation? In what time frame?

! 50% reduction 1 year after cessation

What pharmacological agents are used for treatment of stable angina pectoris? (4)

! Aspirin β -blockers Nitrates Calcium-channel blockers

How do β -blockers work in the treatment of stable angina pectoris?

! Blockage of sympathetic stimulation → ↓ HR/BP/contractility → ↓ cardiac work (O2 consumption)

What is the net therapeutic effect of aspirin on stable angina pectoris?

! morbidity - reduces risk of MI

What is the net therapeutic effect of β -blockers on stable angina pectoris?

! Reduces the frequency of coronary events

What is the mechanism by which nitrates treat stable angina pectoris?

! Generalized vasodilation → ↓ preload → ↓ cardiac work angina

What are the side effects of nitrates? (4)

! Nitrates make you feel SHOT S yncope H eadache O rthostatic hypotension T olerance

What drug can prevent angina if taken before exertion?

!

Nitrates

What is the mechanism by which calcium channel blockers treat stable angina pectoris?

! Vasodilation and afterload reduction decreased work → ↓ angina

Are calcium channel blockers primary or secondary treatment

!

Secondary

Terms / Facts

agents for stable angina pectoris?

treatment

What are the methods of revascularization? (2)

! PTCA (Percutaneous transluminal coronary angioplasty) CABG (Coronary artery bypass graft)

What is the effect of revascularization on incidence of MI?

! Does not reduce incidence; improves symptoms, however.

What management decisions are indicated for all patients with stable angina pectoris? (2)

! Risk factor modification Aspirin

What management decisions are indicated in patients with mild stable angina pectoris? (3)

! Nitrates β -blockers. Calcium- channel blockers if needed.

What are the criteria for mild stable angina? (3)

! Normal EF Mild angina Single-vessel disease

What are the criteria for moderate stable angina? (3)

! Normal EF Moderate angina Two- vessel disease

What management decisions are indicated in patients with moderate stable angina pectoris? (4)

! Nitrates β -blockers Calcium-channel blockers CABG/PTCA if above don't work.

What are the criteria for severe stable angina pectoris? (3)

! Decreased EF Severe angina Three- vessel/left main/LAD disease

What management decision is indicated for patients with severe stable angina pectoris?

! Coronary angiography and consider for CABG

What is the most significant complication of PTCA? What is the risk and in what time frame?

! Restenosis; up to 40% within first 6 months

What intervention helps reduced the rate of restenosis in PTCA?

!

Stents

What patients should be considered for PTCA?

! Patients with one- or two-vessel stable angina pectoris.

What is the treatment of choice in patients with high-risk stable angina pectoris?

!

CABG

What are the indications for CABG in patients with stable angina pectoris? (4)

! Left main disease Three-vessel disease with reduced LV function Two-vessel disease with proximal LAD stenosis Severe ischemia

What kind of lesions are most responsive to PTCA?

!

Proximal lesions

How does the pathophysiology of unstable angina pectoris differ from that of stable angina pectoris?

! With unstable angina, oxygen demand is unchanged; in stable angina, there is increased demand, which precipitates the angina.

Terms / Facts

What is the pathophysiology of unstable angina pectoris?

! Reduced resting coronary blood flow &rarr with no change in O2 demand angina

Why is unstable angina pectoris significant?

! It indicates stenosis that has enlarged via thrombosis, hemorrhage, or plaque rupture.

Patients with what presentations are said to have unstable angina pectoris? (3)

! Patients with angina at rest Patients with new-onset angina that is severe and worsening Patients with chronic angina with increasing frequency, duration or intensity of pain.

What does acute coronary syndrome refer to? (2)

!

Unstable angina or acute MI

What precautions should be taken before stress testing patients with unstable angina pectoris?

! Patients should be medically managed or should undergo cardiac cathertization initially.

How is non-ST elevation MI differentiated from unstable angina pectoris diagnostically?

! In non-ST elevation MI, cardiac enzymes are elevated.

What was the key finding of the ESSENCE trial?

! Enoxaparin is the drug of choice for treatment of unstable angina pectoris.

How does one treat unstable medical angina upon hospital admission? (2)

! Establish IV access Give supplemental oxygen

What pharmacogical interventions are indicated for unstable angina pectoris? (5)

! Aspirin β -blockers LMWH or unfractionated heparin (Enoxaparin) Nitrate (first-line) Glycoprotein IIb/IIIa inhibitors (second line)

For how long should LMWH/unfractionated heparin therapy be given for unstable angina pectoris?

! At least 2 days

What target value of PTT should be maintained with unfractionated heparin administration in unstable angina pectoris?

! 2 to 2.5x normal

Should PTT be followed with LMWH treatment in unstable angina pectoris? !

No

What is catecholaminergic polymorphic ventricular tachycardia?

! An unstable rhythm with a continuously varying QRS complex in any recorded ECG lead in a patient without any structural heart disease.

What is the pathogenesis of myocardial infarction?

! Rupture of atheromatous plaque acute coronary thrombosis interruption of blood supply necrosis of myocardium

What is the most common cause of myocardial infarction?

! Acute coronary

thrombosis

What is the mortality rate of myocardial infarction?

!

30%

The combination of substernal chest pain

!

The combination of substernal chest pain

 

Terms / Facts

 

persisting for longer than 30 mins and

persisting for longer than 30 mins and diaphoreis strongly suggests acute MI (disease).

diaphoreis strongly suggests [

]

(disease).

!

What is the classic clinical presentation of myocardial infarction? (3)

'Crushing' retrosternal chest pain Radiation of pain to left side Diaphoresis

In what patient groups are myocardial infarctions often asymptomatic? (4)

 

!

Post-op patients Elderly Diabetics Women

!

What is the clinical presentation of right ventricular infarct? (5)

Inferior EKG changes Hypotension Elevated JVP Hepatomegaly Clear lungs

What does S-T segment elevation indicate? What can it be diagnostic for?

 

!

Transmural injury; diagnostic of an acute infarct

What are Q waves indicative of?

 

!

Evidence of necrosis

When are Q waves seen in the course of an MI?

 

!

Usually seen late; not acute

What is an S-T segment depression indicative of?

 

!

Subendocardial injury

 

!

Occur very

When in the course of an MI are peaked T waves observed on an EKG?

 

early

!

What are the categories of infarct in terms of EKG morphologies? (2)

ST segment elevation infarct (STEMI) Non-ST segment elevation infarct (NSTEMI)

How much of the heart wall is affected by STEMI?

 

!

Transmural; entire thickness

How much of the heart wall is affected by NSTEMI?

!

Subendocardial; partial involvement of heart wall

What diagnostic test is used to differentiate NSTEMI from unstable angina pectoris?

 

!

Cardiac enzymes are present in NSTEMI but not USA

What test is the diagnostic gold standard for myocardial injury?

 

!

Cardiac enzymes

When does CK-MB increase after myocardial injury? When is the peak reached?

 

!

4 to 8 hours; peak at 24 hours

At what interval should total CK and CK-MB be measured after admission? For how long?

 

!

Every 8 hours for 24 hours

What are the most important cardiac enzymes to order?

 

!

Troponins I and T

When do troponins I and T increase after a myocardial infarction? When do they peak?

!

Increase within 3 to 5 hours Reach a peak in 24 to 48 hours

 

Terms / Facts

 

When do troponins return to normal after myocardial infarction?

!

5 to 14 days

!

Why are troponins preferred to CK-MB for diagnosis of myocardial infarction?

Greater sensitivity and specificity

When should cardiac enzymes be drawn?

 

!

At admission and every 8 hours until three samples are obtained

 

!

Troponin I can be falsely elevated in patients with r enal failure (disease).

Troponin I can be falsely elevated in

patients with r [

]

(disease).

 

What are the only three agents shown to reduce mortality in MI?

 

!

Aspirin ACE inhibitors β - blockers

What is the rationale for using aspirin in a patient with acute MI?

!

Antiplatlet activity reduces coronary reoccclusion by inhibiting platelet aggregation on top of the thrombus

What is the rationale for using β -blockers in a patient with acute MI?

!

HR, contractility and afterload → ↓ mortality

When should ACE inhibitors be administered to a patient with acute MI?

 

!

Within hours of hospitalization if there are no contraindications.

What was the key finding of the CAPRICORN trial?

 

!

Showed that carvedilol reduces risk of death in patients with post-MI LV dysfunction

Myocardial infarction in the anterior region of the heart has what EKG morphologies? (2)

 

!

ST segement elevation in V1-V4 Q waves in V1-V4

Myocardial infarction in the posterior region of the heart has what EKG morphologies? (3)

!

Large R wave in V1 and V2 ST segment depression in V1 and V2 Upright and prominent T wave in V1 and V2

Myocardial infarction in the lateral region of the heart has what EKG morphologies? (1)

 

!

Q waves in leads I and aVL

Myocardial infarction in the inferior region of the heart has what EKG morphologies? (1)

!

Q waves in leads II, III and aVF

What is the rational for using statins in mainenance therapy of MI?

! Stabilizes plaques and lowers cholesterol → ↓ risk of further coronary events

What pharmacologic agents are indicated in patients with MI? (7)

 

! Oxygen Nitroglycerin β -blockers Aspirin Morphine ACE inhibitors IV Heparin

What is the rationale for using nitrates in patients with acute MI? (3)

 

!

Dilate coronary arteries (increase supply) Venodilation (decrease preload and demand) Reduce chest pain

What did the

 
 

!

ACE inhibitor ramipril reduces mortaliti, MI, stroke and renal

HOPE trial

find?

Terms / Facts

disease in patients with high-risk cardiovascular disease

What did the GUSTO trial find?

! t-PA plus heparin gives the greatest mortality benefit in patients with acute MI

What are the two types of revascularization used in acute MI patients?

!

PTCA

Thrombolysis

What is the most important criterion for effectiveness of revascularization in acute MI patients?

! Timing; must be given early

What is the rationale for giving heparin to patients with acute MI?

! Prevention of progression of thrombus formation.

What is the most common cause of in-hospital mortality related to acute MI?

!

CHF

What are the classes of complications related to acute MI? (4)

! Acute MI is a RAMP to lots of complications R ecurrent infarction A rrhthymias M echanical complications P ump failure (CHF)

What is cardiac rehabilitation?

! Physician-supervised regimen of exercise and risk factor reduction after MI

What treatment does premature ventricular contractions call for in a patient post acute MI?

! Observation; no need for antiarrhythmics

What treatment does ventricular tachycardia call for in the context of hemodynamic instability?

!

Electrical

cardioversion

What treatment does ventricular tachycardia call for in the context of hemodynamic stability.

! Antiarrhythmic therapy (IV amiodarone)

What treatment does ventricular fibrillation call for?

! Immediate unsynchronized defibrillation and CPR

What treatment does asytole call for?

! Electrical defribillation followed transcutaneous pacing

In what setting does a second- or third-degree AV block have a dire prognosis?

! In the setting of an anterior MI

What treatment does 2nd- or 3rd-degree AV block call for in the setting of anterior MI?

! Emergent placement of a temporary pacemaker

What is the initial treatment for 2nd- or 3rd- degree AV block in the setting of inferior MI?

! IV atropine followed by temporary pacemaker if conduction is not restored

What is a recurrent infarction?

! Extension of existing infarction or reinfarction of a new area.

 

Terms / Facts

 

What cardiac enzyme is best for assessing recurrent infarction? Why?

!

CK-MB because it returns to normal faster so a re-elevation is detectable.

When does CK-MB return to normal after an acute MI?

 

!

48 to 72 hours

What is the treatment for recurrent infarction?

!

Repeat thrombolysis or urgent cardiac catheterization and PTCA followed by standard medical therapy for MI

What EKG finding suggests reinfarction after an acute MI?

 

!

Repeat ST segment elevation within first 24 hours

What is a free wall rupture? When does it occur most commonly?

 

!

Catastrophic, usually fatal event that occurs during the first 2 weeks after MI (most common 1 to 4 days)

What is the mortality rate of a free wall rupture?

 

!

90%

What is the result of free wall rupture?

 

!

Hemopericardium and cardiac temponade

(2)

What is the treatment for free wall rupture? (3)

!

You need to fix HIS free rupture Hemodynamic stabilization Immediate pericardiocentesis Surgical repair

How does ejection fraction post-MI relate to the risk for stroke? In what time range?

 

!

The lower the EF, the greater the risk for stroke in the next 5 years.

 

!

10 days post-

In what time range post-MI does rupture of the interventricular septum occur?

 

MI

What cardiac pathology results from papillary muscle rupture?

!

Mitral regurgitation

What is the treatment for mitral regurgitation secondary to papillary muscle rupture? (2)

 

!

Emergent surgery (mitral valve replacement) Afterload reduction with nitrprusside or intra-aortic baloon pump

What is a ventricular pseudoaneurysm?

!

Incomplete free wall rupture (myocardial rupture is contained by pericardium)

What is the treatment for a ventricular pseudoaneurysm? Why?

 

!

Emergent surgery because VP can become free wall rupture.

 

!

Ventricul aneursym is associated with a high incidence of ventricular tachyarrhythmias .

Ventricul aneursym is associated

 

with a high incidence of [

]

.

What is the treatment for acute pericarditis secondary to MI?

 

!

Aspirin

What drugs are contraindicated in acute pericarditis secondary to MI? Why?

 

!

NSAIDs and corticosteroids; may hinder myocardial scar formation

What is Dressler's syndrome?

!

Immunologically based syndrome occurring weeks to

 

Terms / Facts

 
 

months after MI

 

What is the clinical presentation of Dressler's syndrome? (5)

!

Fever Malaise Pericarditis Leukocytosis Pleuritis

 

What is the most effective therapy for Dressler's syndrome?

 

!

Aspirin

DDx: Chest pain due to heart, pericardium or vascular causes. (4)

 

!

Angina (stable, unstable, variant) MI Pericarditis Aortic dissectoin

What is the classic triad of asthma?

 

!

Wheezing Cough Dyspnea

 

In what manner do the symptoms of asthma usually appear?

 

!

Chronic with episodic exacerbation

What are the triggers of asthma? (3) !

 

Viral infection Environmental allergens Drugs

What information should one note about asthma exacerbations? (4)

 

!

Frequency Duration Required treatment Severity

What breath sounds are heard in asthma? (2)

 

!

Wheezing Prolonged expiratory

What external signs are observed with physical exam in asthma? (3)

!

Nasal polyps Rhinitis Rash

What physical exam findings does one observe in asthma with exacerbation? (5)

 

!

Asthma exams have HARD, Paradoxical Pulses HR Accessory muscle use RR Diaphoresis Pulsus paradoxis

 

!

Hyperventilation Panic attacks Upper airway obstructor or inhaled foreign body COPD Bronchiectasis CHF

DDx:

Asthma (6)

What is the triad of atopic asthma?

 

!

Asthma + allergic rhinitis + atopic dermatitis

What is the triad of ASA-sensitive asthma?

 

!

Asthma + ASA sensitivity + nasal polyps

What is the clinical triad of allergic bronchopulmonary aspergillosis?

 

!

Asthma + pulmonary infiltrates + allergic rxn to Aspergillus

What are the 'reliever' medications used to quickly relieve the sx of asthma? (2)

!

Short-acting inhaled β 2 -agonists: albuterol, levoalbuterol. Inhaled anticholinergics (ipratropium; bronchodilation)

What is the clinical triad of Churg- Strauss?

 

!

Asthma + eosinophilia + granulomatous vasculitis

What are the controller medications used for asthma? (6)

!

Inhaled corticosteroids (fluticasone, beclamethasone) Long acting β 2 -agonists (salmeterol) Nedocromil/cromolyn Theophylline Leukotriene modifiers Anti-IgE

What should long-acting β 2 agonists always !

 

Always use with inhaled

 
 

Terms / Facts

 

be used with in asthma? Why?

corticosteroids; mortality without.

 

!

Check transcription of genes for

What test can be used to predict response to leukotriene modifiers in asthma?

 

5-lipoxygenase

 

What benefit does bronchial thermoplasty offer patients with asthma?

 

!

sx and # of exacerbations (but no change in FEV 1 )

What is the goal of asthma therapy? What does that goal consist of? (3)

 

!

To achieve complete control = daily sx 2/week, ø nocturnal sx, reliever med 2/wk

What happens to FEV 1 , FEV 1 /FVC, RV and TLC and flow volume loops in asthma?

 

!

FEV 1 FEV 1 /FVC RV and TLC coved flow-volume loop

What are the distinct pathologic features in the sputum samples of patients with asthma? (2)

!

Curschmann's spirals (mucus casts of distal airways) Charcot-Leyden crystals (eosinophil lysophospholipase)

What PEF (peak expiratory flow) findings suggest asthma? (2)

!

60 L/min after bronchodilation 20% diurnal variation

What is the treatment for Step 2 in asthma stepwise therapy?

!

Low-dose ICS

What is the treatment for Step 3 in asthma stepwise therapy?

 

!

Low-dose ICS + LABA

What is the treatment for Step 4 in asthma stepwise therapy?

 

!

Med/high dose ICS + LABA

What is the treatment for Step 5 in asthma stepwise therapy?

 

!

Oral steroids

What is a good predictor of risk of death with asthma exacerbation?

 

!

Previous need for intubation

What suspicions should prompt a CXR in an asthma patient with exacerbation? (2)

!

Suspicion of pneumothorax or pneumonia

!

What are the precipitants of DKA? (4)

Insulin deficiency Infection or inflammation Ischemia or infarction Intoxication

What type diabetes does DKA occur in mostly?

 

!

T1D and ketosis-prone T2D

What happens to acid-base status with DKA?

 

!

anion gap metabolic acidosis

What is the predominant ketone in DKA?

 

!

β -hydroxybutyrate

What is the value for the corrected serum [Na+] in the context of DKA-related hyperglycermia?

 

!

Corrected Na = measured Na + [2.4 x (measured glucose-

 

100)/100]

 

What happens to serum [K+] with DKA? Why?

!

 

Hyperkalemia due to exchange with H+

 

Terms / Facts

 
 

(acidosis) from ICF

 

What happens to total body K+ with DKA?

 

!

K+

What happens to the CBC with DKA?

 

!

Leukocytosis

What happens to total body phosphorous with DKA?

 

!

Decreases

What pancreatic enzyme is elevated with DKA?

 

!

amylase

What is the general treatment strategy for DKA?

 

!

Rule out possible precipitants Aggresive hydration Insulin Electrolyte repletion

What does fluid management consist of in DKA?

!

Aggresive (10-14 mL/kg/h) hydration with normal saline (add 5% glucose once blood glucose reached 250 mg/dL to prevent hypoglycemia)

What does insulin treatment consist of in the management of DKA?

 

!

(1) 10 U IV push of insuin followed by 0.1 U/kg/h; continue insulin until AG normal (2) When AG is normal, give subcutaneous insulin.

What does electrolyte management consist of in DKA? Explain.

 

!

Replace K+ (20-40 mEq/L) if < 4.5 (within 1 to 2 hours of starting insulin); insulin shift of K+ into cells hypokalemia. Replace PO 4 if < 1

 

!

Cerebral edema (if glucose levels decrease too rapidly) Hyperchloremic nongap metabolic acidosis (due to rapid infusion of a large amount of saline)

What are the complications of DKA treatment? Explain.

(2)

 

!

Alcoholic ketoacidosis Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) Hypoglycemia Sepsis Intoxication

DDx:

DKA (5)

What lab tests should be ordered if a patient presents with DKA? (10)

 

!

Arterial blood gas Blood glucose/BUN CBC/Creatinine/CXR/Cultures Electrolytes/ECG UA

What is acute bacterial meningitis?

!

Bacterial infection of the subarachnoid space

List the bacteria that cause adult meningitis in descending order? (4)

 

!

S.pneumoniae N. meningitidis H. influenzae L. monocytogenes

What are the clinical manifestations of acute bacterial meningitis? (6)

!

Fever Headache Stiff neck Photosensitivity AMS Seizures

 

!

Lethargy w/o

What is the atypical presentation of acute bacterial meningitis that may occur in the elderly and immunosuppressed?

fever

What physical exam signs are present in acute bacterial meningitis? (5)

!

Nuchal rigidity Kernig's sign Brudzinski's sign Focal neuro findings Rash

 

Terms / Facts

 

What are the possible causes of recurrent bacterial meningitis?

 

!

CSF leak Dermal sinus Congenital/acquired defects

 
 

!

Blood culutres should be taken before antibiotic therapy in bacterial meningitis

Blood culutres should be taken [

]

antibiotic therapy in bacterial meningitis

 

What is the WBC count in bacterial meningitis?

 

!

> 10,000 WBC

What test should be performed if meningitis is suspected?

 

!

Lumbar puncture

 

!

Empiric antibiotic therapy should be initiated immediately after LP is performed.

Empiric antibiotic therapy should be

 

initiated immediately [ performed.

]

LP is

 

What are the Rule of 2s (bacterial meningitis)?

!

CSF WBC > 2k glc <20 TP > 200 > 98% specificity for bacterial meningitis

 

What is the appearance of CSF in bacterial meningitis?

 

!

Cloudy

What is the opening pressure of CSF in bacterial meningitis? (cm H20)

 

!

18-30

 

!

100-10,000

What range of WBCs is found in the CSF with bacterial meningitis? What is the predominant type?

 

PMNs

 

What is the glucose level in CSF in bacterial meningitis?

 

!

< 45

 

!

Ceftriaxone +

 

What is the empiric abx treatment for a normal adult with meningitis?

Vancomycin

!

What is the empiric abx treatment for an adult > 50 y/o?

Ceftriaxone + Vancoymcin + Ampicillin

What other treatment may be initiated in bacterial meningitis? What is the indication? When should it be administered?

 

!

Dexamethasone if cerebral edema is suspected. Must be administered before or w/ 1st dose of abx.

 

!

Rifampin or

 

What prophylaxis should be given to the contacts of a patient with bacterial meningitis?

 

ceftriaxone

What is the definition of aseptic meningitis? !

Negative bacterial microbiologic data

What are the most common viral etiologies of aseptic meningitis? (4)

 

!

Enterovirus HIV HSV (type 2 >1) VZV

What CSF findings suggest viral meningitis? (3)

 

!

Cell count < 500 w/ > 50% lymphs TP < 80-100 mg/dL Normal glucose

Tx: TB meningitis

!

Antimycobacterial Rx + dexamethasone

 

Tx: Fungal meningitis

!

Amphotericin B + 5-FU

 
 

Terms / Facts

 
 

!

Urethra Urinary

What anatomic regions are affected in lower urinary tract infections? (2)

bladder

 

What anatomic regions are affected in upper urinary tract infections?

 

!

Kidneys (pyelonephritis) Prostate

What is an uncomplicated UTI?

!

Cystitis in immunocompetent nonpregant women w/o underlying structural or neurologic disease

 

!

Upper tract infection in women UTI in men UTI in pregnant women UTI with underlying structural disease or immunosuppression

What is a complicated UTI?

(4)

What is the number one culprit in uncomplicated UTIs?

 

!

E.coli

What microbes are responsible for complicated UTIs? (4)

 

!

E. coli Enterococci Pseudomonas S. epidermidis

What organisms are the most frequent causes of catheter-associated UTIs? (2)

!

Yeast E.coli

What are the clinical manifestations of cystitis? (3)

!

Dysuria Urgency Frequency

How does the clinical presentation of urethritis differ from that of cystitis?

 

!

Urethral discharge may be present

What is the clinical presentation of acute prostatitis? (3)

 

!

Perineal pain Fever Tenderness on prostate exam

What is the clinical presentation of pyelonephritis? (3)

!

Fever w/ shaking chills Flank/back pain Nausea/vomiting

How does the clinical presentation of a renal abscess differ from that of pyelonephritis?

 

!

Persistent fever despite appropriate antibiotics

What are the urinalysis findings of UTIs? (4)

!

Pyuria + Bacteriuria +/- hematuria +/- nitrites

What is the definition of pyuria?

 

!

> 8 WBC/HPF

 

What is the definition of bacteriuria?

!

> 1 organism per oil-immersion field.

What is the criterion for a UTI based on urine culture for an asymptomatic woman?

 

! 10 5 CFU/ml

 

! 100

What is the criterion for a UTI based on urine culture in a symptomatic woman?

 

CFU/ml

What is the criterion for a UTI based on urine culture in a man?

!

1000 CFU/ml

What does the presence of squamous cells in a urinalysis indicate?

 

!

Vulvar or urethral

Terms / Facts

 
 

contamination

 

What is the empiric treatment for uncomplicated cystitis? (2)

 

!

FQ or TMP-SMX x 3 day

What is the empiric treatment for complicated cystitis? (2)

 

!

FQ or TMP-SMX PO x 10- 14 d

What is the empiric treatment for pregnant women with UTI? (3).

!

Ampicillin Amoxicillin Oral cephalosporins x 7 to 10 days

What is the empiric treatment for UTIs in men?

!

Treat as in women, except for 7 days

What is the empiric treatment for urethritis? (2) What is the indication for each part of this treatment?

 

!

Ceftriaxone 125 mg IM x 1 (Neisseria) Doxy 100 mg PO bid x 7 d (Chlamydia)

What is the empiric treatment and duration for acute prostatitis?

! FQ or TMP-SMX Po x 14-28 d (acute)

What is the treatment with duration for chronic prostatitis?

! FQ or TMP-SMX Po x 6-12 weeks

What is the inpatient treatment with duration for pyelonephritis?

 

!

Ceftriaxone IV x 14 d

What is the treatment for a renal abscess?

!

Drainage + antibiotics for pyelonephritis

What test should be conducted in patients with pyelonephritis who fail to defervesce within 72 hours? Why?

 

!

CT to r/o abscess

What is the clinical presentation of rheumatoid arthritis?

!

Pain Swelling Impaired function of joints Morning stiffness

How many joints are involved in the majority of cases of rheumatoid arthritis?

 

!

Polyarticular

What is the precursor lesion to almost all cases of CRC?

 

!

Adenomas

What is the most specific and sensitive test for CRC?

 

!

Colonoscopy

What test is used to complement flexible sigmoidoscopy in evaluating CRC?

 

!

Barium enema

What is the most common site of distant spread of CRC?

 

!

Liver

What age group is at increased risk for CRC?

 

!

> 50 y/o

What kind of adenoma has the highest malignant potential for CRC?

!

Villous adenomas

How is staging performed for CRC?

!

CT scan of abdomen and CXR

What other gastrointestinal diseases increase the risk

 

!

Ulcerative colitis Crohn's

 

Terms / Facts

 

for CRC? (2)

disease

 
 

!

Limited to muscualris mucosa; T1-2, N0,

What does Stage A colorectal cancer mean?

 

M0

What does Stage B1 CRC mean?

 

!

Limited to submucosa/muscularis propria

What does Stage B2 CRC mean?

 

!

Through the entire bowel wall

 

What does Stage B3 CRC mean?

!

Through bowel wall and into adjacent structures

What does Stage C CRC mean?

!

Positive regional lymph nodes

 

What does Stage D CRC mean?

!

Distant metastases

 
 

!

Prophylactic

 

What is the recommended treatment for familial adenomatous polyposis?

 

colectomy

At what age is the risk of CRC 100% with Gardner's Syndrome?

!

Age 40

What is the clinical presentation of Turcot's syndrome? (2)

!

Polyps + cerebellar medulloblastoma or GBM

!

What is Lynch I syndrome?

Early onset CRC with an absence of antecendent multiple polyposis

!

What is Lynch syndrome II?

Lynch syndrome I features + early occurence of other cancers

What is the clinical presentation of CRC? Which symptom is most common? (4)

 

!

Abdominal pain Weight loss Blood in stool Colonic perforation

What is the most common cause of large bowel obstruction in adults?

!

CRC

What is the clinical presentation of right-sided CRCs? (3)

 

!

Anemia Weakness RLQ mass

CRCs on what side of the colon present with melena? And with hematochezia?

 

!

Melena: right side Hematochezia: left side

Why is obstruction unusual with right-sided CRCs?

 

!

Large luminal diameter

What is a common symptom of left- sided CRC?

 

!

Changes in bowel habits secondary to bowel obstruction

What is the most common symptom of rectal cancer?

 

!

Hematochezia

What is the surgical treatment for CRC?

!

Resection of tumor-containing bowel as well as the regional lymphatics

What blood marker should be

!

CEA; levels are checked periodically every 3

 

Terms / Facts

 

obtained before surgical resection of CRC? Why?

 

to 6 months. Elevations strongly suggest recurrence.

 

!

Postoperative chemotherapy:5-FU and leucovorin

What is the adjuvant therapy for Dukes'

 

C

colon cancer?

 

What is the adjuvant therapy for Dukes' B2 or C rectal cancer?

!

5-FU + radiation therapy postoperatively

What follow-up studies are used s/p CRC resection?

!

Stool guaiac Annual CT of abdomen/pelvis CEA levels

In what time frame do the majority of recurrences take place for CRC s/p resection?

!

Within 3 years of surgery

 

!

Radiation therapy is not indicated in the treatment of colon cancer.

therapy is not indicated in the treatment of colon cancer.

[

]

What is the leading cause of neurologic disability?

 

!

Ischemic stroke

What is an evolving stroke?

 

!

Stroke that is worsening

 

What is a completed stroke?

!

One in which the maximal deficit has occurred.

 

!

Reperfusion occurs due to collateral circulation or embolus break up.

Why are symptoms transient

in

a TIA?

What is the usual cause of a TIA?

 

!

Embolism

 

What is the association between TIA and stroke risk?

 

!

TIA = high risk of stroke in subsequent months.

What is the 5-year stroke risk with a TIA?

 

!

30%

What are the most important risk factors for TIA? (2)

 

!

Age HTN

!

What are the types of strokes? (2)

 

Ischemic strokes Hemorrhagic strokes

 

!

Heart (mural

What is the most common source of emboli in ischemic stroke?

thrombus)

 

What are the major causes of stroke? (3)

!

Ischemia due to atherosclerosis Atrial fibrillation with clot emboli to the brain Septic embolic from endocarditis

In what vessels does thrombotic stroke occur most frequently? (2)

 

!

Bifurcation of the common carotid artery Middle cerebral artery

What predisposing factor is found in nearly all cases of lacuanr stroke?

 

!

Hypertension

What is the pathogenesis

 

!

Narrowing of the arterial lumen by thickening of the

of

lacunar strokes?

vessel wall (hyaline arteriolosclerosis) microinfarcts

 

Terms / Facts

 
 

result (lacunes)

 

What is the classic presentation of a thrombotic stroke?

 

!

Patient awakens from sleep with neurologic deficits

What are the two causes of a carotid bruit?

!

Murmur referred from the heart Turbulence in the internal cartoid artery

Describe the onset and severity of symptoms with embolic stroke.

!

Very rapid with maximal deficits initially

Clinical manifestations: MCA stroke (5)

!

MCA stroke can cause CHANGes Contralateral paresis/sensory loss in face and arm Homonymous hemianopia Aphasia (dominant) Neglect (nondominant) Gaze preference toward the side of the lesion

Where is the location of a lesion with pure motor lacunar stroke? !

Internal capsule

Where is the location of a lesion with pure sensory lacunar stroke?

!

Thalamus

What is ataxic hemiparesis?

 

!

Incoordination ipsilaterally

With clumsy hand dysarthria, where is the lesion?

 

!

Pons

What kind of deficit and occurs with anterior cerebral artery stroke? Where?

 

!

Contralateral lower extremity and face weakness and sensory loss

!

What is subclavian steal syndrome?

The term subclavian steal has been used to describe retrograde blood flow in the vertebral artery associated with proximal ipsilateral subclavian artery stenosis or occlusion

!

What is pectus carinatum?

Sternum protrudes from the narrowed thorax

How do people with small airways disease breath when dyspneic or tachypneic?

 

!

Many small breaths from a position of relative inspiration but without very deep breaths.

How should one assess thoracic expansion?

 

!

Place hands on lateral chest wall from the posterior view

What is respiratory alternans?

!

Inward inspiratory movements alternating with normal outward inspiratory movements due to diaphragmatic weakness.

Definition: Chronic bronchitis

!

Chronic cough productive of sputum for at least 3 months per year for at least 2 consecutive years

!

Permanent enlargement of air spaces distal to the terminal bronchioles due to destruction of the alveolar walls

Definition:

Emphysema

Risk factors:

!

Tobacco smoke α 1 -antitrypsin deficiency Environmental factors

COPD (4)

 

Terms / Facts

 
 

(second hand smoke) Chronic asthma

 

Below what value is the FEV1/FEV in COPD?

 

!

< 0.75-0.80

What happens to the forced expiratory time in COPD?

 

!

Greater than or equal to 6 secs

What is the definitive diagnostic test for COPD/

 

!

Pulmonary function testing

What happens to FEV1/FVC in COPD?

 

!

Decrease

 

!

Mild: 70%

What percent reduction in FEV1 compared to the predicted value is indicative of mild disease? And severe disease?

 

Severe: 50%

What happens to TLC in COPD?

 

!

Increased TLC

 

What happens to residual volume in COPD?

 

!

Increased RV

What happens to FRC in COPD?

 

!

Increased FRC

 

What happens to vital capacity in COPD?

 

!

Decreased vital capacity

 

What disease is predominant in COPD of pink puffers?

!

Predominant emphysema

What disease is predominant in COPD of blue bloaters?

 

!

Predominant chronic bronchitis

 

What are the radiographic featuers of COPD on CXR? (3)

!

Hyperinflation Diminished vascular markings Flattened diaphragm

 

What is a good screening test for pulmonary obstruction? What value should prompt PF testing?

!

Peak expiratory flow for screening; < 350 L/min should prompt PFT

What is the most important intervention for COPD treatment?

 

!

Smoking cessation

What does clinical monitoring of COPD patients entail? (3)

!

Serial FEV1 measurements Pulse oximetry Exercise tolerance