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pszurnicki
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What decreases risk of restenosis after PCI?
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Time from admission to tPA?
30 min
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TIme from admission to PCI?
90 min
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POst mI, a stress test determines what??
need for angiography
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Angiography determines what?
need for revascularization
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Prophylactic antiarrhythmics have what effect on mortality?
they increase it
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St segment depression gets what, tpa or heparin?
heparin
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St segment elevation MI gets what? tpa or heparin?
tpa
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ACE inhibitors are best for what type of infarcts?
anterior wall infarcts
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Kussmaul sign?
increase in jugulovenous pressure due to constrictive pericarditis or restrictive cardiomyopathy
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a drop of 10 mm in bp on inhalation is seen in what condition?
cardiac tamponade
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Acute coronary syndromes are associated with what kind of adventitious heart sound?
S4
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WHat carries higher mortality, anterior wall or inferior wall infarcts?
anterior wall infarcts
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Depression of st in chest leads v1 and v2 equals what?
st segment elevation in other leads
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Failure of what organ can cause a false positive troponin level?
renal failure or insufficiency
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ABsolute contraindications to thrombolytics?
- Bleeding into abdomen (melena) or brain
- hypertension (180/110)
- recent surgery in 2 weeks
- non hemorrhagic stroke within last 6 months
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WHat causes pulseless electrical activity?
free wall/cardiac tamponade
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Post infarction routine medications?
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Diastolic or systolic dysfuntion produces a lower EF?
Systolic
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WHat drug is contraindicated in HCM?
Diuretics because they produce less volume
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What is BNP used for?
to exclude CHF as a cause of dyspnea
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What ionotrope drug is used actutely?
Chronically?
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Alternative to using ACEI and ARBs in CHF
?
Hydralazine and nitroglycerin
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Which interventions decrease mortality in CHF?
- Defibrillator
- Ace/ARB
- BB
- Spironolactone
- Hydralazine/nitrates
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What electrolyte disturbance causes digoxin toxicity?
hypokalemia
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digoxin can cause what electrolyte abnormality?
hyperkalemia
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What toxicities can digoxin cause?
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CNS and EKG disturbance is treated with?
DIGIbind
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When do you replace valves in MR and AR with respect to EF and LVESD?
- MR AR
- EF <60% <55%
- LVESD >45mm >55mm
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What effect do standing or valsalva have on heart murmures? What are teh exceptions?
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What effect do leg raising and squatting have on heart murmurs? What are teh exceptions?
- Increase the intensity
- Exceptions are MVP and HCM
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What meds treat MVP and HCM?
BB
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What meds treat AR and MR?
ACEi and diuretics
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Rx for aortic stenosis?
valve replacement
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Rx for MS?
Balloon valvuloplasty
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Rx for bradycardia without symptoms?
nothing
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Rx for 1st degreee heart block?
nothing
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Rx for mortbits type 1?
nothing
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Rx for Morbitz type 2?
pacemaker
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Rx for 3 degree heart block?
pacer
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Adenosine works on what condition only?
sVT
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The only cancer that can be cured by radiation therapy?
Stage 1 Hodgkin Lymphoma
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most common risk factor for cad?
htn
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worst risk factor for cad?
dm
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most common finding in mi?
normal
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infarct where can produce diarhea, brady cardia bc of irritation of diaphragm and stimulation of vagus nerve?
inferior wall mi
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what happens to ischemia/esophageal spasm when given nitroglycerin?
gerd?
- relieves it--ischemia/esophageal spasm
- worsens it--gerd
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3 examples when response to therapy makes the diagnosis?
- opiates and naloxone
- esaphagitis candidiasis and fluconazole
- cns toxo and tmp/smh
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blood pressure difference between two arms means what?
aortic dissection
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how long does it take for ckmb to elevate?
4 and it peaks at 12
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how many mm elevation do you need to see on ekg for it to be significant?
1mm
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time from door to tpa?
30 minutes
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what elevates troponins?
renal failure
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most common cause of epigastric pain?
non ulcer dyspepsia
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only chest pain that is pleuritic and positional?
paricarditis
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pain inbetween the scapula?
aortic dissection
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aortic dissection best initial test?
after that?
most accurate test?
x ray
- tee
- ct angiography
- mra
- arteriography
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test of choice for pe in pregnant woman?
v/q scan
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what is the most specific ekg finiding for pericarditis?
pr segment depression
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Rx for pericarditis?
refractory cases?
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most common cause of mitral stenosis?
rheumatic fever
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Criteria for Bacterial Endocarditis?
- 2 blood cultures
- 1 coxiella burnetti
- consecutive + blood cultures 12 hours apart
- echocardiography showing endocardium involvement or new regurg
- Minor...
- Fever
- Immunologic phenomena
- vascular phenomena
- echocardiography suggestive evidence
- Predispositon
- microbiology evidence not meeting the major criteria
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criteria for rheumatic fever
- dx is 2 major or 1 major and 2 minor + evidence of recent GAS infection
- Joints
- Carditis
- Nodules
- Erythema marginatum
- Syndenhams chorea
- pr prolonged
- Esr
- Arthralgias
- Crp
- Elevated temp
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Stenosis or regurg of what valve produces the most afib? systemic arterial emboli leading to ischemia?
mitral stenosis
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opening snap?
mitral stenosis
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left main bronchus being displaced upward occurs in what valvulopathy?
mitral stenosis
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ace inhibitors help ventricular filling or emptying?
emptying
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preload reduction helps ventricular filling or emptying?
filling
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what effect do diuretics have on the fetus?
growth retardation
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Best initial test for Valvular Heart Disease?
Most accurate test for valvular heart disease?
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medical therapy for Mitral Valve stenosis?
Surgical therapy?
- decreased preload- diuretics and low Na diet
- BB
- surgical-
- balloon valvuloplasty or replacement
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Balloon valvuloplasty is for what patients specifically with mitral valve stenosis?
pregnant patients
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When do you replace the valve in mitral regurg?
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Medical therapy for mitral valve regurg?
Surgical?
- afterload decrease with hydralazine
- valve replacement if EF<60% or LVESD >40 mm
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most common congenital valvular condition?
MVP
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Most common cause of Mitral Regurg?
ischemia
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When do you prophylax for MVP?
never even with a murmur
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most common cause of aortic stenosis?
- calcification in elderly
- bicuspid in the young
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Which valvular disease produces Hypertrophy and vessel congestion?
all of the valvular disease
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MEdical therapy for aortic stenosis?
Surgery?
- none really--maybe afterload decrease
- Replacement
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medical therapy for aortic regurg?
surgical
- afterload decrease
- replacement if EF<55% or LVESD-->55%
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What effect does handgrip have on as, ms, mr, ar?
AMyl nitrate?
squatting?
valsalva?
- increases the murmur
- decreases murmur
- increases the murmur
- decreases murmur
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best drug for ar, as, ms, mr?
best drug for HOCM and MVP?
ace inhibitor or diuretic and amylnitrate
bb
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MCC of dilated cardiomyopathy?
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most common symptoms of HOCM?
sob
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mcc cause of hypertrophic cardiomyopathy?hypertension
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How do you differentiate pericarditis fromMI?
both have st segment elevation but no reciprical lead changes
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Pericardial effusion slow vs fast?
slow effusion--pericardium accomadates
fast--cardiac tamponade
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Ekg changes on cardiac tamponade?
electric alternans
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D/D for pulsus paradoxus?
- cardiac tamponade
- asthma
- copd
- pneumothorax
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D/D for Kussmaul sign?
- constrictive pericarditis
- right ventricle infarction
- cardiac tamponade
- pericarditis
- Tricuspid regurg
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most accurate test for constrictive pericarditis
ct or mri showing calcified pericardiac sac
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rx for bradycardia?
- none unless there is symptoms then
- atropine
- pacemaker
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when do you give a pacer in bradycardia outside of a pt being symptomatic?
in 2nd degree heart block, type 2 or in 3rd degree heart block
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Adams stokes attack?
- brady cardia
- hypotension
- loc
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Diagnosis of MAT?
3 different p morphologies secondary to copd or other respiratory conditions
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Rx for unstable a flutter?
synchronized shock
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what are the classifications of afib?
- duration--paroxysmal(self terminating) vs. persistent >7 days and permanent >1 year
- valvular vs non valvular
- lone a fib <60 yo with no clinical or echo evidence heart disease
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goal of ventricular rate control in a fib?
<100 bpm
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Drug of choice in a fib with
a) thyrotoxicosis
b)copd
d) low blood pressure or chf?
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Is rhythm conversion or rate control preffered in afib?
rate control is prefferred
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who is anticoagulated in afib?
- valvular afib with warfarin, or chads2 score of more than 2
- chads2 score of 1 or 0 ---->aspirin
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Long term rx for afib?
catherer ablation of the firing focus
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Long term rx of WPW?
cathere ablatioin
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why are bb, ccb and digoxin avoided in wpw?
bc they increase the bypass of the electrical current around the av node and increase wpw
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at what percentage stenosis do you surgically revascularize with a stent or bypass a coronary artery?
70 percent
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what lowers mortality in stable angina?
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how is nitroglycerin used in stable angina?
acs?
- stable angina--oral or patch
- acs-- sublingual, paste, iv
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when is clopidogrel used?
- aspirin allergy
- recent stent
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when is prasugrel used?
for angioplasty with stenting
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when is ticlopidine used?
in apiring and clopidogrel allergy
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side effect of niacin?
- hyperglycemia
- hyperuricemia
- itchiness due to histamine
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MOA of niacin?
MOA of fibrates?
MOA of Ezetemibe?
- reduces VLDL secretion
- increase LPL--increased TG clearance
- decreased cholesterol absorption
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MI involving what wall of the heart has the highest mortality associated with it?
anterior wall MI
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st segment elevation in leads v2 thru v4, next best step?
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Complications of PCI?
- restenosis
- rupture of a coronary
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contraindications to thrombolytics in acs?
- 1. bleeding into the bowel or cns
- 2. surgery in the past 2 weeks
- 3. hypertension 185/110
- 4. non hemorrhagic stroke
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When are Gp IIb inhibitors given?
in unstable/nstemi and angioplasty and stent
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when should a patient with unstable angina/nstemi be transferred to angiography?
- when medical therapy fails to improve the chest pain, S develops and score of 3 is met on the timi score
- aspirin in past 7 days, age more than 65, angina 2 in the past 24 hours
- biomarkers
- cad risk factors
- dx of cad
- Ekg changes
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How do you recognize sinus bradycardia from 3 degree heart block producing bradycardia?
3rd degreee heart block will have canon a waves
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which infarctions have the highest likelyhood of developing a systolic dysfunction?
anterior wall mi
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who gets angiography post mi?
those with a positive stress test
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what kind of exercise can one expect to partake in after a normal stress test?
any form of exercise
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when is muga or nuclear ventriculogram used?
to assess the condition of the heart before giving cardiotoxic drugs
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most common cause of death in chf?
arrhythmia and sudden death
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when is an implantable debifrilator indicated in chf?
EF<35%
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when is a biventricular pacemaker used?
EF<35% and QRS is >120msec
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what decreases mortality in diastolic heart failure?
- bb
- diuretics such as loops
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how is acute pulmonary edema managed?
preload reduction-loops, oxygen, morphine, nitra
afterload reduction--hydralazine/nitroprosside
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Rx for taku tsubo cardiomyopathy?
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when should an implantable defibrillator be used in hocm?
in presence of syncopy
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how is HOCM managed?
- bb or other negative ionotropes
- implantable defibrillator if syncopy is present
- ablation of the septum with alcohol or myomectomy
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empiric rx for brain abscess?
- steroids
- antibiotics
- needle aspiration
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sumatriptans are contraindicated in what 3 populations?
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cause of neuroleptic malignant syndrome?
rx
- dopamine antagonists?
- dantrolene
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what two drugs can cause malignant hyperthermia?
rx
- inhalational anesthetics
- succinylcholine
dantrolene
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When is prehypertension of 130/80 treated?
if present with cad risk factors--dm, htn, hyperlipidemia
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anti HTN meds in pregnancy?
- labetalol
- methyldopa
- nifedipine
- hydralazine
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moa of alpha methyl dopa?
alpha 2 agonist
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anti htn not used in depression?
BB
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best initial test for renal artery stenosis?
most accurate
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substitute for ocp causing htn?
- progestin only
- depo progesterone
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who should be screened for aaa?
males over 65 who smoked
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best initial test for aaa?
best initial test for aortic dissection?
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best initial rx for aortic dissection?
bb
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which aortic dissection need surgery?
stanford type A
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Best initial test for PVD?
MOst accurate is ?
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when is a unna boot used?
for chronic venous insufficiency
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everybody on steroids should be on what after 3 months?
- prophylactic bisphosphonate
- calcium
- vitamin d
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ebsteins anomaly is caused by what drug?
lithium
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leaflets are displaced into the right ventricle
ebstein anomaly
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rx for early cyanotic disease?
prostoglandin E to keep PDA open
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Prophylactic meds for people with prolonged QT interval?
bb
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Rx for dvt in a person thats prone to falling?
IVC filter
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When do you give oxygen to COPD pts?
4 Ps?
- when the pulse ox is <88%
- pulmonary htn
- peripheral edema
- polycythemia
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