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What are the three indications for surgical repair of an AAA?
- Symptomatic
- >5.5 cm in diameter
- Rapid growth
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What imaging do you immediately obtain in suspected AAA? What is ordered stat for surgical repair?
- US immediate
- CT for visualization of arteries prior to surgical repair
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What are 4 risk factors for aortic dissection
Pregnancy, Bicuspid aortic valve, Marfans, Hypertension
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What medication is started with suspicion of aortic dissection? What can be added? What if the pt has a CI to the first drug of choice? What are those CI?
- IV labetalo
- lAdd morphine for pain
- Add IV nitroprusside for further BP control
- In a pt with asthma- add Esmolol or verapamil/diltiazem
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What is the difference between the 2 types of aortic dissections? Which has a worse prognosis?
- A- occurs proximal to the L subclavian artery and therefore may lead to aortic regurgitation, bleeding into the pericardial sac and cardiac tamponade. This is referred to as ascending dissection and has a worse prognosis
- B- occurs in the thoracic aorta beyond the L subclavian artery. (Descending)
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What are complications of aortic dissections?
- Intestinal ischemia
- Renal insufficiency
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How does chronic aortic regurgitation develop?
Regurgitation of flow increases the LV end systolic volume. The heart tries to compensate by hypertrophying of the muscle. This allows for a normalized cardiac output. Eventually the ventricle cannot maintain the output and heart failure ensues
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Describe the murmur of aortic regurgitation
High pitched diastolic decrescendo murmur heard at the LUSB with the patient sitting up, leaning forward and exhaling.
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What are the 5 peripheral signs of aortic regurgitation?
- 1-Hill signc (upper extremity and lower extremity BP difference)
- 2- Traube sign (Pistol shots heard over femoral artery)
- 3- Quinckne (pulsations in capillary nailbed)
- 4- Muller (uvular pulsations)
- 5- Corrigan pulse (Brisk carotid pulse)
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Describe the murmur of aortic stenosis
Harsh systolic ejection murmur heard best at the RUSB with radiation to the carotids.
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What physical exam findings may be present in aortic stenosis?
- Delayed carotid upstroke
- precordial thrill
- narrow pulse pressure
- strong PMI
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What 5 physical exam findings may be present in mitral stenosis?
- 1- Parasternal RV heave (w/ pulmonary hypertension)
- 2- Palpable S1 at precordium
- 3- diastolic thrill in left lateral decubitus position at apex
- 4- low pitched diastolic rumble heard with bell at apex in LLDP
- 5- Opening snap after s2 at apex
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How would you differentiate the murmur of aortic stenosis from mitral regurgitation?
- AS is lower pitched compared to MR
- AS radiates to carotid, MR radiates to axilla
- AS does not increase with handgripping, MR increases
- AS increases with amyl nitrate, MR does not.
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How would you differentiate the murmur of HOCM from mitral regurgitation?
- HOCM does not increase with handgripping, MR does
- HOCM increases with valsalva, MR decreases
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What symptoms would you expect to see in tricuspid valvular disease?
- Abdominal discomfort
- jaundice
- aninition
- wasting
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Describe tricuspid regurgitation murmur
- holosystolic at midsternal border
- no thrill, no radiation
- increases with inspiration
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Describe tricuspid stenosis murmur
- diastolic rumble at lower left sternal border
- increases with inspiration
- highpitched and scratchy
- +/- hepatic pulsations
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What is a graham steele murmur?
- Found in patients with pulmonic regurgitation and pulmonary hypertension.
- It is a high pitched decrescendo diastolic murmur at LUSB that also increases with inspiration
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Describe the physical exam findings with atrial septal defect:
- 1- fixed split of S2
- 2- Palpable pulmonary artery
- 3- prominent RV impulse
- 4- systolic ejection murmur
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Describe the physical exam findings in ventricular septal defect:
- 1- systolic thrill
- 2- holosystolic murmur at LLSB that radiates to right parasternal area
- 3-displaced LV impulse
- 4- S3 gallop from increased flow across mitral valve
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Describe physical exam findings of patent ductus arteriosus
- 1- continuous machinery murmur heard best under left clavicle
- 2- bounding pulses
- 3- thrill
- 4- displaced apical impulse
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Describe a pulmonic stenosis murmur
- high frequency systolic click at LUSB that DECREASEs with inspiration
- with or without thrill and RV impulse
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What are the "major Duke criteria" for diagnosis infective endocarditis?
- 1- >2 + BC taken prior to abx
- 2- evidence of valvular involvement (echo or murmur)
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What are the "minor Duke criteria" for diagnosing IE?
- Fever
- immunologic phenomena (GN, osler's nodes, roth spot)
- vascular phenomena (emboli, janeway, conjunctival hemorrahge)
- history of IVDU
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What are the 5 ABSOLUTE contraindications to fibrinolytic therapy?
- 1- active bleeding
- 2- spinal neoplasm
- 3- aortic dissection
- 4- hemorrhagic stroke
- 5- facial trauma within the past 3 months
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What are 6 relative contraindications to fibrinolytic therapy?
- 1- elevated INR
- 2- Ischemic stroke
- 3- HTN >180/110
- 4- recent CPR or internal bleeding
- 5- PUD
- 6- PRIOR STREPTOKINASE
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What is the classic diagnostic imaging finding in TOF
Boot shaped heart on xray
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What are contraindications to CCB treatment?
- conduction abnormalities including 2nd and 3rd degree AV block.
- Sick sinus syndrome
- severe heart failure
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What are three conditions that might show PARADOXICAL PULSE on physical exam?
- 1- COPD
- 2- Pericardial tamponade
- 3- Pericarditis
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Define pulsus paradoxus
Decrease > 10 in systolic pressure on inspiration
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What medication would be used as rheumatic fever prophylaxis in a 12 yr old who is allergic to penicillin?
Oral sulfadiazine
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What type of syncope does head up tilt table testing observe for?
heightened vagal tone
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What EKG finding is present in hyperkalemia?
peaked t waves
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A young boy is diagnosed with HOCM. What medication is contraindicated and why?
Nifedipine because it causes peripheral vasodilation, which may result in decreased left ventricular filling and worsening of outflow tract obstruction.
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What congenital heart defect is an infant born from a diabetic mother most at risk for getting?
Transposition of the great arteries
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What are the three most common mechanical complications post MI?
- 1- papillary muscle rupture (MR)
- 2- ventricular septal rupture
- 3- ventricular free wall rupture
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What does the opening snap heard in mitral stenosis represent? What if the opening snap is absent?
opening snap is the sound of a stenotic mitral valve opening. In progressive MS the valve may be completely calcified and not open as much, thus an absent snap.
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What medicines may precipitate viral pericarditis?
Isoniazid, chemotherapy, phenytoin, hydralazine
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What antihypertensives may worsen a patient with recurrent depression?
beta blockers
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When is adenosine used in ACLS?
Regular, monomorphic tachycardic rhythms, PSVT.
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What is prehypertension?
120-139 / 80-89
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What is the most common cause of secondary hypertension?
renal parenchymal disease
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What populations are diuretics more potent in?
Blacks, elderly, obese, smokers
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What are common side effects of diuretic therapy?
- precipitation of gout
- ed
- rash
- photosensitivity
- hypokalemia
- mild increases in glucose, LDL and triglycerides
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What are common side effects of aldosterone receptor blockers?
- gynecomastia
- hyperkalemia
- metabolic acidosis
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What groups of antihypertensives should be considered in a general black population?
Diuretics or calcium channel blockers
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What drug is commonly used in resistant hypertension?
spironolactone
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What type of antihypertensives are considered renal protective?
ace-inhibitors
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What drug interactions are common with ace-inhibitors?
- lithium -> toxicity
- potassium sparing diuretics -> hyperkalemia
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What antihypertensive is relatively contraindicated in a pt with psoriasis?
beta blockerss
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what are the 4 main types of stroke?
- 1- cardiogenic
- 2- distributive
- 3- hypovolemic
- 4- obstructive
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Define cardiogenic shock
Evidence of tissue hypoxia due to low cardiac output in the presence of adequate intravascular volume
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What is the first line drug for cardiogenic shock and how does it work?
Dobutamine- increases contractility (inotropic) and decreases afterload
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What are drugs used to treat vasodilatory/distributive shock?
- Norepinephrine
- phenylephrine
- vasopressin
(Any drug that will maintain systemic vascular resistance to give adequate tissue perfusion)
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How do alpha blockers treat hypertension?
When alpha receptors in smooth muscler are blocked, total peripheral resistance decreases.
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Where are the main alpha receptors in the body?
smooth muscle, pupil, bladder and prostate
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What is an adrenoreceptor?
Any receptor that responds to norepinephrine
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What are the three types of adrenoreceptors?
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What do alpha agonists cause in non cardiovascular systems?
Eye- Mydriasis, ciliary muscle contaction (increased outflow to treat glaucoma)
prostate contractions
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Alpha agonists in cardiovascular system?
contracts smooth muscle, increases cardiac contraction
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Beta 1 agonists
- increases force of contraction
- increases rate of contraction
- increases renin release
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beta 2 agonist
smooth muscle relaxation
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what is midodrine and what is it commonly used for
alpha agonist, to treat orthostatic hypotension by causing smooth muscle contraction
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What is becks triad and when do you see it?
- 1- soft/distant heart sounds
- 2-hypotension
- 3- JVD
- CARDIAC TAMPONADE
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What is charcots triad and when do you see it?
- acute cholangitis
- 1- fever
- 2- jaundice
- 3- pain
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What is virchows triad?
- stasis
- endothelial injury
- hypercoagulability
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