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Clues to ischemic disease(5)
- dull pain
- 15-30 minutes
- occurs on exertion
- radiates to jaw or left arm
PE findings for ischemic chest pain(7)
S3 (dilated LV)S4 (hypertrophic LV)holosystolic murmur (MR)JVDRales (CHF)EdemaGen: distressed, SOB, clutching chest.
PE findings for ischemic chest pain(7)
- S3 (dilated LV)
- S4 (hypertrophic LV)
- holosystolic murmur (MR)
- JVDRales (CHF)
- Gen: distressed, SOB, clutching chest.
MI: diagnostic testing: 1. first test to do:
2. if choosing between testing and treatment: 3. first treatment to give:
4. Other tests to do:
5. most accurate test:
- 1. EKG
- 2. treat first
- 3. ASA
- 4. CK-MB, troponins, stress test, echo, angiography
- 5. CK-MB
Treatment for ACS:
- Things that lower mortality: ASA-- instant platelet inhibitor
- thrombolytics (if can't to PCI within 90 minutes or new LBBB)
- Clopidogrel (esp if asa allergy)
- lower mortality in some cases
- ace/arb (if low EF)
- don't lower mortality but should still be done: beta blocker
- o2; morphine; nitrates
- Alts: CCB: beta blocker intol, cocaine or vasospasm
- PAcemaker: AV blocks or bradycardialidocaine/ amiodarone: VT or VF
1. first line treatment
2. best benefit
- 1. LMWH
- 2. GPIIb/IIIa inhibitors
when do you use ACE/ARBs in ischemic cardiac disease
cardiac failure (e.g. chf, systolic dysfunction or low ef).
elderly woman with SOB + rales and edema: 1. what tests do you order?
2. what meds do you order?
3. most likley dx:
4. if still symptomatic:
- 1.EKG, CXR, echo, oximetry, monitoring unit, ABG, BMP
- 2. O2, morphine, nitrates, furosemide
- 3. CHF exacerbation* transfer to ICU in CCS!*
- 4. order an inotrope (milrinone, amrinone or dobutamine).
what is the optimal treatment for:
1. murmurs that improve on valsalva (and which murmurs are these?)
2. murmurs that improves with amyl nitrate (and which murmurs are these?)
3. best therapy for regurgitant lesions
4. best therapy for stenotic lesions
- 1. Valsalva = diuretics (AS, AR, MS, MR, VSD)= L heart murmurs
- 2. amyl nitrate = ACE inhibitor (AR, MR, VSD)
- 3. diuretics
- 4. repair (baloon for MS, replace for AS)
75 yo M with hx HTN now with chest pain/ syncope. hear a crescendodecrescendo systolic murmur at the 2nd R intercostal space that radiates to the carotids. what is the dx, w/u, tx?
- Dx: AS
- workup: TTE (best initial test), TEE (more accurate) L heart cath (most accurate), also do EKG and CxR (LVH)
- treatment: Diurese, but overdiuresis is best--> valve replacement is best
75 yo M with hx HTN now with SOB/ fatigue. You hear a decrescendo-crescendo diastolic murmur at the LSBwhat is the dx, w/u, tx and other physical findings?
- Dx: AR
- workup: TTE (best initial test), TEE (more accurate) L heart cath (most accurate), also do EKG and CxR (LVH)
- treatment: ACE/ARB, nifedipine (add loop diuretic in CCS)--> surgery if EF <55% and LV end systolic diameter >55 mm
75 yo immigrant M now with dysphagia and afib. You hear an extra sound in diastole with S1>S2. what is the dx, w/u, tx and other physical findings?
- Dx: MS
- workup: TTE (best initial test), TEE (more accurate) L heart cath (most accurate), also do EKG and CxR (LAH- straightening of LH border and elevation of L mainstem bronchus)
- treatment: diuretics (best initial, but don't alter progression)--> balloon valvuloplasty (incl preg women)
75 yo M w/ PMH MI now with dyspnea on exertion. You hear holosystolic murmur at the apex, radiating to axillawhat is the dx, w/u, tx and other physical findings?
- Dx: MR
- workup: TTE (best initial test), TEE (more accurate) also do EKG and CxR
- treatment: ACE/ ARBS, Nifedipine (best initial, decreases rate of progression), add loop diuretic in CCS--> surgery if EF <60% and LV end systolic diameter >45 mm
7 yo M now with no complaints, on exam You hear holosystolic murmur at the LLSB. what is the dx, w/u, tx and other physical findings?
- Dx: VSD
- workup: echo first--> cath (determine degree of L-->R shunting
- treatment: if mild, will close on its own.
7 yo M now with no complaints, on exam You hear fixed splitting of S2. what is the dx, w/u, tx and other physical findings?
- Dx: ASD
- workup: ?
- treatment: PCI, repair when shunt ratio >1.5:1
what to think about when you hear wide splitting of S2 with delayed P2
what to think about when you hear paradoxical delayed A2?
75 yo M presents w/ SOB...w/u
echo first! (may reveal cardiomyopathy, etc)
dilated cardiomyopathy: etiology, w/u, tx and other physical findings?
- etiology: EtOH, Chagas, ischemia, adriamycin, radiation
- w/u: echo
- treat: ACE/ARBs, beta blockers and spironolactonedig for symptomatic tx
75 yo M presents w/ SOB + S4 gallopddx, etiology, w/u, tx and other physical findings?
- Hypertrophic cardiomyopathy
- w/u: echo
- treat: diuretics + beta blockers
75 yo M presents w/ SOB + kussmaul's sign etiology, w/u, tx and other physical findings?
- Restrictive cardiomyopathy
- kussmaul's sign: increase in JVP on inhalation2/2:
- sarcoidosis, amyloidosis, hemochromatosis, cancer, myocardial fibrosis or glycogen storage diseasese
- w/u: echo, cath (rapid x and y descent) EKG (low voltage) endomyocardial biopsy (most accurate dx test)
- treat: diuretics
pericarditisw/u and tx
- w/u: EKG (ST elev, PR depression)
- tx: NSAIDs--> 1-2 days later reassess--> give prednisone--> reassess
SOB, low BP and JVD
pericardial tamponadew/u, tx
- w/u: EKG (electrical alternans), echo (diastolic collapse of RH), RH cath (equalization of all pressures)
- tx: pericardiocentesis (best initial) most effective: pericardial window
- NEVER GIVE: diuretics
aortic dissectionw/u, tx
- if suspicion:
- w/u: EKG, CXR (widened mediastinum), CTA (most accurate) = TEE= MRA
- tx: beta blockers, --> ICU and surgical consultation--> surgical correction
75 yo M smoker presents w/ pain in calves on exertion. PE notes smooth shiny skin with hair loss. dx, w/u, tx, f/u
- dx: PADw/u: ABI (best initial), Angiography (most accurate)
- tx: best initial: ASA, ACE (for bp control), exercise, cilostazol, statins (LDL <100)--> bypass if gangrene or resting pain. CCBs are ineffective!
- f/u: several weeks.
75 yo M w/ HTN, MI, cardiomyopathy presents to office, w/ palpitations. dx, w/u, tx
- dx: AF vs. Aflutter
- w/u: EKG, if in hospital--> tele vs. holter (if HD stable). in CCA: echo, thyroid, electrolytes (K, Mg, Ca), (troponins, ck-mb if acute onset)
- Tx: unstable: syncrhonized cardioversion- convert in first screen (if SBP <90, CHF, confusion or CP)--> TEE, anticoagulate.
- stable: slow ventricular rate <100 with b-blocker, ccb or dig (iv if in ED)--> anticoagulate with warfarin for INR 2-3
1. what's normal
2. what's PAD
- 1. >= 0.9
- 2. > 10% = obstruction
when to use bb as tx?(4)
- ischemic heart disease
when to use dig?
75 yo M w/ HTN, MI, COPD presents to office, w/ palpitations, tachycardia. EKG shows polymorphic P wavesdx, tx, f/u, what to never use!!
- dx: MAT
- w/u: EKG, holter or tele if high suspicion, in CCS, Echo
- tx: ? NEVER USE BETA BLOCKERS OR DIG!!
75 yo M w/ HTN presents to office, w/ palpitations, tachycardia. EKG shows regular rhythm, but rate of 160-180dx, w/u, tx, f/u
- dx: SVT
- w/u:EKG--> holter or tele if high suspicion, in CCS, Echo
What should you think about in any young patient with vague symptoms and significant unintentional weight loss?
what is the most common cause of secondary hypertension in young patients
renal parenchymal disease
what is the most common cause of HTN in: infants: early childhoodadolescent
- infants: renal artery/ vein thrombosis 2/2 umbilical artery catheters
- early childhood: renal parenchymal disease, coarctation, endocrine, medications
- Adolescent: essential HTN (Obesity), evaluate for renal and renovascular HTN.
what are the clinical risk factors for DVT (10)
- age >40
- prolonged immobility or paralysis
- prior DVT/PE
- hypercoagulable states
- major surgery/ fx
- varicose veins
- heart failure
what are the modalities of DVT ppx from most effective --> least effective
- 1. full dose therapeutic IV heparin- (reserved for MI pts)
- 2. either oral warfarin (INR 2.5) or LMWH-- high risk surgeries
- 3 ICD or calf-length elastic stockings with early ambulation
when is surgical removal of pelvic cysts during pregnancy indicated?
adnexal cysts >5 cm that persists over time--> high risk of rupture, hemorrhage, torsion--> preterm delivery
who should receive ppx for mening?
people living in same household who have prolonged, close contact and healthcare workers w/ direct exposure secretions.
what is nelson's syndrome?
pituitary enlargement and hyperpigmentation following b/l adrenalectomy
what is the underlying etiology of muscle weakness in a critically ill patient after many days of glucose infusion?
what is the management for a patient with a Mobitz II block?
what are the comorbidities of tourette's syndrome
- adhd (60%)
- o-c behavior (32%)
- ocd (23%)
- learning disorder 23%
- conduct disorder 15%
What is the treatment for chronic constipation?
- Psyllium (bulk laxative)
- or miralax
what should you give to a woman on OCPs with mening exposure?
cipro (rifampin lowers steroid levels of OCP)
what bp med do you start on someone who is on lithium?
CCB or B-blocker (diuretics/ ace-i/ arbs can lower gfr or interfere with electrolyte hndling and interfere with Li clearance.
what is the workup for a solitary pulmonary nodule?
compare old cxr--> ct--> VATS/ excisional bs.
what are the 3 principles of ARDS managment?
- 1. inc PEEP first (us to ~9)
- 2. TV: lowest possible valuee <8 mg/kg ibw- want low plateau pressures
- 3. avoid increasing FiO2 >60%PaO2 >55 is goal!
what should you think of with prior URI and new-onset facial asymmetry
what are the 4 abx that have the highest likelihood of causing cdiff?
- amox, amp, Cephalosporines
- *clinda*= highest risk
what is the best CXR view to confirm PTX?
upright PA CXR-- air in apex and lateral regions
what lobe is localized in construction apraxia?
nondominant parietal lobe (aka dressing apraxia)
dom parietal lobe--> acalculia, finger agnosia, agraphia, R-L confusion
what lobes are localized in homonymous upper quadrantanopia and auditory agnosia?
nondominant temporal lobe (also dominant temp lobe)
what lobe localizes to aphasia
dominant temporal lobe
when is hyperbili considered pathologic? (5)
- 1. appears on the first day of life
- 2. bili ^ >5 mg/dL/day
- 3. Bili >12 in a term infant
- 4. direct bili >2 at any time
- 5. hyper bili present ater 2nd week of life
what is the management of a pt with ACUTE adrenal insufficiency
dexamethasone IV--> ACTH stim test
what is the preferred route of refeeding in a malnourished pt?
- IV hydration only if diarrhea and shock (can lead to overhydration and heart failure)
preferred tx for raynaud's phenomenon?
nifedipine (or any ccb) --> nitroglycerine as adjunct
impaired vibration sensation, hyperreflexia, impaired short-term memory, increased reaction time, unstable gait
- 1. posterior and lateral spinal columns
- 2. B12 deficiency
cognintive dfxn, gait disturbance, urinary incontinance
URI + rapid progessive myelopathy (e.g. weakness, paresthesias, urinary retention)=?1. dx
- 1.transverse myelitis
- 2. MRI
- 3. steroids
how long do you treat late latent syphilis or latent syphilis of unknown duration?
3 weeks (penG)
acute fever, chills w/in 24 hours after initiating tx for syphilis:
- 1. jarisch- Herxheimer
- 2. no prevention
how to treat reiter's syndrome? (3)
- 1. abx
- 2. progressive exercise
- 3. DMARD (MTX or sulfasalazine
shiny, discrete, intensely pruritic, polygonal shaped violaceous plaques and papules on flexural surfaces pf extremeties, +/- white lacy pattern on surfaces.
3. what disease is it associated w/ ?
- 1. lichen planus (white lacy= wickham's striae)]
- 2. punch bx for confirmation.
- 3. HCV
what do you use saw palmetto for? what is a/e of saw palmetto?
what is the treatment for priapism?
phenylepherine or epinepherine injection until erection resolves.
watery discharge + dysria in a male: dx? tx approach?
NGU (usually 2/2 chlamydia): tx w/ azithro or doxy--> if tx failure consider other causes (e.g. trich or resistant orgs), and treat with flagyl--> erythromycin
HIV neg pt with high-risk behavior and meningitis w/ following CSF: OP ^low WBC with mostly monos (lymphs or monocytes)^protein, low glucose
1. what's most likely pathogen?
2. what do you treat with?
- 1. cryptococcus
- 2. ampho B and flucystosine--> fluconazole to be continued as outpatient
what is the next step in a pt being treated for crypto meningitis who improves and then relapses?
repeat LP-- can help relieve sx of ^ICP
75 yo M with vertigo, dizziness, diplopia, numbness and dysarthria, what to think about?
vertebrobasilar insufficiency (usually 2/2 emboli, thrombi or dissection)-- labyrinth/ brainstem
what are the gastric findings in a patient with pernicious anemia?
absent rugae in the fundusassociated with AMAG (autoimmune metaplastic atrophic gastritis)-- glandular atrophy, gastric metaplasia, and inflammation
what is the treatment of choice in decompensated liver cirrhosis (regardless of cause)-- eg. variceal bleeding?
liver transplant! especially if CTP score >7
what is the first thing to do when thyroid nodule is detected?
TSH--> normal--> FNA--> low--> radioisotope--> hot--> observe
what is the treatment for papillary thyroid cancer?
near-total thyroidectomy--> radioactive iodine
how do you calculate corrected sodium for someone who is hyperosmolar
(1.6 meq/l for every 100 mg/dL glucose over 100) + Na level= corrected sodiume.g. if a patient has Na of 150 and glucose of 800: (1.6 x 7) + 150= 161.2
what is the test of choice in any patient with ^PSA and bone pain?
bone scan! high suspicion for metastatic bone cancer
low grade fever, LAD (posterior cervical nodes), --> maculopapular rash from top- bottom sometimes complicated by arthritis, thrombocytopenia, encephalitis
high fever--> rash from trunk--> extremeties
what is the HIV regimen of choice in a pregnant woman? which HIV drugs are teratogenic?
Zidovudine, lamivudine, saquinavir (AZT prevents vert transmission, saquinavir is cat B)efavirenz, delavirudine are ? teratogenic
what is the difference between microsporum canus and trichophyton
- microsporum= green fluorescence under woods lamp
- trichophyton does not fluoresce.
what is diet of choice in acute diarrhea?
continue normal age-appropriate diet with limited fats and sugars.
75 yo M with hx minor trauma to knee, now with hypesthesia, swelling, sweating, erythema, movement exacerbating pain, now with bluish mottling 2 months later.
- 1. Complex regional pain syndrome type
- 1= regional symplex dystrophy
- 2. phenoxybenzamine (sympathetic blockade)
what is the treatment of choice for prostate adenocarcinoma in situ?
radical suprapubic prostatic resection with regional lymph node exploration
patient has behavioral problems, and musCLE pain aND Cramps, found to have low calcium, high Phos,
1. what is the dx?
2. what is the Vitamin D level?
- 1. pseudohypoparathyroidism
- 2. VD is normal
Patient has behavioral problems, muscle pain and cramps found to have low Ca, and PTH, and high PO4
2. VD level?
- 1. hypoparathyroidism
- 2. VD normal
what is a long term complication of TURP?
how do you administer antenatal steroids to a mom in early labor?
how long should a post MI patient wait before having sex?
- 2 weeks if uncomplicated,
- 6 weeks if coronary revascularization
what is the next best step in management for an infant with hypertrophic pyloric stenosis?
correct electrolytes--> pyloromyotomy
what is the most effective intervention to decrease risk of a CVA?
what is the typical knee injury associated with the 'dashboard' injury
what is the first step in FTT workup?
dietary history! make sure patient is taking in enough calories!
what is the most effective screening test for PMR?
what is the most effective screening test for GCA/ temporal arteritis?
what is the best screening test for SLE?
how do you calculate SAAG?what does it tell you?
- SAAG: albumin in serum - albumin in ascites
- >1.1= portal HTN (cirrhosis), CHF and alcoholic hepatitis
- <1.1= peritoneal carcinomatosis, TB, nephrotic syndrome, pancreatitis, serositis.
if suspect mallory-weiss tears, what is the most appropriate next step in management?
Upper GI endoscopy