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2014-08-18 18:39:26
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  1. What Rx is C/I in b/l renal arterial stenosis (RAS)?
    ACEi: will prevent sufficient perfusion of kidneys and reduce GFR
  2. What is the MCC of 2dry HTN?
    • RAS: esp in younger Pts
    • Best way to Dx RAS: Duplex doppler U/S of kidneys
  3. ECG 
    Good for detecting?
    Bad for detecting?
    • Good: ischemia, rhthym disfunctions, hypertrophy
    • Bad: etiology of HTN
  4. Indications fo CABG are UnLimiTeD:
    • U: Unable to perform PCI (diffuse Dz)
    • L: Left main coronary artery Dz
    • T: Triple-Vessel dz
    • D: Depressed ventricular fxn
  5. Post-MI Complications
    • 1st d: Heart Failure
    • 2-4 d: Arrhythmia, pericarditis
    • 5-10 d: LV wall rupture (acute pericard tamponade, PEA), papillary mm rupture (sev MR)
    • wks to mo: Ventricular aneurysm (CHF, arrhythmia, persistent ST-elevation, MR, thrombus formation)
  6. HTN Em (911!)
    • key: bp >179/119 and End-organ damage
    • Goal: decr Diast to 100-105 w/in 2-6hrs
    • Goal: decr B/P by 25% over 24-48hrs
    • Monitor 'lytes: esp Na
    • Drugs: Nitroprusside (MC), Nicardipine, Clevidipine, Labetalol (makes transition to PO easier), Fenoldopam 
    • Prego: use Hydralazine 
    • pheochromocytoma: Phentolamine
  7. HTN Urgency
    When: bp >179/119, but NO end-organ damage
  8. NYHA Classification - Satges of Heart Failure
    • Class 1: (mild) no limitations on physical activity or Sx of HF, even with mild exertion
    • Class 2: (mild) Slight lim of phys activ, but Sx w strenuous exercise
    • Class 3: (mod) marked limitations of phys activ, Sx w mild exertion (e.g. walking short distances)
    • Class 4: (Sev) SOB, palpitations or angina, even at rest
  9. Mitral Regurg
    • P/W: CHF 
    • Murmur: PanSys that obscures both S1 and S2 & Rad to Axilla
  10. Mitral Stenosis
    Murmur? / Radiographic sign?
    • MCC: Rheumatic Fever
    • Murmur: Prominent S1 with an opening snap, and diastolic murmur, heard best at apex
    • CXR:"Double Density", LA enlargement, straightening of left heart border.
    • Accentuated sound w?: Squatting or Leg lift (incr venous return
  11. Aortic Regurg
    • P/W: S/Sx of CHF
    • Unique Signs:de Musset sign (head bobbing); Quincke Pulse (visualization of pulse in nailbed); Wide pulse pressure; Water-hammer pulse (wide & bounding); Hill Sign (b/p legs is >40 arm b/p).
    • Murmur: D, decrescendo; L low sternal
  12. Aortic Stenosis
    • Triad of: Angina (MC presentation), SyncopeCHF
    • Murmur: Sys, cresc-decr peaking in mid-sys; best @ 2nd R intercostal space & rad to carotids
  13. Pulmonic Stenosis
    • MC: ASx
    • P/W: CHF Sx
    • Murmur: Sys Cresc-decr ejection murmur, Best @ L upper sternal border
    • Key: Incr w inspiration & Rad diffusely
  14. Squatting & Leg Raising
    Increases murmur intensity from what valvular abnormalities? 
    Decreases murmur intensity for?
    • Increases: MS, MR, AoS, AoR
    • Mech: incr Venous return to heart --> incr murmur
    • Decreases: MVP and HOCM murmurs
  15. Pt has Hx of HTN and DM-2 treated with meds.  ECG shows tall peaked T-waves.  
    What med is causing this?
    Replace current med with?
    • Tall peaked T-waves: =Hyperkalemia...depol and incr resting potential  l/t peaked T-waves and wide QRS
    • Furosemide: Tx of HTN, and K-sparring
    • Replace with: Calcium gluconate (stabilizes myocardium for long enough to decr K-level)
  16. Kawasaki Dz
    • Feat: Acute febrile vasculitis synd of early childhood.
    • Clinical Dx:
    • Fever: >5d
    • & 4/5: Periph Extr involvement (red palms/soles, desqm of finger tips); polymorphous rash, usu generalized; Oropharyngeal erythema, fissuring, crusting of lips, strawberry tongue; B/l non-exudative painless conjunctival infection; Acute non-purl cervical lymphadenopathy (usu u/l)
  17. Anterior Wall MI
    • ECG: ST-elev in pre-cordial leads, w reciprocal ST Depr in inferior leads.
    • D/t: occlusion of Left Ant Descending coronary artery
  18. Acute Inf MI
    ECG: ST-elec inf leads (II, III, and aVF) w/ recipr ST depression ant leads I and aVL
  19. Pericarditis
    • P/w: fever, CP exacb by leaning fwd and relieved by lean back.
    • ECG: diffuse ST-elev
  20. Leads involved in
    Ant wall:
  21. A-fib:
    AV nodal block
  22. Right Coronary Artery
    Branches and What they supply
    • Post Desc: inf wall of LV & Post 1/3 of interventricular septum
    • Marginal: RA and RV
    • SA and AV nodal
    • Common Presentation: sinus bradycardia, AV block, RV myocardial infarction, and/or inferoposterior myocardial infarction (of the LV)
  23. Left Coronary Artery
    Circumflex br: LA & lat wall LV & post wall LV
  24. Framingham Criteria for CHF
    • Dx req: simultaneous presence of @ least 2 Major; or 1 Maj + 2 Minor
    • Major: Paroxysmal nocturnal dyspnea; Jugular vein distention; Rales; cardiomegaly on CXR; Acute PE; S3 gallop; Incr central venous pressure (>16 cm H2O at RA); Hepatojugular reflux; Weight loss  >4.5 kg in 5 d d/t Tx
    • Minor: b/l ankle edema; nocturnal cough; dyspnea on ordinary exertion; hepatomegaly; pleural effusion; 1/3 decr in vital capacity; tachy (HR>120bpm)
  25. Chlorthalidone
    • Thiazide Diuretic: used in CHF
    • MOA: blocks Na and Cl reabs in DCT of kidney
    • Use: solo, or synergistic w/ loop diuretics (furosemide)
    • Loops: block Na/K/Cl reabs on loop of Henle
  26. Acute LBBB
    Tx: same as STEMI ==> Cardiac Catheterization
  27. Livedo reticularis
    S/E: of card cath. Embolization of released cholesterol in subQ tissues
  28. Cardiac Catheterization
    • Indications: acute MI and unstable angina refract to medical intervention
    • Fxn: meas blood flow / pressures in heart chambers and vessels
    • S/E: Livedo reticularis - skin becomes mottled and discolored d/t ischemia
  29. Beta-bl O/D Tx
    Tx: Glucagon
  30. Split S2
    • Physiologic: AoV closes before PulmV (incr with Inhl)
    • Pathologic: (Wide / Fixed / Paradoxical)
    • Wide: Pulm Stenosis or RBBB (path: d/t amnt time for RV to eject blood --> delay pulmV closing)
    • Fixed: A/w Atrial Septal Defect (same amnt of blood shunted through ea beat)
    • Paradoxical: AoS, or LBBB (PulmV closes before AoV)
  31. LVH Causes:
    • Chronic exposure to:
    • Pressure overload state: AoS or Chr-HTN (*MCC of LVH = HTN)
    • Volume overload state: AoR or MR, and Dilated Cardiomyopathy (DCM)
  32. 2 causes of Pressure overload state
    Aortic Stenosis and Chronic Hypertension
  33. ECG of LVH
    Sokolov-Lyon Criteria: Depth of S-wave in V1 + tallest R-wave height in V5-6 must be >35mm
  34. Tx of HTN in LVH
    ARBs: (e.g. Losartan) shown to decr heart mass of LV