IM

Terms / Facts DDx: Abdominal pain of gastroduodenal origing (3) !

DDx: Abdominal pain of intestinal origin (6)

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DDx: Abdominal pain of urinary tract origin (4)

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Acute cholecystitis Chronic cholecystitis Cholangitis

!

DDx: Abdominal pain of pancreatic origin (3)

DDx: Abdominal pain of gynecological origin (6)

Acute pancreatitis Chronic pancreatitis Malignancy

Cystitis Acute retention of urine Acute pyelonephritis Ureteric colic

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

DDx: Abdominal pain of vascular origin (2) DDx: Abdominal pain of peritoneal origin (2) DDx: Abdominal pain referred from other locations (3) !

DDx: Abdominal swelling in the RUQ (4) !

DDx: Abdominal swelling in the LUQ (6)

DDx: Abdominal swelling in the umbilical region (5) !

DDx: Abdominal swelling in the suprapubic region (4)

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Primary periotonitis Secondary peritonitis

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Myocardial infarction Pericarditis Testicular torsion

Right kidney carcinoma Right colonic carcinoma Feces Diverticular mass

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Lipoma Epigastric hernia Carcinoma of the transverse colon Feces Diverticular mass

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Paraumbilical/umbilical hernia Malignancy Carcinoma Feces Diverticular mass

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

DDx: Abdominal swelling in the LLQ (3)

DDx: Acute anorectal pain (4)

Aortic aneurysm Mesenteric embolus

Splenomegaly Gastric carcinoma Left kidney carcinoma Feces Diverticular mass Pancreatic pseudocyst

DDx: Abdominal swelling in the epigastrium (5)

DDx: Abdominal swelling in the RLQ (5)

Peptic ulcer Gastritis Malignancy

Appendicitis Obstruction Diverticulitis Gastroenteritis Mesenteric adenitis Strangulated hernia

DDx: Abdominal pain of hepatobiliary origin (3)

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!

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Carcinoma of the sigmoid colon Diverticular mass Feces !

Acute/chronic bladder retention Pregnancy Fibroids Diverticular mass

Fissure-in-ano Perianal hematoma Thrombosed

1!

Terms / Facts hemorrhoids Perianal abscess DDx: Chronic anorectal pain (3) DDx: Arm pain (5)

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Fistula-in-ano Anorectal malignancy Chronic perianal spesis

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

DDx: Arm swellings (2) DDx: Ascites (5)

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Trauma Infection (cellulitis, lymphangitis)

Cirrhosis Cardiac failure Nephrotic syndrome Carcinomatosis Abdominal/pelvic tumor

DDx: Axillary swellings (5)

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Acute abscess Sebaceous cyst Lipoma Lymphadenopathy Breast lump !

DDx: Backache (congenital) (3) !

DDx: Backache of traumatic origin (4)

Kyphoscoliosis Spina bifida Spndylolithesis Vertebral fractures Ligamentous injury Joint strain Muscle tears !

DDx: Backache of inflammatory origin (2)

Ankylosing spondylitis Rheumatologic disorder !

DDx: Backache of neoplastic origin (2) DDx: Backache of degenerative origin (2)

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Osteoarthritis Intervertebral disc lesions !

DDx: Backache of metabolic origin (2) DDx: Backpain of gynecological origin (2) DDx: Backpain of renal origin (2) DDx: Breast lumps (discrete) (5)

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DDx: Chest pain (5)

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Pelvic inflammatory disease Endometrosis

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Renal calculus Renal carcinoma

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

Pregnancy Lactation Puberty Mastitis

Non-/Cyclical mastalgia Duct ectasia Breast abscess Pregnancy Lactation Angina/Myocardial infarction GERD Pneumonia/Pneumothorax Chest wall injury Depression

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

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Osteoporosis Osteomalacia

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DDx: Breast lumps due to generalized swelling (4) DDx: Breast pain

Metastases Primary tumors

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300/ # large boxes between 2 QRS complexes

Count the number ofo complexes that occur in

2!

Terms / Facts from an EKG if the rhythm is irregular? What rule determines whether the rhythm is sinus on an EKG?

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

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

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

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I and aVF are both upright and positive !

I is upright and aVF is upside down

!

I is upside down and aVF is upright

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I and aVF are both upside down or negative

What EKG findings indicate a left axis deviation? What EKG findings indicate right axis deviation? What EKG findings indicate extreme right axis deviation?

Normal sinus rhythm

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What is the time range of a normal PR interval? What disease is a short PR interval associated with?

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0.12 to 0.20 seconds

Wolff-Parkinson-White syndrome

What kind of EKG appearance characterizes Wolff-Parkinson-White ! Delta wave syndrome? ! PR > 0.2 seconds What PR interval indicates a first-degree block? !

What is the length of a normal QRS complex? !

What R wave width on lead I indicates LVH?

R I > 15 mm !

What R wave width on lead II indicates LVH? What R wave width on lead aVF indicates LVH? What R wave width on lead aVl indicates LVH? What R wave width on lead V5 indicates LVH? What R wave width on lead V6 indicates LVH?

≤ 0.12 s

> 20 mm

!

> 20 mm

!

> 11 mm

!

> 26 mm

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> 26 mm

! LVH If the sum of the widths of R I and S III is > 25 mm, what cardiac pathology is indicated? ! Tall or peaked p waves in limb or What EKG morphology indicates right atrial precordial leads hypertrophy?

What EKG morphology indicates left atrial hypertrophy?

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Broad or notched p waves in limb leads

3!

Terms / Facts !

The presence of a Q wave indicates what cardiac pathology? !

What mechanical event does the QRS complex represent?

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What electrical event does the ST segment represent? The horizontal segment of baseline that follows the QRS complex is known as the [...] segment. What electrical event does the T wave represent?

Ventricular depolarization

Plateau phase of venricular repolarization

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

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The rapid phase of ventricular repolarization !

What are the boundaries of the ST segment? !

What parts of the EKG represent ventricular systole?

Ventricular contraction (initiation) !

What electrical event does the QRS complex represent?

Old infarction

End of the S to the beginning of the T

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? !

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

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

What is deflection with respect to an EKG? !

Positive deflections are [...] on the EKG. Negative deflections are [...] on the EKG. What kind of electrical activity produces a positive deflection on an EKG?

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The direction of a wave on an EKG

Positive deflections are upward on the EKG. Negative deflections are downward on the EKG.

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

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

How many leads does a standard EKG have? In the aVR lead, what limb electrode is positive?

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

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Ca2+

0.04 s

12 leads

Right arm positive !

Left arm positive !

Foot (left)

4!

Terms / Facts !

What are the lateral leads? Why are leads AVL and I called the lateral leads?

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Leads I and AVL

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

What are the inferior leads? (3) Why are leads II, III and AVF called inferior leads?

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Leads II, III and AVF

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? What is the orientation of electrode V2?

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Front to back of the patient !

What is the deflection of V1 and V2 normally? !

What is the deflection of V6 normally? What part of the heart are the V3 and V4 leads oriented over? What plane do the six limb leads lie in? What plane do the six chest leads lie in?

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What is the normal heart rate range? What is the heart's normal pacemaker?

Negative Positive

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Interventricular septum

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Frontal plane Horizontal plane

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60-100 bpm !

SA node !

What is the inherent rate of the AV junctional automaticity focus? What is the inherent rate of the atrial automaticity focus? What is coronary ischemia?

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What causes stable angina pectoris?

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60-80 bpm

Stable angina occurs when oxygen demand exceeds available blood supply. !

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

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

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40-60 bpm

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

When does stable angina occur?

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

AV node

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

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

5!

Terms / Facts ↑ Homocysteine, History (family) Diabetes mellitus !

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

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

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

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

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

What ejection fraction is associated with increased mortality in stable angina pectoris? In what situations is stress ECG used? (3)

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! !

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

EF < 50%

Rest Nitroglycerin Not usually, unless a prior cardiac pathology is present

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

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

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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 a patient with stable angina pectoris? What is the course of treatment for a patient with a positive stress test?

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What is the course of treatment for a patient with a positive stress echocardiograph? What criteria make a stress test positive? (4)

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ST-segment depression

! !

Stress echocardiography

Cardiac catherization should be performed.

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

Why is stress echocardiography preferred to stress ECG?

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Cardiac catheritization should be performed

What is the preferred test for assessing stable angina pectoris?

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?

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Coronary angiography for visualization

What is the most accurate method of identifying the presence !

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

What relieves stable angina pectoris? (2)

What is a stress ECG?

> 50%

Coronary

6!

Terms / Facts and severity of CAD?

arteriography !

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

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

What is the mechanism by which IV adenosine and dipyramidole work in pharmacologic stress testing? Explain how myocardial perfusion scintigraphy works.

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IV adenosine IV dipyramidole IV dobutamine

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. 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? !

What pharmacological agents are used for treatment of stable angina pectoris? (4) How do β-blockers work in the treatment of stable angina pectoris?

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50% reduction 1 year after cessation

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

What is the net therapeutic effect of β-blockers on stable angina pectoris? What is the mechanism by which nitrates treat stable angina pectoris? !

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Aspirin β-blockers Nitrates Calcium-channel blockers

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

What are the side effects of nitrates? (4)

Pharmacologic stress test

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↓ morbidity - reduces risk of MI

Reduces the frequency of coronary events

Generalized vasodilation → ↓ preload → ↓ cardiac work ↓ angina

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

What drug can prevent angina if taken before exertion?

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Nitrates

! Vasodilation and afterload reduction What is the mechanism by which calcium → decreased work → ↓ angina channel blockers treat stable angina pectoris? Are calcium channel blockers primary or secondary treatment ! Secondary

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7!

Terms / Facts agents for stable angina pectoris? What are the methods of revascularization? (2)

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treatment 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) !

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

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

What management decisions are indicated in patients with moderate stable angina pectoris? (4) What are the criteria for severe stable angina pectoris? (3)

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Risk factor modification Aspirin

Nitrates β-blockers. Calciumchannel blockers if needed.

Normal EF Mild angina Single-vessel disease

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

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Normal EF Moderate angina Twovessel disease !

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

Decreased EF Severe angina Threevessel/left main/LAD disease

What management decision is indicated for patients with severe stable angina pectoris? What is the most significant complication of PTCA? What is the risk and in what time frame?

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Coronary angiography and consider for CABG !

Restenosis; up to 40% within first 6 months

What intervention helps reduced the rate of restenosis in PTCA? What patients should be considered for PTCA?

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Stents

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

! CABG What is the treatment of choice in patients with high-risk stable angina pectoris? ! Left main disease Three-vessel disease with What are the indications for reduced LV function Two-vessel disease with CABG in patients with stable proximal LAD stenosis Severe ischemia angina pectoris? (4)

What kind of lesions are most responsive to PTCA? !

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

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Proximal lesions

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

8!

Terms / Facts !

What is the pathophysiology of unstable angina pectoris? Why is unstable angina pectoris significant?

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

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

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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.

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

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What does acute coronary syndrome refer to? (2) What precautions should be taken before stress testing patients with unstable angina pectoris?

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

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

What was the key finding of the ESSENCE trial?

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

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

How does one treat unstable medical angina upon hospital admission? (2) What pharmacogical interventions are indicated for unstable angina pectoris? (5)

Unstable angina or acute MI

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Establish IV access Give supplemental oxygen

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

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At least 2 days

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2 to 2.5x normal

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

What is catecholaminergic polymorphic ventricular tachycardia? !

What is the pathogenesis of myocardial infarction?

No

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

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

What is the most common cause of myocardial infarction? What is the mortality rate of myocardial infarction? The combination of substernal chest pain !

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Acute coronary thrombosis !

30%

The combination of substernal chest pain

9!

Terms / Facts persisting for longer than 30 mins and diaphoreis strongly suggests [...] (disease).

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

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

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Post-op patients Elderly Diabetics Women

Inferior EKG changes Hypotension Elevated JVP Hepatomegaly Clear lungs

What does S-T segment elevation indicate? What can it be diagnostic for? What are Q waves indicative of?

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Transmural injury; diagnostic of an acute infarct

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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 !

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

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

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

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How much of the heart wall is affected by STEMI? How much of the heart wall is affected by NSTEMI?

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Transmural; entire thickness

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? When does CK-MB increase after myocardial injury? When is the peak reached? At what interval should total CK and CK-MB be measured after admission? For how long? What are the most important cardiac enzymes to order? When do troponins I and T increase after a myocardial infarction? When do they peak?

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Occur very early

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Cardiac enzymes

4 to 8 hours; peak at 24 hours !

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Every 8 hours for 24 hours Troponins I and T

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

10!

Terms / Facts When do troponins return to normal after myocardial infarction? Why are troponins preferred to CK-MB for diagnosis of myocardial infarction? When should cardiac enzymes be drawn?

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Greater sensitivity and specificity

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

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

Aspirin ACE inhibitors βblockers

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? !

When should ACE inhibitors be administered to a patient with acute MI? What was the key finding of the CAPRICORN trial?

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↓ HR, contractility and afterload → ↓ mortality

Within hours of hospitalization if there are no contraindications.

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) !

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

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

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) Myocardial infarction in the inferior region of the heart has what EKG morphologies? (1) What is the rational for using statins in mainenance therapy of MI? What pharmacologic agents are indicated in patients with MI? (7) What is the rationale for using nitrates in patients with acute MI? (3) What did the HOPE trial find?

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5 to 14 days

At admission and every 8 hours until three samples are obtained

Troponin I can be falsely elevated in patients with r [...] (disease).

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

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Q waves in leads I and aVL Q waves in leads II, III and aVF

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

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Oxygen Nitroglycerin β-blockers Aspirin Morphine ACE inhibitors IV Heparin

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

ACE inhibitor ramipril reduces mortaliti, MI, stroke and renal

11!

Terms / Facts disease in patients with high-risk cardiovascular disease What did the GUSTO trial find?

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

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

!

PTCA Thrombolysis

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Timing; must be given early

Prevention of progression of thrombus formation.

! CHF What is the most common cause of in-hospital mortality related to acute MI? ! Acute MI is a RAMP to lots of complications R What are the classes of ecurrent infarction A rrhthymias M echanical complications related to acute complications P ump failure (CHF) MI? (4)

What is cardiac rehabilitation?

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

What treatment does ventricular fibrillation call for? What treatment does asytole call for?

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Electrical defribillation followed transcutaneous pacing

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

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Antiarrhythmic therapy (IV amiodarone)

Immediate unsynchronized defibrillation and CPR

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

What is a recurrent infarction?

Electrical cardioversion

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In the setting of an anterior MI

Emergent placement of a temporary pacemaker

IV atropine followed by temporary pacemaker if conduction is not restored

Extension of existing infarction or reinfarction of a new area.

12!

Terms / Facts What cardiac enzyme is best for assessing recurrent infarction? Why?

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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? !

What is the treatment for recurrent infarction?

!

48 to 72 hours

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

What EKG finding suggests reinfarction after an acute MI? !

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

Repeat ST segment elevation within first 24 hours

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) ! You need to fix HIS free rupture Hemodynamic stabilization Immediate pericardiocentesis Surgical What is the treatment for repair free wall rupture? (3) !

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.

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

!

10 days postMI

! Mitral regurgitation What cardiac pathology results from papillary muscle rupture? ! Emergent surgery (mitral valve What is the treatment for mitral replacement) Afterload reduction with regurgitation secondary to papillary nitrprusside or intra-aortic baloon pump muscle rupture? (2) !

What is a ventricular pseudoaneurysm?

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

What is the treatment for a ventricular pseudoaneurysm? Why? Ventricul aneursym is associated with a high incidence of [...] .

!

Emergent surgery because VP can become free wall rupture.

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

What is the treatment for acute pericarditis secondary to MI? What drugs are contraindicated in acute pericarditis secondary to MI? Why? What is Dressler's syndrome?

!

!

!

!

Aspirin

NSAIDs and corticosteroids; may hinder myocardial scar formation

Immunologically based syndrome occurring weeks to

13!

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? !

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

Wheezing Cough Dyspnea !

In what manner do the symptoms of asthma usually appear? What are the triggers of asthma? (3)

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What breath sounds are heard in asthma? (2)

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Frequency Duration Required treatment Severity

!

Wheezing Prolonged expiratory

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

DDx: Asthma (6)

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Nasal polyps Rhinitis Rash

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

What is the triad of atopic asthma?

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Asthma + allergic rhinitis + atopic dermatitis !

What is the triad of ASA-sensitive asthma?

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What are the 'reliever' medications used to quickly relieve the sx of asthma? (2) What is the clinical triad of ChurgStrauss? What are the controller medications used for asthma? (6)

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Asthma + ASA sensitivity + nasal polyps !

What is the clinical triad of allergic bronchopulmonary aspergillosis?

Asthma + pulmonary infiltrates + allergic rxn to Aspergillus

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

Asthma + eosinophilia + granulomatous vasculitis

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 !

!

Chronic with episodic exacerbation

Viral infection Environmental allergens Drugs

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

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

Aspirin

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

What is the classic triad of asthma?

!

Always use with inhaled

14!

Terms / Facts corticosteroids; ↑ mortality without.

be used with in asthma? Why?

!

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

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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? !

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

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

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What benefit does bronchial thermoplasty offer patients with asthma?

Check transcription of genes for 5-lipoxygenase

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

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

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

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≥ 60 L/min ↑ after bronchodilation ≥20% diurnal variation

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

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

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

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

!

What are the precipitants of DKA? (4)

!

Low-dose ICS + LABA

!

Oral steroids

Previous need for intubation

Suspicion of pneumothorax or pneumonia

Insulin deficiency Infection or inflammation Ischemia or infarction Intoxication !

What type diabetes does DKA occur in mostly? What happens to acid-base status with DKA?

!

!

What is the value for the corrected serum [Na+] in the context of DKA-related hyperglycermia? What happens to serum [K+] with DKA? Why?

!

T1D and ketosis-prone T2D ↑ anion gap metabolic acidosis !

What is the predominant ketone in DKA?

!

!

Low-dose ICS

Med/high dose ICS + LABA

What is the treatment for Step 5 in asthma stepwise therapy? What is a good predictor of risk of death with asthma exacerbation?

!

β-hydroxybutyrate

Corrected Na = measured Na + [2.4 x (measured glucose100)/100]

Hyperkalemia due to exchange with H+

15!

Terms / Facts (acidosis) from ICF !

What happens to total body K+ with DKA? !

What happens to the CBC with DKA?

Leukocytosis !

What happens to total body phosphorous with DKA? What pancreatic enzyme is elevated with DKA? !

What is the general treatment strategy for DKA? What does fluid management consist of in DKA?

!

!

!

What does electrolyte management consist of in DKA? Explain.

DDx: DKA (5)

!

↑ amylase

!

Rule out possible precipitants Aggresive hydration Insulin Electrolyte repletion

!

(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. 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)

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

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

!

What is acute bacterial meningitis?

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

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

Bacterial infection of the subarachnoid space !

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

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

Fever Headache Stiff neck Photosensitivity AMS Seizures

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

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

!

Decreases

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?

What are the complications of DKA treatment? Explain. (2)

↓ K+

!

Lethargy w/o fever

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

16!

Terms / Facts !

What are the possible causes of recurrent bacterial meningitis? Blood culutres should be taken [...] antibiotic therapy in bacterial meningitis

!

CSF leak Dermal sinus Congenital/acquired defects Blood culutres should be taken before antibiotic therapy in bacterial meningitis !

What is the WBC count in bacterial meningitis?

!

What test should be performed if meningitis is suspected? !

Empiric antibiotic therapy should be initiated immediately [...] LP is performed. !

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

> 10,000 WBC Lumbar puncture

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

CSF WBC > 2k glc 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) !

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

What is the empiric abx treatment for a normal adult with meningitis? What is the empiric abx treatment for an adult > 50 y/o? !

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

!

!

!

What are the most common viral etiologies of aseptic meningitis? (4) What CSF findings suggest viral meningitis? (3) Tx: TB meningitis Tx: Fungal meningitis

!

!

!

< 45

Ceftriaxone + Vancomycin

Ceftriaxone + Vancoymcin + Ampicillin

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

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

100-10,000 PMNs !

What is the glucose level in CSF in bacterial meningitis?

18-30

!

Rifampin or ceftriaxone

Negative bacterial microbiologic data !

Enterovirus HIV HSV (type 2 >1) VZV

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

Antimycobacterial Rx + dexamethasone !

Amphotericin B + 5-FU

17!

Terms / Facts !

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

What anatomic regions are affected in upper urinary tract infections? !

What is an uncomplicated UTI? What is a complicated UTI? (4)

!

Urethra Urinary bladder

Kidneys (pyelonephritis) Prostate

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 the number one culprit in uncomplicated UTIs? !

What microbes are responsible for complicated UTIs? (4)

E.coli

E. coli Enterococci Pseudomonas S. epidermidis

What organisms are the most frequent causes of catheter-associated ! Yeast E.coli UTIs? (2) ! Dysuria Urgency Frequency What are the clinical manifestations of cystitis? (3) !

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

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

!

Perineal pain Fever Tenderness on prostate exam

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

How does the clinical presentation of a renal abscess differ from that of pyelonephritis? What are the urinalysis findings of UTIs? (4)

!

!

Persistent fever despite appropriate antibiotics

Pyuria + Bacteriuria +/- hematuria +/nitrites !

What is the definition of pyuria? What is the definition of bacteriuria?

Urethral discharge may be present

!

> 8 WBC/HPF

> 1 organism per oil-immersion field.

What is the criterion for a UTI based on urine culture for an asymptomatic woman? What is the criterion for a UTI based on urine culture in a symptomatic woman? What is the criterion for a UTI based on urine culture in a man? What does the presence of squamous cells in a urinalysis indicate?

!

!

!

!

≥ 10 5 CFU/ml

!

≥ 100 CFU/ml

≥ 1000 CFU/ml

Vulvar or urethral

18!

Terms / Facts contamination !

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

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

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

FQ or TMP-SMX PO x 1014 d

Ampicillin Amoxicillin Oral cephalosporins x 7 to 10 days !

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

FQ or TMP-SMX x 3 day

!

Treat as in women, except for 7 days 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? What is the treatment with duration for chronic prostatitis?

!

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

!

FQ or TMP-SMX Po x 6-12 weeks

! Ceftriaxone IV x 14 d What is the inpatient treatment with duration for pyelonephritis? ! Drainage + antibiotics for pyelonephritis What is the treatment for a renal abscess? ! CT to r/o What test should be conducted in patients with pyelonephritis who abscess fail to defervesce within 72 hours? Why?

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? !

What is the precursor lesion to almost all cases of CRC? What is the most specific and sensitive test for CRC?

!

Adenomas

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? What age group is at increased risk for CRC?

Polyarticular

!

Liver

> 50 y/o

What kind of adenoma has the highest malignant potential for ! Villous adenomas CRC? ! CT scan of abdomen and CXR How is staging performed for CRC? What other gastrointestinal diseases increase the risk !

!

Ulcerative colitis Crohn's

19!

Terms / Facts for CRC? (2)

disease !

What does Stage A colorectal cancer mean? !

What does Stage B1 CRC mean?

Limited to submucosa/muscularis propria !

What does Stage B2 CRC mean? What does Stage B3 CRC mean?

Limited to muscualris mucosa; T1-2, N0, M0

!

Through the entire bowel wall

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 !

What is the recommended treatment for familial adenomatous polyposis?

Prophylactic colectomy !

At what age is the risk of CRC 100% with Gardner's Syndrome? What is the clinical presentation of Turcot's syndrome? (2) What is Lynch I syndrome? What is Lynch syndrome II?

!

!

Polyps + cerebellar medulloblastoma or GBM

Early onset CRC with an absence of antecendent multiple polyposis !

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? !

What is the clinical presentation of right-sided CRCs? (3) CRCs on what side of the colon present with melena? And with hematochezia?

!

Why is obstruction unusual with right-sided CRCs? What is a common symptom of leftsided CRC?

!

What is the surgical treatment for CRC? What blood marker should be

!

!

CRC

Anemia Weakness RLQ mass Melena: right side Hematochezia: left side !

Large luminal diameter

Changes in bowel habits secondary to bowel obstruction

What is the most common symptom of rectal cancer?

!

Age 40

!

Hematochezia

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

CEA; levels are checked periodically every 3

20!

Terms / Facts obtained before surgical resection of CRC? Why?

to 6 months. Elevations strongly suggest recurrence. !

What is the adjuvant therapy for Dukes' C colon cancer?

Postoperative chemotherapy:5-FU and leucovorin

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

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

!

5-FU + radiation therapy postoperatively

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? !

[...] therapy is not indicated in the treatment of colon cancer.

!

What is a completed stroke? Why are symptoms transient in a TIA?

Within 3 years of surgery

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

What is the leading cause of neurologic disability? What is an evolving stroke?

!

Ischemic stroke

Stroke that is worsening

!

One in which the maximal deficit has occurred.

!

Reperfusion occurs due to collateral circulation or embolus break up. !

What is the usual cause of a TIA? !

What is the association between TIA and stroke risk?

Embolism

TIA = high risk of stroke in subsequent months. !

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

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

!

!

Age HTN

Ischemic strokes Hemorrhagic strokes

What is the most common source of emboli in ischemic stroke? What are the major causes of stroke? (3)

30%

!

Heart (mural thrombus)

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

! Hypertension What predisposing factor is found in nearly all cases of lacuanr stroke? What is the pathogenesis ! Narrowing of the arterial lumen by thickening of the of lacunar strokes? vessel wall (hyaline arteriolosclerosis) → microinfarcts

!

21!

Terms / Facts result (lacunes) !

What is the classic presentation of a thrombotic stroke? What are the two causes of a carotid bruit?

!

Patient awakens from sleep with neurologic deficits

Murmur referred from the heart Turbulence in the internal cartoid artery

Describe the onset and severity of symptoms with embolic stroke. !

Clinical manifestations: MCA stroke (5)

!

Very rapid with maximal deficits initially

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? !

What is ataxic hemiparesis?

!

!

!

What is pectus carinatum?

How should one assess thoracic expansion?

Risk factors: COPD (4)

!

!

!

Contralateral lower extremity and face weakness and sensory loss

!

!

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

Place hands on lateral chest wall from the posterior view

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

!

Definition: Emphysema

Pons

Sternum protrudes from the narrowed thorax

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

Definition: Chronic bronchitis

!

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 subclavian steal syndrome?

What is respiratory alternans?

Thalamus

Incoordination ipsilaterally

With clumsy hand dysarthria, where is the lesion? What kind of deficit and occurs with anterior cerebral artery stroke? Where?

!

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 Tobacco smoke α 1 -antitrypsin deficiency Environmental factors

22!

Terms / Facts (second hand smoke) Chronic asthma !

Below what value is the FEV1/FEV in COPD? !

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

What happens to TLC in COPD?

! ! !

What happens to vital capacity in COPD?

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

!

Decrease

!

Mild: 70% Severe: 50%

Increased RV

Increased FRC

Decreased vital capacity

What disease is predominant in COPD of pink puffers? !

What disease is predominant in COPD of blue bloaters?

!

Increased TLC

What happens to residual volume in COPD? What happens to FRC in COPD?

< 0.75-0.80

!

Predominant emphysema

Predominant chronic bronchitis

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

! Smoking cessation What is the most important intervention for COPD treatment? ! Serial FEV1 measurements Pulse What does clinical monitoring of COPD oximetry Exercise tolerance patients entail? (3)

Within what time range do respiratory symptoms improve in COPD after cessation of smoking? What happens to the FEV1 of a COPD patient after smoking cessation? Tx: COPD (4)

!

1 year

Decline of FEV1 returns to the rate of someone who has never smoked

Corticosteroids Oxygen Prevention (smoking cessation, pneumococcal vaccine) Dilators (beta agonists, anticholinergics)

What are the criteria for continous or ! intermittent long-term oxygen therapy in COPD? (3)

!

!

!

PaO2 55 mm Hg OR O2 saturation < 88% OR PaO2 55-59 mm Hg + polycythemia or

23!

Terms / Facts evidence of cor pulmonale !

1st line: metered-dose inhaler of bronchodilator 2nd: inhaled glucocorticoids can be used as well; start w/ low dose

Tx guidelines for mild to moderate COPD? (2) !

Tx guidelines for severe COPD? (3)

Bronchodilators Continuous oxygen therapy Pulmonary rehabilitation !

Definition: Acute COPD exacerbation

CXR → β 2 -agonist → systemic corticosteroids → antibiotics → supplemental oxygen → non-invasive positive pressure ventilation

!

Tx: acute exacerbations of COPD (6)

Persistent increase in dyspnea (not relieved w/ bronchodilators)

What antibiotics should be used in acute exacerbations of COPD? (2) What are the complications of COPD? (4) !

What is bronchiectasis?

!

!

azithromycin levofloxacin

Acute exacerbations Secondary polycythemia Pulmonary HTN and cor pulmonale

Permanent, abnormal dilation and destruction of bronchial walls. !

What is the most common cause of bronchiectasis? !

Clinical presentation: bronchiectasis (4) !

Dx: Bronchiectasis (3) Tx: Bronchiectasis (2)

!

Chronic cough Dyspnea Hemoptysis Recurrent or persistent pneumonia

High-resolution CT scan PFTs Bronchoscopy

Abx for acute exacerbations Bronchial hygiene (hydration, chest physiotherapy, inhaled bronchodilators)

What are the two pathologic subtypes of lung cancer? Risk factors: Lung cancer (5)

!

!

!

Small cell lung cancer (25%) Non-small cell lung cancer (75%)

Cigarette smoke COPD Radon Asbestos Passive smoke

How is non-small cell lung cancer staged? How is small cell lung cancer staged? (2)

!

TNM system

Limited - confined to chest plus supraclavicular nodes, but not cervical or axillary nodes Extensive - outside of chest and supraclavicular nodes

What cancer is most commonly associated with superior vena cava syndrome?

!

Cystic Fibrosis

!

Small cell lung cancer

24!

Terms / Facts What type of neoplasm is Pancoast's tumor generally? !

Diagnosis: lung cancer (3)

!

Squamous cell carcinoma

CXR CT scan Tissue biopsy !

Cytologic examination of sputum detects lung neoplasms from wht location? !

Tx: non-small cell lung cancer

Central but not peripheral

Surgery w/ radiation therapy as adjunct !

What is the 5-year survival rate for lung cancer patients? !

Tx: small cell lung cancer For what stage of small cell lung cancer is radiation therapy a useful adjunct? When not? Is surgery a useful treatment in small cell lung cancer? Explain.

!

14%

chemotherapy radiation is useful in limited stage disease but not extensive !

No; tumors are usually unresectable

! Metastatic cancer What is the most comon cause of mediastinal mass in older patients? ! Thyroid Teratogenic tumors Thymoma Terrible Ddx: anterior mediastinal mass lymphoma (4) !

Ddx: middle mediastinal mass (5) !

Ddx: posterior mediastinal mass (5)

cyst lung cancer lymphoma aneurysm morgani hernia

Neurogenic tumor Esophageal mass Enteric cyst Aneurysms Bochdalek's hernia !

What is the test of choice for diagnosing a mediastinal mass? What is the most common presentation of a mediastinal mass? What are the clinical manifestations of a mediastinal mass? (5) !

What is oropharyngeal dysphagia? !

What is esophageal dysphagia? Etiology: achalasia (3) Sx: achalasia (3) Dx: achalasia

!

!

!

!

!

CT scan

Asymptomatic

SVC syndrome Dysphagia Nerve compression (hoarseness, horner's, diaphragmatic paralysis) Chest pain Dyspnea

Oropharyngeal: inability to propel food from mouth through UES into esophagus Esophageal: difficulty swallowing & passing food from esophagus into stomach

idiotpathic (most common) pseudoachalasia (due to GE jxn tumor) chagas disease dysphagia (solid and liquid) chest pain regurgitation !

barium swallow

25!

Terms / Facts What radiologic finding is associated with barium swallow in achalasia? !

Tx: achalasia (3)

!

!

congenital GVHD Fe-deficiency anemia

Excessive transient relaxations of lower esophageal sphincter (LES) or incompetent LES → Mucosal damage (esophagitis) due to prolonged contact w/ acid can evolve to stricture

Pathophysiology: GERD

!

Risk factors: GERD (4) !

hiatal hernia obesity hypersecretory states delayed emptying supine position fatty foods caffeine alcohol cigarettes CCB pregnancy !

Clinical manifestations (esophageal): GERD (5)

heartburn atypical chest pain regurgitation dysphagia water brash !

Clinical manifestations (extraesophageal): GERD (4) !

Dx: GERD (2)

!

Failure to respond to PPI Alarm features (dysphagia, odynophagia, vomiting, wt loss, palpable mass, age > 55 y)

What diagnostic study is indicated for uncertain dx of GERD w/ a normal EGD? !

cough asthma laryngitis dental erosions

Hx and Empiric trial of PPI

When is EGD indicated for diagnosis of suspected GERD? (2)

Tx (lifestyle): GERD (4)

dilated esophagus w/ distal 'bird's beak'

Heller myotomy Balloon dilation Botulinum toxin

Etiologies: esophageal webs (3)

Precipitants: GERD (7)

!

!

high res manometry w/ 24-h esophageal pH monitoring

avoid precipitants lose weight avoid large and late meals elevate head of bed !

Tx (medical): GERD !

Tx (surgical): GERD Complications: GERD (2)

!

PPI

fundoplication

Barrett esophagus Esophageal adenocarcinoma

How does one manage the complications of GERD?

!

surveillance EGD w/ biopsy !

How frequently should one perform EGD w/ bx surveillance if a patient has Barrett's esophagus w/ no dysplasia? How frequently should one perform EGD w/ bx surveillance if a patient has Barrett's esophagus w/ low grade dysplasia? How does one manage Barrett's esophagus w/ high grade dysplasia?

!

!

!

q3 y q6 mos

Endoscopic mucosal resection to r/o cancer, then RFA or other ablative Rx

26!

Terms / Facts !

Definition: dyspepsia

upper abdominal sx (discomfort, pain, fullness, bloating, burning) !

Etiology (functional): dyspepsia (2)

visceral afferent hypersensitivity abnormal gastric motility !

Etiology (organic): dyspepsia (3) !

Tx: functional dyspepsia (2) What are the cardiac causes of chest pain? (4) !

Sx: unstable angina (4)

!

GERD PUD Gastric cancer H. pylori eradication PPI

Pericarditis/myopericarditis Unstable angina MI Aortic dissection

Substernal pressure that radiates into the neck, jaw and L arm Dyspnea Diaphoresis N/V

What exacerbates unstable angina? And improves? (2) Dx: unstable angina (2)

!

!

↑ w/ exertion ↓ w/ NTG or rest

EKG Stress test (make sure to stabilize with medical management beforehand)

What kind of EKG changes are seen in unstable angina? ! ↑/↓ ST T-wave inversion (2) ! Substernal pressure that radiates into the neck, jaw and L arm Sx: myocardial Dyspnea Diaphoresis N/V infarction Dx: myocardial infarction (3) !

Sx: pericarditis (2)

!

EKG changes (↑/↓ ST, T-wave inversion) tropinin I/T CK-MB

Sharp pain that radiates into the trapezius pericardial friction rub pericardial effusion

What kind of EKG changes are associated with pericarditis? (2) !

Sx: myocarditis (5)

!

!

Diffuse ST segment elevation ↓ PR interval

EKG changes ↑ troponin

abrupt onset severe tearing, knifelike pain radiating anteriorly or to the posterior mid-scapular region HTN or HoTN Weak pulses Focal neurological deficits Aortic insufficiency

What are the radiologic findings of aortic dissection? (2) What are the pulmonary causes !

!

!

Sharp pain that radiates into the trapezius pericardial friction rub pericardial effusion ↓ EF +/- s/s CHF

Dx: myocarditis (2) Sx: aortic dissection (5)

↑ w/ respiration ↓ w/ sitting forward

!

What exacerbates pericarditis? and improves?

!

Widened mediastinum on CXR False lumen on CT

Pneumonia Pleuritis Pneumothorax Pulmonary

27!

Terms / Facts of chest pain? (5) Sx: pneumonia (6)

embolism Pulmonary hypertension Pleuritic pain dyspnea fever cough w/ sputum ↑ RR crackles

!

!

CXR: pneumonia !

Sx: pleuritis (2) Sx: pneumothorax (3)

pulmonary infiltrate

sharp, pleuritic pain friction rub

sudden onset, sharp, pleuritic pain hyperressonance ↓ breath sounds

!

!

CXR: pneumothorax Sx: pulmonary emobolism (4)

air in the pleural space

sudden onset pleuritic pain ↑ RR &HR ↓S a O 2 EKG changes

!

!

What imaging study should be ordered for suspected pulmonary embolism? !

Sx: pulmonary hypertension (3)

Exertional pressure dyspnea ↓ SaO2 !

Auscultation: pulmonary hypertension (2) What are the GI causes of chest pain? (7)

!

Loud P2 right sided S3 and/or S4

Esophageal reflux Esophospasm Mallory-Weiss tears Boerhaave syndrome PUD Biliary disorder Pancreatitis !

Sx: esophageal spasm

intense substernal pain !

Aggravating/alleviating factors: esophageal spasm (1/2)

↑ swallowing ↓ nitroglycerin and calcium-channel blockers !

Dx: esophageal spasm

manometry !

Precipitating factors: Mallory-Weiss tears !

Dx: mallory weiss tears Sx: Boerhaave syndrome

!

Vomiting

EGD

Severe pain Palpable subcutaneous emphysema !

Aggravating factor: Boerhaave syndrome

!

Radiologic finding: Boerhaave syndrome Sx: biliary disorders (2) Aggravating factor: biliary disorder

↑ w/ swallowing !

Precipitating factor: Boerhaave syndrome

!

CT angiogram

!

vomiting

mediastinal air on chest CT RUQ pain N/V !

↑ fatty foods

28!

Terms / Facts !

Dx: biliary disorder (2) !

Sx: pancreatitis

Epigastric/back discomfort ↑ amylase ↑ lipase abd CT

!

Dx: pancreatitis (3)

!

What are the miscellaneous causes of chest pain? (3)

Sx: herpes zoster (2)

!

Intense unilateral pain dermatomal rash w/ sensory findings !

What is the initial approach to a patient presenting with chest pain (5) Definition: Diabetes Mellitus

!

Chostochondritis Herpes Zoster Anxiety

Localized sharp pain that ↑ w/ movement and is reproduced by palpation

!

Sx: chostochondritis

RUQ U/S LFTs

Focused hx Targeted exam 12 lead EKG cardiac biomarker (CK-MB and Tn) CXR

Fasting glucose >/= 126 mg/dL x 2 Random glc >/= 200 mg/dL x 2 (or 1 if severe hyperglycemia w/ acute metabolic decompensation) 75 g OGTT w/ 2-h glc >/= 200 mg/dL !

What percentage of the US population has pre-Diabetes? !

Definition: Impaired fasting glucose !

Definition: Impaired glucose tolerance

100-124 mg/dL

140-199 mg/dL 2h after 75 g OGTT

What inteventions can be used to prevent progression of pre-diabetes to frank DM? Give them in order of risk reduction.

!

TZD (60%) > Diet/exercise (58%) > metformin (31%) !

HbA1c above what level is sufficient to diagnose DM? Pathogenesis: Type 1 DM

!

>/= 6.5%

islet cell destruction → absolute insulin deficiency !

What autoantibodies are found in type I DM?(3) !

Risk factors: type II DM (3) Clinical manifestations: Diabetes Mellitus

!

anti-GAD anti-islet cell anti-insulin

FHx Obesity Sedentary lifestyle Polyuria Polydipsia Polyphagia w/ unexplained weight loss

What is the first line therapy for T2DM w/ HbA1c >/= 7%

!

Metformin + lifestyle mod !

By how much does metformin reduce HbA1c? Contraindications: metformin (2)

!

What complications does DM cause to the eye?

!

~40%

~ 1.5%

Renal (Cr> 1.5) or liver failure !

Retinopathy

29!

Terms / Facts How does one treat proliferative retinopathy 2/2 DM?

!

photocoagulation surgery

! retinopathy With what other diabetic complication does diabetic nephropathy present? ! strict BP control using ACE inhibitors or ARBs Tx: diabetic nephropathy !

Sx: symmetric diabetic neuropathy (3) Sx: autonomic diabetic neuropathy (5)

!

symmetric distal sensory loss paresthesias +/motor loss

gastroparesis constipation neurogenic bladder erectile dysfunction orthostasis

Sx: diabetic mononeuropathy Complications (dermatologic): Diabetes Mellitus (3)

!

sudden onset peripheral or CN deficit

!

Necrobiosis lipoidica diabeticorum Lipodystrophy Acanthosis nigricans !

What criteria are used to classify hypertension? !

Definition (JNC VII): Normal pressure Definition (JNC VII): Pre-HTN

!

Definition (JNC VII): Stage 1 HTN

Systolic < 120 mm Hg Diastolic < 80 mm Hg

Systolic: 120-139 mm Hg Diastolic: 80-89 mm Hg !

Systolic: 140-159 mm Hg Diastolic: 90-99 mm Hg !

Definition (JNC VII): Stage 2 HTN

Systolic: ≥ 160 mmHg Diastolic ≥ 100 mmHg !

When is the onset of essential HTN? !

What are the etiologies of HTN? (2) !

What infections are diabetics more susceptible to? (5)

Definition: Heart failure

UTI Candidiasis Osteomyelitis of foot Mucormycosis Necrotizing extern otitis !

q3-6 mo;

(1) failure of the heart to pump blood forward at sufficient rate to meet metabolic demands of peripheral tissues or (2) ability to do so only at abnormally high cardiac filling pressures

Sx: low output heart failure (4) Sx: congestive heart failure (left sided) (3) Sx: congestive heart failure (right sided) (4)

!

25-55 yr

Essential Secondary

How often should HbA1c be checked? What is the target goal? !

JNC VII

!

anorexia fatigue exercise intolerance weakenss !

dyspnea orthopnea paroxysmal nocturnal dyspnea

!

peripheral edema RUQ discomfort bloating satiety

30!

Terms / Facts !

Definition: class I heart failure (NYHA) Definition: class II heart failure (NYHA) Definition: class III heart failure (NYHA)

no sx w/ ordinary activity !

sx w/ ordinary activity

!

sx w/ minimal activity !

Definition: class IV heart failure (NYHA) !

Precipitants: acute heart failure (5) Tx: acute decompensated heart failure (5) Goals of workup: HTN (3)

!

!

sx @ rest

MI renal failure hypertensive crisis drugs worsening aortic stenosis Lasix w/ monitoring of UOP Morphine Nitrates Oxygen Position (sitting up & legs danging over bed)

(1) identify CV risk factors or other diseases that would modify prognosis or rx (2) reveal 2° causes of HTN (3) assess for target organ damage

What are renal causes of 2° HTN? (2)

!

renal parenchymal renovascular (atherosclerosis, FMD, PAN, scleroderma) !

What findings are suggestive of renovascular 2° HTN? (4)

ARF induced by ACEI/ARB recurrent flash pulm edema renal bruit hypokalemia !

What is the most common cause of new cases of blindness among working-age people? What is the most common cause of end stage renal disease? !

What are the primary headache syndromes? (3) !

Sx: cluster headache (4)

!

!

What warning signs should prompt neuroimaging w/ headache? (5)

!

Headache diary Stress reduction

worst ever, worsening over days, wakes from sleep vomiting, aggravated by exertion or Valsalva age > 50 y fever abnl neuro exam

POUNDing P ulsatile duration 4-72 h O urs U nilateral N ausea/vomiting D isabling LR= 3 if 3 critera are met, LR=24 if 4 or more

What doex prophylactic treatment of migraine consist of? (5) Definition: complicated migraine

!

tension Migraine cluster

oxygen triptans CCB

What does non-pharmacologic treatment of headache consist of? (2)

!

Diabetes

periodic, paroxysmal brief, sharp orbital headache lacrimation rhinorrhea unilateral horner's syndrome

Tx (acute): cluster headache (3)

Sx: migraine (5)

!

Diabetes

!

!

TCA Beta-blockers CCB Valproic acid Topiramate

accompanied by stereotypical neurologic deficit tha

31!

Terms / Facts tmay last hours Definition: common migraine Definition: classical migraine !

What does abortive therapy of migraine consist of? (4)

!

HA w/o aura

!

HA w/o aura

Triptans ASA/acetaminophen/high-dose NSAIDs Metoclopramide IV Prochlorperazine IV/IM !

What is the most common cause of peptic ulcer disease? !

Sx: PUD

H. pylori

Epigastric abdominal pain !

Complications: PUD (3)

UGIB Perforation & penetration Gastric outlet obstruction

What drug class is responsible for almost half of gastric and duodenal ! NSAIDs erosions? ! Stool antigen test What diagnostic test is used to confirm eradication of H.pylori What diagnostic test is required to make definitive diagnosis of PUD? Why is a serologic test not used to confirm eradication of H. pylori in PUD? !

Tx: H. pylori-related PUD

!

!

What is Dieulafoy's lesion? Etiologies: Lower GI bleed (5)

Serology can stay (+) for weeks to years

Gastric acid suppression w/ PPI Lifestyle changes

What drugs can be given in conjunction with NSAID/ASA to prevent PUD in susceptible persons? (2) Etiologies: upper GI bleed (6)

!

Misoprostol H2-receptor antagonist

Peptic ulcer (50%) Varices (10-30%) Gastritis/gastropathy/duodenitis (15%) Mallory-weiss tear (10%) Vascular lesions (5%) !

lesion of superficial ectatic artery usually in cardia -> sudden, massive UGIB !

Clinical manifetations: UGIB (5)

Diverticular hemorrhage Neoplastic disease Colitis Angiodysplasia Anorectal !

N/V Hematemesis Coffee-grind emesis Epigastric pain Melena

Clinical manifestations: LGIB (4) What does initial management of GI bleeding consist of? (5)

!

diarrhea tenesmus hematochezia brbpr !

Assess severity Resuscitation Transfuse Reverse coagulopathy Triage

Tachycardia in a patient with GI bleeding indicates approximately !

!

EGD

Sequential Rx (PPI + abx x 5d -> PPI + 2 different abx x 5 d)

Tx: H. pylori-negative PUD

!

!

10% volume

32!

Terms / Facts how much blood loss?

loss !

Orthostatic hypotension in a patient with GI bleeding suggests how much volume loss? !

Shock in a patient with GI bleeding suggests how much volume loss? If a patient presents with monoarticular joint pain, what is the first problem to rule out? Definition: Gout

!

!

20% 30%

Infected joint

monosodium urate (MSU) crystal deposition in joints and other tissues

What is the ratio of prevalence of gout in men to women?

!

9:1 men to women

What is the most common cause of inflammatory arthritis in men over 30 ! Gout y? ! ↑ serum uric acid related to metabolic syndrome HTN CKD ↑ Risk factors: intake of meat, seafood, EtOH gout (4) !

Etiologies: gout (2) !

Clinical manifestations: gout (5) Dx: gout (5)

!

primary hyperuricemia secondary hyperuricemia Gout is for BRATS Bursitis Renal sx (urate stones, urate nephropathy) Asymptomatic hyperuricemia Tophi Sudden onset, painful monoarticular arthritis

I SWEAR it's gout serum UA, WBC, ESR, athrocentesis (definitive diagnosis has negative birefringent crystals), radiographs !

What are the ARA diagnostic criteria for rheumatoid arthritis? (7) How many must be fulfilled for diagnosis of RA? !

What joint is classically involved in gout? !

Tx (acute): gout (3) Tx (chronic): gout (3)

!

Metatarsophalangeal joint of the first toe (big toe podagra)

NSAIDs Colchicine Corticosteroids

The pt HAD gout, but no longer hydration antihyperuricemic therapy (allopurinol, febuxostat, probenecid) dietary changes !

Definition: chondrocalcinosis Etiologies (metabolic): CPPD (3)

calcification of cartilage visible on radiographs, resulting from CPPD deposition in articular cartilage, fibrocartilage or menisci !

3 H's Hemochromatosis Hypothyroidism Hyperparathyroidism

Clinical manifestations: CPPD (3)

!

4 criteria must be fulfilled Morning stiffness Involvemnet of 3+ joints Involvement of hand joints Symmetric arthritis Presence of rheumatoid nodules Positive rheumatoid factor Radiologic changes

!

Pseudogout Pseudo-RA Premature OA

33!

Terms / Facts !

Pathogenesis: CPPD

(1) ↑ synovial & joint fluid levels of inorganic pyrophosphate produced by articular chondrocytes from ATP hydrolysis in response to various insults or inherited defects favors CPPD crystallogenesis and deposition in the cartilage matrix (2) Crystals activate cryopyrin inflammasome → IL-1β → inflammation !

Clinical manifestations: pseudogout

acute mono- or asymmetric oligoarticular arthritis !

What joints are affected by pseudogout? (3) Definition: pseudo-RA Dx: CPPD (3)

knees wrists MCP joints

!

chronic polyarticular arthritis w/ morning stiffness +/- RF

!

arthrocentesis radiographs CMP !

What are the findings on athrocentesis w/ CPPD? (2) !

Tx (acute): CPPD (3) Clincial manifestations (MSK): rheumatoid arthritis (5)

!

!

Clinical manifestations (pulmonary): rheumatoid arthritis (3)

rhomboid-shaped, weakly positively birefringent crystals WBC 2000-100,000/mm3, > 50% polys NSAIDs colchicine corticosteroids

morning stiffness polyarthritis > monoarthtiris joint deformities (ulnar deviation, swan neck, boutonierre, cock up toes) C1-C2 instability rheumatoid nodules ILD (COP, fibrosis, nodules, Caplan's syndrome) pleural disease (pleuritis, pleural effusions) airway disease (bronchiolitis, bronchiectasis, cricoarytenoid arthritis)

! pericarditis myocarditis Clinical manifestations (cardiac): rheumatoid arthritis (2) ! glomerulonephritis nephrotic clinical manifestations (renal): rheumatoid syndrome arthritis (2)

clinical manifestations (heme): rheumatoid arthritis (3)

!

anemia of chronic disease leukemia lymphoma !

clinical manifestations (constitutional): rheumatoid arthritis (2) clinical manifestations (ocular): rheumatoid arthritis (3)

!

scleritis episcleritis keratoconjunctivitis sicca !

What are the major diagnoses that have to be considered in a nontraumatic swollen joint? (4) Dx (studies): rheumatoid arthritis (4) Tx: rheumatoid arthritis (3)

!

!

!

fever weight loss malaise

gout infectious arthritis osteoarthritis rheumatoid arthritis

Rheumatoid factor ACPA or anti-CPP ↑ ESR and CRP radiographs of hands and wrists

nonselective NSAIDs glucocorticoids DMARD (disease-

34!

Terms / Facts modifying anti-rheumatic drugs) w/in 3 mo !

What laboratory studies are included in the workup of GI bleeding? (3) !

Diagnostic study: UGIB !

Diagnostic study: LGIB

!

!

arteriography tagged RBC scan

octreotide w/ Abx (ceftriaxone/norfloxicin) prophylaxis !

Tx (non-pharamcologic): GI varices !

Tx: Mallory-Weiss tear

endoscopic band ligation (> 90% success) usually stops spontaneously !

Tx: bleeding 2/2 esophagitis/gastritis (2) !

Tx: bleeding 2/2 PUD Tx: bleeding 2/2 diverticular disease Tx: bleeding 2/2 angiodysplasia !

Definition: Obscure GIB !

Etiologies: Obscure GIB (5) Dx: obscure GIB (2)

!

PPI H2RA

PPI + endoscopic therapy

!

usually stops spontaneously (75%) endoscopic rx if doesn't stop

!

usually stops spontaneously Endo Rx if doesn't stop

continued bleeding despite (-) EGD & colonoscopy

Dieulafoy's lesion Small bowel angiodysplasia CRC Crohn's disease Meckel's diverticulum

repeat EGD w/ push enteroscopy/colonoscopy (perform when bleeding is active) video capsule Tc-99m pertechnetate scan (meckel's scan)

What is a reliable sign of anemia in the elderly? Sx: anemia (3) Signs: anemia (3)

!

!

Conjunctival pallor

pallor tachycardia orthostatic hypotension !

CBC w/ measurement of RBC indices Peripheral blood smear Reticulocyte count

Clinical manifestations: iron deficiency anemia (4) Tx: iron deficiency anemia

!

fatigue exertional dyspnea angina (if CAD)

What should initial workup of anemia consist of? (3)

!

EGD

First ru/o UGIB then colonoscopy

What studies should be used to assess recurrent or unstable GI bleeding? (2) Tx (pharmacologic): GI varices

Hct/plt PT/PTT LFTs

!

!

angular cheilosis atrophic glossitis pica koilonychia

oral Fe tid (6 wks to correct anemia, 6 mo to replete Fe stores)

35!

Terms / Facts !

Signs: HbH disease (3) Tx: thalassemias (3)

!

severe anemia hemolysis splenomegaly

transfusions + deferoxamine, deferasirox splenectomy HSCT in children w/ β-thal major !

What are Papenheimer bodies?

Fe-inclusion bodies seen in sideroblastic anemia !

What is the MCV/RBC in the thalassemias?

MCV/RBC < 13 !

What hemoglobin increases in β-thalassemia minor? !

What are the "warning signs" of diarrhea? (6) !

PEx findings: acute diarrhea (5)

!

Imaging: acute diarrhea (2) !

Ddx: acute diarrhea (4)

fever significant abd pain blood or pus in stools severe dehydration > 6 stools/d

vol depletion (VS, UOP, axillae, skin turgor, MS) fever abd tenderness ileus rash !

Labs: acute diarrhea (5)

Fecal WBC Stool cx BCx Electrolytes Stoop O&P CT/KUB if suspected toxic megacolon sig/colo if immunosupp or cx (-)

Infectious Preformed toxin Med-induced Initial presentation of chronic diarrhea !

Tx: acute diarrhea w/ no warning signs (3)

oral hydration loperamide bismuth subsalicylate !

Tx: acute diarrhea w/ moderate dehydration

50-200 mL/kg/d of oral solution (gatorade, etc) !

Prophylaxis: traveler's diarrhea

bismuth or rifaximin

Why should abx therapy be avoided if E. coli O157:H7 is suspected?

!

What is the empiric abx treatment for non-hospital acquired inflammatory diarrhea? !

Dx: c.difficile-associated diarrhea (2) Tx: mild c.difficile-associated diarrhea

Tx: severe c.difficile-associated diarrhea Complications: celiac disease (2)

!

!

!

May increase risk of HUS !

FQ x 57d

Stool ELISA Stool cytotoxin assay

!

Metronidazole 500 mg PO tid x 10-14 d !

Tx: moderate c.difficile-associated diarrhea

Tx: whipple's

HbA2

vancomycin 125-500 mg PO qid x 10-14 d !

vancomycin PO + metronidazole IV

T-cell lymphoma Small bowel adenocarcinoma

PCN + streptomycin of 3rd-gen cephalosporin x 10-14d →

36!

Terms / Facts disease

bactrim for 1+ year !

What are the lab findings of inflammatory chronic diarrhea? (4)

+ fecal WBC + lactoferrin + caloptectin + FOB !

What lab test does one perform to assess for malabsorption? Tx: constipation

!

bulk laxatives → osmotic laxatives → stimulant laxative

What drug is used for opiod-induced constipation? !

Dx: constipation Etiologies (medication): constipation (5) Etiologies (obstruction): constipation (4)

!

opioids anticholinergics CCB diuretics NSAIDs

Parkinson's Hirschsprung's Amyloid MS Spinal injury Autonomic neuropathy Electrolyte imbalance (↑ Ca, ↓ K, ↓ Mg) DM hypothyroidism uremia pregnancy panhypopit porphyria

!

loss of intestinal peristalsis in absence of mechanical obstruction

!

acute colonic adynamic ileus in presence of competent ileocecal valve

intra-abdominal process (surgery, pancreatitis, peritonitis) severe medical illness intestinal ischemia meds electrolyte abnl

Precipitants: adynamic ileus (5) !

NPO Mobilize decompression erythromycin neostigmine

clinical manifestations: adynamic ileus (5) Dx: adynamic ileus

H&P w/ DRE

!

!

Definition: Ogilvie's disease

Methylnaltrexone

The CARS can't move through the bowel cancer anal stenosis rectocele stricture

Etiologies (metabolic/endo): constipation (7) Definition: adynamic ileus

!

!

!

Etiologies (neurological): constipation (6)

Tx: adynamic ileus (5)

+ fecal fat

!

!

abd. discomfort N/V abd. distention ↓ or absent bowel sounds hiccups supine & upright KUB vs. CT

Describe the workup algorithm for chronic diarrhea.

!

Pathophysiology: CHF Definition: Systolic Heart Failure Definition: Diastolic Heart Failure

!

!

!

Inability to expel sufficient blood !

Failure to relax and fill normally

37!

Terms / Facts Dx: Heart Failure (6)

!

CXR BNP Echo PA Catheterization EKG Coronary angiography

What are the CXR findings with HF? (4)

!

Pulm edema Pleural effusions +/- cardiomegaly Cephalization Kerley B lines

In HF, what findings suggest ↓ perfusion to vital organs? (4)

!

!

Echo findings: systolic dysfunction (HF) !

PA Cath findings: HF (3) !

Tx: Mild CHF (NYHA Class I to II) (3)

!

Tx: Moderate to Severe CHF (NYHA Class III to IV) (2) !

s/s: RHF (6)

!

↑ EF ↑ chamber size

↑ PCWP ↓ CO ↑ SVR

Mild restriction of sodium intake (< 4 g/day) Start loop diuretic if volume overload or pulmonary congestion present ACE inhibitor as first-line

Tx: Mild to Moderate CHF (NYHA Class II to III) (2)

Signs: Heart Failure (5)

↑ BUN ↑ Cr ↓ serum Na Abnormal LFTs

!

Start loop diuretic and an ACE inhibitor Add β-blocker if moderate disease

Add Digoxin (to loop diuretic and ACE inhibitor) Add spironolactone if still symptomatic

Displaced PMI pathologic S3 pathologic S4 rales/crackles dullness to percussion

Peripheral pitting edema Nocturia JVD Hepatomegaly Ascites RV heave !

What is the initial test of choice for CHF workup? What BNP level is strongly associated with the presence of decompensated CHF? What EF level is the cutoff for systolic dysfunction? What was the major finding of the RALES trial?

!

What did the COMET trial find?

!

!

BNP > 100 pg/ml

!

EF < 40%

!

Diuretic + ACE inhibitor

ACE inhibitors reduce mortality, prolong survival and alleviate sx in CHF

Carvedilol led to significant improvement in survival compared to metoprolol in HF

What are the indications for digoxin in HF? (3)

!

EF < 30% Severe CHF Severe a-fib

What is the overall 5-year mortality for all patients with CHF?

!

!

Spironolacton reduces morbidity and mortality in patients with class III/IV HF

What should be the initial treatment in most symptomatic patients with HF? What did the CONSENSUS and SOLVD studies find?

Echocardiogram

!

50%

38!

Terms / Facts What is the 6040-20 rule?

!

Total body water = 60% of body weight ICF = 40% of body weight (2/3 TBW) ECF = 20% of body weight (1/3 TBW) !

What percentage of ECF is interstitial fluid? !

What fraction of ECF is plasma? !

What is the normal output range of urine/day? !

Definition: Syncope

!

!

Vasovagal syncope

↑ sympathetic tone → vigorous contraction of LV → mechanoreceptors in LV trigger ↑ vagal tone (hyperactive Bezold-Jarisch reflex) → ↓ HR and/or ↓ BP

!

Pathophysiology: vasovagal syncope

What study can reproduce the symptoms of vasovagal syncope? !

What are the premonitory sx of vasovagal syncope? (4) !

Tx: vasovagal syncope (4)

!

!

Tilt-table study

Pallor Diaphoresis Lightheadedness N/V

emotional stress pain fear extreme fatigue

Hypovolemia Diuretics Vasodilators Autonomic neuropathy (DM, PD, Shy-Drager, Lewy Body Dementia, Amyloidosis)

Tx: syncope 2/2 orthostatic hypotension What is a common cerebrovascular cause of syncope? !

What is the main goal of diagnosis of syncope?

! !

increase sodium intake and fluids TIA involving the vertebrobasilar circulation

Differentiate between cardiac and noncardiac etiologies because prognosis is poorest for those with underlying heart disease

H&P EKG (all patients) Tilt-table testing Echocardiogram (if there is evidence of structural heart disease or abnormal EKG)

How long does one treat nosocomial pneumonia? Definition: hospital-acquired pneumonia

!

!

midodrine fludrocortisone disopyramide SSRI

Precipitants: vasovagal syncope (4)

!

800 to 1500 mL

Arrhythmias (SSS, VT, AV block, RSVT) Obstruction of flow (AS, hypertrophic CMP, pulmonary HTN, etc.) Massive MI

What is the most common cause of syncope?

Dx: syncope

1/3 ECF

transient loss of consciousness/postural tone 2/2 acute decrease in cerebral blood flow

Etiologies (cardiogenic): syncope (3)

Etiologies: orthostatic hypotension (4)

2/3 ECF

!

!

8 days

pneumonia acquiried withing 3 months of a hospital admission

39!

Terms / Facts !

What are premature atrial complexes? !

Etiologies: premature atrial complexes (5)

!

Definition: premature ventricular complex

Adrenergic excess EtOH/tobacco Electrolyte imbalances Ischemia infection !

EKG finding: premture atrial complexes

Early beats arising within the atria, firing on its own

early P waves that differ in morphology from the normal sinus P wave

early beat that fires on its own from a focus in the ventricle and then spreads to the other ventricle

EKG finding: premature ventricular complexes Patients with frequent, repetitive PVCs and underlying heart disease are at increased risk for [...] Definition: atrial fibrillation

!

!

!

Patients with frequent, repetitive PVCs and underlying heart disease are at increased risk for SCD due to cardiac arrhythmia

paroxysmal (self-terminating) vs. persistent (sustained > 7 d) vs. permanent (typically > 1 y when cardioversion has failed) Valvular vs. nonvalvular Lone AF !

Etiologies (cardiac): atrial fibrillation (5)

CHF myo/pericarditis ischemia/MI hypertensive crisis cardiac surgery !

Etiologies (pulmonary): atrial fibrillation (2) !

Etiologies (metabolic): atrial fibrillation (2)

!

Etiologies (drugs): atrial fibrillation (5)

!

Pathophysiology: atrial fibrillation (3) !

acute pulmonary disease (COPD flare, pneumonia) PE

high catecholamine states (stress, infection, postop, pheo), thyrotoxicosis alcohol (holiday heart) cocaine amphetamines theophylline caffeine

Etiologies (neurogenic): atrial fibrillation (2)

!

subarachnoid hemorrhage ischemic stroke

Ectopic foci → chaotic, uncoordinated beating → loss of atrial contraction → HF; LA stasis → thromboemboli; tachycardia → CMP fatigue exertional dyspnea palpitations dizziness angina syncope !

Dx: atrial fibrillation EKG findings: atrial fibrillation

!

wide QRS complexes

chaotic, uncordinated firing of multi foci of automaticity in the atria leading to rapid ventricular beating

Classification: atrial fibrillation (6)

Sx: atrial fibrillation (6)

!

!

EKG

irregularly irregular rhythm

40!

Terms / Facts !

Tx: acute atrial fibrillation in a hemodynamically unstable patient

Rate control → anticoagulation → cardioversion

!

What are the general treatment goals of atrial fibrillation? (3)

immediate electrical cardioversion to sinus rhythm

!

What is the target rate for rate control in a-fib?

60 to 100 bpm

! CCBs (preferred) Beta-blockers (alternative) What drugs are used to Digoxin/amiodarone (LV systolic dysfunction) achieve rate control in AFib? (3) ! Electrical (preferred) Pharmacological How is cardioversion achieved in afib tx? (2) ! Ibutilide Procainamide Flecainide What drugs can be used for pharmacological Sotalol Amiodarone cardioversion in AFib? (5)

If a patient has been in AFib > 48 hrs, how should one treat?

!

Obtain TEE to image left atrium. If no thrombus is present, start IV heparin and perform cardioversion within 24 hours. Anticoagulation required for 4 weeks after cardioversion !

What drugs are used for rate control with chronic AFib? (2) !

Tx: chronic AFib

chronic anticoagulation (warfarin( !

Which leads are the inferior leads? (3) !

Which leads are left lateral? (4)

Leads II, III and AVF

Leads I and AVL, V5, V6 !

Angle of Lead II?

60

!

Angle of Lead III?

120 !

Angle of Lead AVF? Angle of Lead I? Angle of Lead AVL?

!

-30

! !

Which precordial leads overlie the interventricular septum?

What causes the Q wave? !

Leads V1 and V2 Leads V5 and V6 !

Leads V3 and V4 !

Which leads are the anterior group?

!

0

-150

Which precordial leads lie over the right ventricle? Which precordial leads overlie the left ventricle?

90

!

!

Angle of Lead AVR?

What is R-wave

Beta blocker CCB

!

V1-V4

Septal depolarization

pattern of progressively increasing R-wave amplitude moving

41!

Terms / Facts progression?

right to left in the precordial leads is called R-wave progression

What does the QT interval encompass?

!

time from the beginning of ventricular depolarization to the end of ventricular repolarization !

The duration of the QT interval is proportionate to the [...] !

What are the five basic types of arrhythmias?

Arrhythmias of sinus origin Ectopic rhythms Reentrant arrhythmias Conduction blocks Preecitation syndromes !

What is sinus arrest? !

What is asystole?

The duration of the QT interval is proportionate to the heart rate

Sinus node stops firing

Prolonged electrical inactivity !

What is the intrinsic rate of atrial pacemakers? What is the intrinsic rate of junctional pacemakers? What is the intrinsic rate of ventricular pacemakers? !

What is the intrinsic rate of the SA node? !

What does a junctional escape look like on EKG? !

What does a wide QRS usually imply?

!

40-60 bpm

!

30-45 bpm

60-100 bpm

Origin of ventricular depolarization is within the ventricles themselves !

From AV node or ventricles; from below atria

Are normal P waves present? Are the QRS complexes narrow or wide? What is the relationship between P waves and QRS complexes? Is the rhythm regular or irregular?

What are the five types of sustained supraventricular arrhythmias?

!

Paroxysmal superventricular tachycardia (PSVT) Atrial flutter Atrial fibrillation Multifocal atrial tachycardia Paroxysmal atrial tachycardia

What is the most common mechanism driving PSVT?

!

Reentrant circuit looping within the AV node

What is the appearance of atrial flutter on EKG? What is the usual mechanism of atrial flutter?

!

What is the appearance of atrial !

!

Saw-toothed pattern

reentrant circuit that runs largely around the annulus of the tricuspid valve

What ratio AV block is common with atrial flutter?

!

!

P wave inversion in leads II and AVR

If no p waves are present, what does that say about the origin of an arrhythmia? What four questions should one ask to assess rhythm?

60-75 bpm

!

2:1 block

Irregularly irregular appearance of QRS

42!

Terms / Facts fibrillation on EKG?

complexes in the absence of discrete p waves !

Thrombolytic therapy within what time frame gives the best results in acute MI? !

Indications: thrombolytic therapy (MI)

first 6 hours, but up to 24 hrs from onset of pain

ST elevation in two contiguous EKG leads in patients with onset within 6 hours who have been refractory to nitroglycerin

What is the first line thrombolytic medication in most medical centers? !

!

What did the PAMI trial show?

PTCA reduces mortality more than t-PA

What are the only agents shown to reduce mortality in MI? (3) !

!

!

!

!

!

!

Severe headache Visual disturbances Altered mentation

reduce MAP by 25% in 1 to 2 hrs If severe (diastolic > 130) or if HTN encephalopathy is present, lower BP with IV agents (nitroprusside/labetalol)

Tx: hypertensive urgencies What are the effects of metabolic acidosis? (5)

Elevated BP levels alone without end-organ damage

Step 1: lower BP with antihypertensive agent Step 2: order CT scan of the head to r/o intracranial bleeding Step 3: If CT negative, proceed to LP

Clinical presentation: hypertensive emergency (3) Tx: hypertensive emergencies (2)

Maintenance therapy; reduce risk of further coronary events

Noncompliance with antihypertensive tx/dialysis Cushing's syndrome Drugs (cocaine, LSD, methamphetamines) Hyperalodosteronism Eclampsia Vasculitis Pheochromocytoma

Approach to a patient with severe headache and markedly elevated BP? (3)

!

Aspirin Beta-blocker ACE inhibitors

BP > 220 and/or diastolic BP > 120 in addition to end-organ damage !

Definition: Hypertensive urgency Etiologies: Hypertensive emergency (7)

!

Oxygen Nitroglycerin Beta-blocker Aspirin Morphine ACE inhibitor IV heparin

How do statins figure into the therapy of MI? Why? Definition: Hypertensive emergency

t-PA

Trauma (head or traumatic CPR) Recent invasive procedure/surgery Acute PUD Previous stroke Uncontrolled HTN (>180/110) Dissecting aortic aneurysm

Contraindications: thrombolytic therapy (MI) (6)

Tx (acute): myocardial infarction (7)

!

!

BP should be lowered within 24 hours using oral agents !

CNS depression ↓ Pulmonary Blood Flow Arrhythmias

43!

Terms / Facts Impared myocardial function Hyperkalemia What are the effects of alkalosis? (3) Definition: anion gap

!

!

↓ cerebral blood flow arrhythmias tetany/seizures

AG (mEq/L) = [Na+] - ([Cl-]+[HCO3-]) !

What is the normal range for angion gap? !

Give the five step analysis of acid-base disorders.

8 to 15 mEq/L

Step 1: Acidemia (pH < 7.38) or alkalemia (pH>7.42) Step 2: Primary or metabolic disturbance (Look at PCO2 on ABG or HCO3 on metabolic panel) Step 3: Is there appropriate compensation? Step 4: Is there anion gap metabolic acidosis? Step 5: If there is metabolic acidosis, is there another concomitant metabolic disturbance?

How does one determine if there is acidemia or alkalemia?

!

Look at pH. < 7.38 = acidemia > 7.42 =alkalemia

How does one determine if an acid-base disturbance is primary respiratory or metabolic?

!

Look at HCO3 or PCO2 on Chem 7 or ABG respectively

! PCO2 = [1.5x(serum What formula is used to determine if appropriate HCO3)] +8 (+/-2) compensation has occured with primary metbaolic acidosis? ! Metabolic acidosis With what acid-base disorder does Kussmaul breathing occcur? ! Decreased CO and tissue perfusion by diminishing the How does acidosis affect responsiveness of the myocardium to catecholamines cardiac output? Explain.

What equation gives the compensation for acute respiratory acidosis? What equation gives the compensation for acute respiratory alkalosis? What equation gives the compensation for chronic respiratory acidosis? What equation gives the compensation for chronic respiratory alkalosis?

↑ PaCO2 = 0.75 x ΔHCO3

!

What equation gives the predicted respiratory compensation for a metabolic alkalosis? !

↑ HCO3= 0.1 x ΔPaCO2

!

↓ HCO3 = 0.2 x Δ PaCO2

!

↑ HCO3 = 0.4 x Δ PaCO2

!

↓ HCO3 = 0.4 x ΔPaCO2

If PaCO2 is too low by prediction, what other acid-base disorder is concomitantly occurring? If PaCO2 is too high by prediction, what other acid-base disorder is concomitantly occurring?

!

!

!

1° resp. alkalosis 1° resp. acidosis

44!

Terms / Facts If HCO3 is too low by prediction, what other acid-base disorder is concomitantly occurring? If HCO3 is too high by prediction, what other acid-base disorder is concomitantly occurring?

!

1° met. acidosis

!

1° met. alkalosis

!

One irritable automaticity focus in the atria fires at about 250 to 350 bpm, giving rise to regular atrial contractions; ventricular rate is one-half to one-third of atrial rate because only every two or three flutter waves conduct to the ventricles

!

COPD (most common) Heart disease: RHD, CAD, CHF Atrial Septal Disease

Patholophysiology: atrial flutter

Etiologies: atrial flutter (3)

!

EKG findings: atrial flutter

EKG: saw-tooth baselines with QRS every second or third wave !

Tx: atrial flutter

similar to AFib

Patients with what other disease usually display multifocal atrial tachycardia?

!

Severe pulmonary disease (COPD)

! Paroxysmal SVT What is the most common cause of supraventricular tachyarrhythmia? ! All automaticity foci pace with a regular All automaticity foci pace with a rhythm regular [...]

Definition: sinus arrhythmia

!

normal (but minimal) increase in HR during inspiration and minimal decrease in HR during expiration !

Where are the automaticity foci in the AV node? Which bundle branch depolarizes the interventricular septum? Why? !

What does a U wave represent? !

Definition: overdrive suppression

Distal (junctional). No automaticity foci in the proximal AV node !

Final phase of Purkinje repolarization following a T wave

The mechanism whereby the automaticity focus with the highest pacing rate suppresses all slower automaticity foci in the heart !

Rhythms that lack a constant duration between paced cycles are said to be [...] What does it mean for an automaticity focus to be parasystolic? Explain. Definition: wandering !

!

Left bundle branch; has terminal fibers in the septum. Right bundle branch does not.

!

Rhythms that lack a constant duration between paced cycles are said to be irregular

The focus paces but can't be overdrive suppressed because of an entrance block (due to a structural pathology or hypoxia)

Irregular rhythm produced by the pacemaker activity

45!

Terms / Facts pacemaker

wandering from the SA node to nearby atrial automaticity foci !

What does the P' wave represent?

Atrial depolarization by an automaticity focus as opposed to the normal Sinus-paced P waves !

What is the HR of wandering pacemaker? !

Describe the ventricular rhythm of a wandering pacemaker? !

Why does multifocal atrial tachycardia occur?

What kind of waveform can't be discerned in AFib? !

Definition: escape beat

!

Irregular ventricular rhythm

Atrial automaticity foci are damaged, showing early signs of parasystole → resistance to overdrive suppression !

Describe the ventricular rhythm of MAT.

Definition: escape rhythm

!

Irregular ventricular rhythm

No discernbible P' waves; chaotic atrial spikes

An automaticity focus escapes overdrive suppression to pace at its inherent rate An automaticity focus transienty escapes overdrive suppression to emit one beat !

Definition: sinus arrest

Very sick SA node ceases pacemaking completly !

Definition: idiojunctional rhythm

Heart rhythm determined by the pacing of the junctional automaticity foci

What abnormality in the SA node gives rise to en escape rhythm? What abnormality in the SA node gives rise to en escape beat? What automaticity focus can produce retrograde atrial depolarization? EKG finding: retrograde atrial depolarization !

What conditions can give rise to a ventricular escape rhythm? (2) !

Definition: StokesAdams syndrome Explain how ventricular escape beats happen most commonly.

!

< 100 bpm

!

!

! !

Sinus arrest Sinus block

Junctional automaticity focus

inverted p' wave with upright QRS

(1) Complete conduction block high in the ventricular conduction system (2) Total failure of SA node and all automamticity foci above the ventricles

When pacing from a ventricular focus is so slow that blood flow to the brain is significantly reduced to the point of syncope !

Burst of cardiac parasympathetic innervation depresses the SA node, atrial and junctional foci but not the ventricular foci, leading to a ventricular escape beat

46!

Terms / Facts Definition: premature beat

!

an irritable focus spontaneously fires a single stimulus

! Ventricular automaticity foci Which automaticity foci are most sensitive to O2 status? ! Digitalis Adrenergic excess/sympathetic stimulation What are the causes of atrial Stimulants (caffeine, cocaine, amphetamines) and junctional foci Hyperthyroidism Stretch irrititability? (5)

What is the effect of a premature stimulus on the other automaticity centers? Explain the mechanism of a premature atrial beat with aberrant ventricular conduction.

!

!

!

Premature P' with no QRS response followed by reset sinus rhythm

Coupling of a PAB to end of each normal cycle !

Definition: atrial trigeminy

When a PAB fires after two normal cycles

With a junctional escape rhythm with no retrograde atrial depolarization, what does the EKG look like? Definition: premature junctional beat

!

Definition: junctional bigeminy Definition: junctional trigeminy

!

Lone QRS complexes without P waves

!

When a premature junctional beat is coupled to a normal (SA-node generated) cycle When a premature junctional beat is coupled with two consecutive normal cycles

!

Definition: premature ventricular contraction

Why is the QRS of a PVC wider than a normal QRS?

!

Low O2 Low K+ Structural pathology (MP, myocarditis, stretch)

Premature ventricular beat produced by an irritable ventricular automaticity focus

!

(1) Great width and enormous amplitude QRS complex early in cycle (2) QRS opposite polarity of the normal QRS

!

The wave of depolarization originating in the left ventricle spreads unopposed to the right ventricle

EKG finding: premature ventricular contraction (2)

!

!

Irrititable junctional focus within the AV node fires suddently, conducting a premature stimulus to the ventricles, and sometimes, retrograde to the atria

What are the causes of ventricular focus irritability? (3)

What EKG ! feature follows the PVC? Why?

Resets the automaticity center

Premature atrial impulse reaches one of the bundle branches while it is still refractory (and the other is not). This causes asynchronous depolarization of the ventricles, leading to a widened QRS

EKG finding: non-conducted premature atrial beat Definition: atrial begeminy

!

Compensatory pause; the PVC doesn't depolarize the SA so the SA discharges on schedule, but the ventricles are refractory and

47!

Terms / Facts the SA-generated impulse can't progress !

What number of PVC's is considered pathological? !

Definition: ventricular bigeminy !

Definition: ventricular trigeminy Definition: ventricular parasystole

!

Clinical presentation: adrenal insufficiency (8) !

PVC coupled to a normal beat PVC coupled to two normal cycles

Ventricular automaticity focus that suffers from entrance block and is not vulnerable to overdrive suppression; paces at its inherent rate in the background of dominant sinus rhythm !

Etiologies: primary adrenal insufficiency (4)

Weakness Weight loss Hyperpigmentation Hyponatremia Anorexia Nausea Orthostatic hypotension Abdominal pain

Idiopathic (autoimmune) Infectious (tuberculosis/fungal/cryptococcus/toxoplasmosis) Iatrogenic (bilateral adrenalectomy) Metastatic disease

Etiologies: secondary adrenal insufficiency (2)

!

long-term steroid therapy hypopituitarism !

Etiologies: Tertiary adrenal insufficiency Dx: adrenal insufficiency (3)

!

hypothalamic disease

cortisol levels (am) cosyntropin stimulation test MRI if secondary/tertiary suspected

What is the normal repsonse to a cosyntropin stimulation test? !

Tx (acute): adrenal insufficiency Tx (chronic): adrenal insufficiency (2)

6 PVC's per minute

!

!

≥ 18 ug/ml within 60 mins

volume resusication w/ normal saline + hydrocortisone IV

Hydrocortisone or prednisone Fludrocortisone (not needed in secondary insufficiency)

Why is hyponatremia seen in primary adrenal insufficiency? Why is hyponatremia seen in secondary adrenal insufficiency?

!

!

Mineralcorticoids are decreased as well as glucocorticoids

Aldosterone is normal but decreased cortisol removes suppresion on ADH → SIADH !

Give the stepwise workup of adrenal insufficiency. !

In lead V1, what is the polarity of the QRS complex normally?

!

In lead V6, what is the polarity of the QRS complex normally? Over what part of the heart do leads V3 and V4 lie?

!

!

Negative Positive Septum

48!

Terms / Facts !

What condition produces multifocal PVCs? !

What is the R on T phenomenon?

Severe cardiac hypoxia

When a PVC falls on a T wave; vulnerable period. Dangerous arrhythmias may result. !

Paroxysmal atrial tachyarrhythmia is usually a sign of [...] !

EKG findings: PAT with block

two p' waves for each QRS response on EKG

!

Definition: paroxysmal atrial tachycardia

Paroxysmal atrial tachyarrhythmia is usually a sign of digitalis excess or toxicity

sudden, rapid firing of a very irritable atrial automaticity focus !

Rate: paroxysmal atrial tachycardia !

Definition: paroxysmal junctional tachycardia

tachyarrhythmia caused by the sudden rapid pacing of a very irritable automaticity focus in the AV junction

EKG findings: paroxysmal junctional tachycardia (PJT)

!

QRS complexes with either (1) no p' wave or (2) retrograde p waves !

Definition: supraventricular tachycardia !

Definition: paroxysmal ventricular tachycardia

What is a capture beat on the EKG of VT?

!

!

either PAT or PJT

tachyarrhythmia produced by a very irritable ventricular automaticity focus !

Rate: VTach What is a fusion beat on the EKG of VT?

150-250 bpm

150-250 bpm

When a sinus pased depolarization stimulus meets a depolarization progressing from a ventricular focus

A normal appearing QRS in the midst of ventricular tachycardia produced by a sinus-paced depolarization that is able to pass normally through the AV node

Ventricular tachycardia often indicates [...]

!

Ventricular tachycardia often indicates coronary insufficiency !

What width range do QRS complexes in VT fall in? Definition: torsades de pointes

!

form of very rapid VT caused by low K+, meds that block K+ channels or Long QT syndrome !

Rate: torsades de pointes Rate: atrial flutter

!

250 to 350 bpm

250 to 350 bpm !

EKG findings: ventricular flutter Rate: ventricular flutter

!

0.14 sec or greater

!

Sine wave pattern 250-350 bpm

49!

Terms / Facts !

What is fibrillation?

totally erratic rhythm caused by continuous, rapid rate discharges from numerous automaticity foci in either the atria or in the ventricles

Why do atrial foci all pace at once in AFib? !

What causes ventricular fibrillation?

!

The irritable atrial foci are parasystolic

Rapid-rate discharges from many irritable, parasystolic ventricular automaticity foci, producing an erratic, rapid twitching of the ventricles !

EKG findings: ventricular fibrillation

totally erratic appearance and lack of any identifiable waves on EKG !

What does ventricular flutter usually evolve into? !

Rate: ventricular fibrillation !

Rate: atrial fibrillation !

Ventricular fibrillation is a type of cardiac [...] !

!

!

Delta wave

(1) rapid conduction: SVTs may be rapidly conducted 1:1 through accesory pathway (2)some Kent bundles may have automaticity foci that can initiate a paroxysmal tachycardia (3) re-entry through Kent bundle (circus re-entry loop)

Give the mechanisms by which Wolff-Parkinson-White syndrome can produce a paroxysmal tachycardia.(3)

AV node is bypassed by an extension of the anterior internodal tract (James); with no conduction delay, the James bundle can conduct atrial depolarizations directly to the His Bundle without delay, which can cause rapid ventricular arrhythmias !

EKG findings: Lown-GanongLevine syndrome (3)

Definition: First degree AV block Definition: second degree AV block Definition: third degree AV block

Shortened PR interval ( 0.2 s consistently, and P-QRS-T is normal in every cycle

Wenckebach blocks correspond to what part of the conduction system? !

Mobitz blocks correspond to what part of the conducting system? !

What happens in a Mobitz AV block?

!

What is the CHADS2 score?

!

His Bundle and Bundle Branches

Successively proloned PR intervals followed by a completely dropped QRS

!

Clinical prediction rule for estimating the risk of stroke in patients with non-rheumatic atrial fibrillation !

CHF = 1 Hypertension =1 Age > 75 years=1 Diabetes Mellitus=1 Stroke (prior) or TIA=2

Give the risk stratification designations for CHADS2 scores and the corresponding anticoagulation therapy !

Tx: Wolff-Parkinson-White Syndrome What types of drugs should one avoid in WFW? !

!

!

0 = low risk = none or aspirin 1 = moderate = aspirin or warfarin 2+ = moderate or high = warfarin

Radiofrequency ablation of one arm of reentrant loop

Drugs active on the AV node (digoxin) because they accelerate conduction through the accessory pathway

CAD with prior MI (most common) Hypotension Active ischemia Prolonged QT syndrome Cardiomyopathies Congenital defects Drug toxicity !

What is the most common cause of cardiac arrest? !

Definition: sustained VT !

Why should patients with nonsustained VT have a through cardiac workup? Clinical presentation: ventricular

!

AV node

(1) Initial dose of prednisone 40-60 mg (2) Taper down to 10 mg/day over by 10% decrements every 1-2 weeks (3) Slow taper in 1 mg decrements over 9 months to 1 year (4) Low dose aspiring

What are the criteria in the CHADS2 score?

Etiologies: Ventricular tachycardia (7)

!

Total block of several (2 or more) pace atrial depolarizations (P waves) before conduction to the ventricles is successful

What happens in a Wenckebach block? Tx: temporal (giant cell) arteritis (4)

< 0.2 s

!

VFib/VT

VT > 30 s

VT is an independent risk factor for sudden death when CAD and LV dysfunction are present

Palpitations Angina Lightheadedness Impaired

51!

Terms / Facts tachycardia (5)

consciousness Dyspnea !

Physical exam: ventricular tachycardia (2) !

Tx: sustained VT in hemodynamically stable patient (SBP > 90) !

Tx: sustained VT in hemodynamically unstable patient (3) Tx: nonsustained VT

!

Pharmacological cardioversion w/ IV amiodarone, IV procainamide, or IV sotalol IDC placement Immediate synchronous DC cardioversion Follow with IV amiodarone to maintain sinus rhythm IDC placement

No treatment if no underlying heart disease If underlying cardiac disease, order an echo; if inducible, sustained VT found, ICD placement recommended !

What are the causes of prolonged QT?

Cannon a waves in the neck S1 that varies in intensity

QT: Prolonged QT syndrome W: WPW I: Infarction D: Drugs T: Torsades H: Hypokalemia, hypocalcemia, hypomagnesemia !

What do the QRS complexes in a bundle branch block look like? !

Explain the appearance of the wide QRS complex in a bundle branch block EKG.

Wide QRS with R and R'

Non-simulataneous depolarization of the right and left ventricles due to the slow conduction down one blocked bundle branch !

How wide should a QRS be in order to diagnose BBB? In what leads should one look for a RBBB? In what leads should one look for a LBBB? !

What does an inverted T wave indicate?

3 squares (> 0.12 s) !

V1-V2

!

V5-V6

Area of ischemia !

In what leads should one look for an inverted T wave? What does ST-segment elevation signify? !

EKG findings: Brugada syndrome EKG findings: pericarditis (2)

!

!

That the myocardial infarction is acute

RBBB pattern QRS w/ ST elevation in V1-V3

ST segment elevation T wave elevation (sometimes) !

What drug can cause ST segment depression? !

What do significant Q waves signify? How wide and tall are significant Q aves?

!

V1-V6

!

Digitalis

Necrosis due to MI

1 small square wide or 1/3 of QRS amplitude

52!

Terms / Facts !

Explain how Q waves are formed in the setting of MI.

Positive electrode sees through the necrotic void and produces negative deflection

What is the recurrence rate of VFib that is not associated with ! 30% within 1 year MI? ! Ischemic heart disease (most common) Antiarrhythmic drugs Etiologies: (prolonged QT) AFib with rapid ventricular rate in WFW VFib (3) !

Clinical presentation: VFib (2) Tx: VFib

!

Cannot measure BP; absent heart sounds and pulse Patient is unconscious

Immediate defibrillation and CPR

If VFib persists despite defribillation, what pharmacological interventions are called for? (2)

!

!

Definition: Sinus bradycardia !

Etiologies: sinus bradycardia (3) Definition: sick sinus syndrome

!

Sinus node dysfunction characterized by persistent spontaneous sinus bradycardia

Tx: sick sinus syndrome Tx: Mobitz type II block

!

Dizziness Confusion Fatigue CHF

!

Pacemaker implantation

!

Pacemaker implantation !

Tx: 3rd-degree heart block !

Sinus rate < 60 bpm

ischemia increased vagal tone antiarrhythmic drugs

Clinical presentation: sick sinus syndrome (4)

Tx: Dilated Cardiomyopathy (3)

Epinephrine (1 mg IV bolus and then every 3 to 5 mins) IV amiodarone followed by shock

pacemaker implantation

Digoxin, diuretics, vasodilators and cardiac transplantation Remove offending agent if possible Anticoagulation

Clinical presentation: hypertrophic cardiomyopathy (3) !

Physical exam: hypertrophic cardiomyopathy (4)

!

!

Etiologies: restrictive cardiomyopathy (6) Clinical presentation: restrictive cardiomyopathy

!

!

Dyspnea Angina Arrhythmias

Sustained PMI Loud S4 Systolic ejection murmur Rapidly increasing carotid pulse with two upstrokes

Dx: hypertrophic cardiomyopathy (3) Tx: hypertrophic cardiomyopathy (4)

!

!

CXR Echo EKG

β-blockers CCBs Treat AFib if present Myomectomy (90% cure rate) idiopathic scleroderma carcinoid syndrome amyloidosis sarcoidosis hemochromatosis right sided>left sided heart failure w/ peripheral edema diuretic refractoriness thromboembolic events poorly

53!

Terms / Facts (4)

tolerated tachyarrhythmias !

↑ JVP +/- Kussmaul's sign S3/S4 Congestive hepatomegaly +/- ascites and jaundice

!

Treat underlying disease Gentle diuresis Anticoagulation

Physical exam: restrictive cardiomyopathy (3) Tx: restrictive cardiomyopathy (3)

Why shouldn't digoxin be given to someone with amyloidosis !

Etiologies: acute pericarditis (5)

!

Infectious Neoplastic (metastatic cancer) Autoimmune (SLE, RA, scleroderma, drug induced lupus) Uremia Dressler's syndrome !

Clinical presentation: acute pericarditis (3) Physical exam: acute pericarditis

!

Chest pain (pleuritic, positional) Fever Pericardial effusions

pericardial friction rub best heard at LLSB w/ diaphragm [sound:rub2.mp3] !

EKG findings: acute pericarditis

Diffuse ST elevation and PR depression !

Dx: acute pericarditis (3) !

Tx: acute pericarditis (2)

EKG CXR Echo

NSAIDs +/- colchicine glucocorticoids !

Clinical presentation: constrictive pericarditis !

Physical exam: constrictive pericarditis (5)

!

What should cardiac catheterization show in constrictive pericarditis? (2) !

EKG findings: constrictive pericarditis (2) Tx: constrictive pericarditis Physical exam: pericardial effusion (4)

!

EKG CXR Echo Cardiac cath !

Elevated and equal diastolic pressures in all chambers square root sign

Low QRS voltages Generalized T wave flattening or invesion

Complete resection of the pericardium is definitive therapy !

Muffled heart sounds Soft PMI Dullness at left lung base Pericardial fricction rub !

Echocardiogram CXR

What is the imaging study of choice for pericardial effusion?

!

RHF > LHF

JVD Kussmaul's sign Pericardial knock Ascites dependent edema

Dx: constrictive pericarditis (4)

Dx: pericardial effusion

Can precipitate arrhythmias

!

Echocardiogram

54!

Terms / Facts !

EKG findings: pericardial effusion (2) !

Tx: pericardial effusion (2) !

pericardiocentesis (if cardiac tamponade suspected) observation (if minor) penetrating trauma to the thorax iatrogenic (central line, pacemaker, pericardiocentesis( pericarditis post-MI with free wall rupture

Etiologies: cardiac tamponade (4)

!

Physical exam: cardiac tamponade

Elevated JVP most common finding Narrowed pulse pressure Pulsus paradoxus !

Clinical presentation: cardiac tamponade (2) !

Dx: cardiac tamponade (4) Tx: cardiac tamponade (2)

!

Echocardiogram CXR EKG Cardiac cath

!

Rheumatic heart disease Mitral annular calcification

Clinical manifestations: mitral stenosis (3) !

Etiologies: demand ischemia (6)

!

!

Coronary artery spasm Coronary embolism Anemia Arrhythmias Hyper/hypotension !

!

Etiologies: hospital-acquired pneumonia Sx: "typical" pneumonia (4)

!

S. pneumoniae H. flu Klebsiella and other GNR S. aureus

GNR bugs including pseudomonas, klebsiella, e.coli, enterobacter MRSA

acute onset fever cough w/ purulent sputum dyspnea pleuritis chest pain !

Clinical manifestations: "atypical" pneumonia (4)

Physical exam: "typical"

Dyspnea Pulmonary edema AFib

mismatch between myocardial oxygen demand and supply

Etiologies: community acquired pneumonia (6)

Definition: COPD exaccerbation (GOLD criteria)

!

Loud S1 Opening snap following S2 Low-pitched middiastolic rumble at apex [sound:ms.mp3]

Definition: demand ischemia

!

cardiogenic shock w/o pulmonary edema dyspnea

pericardiocentesis (nonhemorrhagic) emergent surgery w/ pericardiocentesis as temporizing measure (hemorrhagic)

Etiologies: mitral stenosis (2)

Physical exam: mitral stenosis

Low QRS voltages T wave flattening

!

insidious onset dry cough extrapulm sx (N/V, diarrhea, headache, myalgias, sore throat) patchy interstitial pattern on CXR Cough increases in frequency and severity Sputum production increases in volume and/or changes character Dyspnea increases !

Tachycardia/tachypnea Late inspiratory crackles

55!

Terms / Facts community-acquired pneumonia (4)

Pleurla friction rub Dullness to percussion !

CXR: community acquired pneumonia !

What is the classic clinical presentation of atypical pneumonia? !

!

Physical exam: atypical pneumonia (4) CXR: atypical pneumonia (2) !

Sore throat and headache followed by a nonproductive cough and dyspnea

Mycoplasma pneumoniae C. pneumoniae C. psittaci Coxiella burnetti Legionella spp. Viruses (influenza, adenoviruses, RSV, parainfluenza)

Etiologies: atypical pneumonia (6)

Dx: pneumonia (4)

Pulse-temperature dissociation (normal pulse in the setting of high fever) Wheezing Rhonchi Crackles !

diffuse reticulonodular infiltrates absent/minimal consolidation

sputum gram stain sputum bacterial culture blood cultures (before abx) CXR

Tx (empiric): communityacquired pneumonia, hospitalized (2)

!

Tx (empiric): communityacquired pneumonia, outpatient (2)

3rd-generation cephalosporin (ceftriaxone) + macrolide (azithromycin) New generation FQs (moxifloxacin/levofloxacin) !

No recent abx: macrolide or doxycycline Recent abx: macrolide + high-dose augmentin or 2nd. generation ceph.

Tx (empiric): hospital-acquired pneumonia Definition: CURB-65

!

lobar consolidation

!

Vancomycin + Zosyn + FQ

Clinical prediction rule for mortality in community-acquired pneumonia Confusion Uremia RR ≥ 30 BP < 90/60 Age ≥65 !

What CURB-65 score warrants inpatient admission? Complications: pneumonia (3) Workup/tx sequence: pneumonia (6)

!

!

Pleural effusion Pleural empyema ARDS

CXR Lab tests - CBC w/ diff, BUN, creatinine, glucose, electrolytes O2 saturation Pretreatment cultures (2) Gram stain and sputum culture Abx therapy (empiric) !

In what leads are Q waves seen with a lateral infarct?

In what leads are Q waves seen with an inferior infarct? EKG findings: posterior infarct in left ventricle

!

Leads I and AVL !

In what leads are Q waves seen with an anterior infarct?

!

Score of ≥2

!

Leads V1-V4

Leads II, III and AVF

Large R wave in V1-V2 ST segment depression in V1-V2

56!

Terms / Facts !

EKG findings: anerior infarct (2)

ST elevation and Q waves in V1-V2 Q waves !

Left bundle branch; Q wave would occur in the middle of QRS complex

In what circumstance is it nearly impossible to diagnose an infarction from EKG? Why?

! Right coronary artery A posterior infarct is usually caused by occlusion of wht vessel? ! blocks of either the anterior or posterior division of the left Definition: bundle branch hemiblock

EKG findings: anterior hemiblock

!

Q waves in lead I Wide/deep S wave in lead III

What happens to the axis in anterior hemiblock? What happens to the axis with posterior hemiblocks? EKG findings: posterior hemiblock (2) !

EKG findings: pulmonary embolus (3) EKG findings: COPD

!

!

!

Right axis deviation

Deep or wide S in lead I Q wave in lead III

QRS complexes of small amplitude in all leads !

Peak T waves Wide, flat P waves QRS widening !

EKG findings: Hypokalemia

T wave flattening U waves !

EKG findings: Hypercalcemia !

EKG findings: hypocalcemia EKG findings: Digitalis effect !

!

Short QT

Prolonged QT

curved ST segment depression

Wide, notched P wave Wide QRS Depressed ST segment Prolonged QT interval

What happens to the mean QRS vector in hypertrophy?

!

What tends to happen to the mean QRS vector (axis) of the heart with an infarct? Why?

Deviation toward the ventricle that is hypertrophied !

Points away from infarct due to unopposed depolarization

A negative QRS in lead I indicates deviation of the axis to what side? What does a negative QRS in lead AVF say about mean QRS vector?

!

!

Right axis deviation

Points into the negative sphere (away from AVF)

A normal axis has positive QRS complexes in which leads?

!

Left axis deviation

Large Q wave and T wave inversion V1-V4 Transient Right BBB Wide S in Lead I

EKG findings: Hyperkalemia (3)

EKG findings: Quinidine effects (4)

!

!

Leads I and AVF

57!

Terms / Facts !

How does one find left axis deviation? (2)

Positive QRS in lead I Negative QRS in lead AVF

!

How does one find right axis deviation? (2)

Negative QRS in lead I Positive QRS in lead AVF !

What is the normal sign of QRS complex in V2? Why?

Negative; the thick left ventricle is mostly posterior !

Which precordial leads are usually isoelectric? EKG findings: leftward axis rotation

!

isoelectric (transitional) QRS in leads V5-V6

!

EKG findings: rightward axis rotation

Isoelectric (transitional) QRS in leads V1-V2

What EKG lead gives the most accurate information about the atria? What is a diphasic wave?

!

If the initial portion of the diphasic P wave is the larger of the two phases, then there is [...] atrial enlargment

!

Lead V1

!

!

Atrial enlargement

If the initial portion of the diphasic P wave is the larger of the two phases, then there is right atrial enlargment

Small initial component and larger terminal component in diphasic P wave !

What does V1 look like with right ventricular hypertrophy? !

What is the normal appearance of QRS in lead V1? !

What does V1 look like with left ventricular hypertrophy? What does V5 look like with left ventricular hypertrophy? !

How does one check an EKG for left ventricular hypertrophy? !

What do T waves look like in the left chest leads with LVH?

What does left ventricular strain look like? In what lead? The characteristic EKG sign of ischemia is an [...]

!

!

Large R wave Deep S wave

Really deep S wave Very tall R wave in V5

mm of S in V1 + mm of R in V5 > 35 = LVH

Inverted T wave with a gradual downslope and very steep return

What does right ventricular strain look like? In what lead?

!

!

A wave that has both positive and negative portions

What is a diphasic P wave characteristic of?

EKG findings: left atrial enlargement

V3-V4

!

Depressed and humped ST segment in V1

!

Depressed and humped ST segment in V5

The characteristic EKG sign of ischemia is an inverted T wave

58!

Terms / Facts !

In which leads are T wave inversion most common in ischemia? !

Marked T wave inversion in leads V2-V3 is indicative of what syndrome? !

What EKG sign is indicative of acute myocardial injury? Physical exam: COPD (6)

!

V1-V6

Wellens syndrome; stenosis of the LAD ST segment elevation/depression

↑ AP diameter hyperressonance ↓ diaphragmatic excursion ↓ breath sounds ↑ expiratory phase rhonchi wheezes !

Clinical manifestations: COPD (3) !

Exacerbation triggers: COPD (2)

Chronic cough Sputum production Dyspnea

Infxn (S. pneumoniae, H. influenzae, M. catarrhalis) Cardiopulmonary disease, incl. PE !

What are the criteria for continous or intermitten long-term oxygen therapy in COPD? (2)

PaO2 55 mg or O2 sat < 88% PaO2 55 to 59 plus polycythemia or evidence of cor pulmonale

Definition (GOLD): COPD Stage I (mild) Tx: Stage I (GOLD) COPD

!

FEV1/FVC Beta agonist) Tx: Stage II (GOLD) COPD Rehabilitation (2) Definition (GOLD): Stage III COPD (severe) (2) !

Tx: Stage III (GOLD) COPD

!

Fev1/FVC < 70% Fev1 30-50%

Standing LA dilator + inh. steroid if increased exacervations !

Tx: Stage IV (GOLD) COPD (3)

Standing LA dilator + inh. steroids + O2 !

Definition: Stage IV (GOLD) COPD

Fev/FVC < 70% FEV1 < 30%

What is the most common location for diverticulosis? !

Clinical manifestations: diverticulosis (2)

! !

Tx: diverticulosis (2) Complications: diverticulosis (2)

!

!

Sigmoid colon

Usually asymptomatic; incidentally found by barium enema or colonoscopy Vague, LLQ discomfort, bloating, constipation/diarrhea

Dx: diverticulosis

Pathophysiology:

!

Barium enema

High-fiber foods Psyllium !

Painless rectal bleeding Diverticulitis

Impaction of food and bacteria in diverticulum → fecalith

59!

Terms / Facts formation → obstruction → compromise of the diverticulum's blood supply, infection, perforation

diverticulutis

Dx: diverticulitis (2)

!

Abdominal/pelvic CT w/w/o oral contrast (test of choice) Abd radiograph !

Which diagnostic tests are contraindicated in diverticulutis? Why? !

Clinical manifestations: diverticulutis (3) DDx: diverticulutis (6)

!

LLQ abdominal pain Fever Nausea/Vomiting/Constipation

IBD Infectious colitis PID Tubal pregnancy Cystitis Colorectal cancer !

Tx: diverticulutis (mild) (2) Tx: diverticulitis (severe) (2)

!

Metronidazole + FQ 7-10d Liquid diet

Inpatient - NPO, IV fluids, NG tube IV abx amp/gent/MNZ or zosyn !

When is surgery indicated for tx of diverticulitis? !

Definition: angiodysplasia of the colon

If medical management doesn't work or if there are 2+ episodes

Tortuous, dilated veins in the submucosa of the colon wall

Complication: angiodysplasia of the colon

!

Tx: angiodysplasia of the colon !

Clinical manifestations: acute mesenteric ischemia (5)

Lower GI bleeding (low grade usually) Colonoscopy

self-resolving colonoscopic coagulopathy if persistent

SMA embolism Nonocculusive mesenteric ischemia SMA thrombosis Venous thrombosis Focal segmental ischemia of the small bowel !

Sudden onset abd pain out of proportion to the abd tenderness on examv (occlusive) Abd distension & pain (nonocclusive) N/V Hematochezia Intestinal angina

Physical exam: acute mesenteric ischemia (2) Dx (studies): acute mesenteric ischemia (2)

!

Peritoneal signs Abd distention (FOBT ~ 75% pts) May be unremarkable

!

Mesenteric angiography (definitive) CT angiogram (test of choice)

Lab findings: acute mesenteric ischemia (4)

!

!

!

Dx: angiodysplasia of the colon

Etiologies: acute mesenteric ischemia (5)

Barium enema and colonscopy due to acute risk of perforation

!

↑ WBC ↑ amylase ↑ LDH acidosis w/ ↑ lactate

60!

Terms / Facts !

Tx: acute mesenteric ischemia (3)

IV fluids Broad-spectrum abx Resection if necrotic !

Tx: acute mesenteric ischemia due to SMA embolism (2)

!

When is intra-arterial infusion of papaverine indicated in acute mesenteric ischemia? !

Tx: acute mesenteric ischemia due to SMA thrombosis

!

When SMA spasm (nonocclusive) is suspected

percutaneous or sugical revascularization

What is the strongest predictor of survival of acute intestinal ischemia? Signs: intestinal infarction (5)

Fibrinolytics Surgical embolectomy

!

Dx prior to infarction of bowel

Hypotension Tachypnea Fever AMS Lactic acidosis

How do clincial presentations of an embolic vs thrombotic acute mesenteric ischemia differ?

!

Embolic: sx are more sudden and painful Thrombotic: sx are more grandual and less severe

! Vasopressors What drug class should be avoided acute mesenteric ischemia is occurring? ! Atherosclertoic occlusive disease of main Etiology: chronic mesenteric mesenteric vessels ischemia !

Clinical presentation: chronic mesenteric ischemia (2)

Abdominal angina (postprandially) Significant weight loss due to abdominal angina !

Dx: chronic mesenteric ischemia !

Tx: chronic mesenteric ischemia !

Definition: Ogilvie's syndrome

Etiologies: Ogilvie's syndrome (3) Tx: Ogilvie's syndrome (3)

!

surgical revascularization (definitive)

s/s of large bowel obstruction w/o mechanical obstruction !

recent surgery/trauma serious medical illness medications

Stop offending agent Supportive measures (IV fluids, electrolyte repletion) Decompression with gentle enemas or NG suction

Complications: pseudomembranous colitis (3) Clinical manifestations: pseudomembranous colitis (3) Definition: colonic volvulus

!

!

Toxic megacolon Colonic perforation Anasarca/electrolyte imbalances !

Profuse, watery diarrhea Crampy abdominal pain Toxic megacolon w/ risk of perforation

Twisting of a loop intestine about its mesenteric attachment site

What are the most common sites of colonic

!

Mesenteric arteriography

!

Sigmoid colon (75%) Cecal volvulus

61!

Terms / Facts volvulus? (2)

(25%)

Clinical manifestations: colonic volvulus (4) !

Dx: colonic volvulus (3) Tx: sigmoid volvulus

!

Acute onset colicky abdominal pain Obstipation, abdominal distention Anorexia N/V

Plain films Sigmoidoscopy (dx and tx for sigmoid volvulus) Barium enema !

nonoperative reduction (decompression vs sigmoidoscopy) !

What is Reynold's pentad?

Fever Severe jaundice RUQ pain Confusion Hypotension !

What is Charcot's triad? In what disease is it seen? !

Definition: cholangitis

Infection of the biliary tract 2/2 obstruction → biliary stasis & bacterial overgrowth

Etiologies: cholangitis (3)

Tx:cholangitis (3)

!

BD stone (85%) Malignant or benign stricture Flukes !

Workup/approach: cholangitis (4) Dx: cholangitis (3)

Cholangitis: Fever Severe Jaundice RUQ pain

Blood cultures IV fluids IV abx after cultures Decompress CBD when patient stable

!

RUQ U/S Labs (CBC, LFTs, amylase) ERCP (don't perform during acute phase)

!

IV abx IV fluids ERCP (patients who dont' respond to abx and supportive care)

What vaccinations should all patients with HCV receive? !

What are the most important causes of thyrotoxicosis w/ low radioactive iodine uptake? (5) Clinical manifestations: Pulmonary embolism (4)

!

!

HBV and HAV vaccinations, if not already immune

Subacute painless thyroiditis Subacute granulomatous thyroiditis Iodine-induced thyroid toxicosis Levothyroxine overdose Struma ovarii Dyspnea Tachycardia Sudden-onset pleuritic chest pain Cough Hemoptysis !

What kind of lesion does positive pronator drift indicate?

Upper motor neuron lesion !

What laboratory value in a parapneumonic effusion is most indicative of empyema? A low pH ( 3.0 Encephalopathy: Severe Ascites: uncontrolled Nutritional status: Poor

At what Child's score should a cirrhotic patient be evaluated for transplant? What serum ascites albumin gradient indicates portal HTN? !

! !

Dx: hemochromatosis (2)

!

!

!

> 1.1 g/dL

Fatigue Arthralgias Bronze skin Hypogonadism DM Labs (serum iron, ferritin, iron sat. TIBC) Liver bx required for dx

Lab findings: hemochromatosis (4) Tx: hemochromatosis (4)

Child class B

Order period labs (LFTs 3-4 months) Perform endoscopy to determine presence of esophageal varices CT-guided biopsy if HCC suspected

How does one monitor a patient w/ cirrhosis? (3) Sx: hemochromatosis (5)

!

!

↑ serum iron ↑ serum ferritin ↑ Fe sat ↓ TIBC

Repeated phlebotomies Deferoxamine Treat complications Consider liver transplant

64!

Terms / Facts

!

Tx: Wilson's disease (2)

↑ 24-hr urine Cu ↓ serum ceruloplasmin ↓ penicillamine challenge with ↑ urine Cu excretion

!

Lab findings: Wilson's disease (3)

Cheltion therapy w/ penicillamine + pyridoxine Zinc (decreases intestinal uptake of copper)

What are the two pathologic types of HCC? (2) !

Clinical presentation: HCC (6) Dx: HCC (3)

!

!

abdominal pain weight loss anorexia fatigue s/s of chronic liver disease paraneoplastic syndromes

Liver biopsy Labs (hep B/C, LFTs, PT/PTT, tumor markers) Imaging !

Tx: HCC (2)

Liver resection Liver transplantation !

Definition: hemobilia

Blood draining into the duodenum via CBD !

Tx: amebic liver abscess !

Etiologies: liver abscess (2)

!

Tx: hydatid liver cyst (2) !

Definition: Budd-Chiari

!

!

Dx: Budd-Chiari (2) !

IV metronidazole

Biliary tract obstruction GI infection Surgical resection Mebendazole

Liver disease caused by occlusion of hepatic venous outflow, which leads to hepatic congestion and subsequent microvascular ischemia

Etiologies: BuddChiari (4)

Tx: BuddChiari (3)

Nonfibrolamellar (hep B/C associated) Fibrolamellar

Myeloproliferatie disorder Hypercoagulable state Tumor invasion Pregnancy Hepatic venography Serum ascites albumin gradient > 1.1 g/dl

Medical therapy - anticoagulation, thrombolytics, diuretics Surgery (balloon angioplasty w/ stent, TIPS) Liver transplantation

What are the signs of a conjugated hyperbilirubinemia? (2) !

Definition: cholelithiasis !

Clinical manifestations: cholelithiasis (3)

Definition: Boas' sign !

Complications: cholelithiasis (5)

!

!

Pale stools Dark urine

Stones in the gallbladder

Biliary colic = episodic RUQ or epigastric abd painn Radiation of painn to scapula Nausea !

Dx: cholelithiasis

!

RUQ U/S

Referred right subscapular pain w/ biliary colic

Cholecystitis w/ prolonged obstruction of cystic duct Choledocholithiasis Gallstone ileus Malignancy Mirizzi's syndrome: common hepatic duct compression by cystic duct stone

65!

Terms / Facts !

Cholecystectomy (laparoscopic) Ursodeoxycholic acid (rare) for cholesterol stones if poor surgical candidate or uncomplicated biliary pain

Tx: symptomatic cholelithiasis (2)

What is the best indicator of the severity of TCA overdose? Tx: prolactinoma (2)

!

!

First line: dopaminergic agents (cabergolin/bromocriptine) Second line: surgery only if impaired vision does not improve with drug treatment

A normal/high pCO2 in the context of an acute asthma exacerbation is indicative of what? !

!

What are the types of pleural effusions? (2) !

Decompensation - intubation may be required

Inhaled B2 agonist (first-line) via nebulizer/MDI Corticosteroids (IV or PO) Oxygen (titrate to achieve >90% SaO2)

Tx: acute severe asthma exacerbation (3)

!

Exudative Transudative

Rapid decline in renal function, with an increase in serum creatinine level (relative increase of 50% or absolute of 0.5-1.0 mg/dL)

Definition: Acute renal failure

What are the most common clinical manifestations of acute renal failure? (2)

!

!

!

Workup: acute renal failure

Clinical manifestations: prerenal ARF (5) !

!

Dry mucous membranes Hypotension Tachycardia Decreased tissue turgor Oliguria/anuria

Oliguria BUN:Cr > 20:1 Urine osmolality > 500 FeNa < 1% Bland urine/hyaline casts

Etiologies: acute tubular necrosis

!

Daily weights, I/Os BP Serum electrolytes Hb/Hct for anemia Watch for infection

!

!

Infection

H&P Urine evaulation Renal U/S Serologies (if indicated)

Categories: ARF (3)

Lab findings: ATN (4)

Weight gain Edema

Hypovolemia CHF Peripheral vasodilation (sepsis, etc.) Cirrhosis/hepatorenal syndrome Drugs (NSAIDs, ACE inhibitors, cyclosporin)

How does one monitor a patient with ARF? (5)

Lab findings: prerenal ARF

!

!

What is the most common cause of death with ARF? Etiologies: prerenal failure (5)

EKG w/ wide QRS

Prerenal Intrinsic Postrenal !

Ischemia Toxins

BUN:Cr < 20 FeNa > 2% Urine osmolality < 350 mOsm/kg Brown muddy casts

66!

Terms / Facts Etiologies: postrenal ARF (5)

!

urethral obstruction 2/2 BPH nephrolithiasis obstruction of solitary kidney retroperitoneal fibrosis obstructing neoplasms !

Urinalysis Urine chemistry Serum electrolytes Bladder cath (dx and tx) Renal U/S

What tests/procedures should be ordered for any patient with ARF? (5)

!

In the early phase of ARF, what are the most common mortal complications? (2) !

Tx: acute renal failure (general) (5)

Hyperkalemic cardiac arrest Pulmonary edema

Avoid meds that decrease renal blood flow Correct fluid imbalance Correct electrolyte imbalances Optimize cardiac output Order dialysis if symptomatic uremia !

WBC casts suggest what etiologies of renal failure?

Pyelonephritis Acute interstitial nephritis !

RBCs and RBC casts suggest what etiology of ARF? !

Tx: prerenal ARF (3) Tx: intrinsic ARF (2)

treat underlying disorder give NS to maintain euvolemia and restore BP Eliminate offending agents !

Supportive therapy for ATN Furosemide trial if patient is oliguric !

Tx: postrenal ARF

bladder catherization to decompress urinary tract !

Definition: chronic kidney disease Etiologies: CKD (5)

!

≥ 3 mos of reduced GFR (

Diabetes (most common) HTN Chronic GN AIN PKD !

Definition: Stage I CKD

!

Definition: Stage 2 CKD

GFR > 90 ml/min GFR 60-89 ml/min

Definition: Stage 3 CKD Definition: Stage 4 CKD Definition: Stage 5 CKD Definition: uremia

!

!

!

30-59 ml/min

!

15-29 ml/min

GFR < 15 ml/min or dialysis

Signs and symptoms associated with accumulation of nitrogenous wastes due to impaired renal function

Clinical manifestations (general): uremia (5)

!

Clinical manifestations (skin): uremia (4)

N/V anorexia malaise fetor uremicus metallic taste !

Uremic frost Pruritis Calciphylaxis NSF

Clinical manifestations (cardiovascular): uremia (3)

!

Glomerular disease

!

pericarditis hypertension CHF

67!

Terms / Facts Clinical manifestations (neurologic): uremia (4)

!

Encephalopathy seizures Neuropathy restless legs !

Clinical manifestations (Hematologic): uremia (2) !

Clinical manifestations (metabolic): uremia (5) !

Dx: CKD (4)

anemia bleeding

Hyperkalemia Hyperphosphatemia Acidosis Hypocalcemia 2° hyperparathyroidism/osteodystrophy

Urinalysis Chem 7 CBC Renal US !

ACE inhibitors are first line Goal 130/80

!

Low protein Low salt Restrict K+

Tx (BP control): CKD Tx (diet): CKD (3) Tx (anemia): CKD Tx (metabolic acidosis): CKD

!

Treat with erythropoietin

!

Oral bicarb or sodium citrate if HCO3 < 22

!

Tx (electrolytes): CKD (2) !

Indications (absolute): dialysis (5)

calcium citrate/acetate vitamin D/calcium

Acidosis Electrolyte imblances Intoxications/ingestions Overload Uremia

What are the two major methods for dialysis?

!

Hemodialysis Peritoneal dialysis !

What is the preferred access route for hemodialysis? !

Definition: proteinuria

> 150 mg protein/24hr

What are the classifications of proteinuria? !

Clinical manifestations: nephrotic syndrome (5) !

Etiologies: nephrotic syndrome (6) Dx: nephrotic syndrome (3) Tx: nephrotic syndrome (5)

!

Definition: hematuria

!

Glomerular Tubular Overflow

Urine protein > 3.5g/24hr Hypoalbuminemia Hyperlipidemia Hypercoagulable state Edema

Primary glomerular disease Systemic disease Drugs/toxins Infection Multiple myeloma Malignant HTN !

Urine dipstick Urinalysis renal biopsy (if other methods don't help)

Treat underlying disease ACE inhibitors (decreases protein loss) Diuretics Treat HL Vaccinate against influenza and pneumococcus !

What is the general etiology of microscopic hematuria? And gross hematuria?

> 3 erythrocytes/HPF on urinalysis !

Microscopic: glomerular Gross: nonglomerular or urologic

What diseases should be suspected with gross painless hematuria? (2)

!

AV fistula

!

Bladder cancer Kidney cancer

68!

Terms / Facts ! Nephrolithiasis Neoplasms Foley trauma BPH Etiologies (extrarenal): hematuria (4) ! Vascular (renal thrombosis, infarcts, etc) Glomerular Etiologies (intrarenal): disease PKD Nephrolithiasis Neoplasms Trauma/exercise hematuria (6) !

Dx: hematuria (4)

Urine dipstick Urinalysis Cytology Renal bx

!

Tx: hematuria (2)

treat underlying disease maintain urine volume !

Clinical manifestsion: Goodpasture's syndrome (6) Tx: ANCA+/Anti-GBM GN Tx: SLE nephritis Definition: Acute Interstitial Nephritis !

Etiologies: AIN (3)

!

steroids ASAP + cyclophosphamide + plasmapheresis

!

IV cyclophosphamide + steroids

!

Inflammation involving interstitium that surrounds glomeruli and tubules

!

Fever Eosinophilia Acute renal insufficiency Rash FEAR AIN

Renal function tests (BUN/Cr) Urinalysis (eos strongly suggestive) !

Tx: AIN (2)

!

Toxins (most common) Infection Collagen vascular diseases (e.g. sarcoidosis)

Clinical manifestations: AIN (4) Dx: AIN (2)

Fever Myalgia Rapidly progessive renal failure Hemoptysis Cough Dyspnea

Remove offending agent Treat infection if present

What is the definitive diagnosis for AIN? !

!

Renal bx

Slowly progressive form of interstitial nephritis that can lead to progressive scarring of the interstium, renal failure and ESRD over time

Definition: Chronic interstitial nephritis !

Etiologies: chronic interstitial nephritis (5)

urinary tract obstruction reflux nephropathy heavy analgesic use heavy metal exposure arteriolar nephrosclerosis w/ HTN

! Nephrocalcinosis/nephrolithiasis What are the sequelae of RTA I that leads to symptom manifestations? ! MM Autoimmune diseases Meds (analgesics) Etiologies: RTA I (3) !

Tx: RTA I (2)

correct acidosis w/ sodium bicarb administer phosphate salts

Etiologies: Type II RTA (4) Tx: RTA II (2)

!

!

!

Fanconi's syndrome Cystinosis Wilson's Paraprotein (MM, amyloid)

Na restriction (increases bicarb reabsorption) Don't give bicarb to correct acidosis

69!

Terms / Facts !

Clinical manifestations: PKD (4)

Hematuria Abd pain HTN Palpable kidneys !

Dx: PKD Tx: PKD (3)

!

U/S

Drain cysts if symptomatic Treat infection w/ abx Control HTN !

Dx: medullary sponge kidney disease !

Clinical manifestations: renal artery stenosis (2)

!

Physical exam: renal artery stenosis !

Dx: renal artery stenosis (2) Tx: renal artery stenosis (2)

!

IVP

HTN Renal insufficiency Abdominal bruit

Renal arteriogram (w/o contrast if possible) MRA

Revascularizaztion w/ PRTA Conservative medical therapy (ACEi, CCBs) if PRTA or surgery contraindicated

Definition: Hypertensive Nephrosclerosis

!

Systemic HTN increases capillary hydrostatic pressure in the glomeruli, leading to benign or malignant sclerosis

What common antihypertensive is contraindicated in renovascular HTN?

!

ACEi

! Hematuria Flank pain N/V Dysuria UTI Clinical manifestations: nephrolithiasis (5) ! Noncrast helic CT scan Strain urine for stone 24-h urine Workup: nephrolithiasis x2 (3) !

Analgesia Aggresive PO/IV hydration Abx if UTI Lithotripsy/percutaneous nephrolithotomy if ongoing obstruction

Tx (acute): nephrolithiasis (4) Tx (chronic): nephrolithiasis

!

Increase fluid intake (> 2 L/d) Limit Ca+ intake Thiazide diuretics Allopurinol (uric acid stones)

What diuretics should be used in renal insufficiency? (2) !

What diuretics should be used for CHF? (2) What diuretics should be used with cirrhosis? (2)

!

!

Loop diuretic + thiazide

Lasix + spironolactone (1:2.5 ratio)

What diuretic should be used with severe metabolic alkalosis? Clinical manifestations: urinary tract obstruction (5)

!

Dx: urinary tract obstruction (3) Tx: lower urinary tract obstruction (2)

!

Loop diuretic + thiazide

!

Acetazolamide

Renal colic/pain oliguria recurrent UTIs hematuria/proteinuria renal failure !

renal U/S initial test IVP Urinalysis !

urethral catheter prostatectomy (if BPH)

70!

Terms / Facts !

Tx: upper urinary tract obstruction (2) Definition: Solitary Pulmonary Nodule

!

nephrostomy tube drainage ureteral stent

Single, well circumscribed nodule seen on CXR with no associated mediastrinal or hilar lymph node involvement !

What does the initial evaluation of SPN consist of? Dx: SPN (3)

!

PET Transthoracic needle biopsy Video assisted thorascopic surgery !

Management: low risk SPN

Serial CT q3mo !

Management: medium-risk SPN !

Management: high risk SPN Etiologies: pleural effusion (4)

!

Physical exam: pleural effusion (3)

!

VATS w/ lobectomy if malignant

!

Exterional dyspnea Peripheral edema Orthopnea

Dullness to percussion Decreased breath sounds over effusion Decreased tactile fremitus !

Dx: pleural effusion (2) Tx: transudative effusions (3)

PET or bx

CHF Pneumonia Malignancies (lung/breast/lymphoma) PE

Clinical manifestations: pleural effusion

!

CXR Thoracentesis

Diuretics Na restriction Therapeutic thoracentesis (if massive) !

Tx: parapneumonic effusions (2)

Abx Chest tube drainage if complicated !

Classic ECG finding in atrial flutter. Definition of unstable angina.

!

Sawtooth P waves

Angina is new, is worsening, or occurs at rest

Antihypertensive for a diabetic patient with proteinuria. !

Beck's triad for cardiac tamponade.

!

ACEI

?-blockers, digoxin, calcium channel blockers

Hypercholesterolemia treatment that ? flushing and pruritus. Treatment for atrial fibrillation.

!

Hypotension, distant heart sounds, and JVD !

Drugs that slow AV node transmission.

!

Niacin

Anticoagulation, rate control, cardioversion !

Treatment for ventricular fibrillation. Autoimmune complication occurring 2-4 weeks post-MI.

!

CT scan + Hx

!

Immediate cardioversion

Dressler's syndrome: fever, pericarditis, ? ESR

71!

Terms / Facts IV drug use with JVD and holosystolic murmur at the left sternal border. Treatment? !

Diagnostic test for hypertrophic cardiomyopathy.

Classic ECG findings in pericarditis. ! !

Eight surgically correctable causes of hypertension.

Treat existing heart failure and replace the tricuspid valve

Echocardiogram (showing thickened left ventricular wall and outflow obstruction) !

A fall in systolic BP of > 10 mmHg with inspiration.

Definition of hypertension.

!

!

Pulsus paradoxus (seen in cardiac tamponade)

Low-voltage, diffuse ST-segment elevation

BP > 140/90 on three separate occasions two weeks apart

Renal artery stenosis, coarctation of the aorta, pheochromocytoma, Conn's syndrome, Cushing's syndrome, unilateral renal parenchymal disease, hyperthyroidism, hyperparathyroidism !

Evaluation of a pulsatile abdominal mass and bruit. Indications for surgical repair of abdominal aortic aneurysm. Treatment for acute coronary syndrome.

!

!

Abdominal ultrasound and CT

> 5.5 cm, rapidly enlarging, symptomatic, or ruptured

Morphine, O2, sublingual nitroglycerin, ASA, IV ?blockers, heparin

! Abdominal obesity, high triglycerides, low HDL, hypertension, What is the insulin resistance, prothrombotic or proinflammatory states metabolic syndrome? ! Exercise stress Appropriate diagnostic test? ? A 50-year-old male with treadmill with ECG angina can exercise to 85% of maximum predicted heart rate. Appropriate diagnostic test? ? A 65-year-old woman ! Pharmacologic stress test (e.g., dobutamine echo) with left bundle branch block and severe osteoarthritis has unstable angina. ! Angina, ST-segment changes on ECG, or Signs of active ischemia during stress ? BP testing.

ECG findings suggesting MI.

!

ST-segment elevation (depression means ischemia), flattened T waves, and Q waves

A young patient has angina at rest with ST-segment elevation. Cardiac enzymes are normal. Common symptoms associated with silent MIs.

!

!

CHF, shock, and altered mental status !

The diagnostic test for pulmonary embolism. An agent that reverses the effects of heparin.

!

Prinzmetal's angina

!

V/Q scan Protamine

72!

Terms / Facts !

The coagulation parameter affected by warfarin. !

A young patient with a family history of sudden death collapses and dies while exercising. !

Endocarditis prophylaxis regimens.

!

Hypertrophic cardiomyopathy

Oral surgery—amoxicillin; GI or GU procedures— ampicillin and gentamicin before and amoxicillin after !

The 6 P's of ischemia due to peripheral vascular disease. Virchow's triad.

Pain, pallor, pulselessness, paralysis, paresthesia, poikilothermia

Stasis, hypercoagulability, endothelial damage !

The most common cause of hypertension in young women. !

The most common cause of hypertension in young men. !

Stuck-on appearance.

Seborrheic keratosis !

The most common type of skin cancer; the lesion is a pearly-colored papule with a translucent surface and telangiectasias. !

Honey-crusted lesions.

!

Psoriasis Basal cell carcinoma

Impetigo

A febrile patient with a history of diabetes presents with a red, swollen, ! painful lower extremity. ! Pemphigus vulgaris + Nikolsky's sign. !

!

Acanthosis nigricans. Check fasting blood sugar to rule out diabetes !

Dermatomal distribution. !

Flat-topped papules. !

Varicella zoster

Lichen planus

Erythema multiforme !

A lesion characteristically occurring in a linear pattern in areas where skin comes into contact with clothing or jewelry. !

Presents with a herald patch, Christmas-tree pattern. A 16-year-old presents with an annular patch of alopecia with broken-off, stubby hairs.

!

Contact dermatitis

Pityriasis rosea

Alopecia areata (autoimmune process)

Pinkish, scaling, flat lesions on the chest and back. KOH prep has ! a "spaghetti-and-meatballs" appearance.

!

Cellulitis

Bullous pemphigoid

A 55-year-old obese patient presents with dirty, velvety patches on the back of the neck.

Iris-like target lesions.

OCPs

Excessive EtOH

Red plaques with silvery-white scales and sharp margins.

- Nikolsky's sign.

PT

Pityriasis

73!

Terms / Facts versicolor !

Four characteristics of a nevus suggestive of melanoma.

Asymmetry, border irregularity, color variation, large diameter !

Premalignant lesion from sun exposure that can ? squamous cell carcinoma. !

Dewdrop on a rose petal. Cradle cap.

!

Actinic keratosis

Lesions of 1° varicella

Seborrheic dermatitis. Treat with antifungals

Associated with Propionibacterium acnes and changes in androgen ! Acne vulgaris levels. ! Herpes simplex A painful, recurrent vesicular eruption of mucocutaneous surfaces. ! Lichen Inflammation and epithelial thinning of the anogenital area, sclerosus predominantly in postmenopausal women. !

Exophytic nodules on the skin with varying degrees of scaling or ulceration; the second most common type of skin cancer. The most common cause of hypothyroidism. !

Lab findings in Hashimoto's thyroiditis.

!

Hashimoto's thyroiditis

High TSH, low T4, antimicrosomal antibodies !

Exophthalmos, pretibial myxedema, and ? TSH. The most common cause of Cushing's syndrome.

!

Squamous cell carcinoma

Graves' disease

Iatrogenic steroid administration. The second most common cause is Cushing's disease

! Hypoparathyroidism A patient presents with signs of hypocalcemia, high phosphorus, and low PTH. ! Signs and symptoms of hypercalcemia Stones, bones, groans, psychiatric overtones. ! 1° hyperaldosteronism (due to A patient complains of headache, weakness, and Conn's syndrome or bilateral polyuria; exam reveals hypertension and tetany. adrenal hyperplasia) Labs reveals hypernatremia, hypokalemia, and metabolic alkalosis. A patient presents with tachycardia, wild swings in BP, ! Pheochromocytoma headache, diaphoresis, altered mental status, and a sense of panic. ! ?-antagonists (phentolamine and Should ?- or ?-antagonists be used first in phenoxybenzamine) treating pheochromocytoma?

A patient with a history of lithium use presents with copious amounts of dilute urine. Treatment of central ! DI.

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Nephrogenic diabetes insipidus (DI)

Administration of DDAVP ? serum osmolality and free water

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Terms / Facts restriction A postoperative patient with significant pain presents with hyponatremia and normal volume status. An antidiabetic agent associated with lactic acidosis. A patient presents with weakness, nausea, vomiting, weight loss, and new skin pigmentation. Labs show hyponatremia and hyperkalemia. Treatment?

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SIADH due to stress

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Metformin

1° adrenal insufficiency (Addison's disease). Treat with replacement glucocorticoids, mineralocorticoids, and IV fluids !

Goal hemoglobin A1c for a patient with DM. Treatment of DKA.

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4 (2) mo) Tx: developmental dysplasia of the hip (2) • Hip harness Spica cast What organs are most commonly injured with blunt • Spleen > liver > abdominal trauma? (3) intestines Definition: Kehr • Ipsilateral shoulder pain referred from the abdomen due to sign irritation the phrenic nerve and diaphragm Dx: blunt abdominal • (1) FAST (2) CT w/ IV contrast (if FAST negative but trauma (2) suspicion high) What radiographic sign on CXR indicates • free air in the peritoneal cavity perforation of a hollow viscus? (usually under the diaphragm) What diagnostic test should be used to confirm proper placement of a • Chest xcentral venous catheter? ray Definition: Leriche • Bilateral hip/buttock/thigh claudication Impotence syndrome Symmetric atrophy of bilateral extremities Pathophysiology: Leriche • Atherosclerosis at the bifurcation of the aorta into syndrome the common iliac arteries On what side of the body is diaphragmatic • Left side because right side is rupture more common? Why? protected by the liver What is the most commonly injured ligament of the knee? • MCL What kind of insult causes • Forceful abduction of the knee, often with a MCL injury? torsional component of motion Physical exam: MCL tear • Swollen knee due to effusion Positive valgus stress (2) test Dx: MCL tear • MRI Tx: MCL tear • bracing and early ambulation What are the components of the • Motor response (6) Verbal response (5) Glasgow Coma Score? Eye opening (4) At what GCS level does one intubate? • GCS of 8 = intubate What is the most common site for metatarsal stress fracture? • Second metatarsal Tx: stress fracture (metatarsal) • Rest, analgesia, hard-soled shoe Tx: sharp, penetrating abdominal trauma in a • Exploratory hemodynamically unstable patient laparotomy

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Terms / Facts Tx: sharp, penetrating abdominal trauma in a • exploratory hemodynamically stable patient laparoscopy Definition: • Subluxation of head of radius at elbow joint; due commonly nursemaid elbow to swinging children by the arm Tx: nursemaid • Closed reduction by gentle passive elbow flexion and forearm elbow supination • Selective damage to central spinal cord due to hyperextension Definition: central injuries in elderly patients w/ degenerative changes in the cord syndrome cervical spine Clinical manifestations: central cord • Upper extremity > lower extremity syndrome weakness Clinical manifestations: anterior cord syndrome • bilateral spastic motor paresis What is the most common etiology of anterior cord • Occlusion of the vertebral syndrome? artery What features distinguish • Unilateral infiltrate (usually bilateral in ARDS) pulmonary contusion from Onset: usually within 24-48 hrs in ARDS vs within ARDS? (2) first 24 hours for contusion What does treatment of asymptomatic patients • Asymptomatic: no treatment with Paget's disease of bone consist of? And of Symptomatic: bisphosphonates symptomatic patients? • Stones (nephrolithiasis/nephrocalcinosis) Bone (bone aches/pains, Sx: osteitis fibrosa cystica) Groans (muscle pain, abdominal pain, gout, hypercalcemia constipation) Psychiatric overtones (depression, fatigue, anorexia, (4) lethargy, etc.) Etiologies: primary • Adenoma (80%) Hyperplasia (15-20%) hyperparathyroidism (3) Carcinoma (< 1% cases) • BMP (Ca++ levels ↑) PTH levels normal or Lab studies & findings: primary elevated Urine cAMP elevated hyperparathyroidism (4) Chloride/phosphorous ratio > 33 Radiographic findings: primary • Subperiosteal bone resoprtion hyperparathyroidism (2) Osteopenia What imaging study is obtained before surgical treatment of • Sestamibi primary hyperparathyroidism? scan • Serum calcium at least 1 mg/dl What are the indications for above ULN Young (< 50 y/o) BMD parathyroidectomy in asymptomatic patients less than T -2.5 at any site Reduced with primary hyperparathyroidism? (4) renal function If a sestamibi scan in a patient with primary • Bilateral neck hyperparathyroidism is negative but shows many exploration w/ abnormal glands, what kind of surgery is indicated? intraoperative PTH level What is the most common mechanism of atrial • Re-entrant rhythm in within the flutter? atria • Progesterone → ↑ respiratory rate via stimulation Pathophysiology: respiratory of dorsal respiratory group → chronic compensated alkalosis of pregnancy respiratory alkalosis Tx: congenital prolonged QT syndrome (Jervell-Lange-Nielson • beta syndrome or Romano-Ward) blockers Clinical manifestations: Jervell-Lange• Syncopal episodes w/o following Nielson syndrome (2) disorientation Hearing impairment What is the most common form of drug-induced chronic • Analgesic renal failure? nephropathy

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Terms / Facts What is the best initial screening test for • Cosyntropin stimulation test w/ adrenal insufficiency? cortisol and ACTH levels What is the most common cause of ductopenia in • Primary biliary adults? cirrhosis What is the only drug FDA approved for ALS treatment? • Riluzole; glutamate What is its mechanism? inhibitor What kind of immunological response is induced by the • T-cell-independent B23-valent pneumococcal vaccine? cell response • Chest CT to look for What diagnostic study is required whenever a new thymoma (present in 15% of diagnosis of myasthenia gravis is made? Why? cases) Hypocalcemia with concordant • Hypocalcemia with concordant changes changes of serum calcium and of serum calcium and phosphate levels are phosphate levels are usually caused by usually caused by vitamin D deficiency [...] Clinical manifestations: primary • painless chancre that resolves in 3-6 syphilis weeks Clinical manifestations: • truncal rash that extends to the periphery, including secondary syphilis (2) palms and soles generalized lymphadenopathy What type of urethral injury is most commonly associated • Posterior urethral with pelvic fractures? injury Clinical manifestations: posterior • Suprapubic pain Inability to void urethral injury (2) following major trauma Physical exam: • blood at the urethral meatus high-riding prostate due to posterior urethral displacement of the prostate by a pelvic hematoma scrotal injury (3) hematoma Tx: Carbon monoxide poisoning • 100% oxygen via nonrebreather facemask If a patient with suspected PVD has normal ABIs, what further • Exercise testing should be pursued? ABIs What injury is most commonly associated with anterior • Burst fracture of the cord syndrome? vertebra What is the next step in a patient with a gunshot wound below • Exploratory the nipple who is hemodynamically unstable? laparotomy What are the first compensatory physiological • Tachycardia Peripheral changes to hemorrhage? (2) vasoconstriction Clinical manifestations: retroperitoneal abscess • Fever Chills Deep abdominal (3) pain Tx: pancreatic • Immediate placement of a percutaneous drainage catheter with abscess culture of the drained fluid and surgical debridement Tx: mastitis • antibiotics (dicloxacillin or cephalosporins) Analgesics Continuation (3) of breast-feeding from the affected breast What is the radiologic finding for blunt aortic injury? • Widened mediastinum What is the most common cause of spinal • Thoracic and thoracoabdominal aortic cord ischemia and infarction? aneurysm repair surgeries • Flaccid paralysis Bowel/bladder Incontinence Clinical presentation: anterior Sexual dysfunction Hypotension Loss of tendon spinal artery syndrome (5) reflexes Dx: esophageal perforation • Water-soluble contrast esophagram Where do diabetic foot ulcers • Plantar surface of the foot under points of classicaly occur? greatest pressure What surgery commonly causes early dumping syndrome? • Partial gastrectomy

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Terms / Facts Clinical manifestations: early • postprandial abdominal cramps weakness dumping syndrome (4) light-headedness diaphoresis What imaging modalities is can detect uric acid stones? (2) • CT abdomen IVP Parotid surgery involving the deep lobe • Parotid surgery involving the deep lobe of the parotid gland carries a of the parotid gland carries a significant significant risk of [...] palsy risk of facial nerve palsy What is the most common bone in the body to be affected by stress • fractures? Tibia Where do tibial stress fractures classically • Anterior part of the middle third of occur? the tibia What are the best diagnostic modalities for tibial stress • MRI Bone fractures? (2) scan What are the most common • Arnold-Chiari malformation Prior spinal cord causes of syringomyelia? (2) injuries (classically, whiplash from MVA) Definition: Ludwig • rapidly progressive bilateral cellulitis of the submandibular angina and sublingual spaces What is the classic etiology of Ludwig • Infector second or third mandibular angina? molar Clinical manifestations: Ludwig angina • Fever Dysphagia Odynophagia (4) Drooling What is the most common cause of death with Ludwig angina? • asphyxiation Tx: Ludwig angina (2) • Antibiotics Removal of infected molar Definition: Legg-Calve-Perthes • Idiopathic avascular necrosis of the femoral disease capital epiphysis Tx: Legg-Calve• Observation and bracing Surgery if the femoral head is not Perthes disease (2) well contained within the acetabulum What is the typical course of a congenital • Spontaneous resolution by 12 hydrocele? months If a congenital hydrocele does not disappear within a • Surgical repair due to the year, what treatment may be indicated? Why? risk of inguinal hernia Clinical presentation: • GI sx followed by triad of:Periorbital edema trichinellosis (4) Myositis Eosinophilia Tx: severe symptomatic hyponatremia (< 120 • hypertonic saline (3%) meq/L) infusion What type of catherization is best for minimizing • Intermittent UTIs? catheterization • abdominal pain w/ diarrhea and/or constipation pain Clinical manifestations: relief with bowel movements bloating sense of irritable bowel syndrome (4) incomplete emptying Prophylaxis: M. avium complex in HIV patient • Azithromycin or (2) clarithromycin What is the mechanism by which • Disrupts thermoregulation and the fluphenazine (antipsychotic) causes body's shivering mechanism hypothermia? • All sexually active women < 24 y/o and other What are the routine screening asymptomatic women at increased risk for guidelines for C. trachomtis? infection What is the best initial diagnostic test for • Panendoscopy (esophagoscopy, squamous cell carcinoma of the head/neck? bronchoscopy, laryngoscopy) Describe the following parameters in • Calcium: decreased Phosphate: tumor lysis syndrome: calcium, Increased Potassium: increased Uric acid:

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Terms / Facts phosphate, potassium, uric acid increased What is the most significant cause of morbidity in patients with • Diffuse axonal traumatic brain injury? injury In cases of suspected child abuse, what test should be • Complete skeletal ordered? survey What is the leading complication of • Bacterial infection leading to sepsis surface body burns? and septic shock Clinical presentation: • acute-onset severe substernal pain subcutaneous esophageal perforation (2) emphysema in the neck/mediastinal emphysema Clinical presentation: acute • Fever Chest pain leukocytossis sternal wound mediastinitis (5) drainage mediastinal widening on chest x-ray Tx: acute mediastinitis • Drainage Surgical debridement Prolonged antibiotic (3) therapy • Conservative medical therapy initially CT guided Tx algorithm: percutaneous drainage (if > 3 cm); if < 3 cm, IV abx and diverticulitis observation If unresolved after drainage, surgery for drainage complicated by abscess and debridement • Sigmoid resection; fistulas, perforation What surgery should be performed for with peritonitis, obstruction and recurrent diverticulitis? What are the indications? attacks What is the only region of the bladder covered by • Dome of the peritoneum? bladder Definition: Volkmann's • Final end point of compartment syndrome in which ischemic contracture the dead muscle has been replaced by fibrous tissue What is the immediate management of splenic • IV fluids first, then: Stable: trauma in a hemodynamically stable patient? And CT abdomen Unstable: hemodynamically unstable? exploratory lapartomy Definition: torus • benign bony growth (exostosis) located on the midline palatinus suture of the hard palate After blunt trauma to the chest, if • After blunt trauma to the chest, if an x-ray an x-ray shows a deviated shows a deviated mediastinum with a mass in mediastinum with a mass in the left the left lower chest, one should suspect a lower chest, one should suspect a diaphragmatic hernia w/ herniation of [...] abdominal viscera Dx: diaphragmatic hernia (2) • Barium swallow or CT scan w/ oral contrast What can happen to the extremities upon • Ischemia-reperfusion injury leading reperfusion after ischemia (4-6 hours)? to compartment syndrome Tx: compartment syndrome • emergent fasciotomy Tx: cardiac • immediate decompression by pericardiocentesis or surgical tamponade pericardiotomy Radiologic findings: acute cardiac • normal cardiac silhouette w/o tension tamponade pneumothorax [...] is the preferred way to • Orotracheal intubation with rapid sequence establish an airway in an apneic intubation is the preferred way to establish an patient with a cervical spine airway in an apneic patient with a cervical spine injury injury What are the best methods for • preoperative intensive active breathing prevention of post-operative exercises incentive spirometry forced atelectasis? (3) expiration techniques Tx: penile • emergent surgery to evacuate penile hematoma and mend torn fracture tunica albuginea

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Terms / Facts Dx: penile fracture • emergent urethrogram to assess for urethral injury What is the most common cause of penile • Sexual intercourse with the woman fracture? on top • Acute pain and swelling of the midline Acute pain and swelling of the midline sacrococcygeal skin and subcutaneous sacrococcygeal skin and subcutaneous tissues are most commonly due to pilonidal tissues are most commonly due to [...] disease Tx: pilonidal disease • drainage of abscesses and excision of sinus tracts If a FAST exam is inconclusive, what is the test of choice for • diagnostic detecting intraperitoneal hemorrhage in an unstable trauma peritoneal lavage patient? Diangose: patient with anterior chest trauma w/ elevated • myocardial CVP/PCWP and unrepsonsive hypotension after bolus of IV contusion fluid Clinical presentation: flail chest • respiratory distress tachypnea w/ shallow (2) breaths Clinical manifestations: gastric • early satiety w/ postprandial pain nausea outlet syndrome (4) nonbilious vomiting weight loss Physical exam: gastric outlet syndrome • abdominal succussion splash Definition: Mohs • Microscopic shaving of basal cell cancer such that 1-2 mm of surgery clear margins are achieved Indications: Mohs surgery for • Patients with high risk features Lesions in BCC (2) functionally critical areas Tx (pharmacological): condylomata • TCA Podophyllin 5-Fu epi gel acuminata (5) Imiquimod Interferon alpha What is the glucose concentration • Low glucose (< 30 mg/dl) because of exudative pleural effusion? Why? high leukocyte metabolic activity Drug of choice: dermatitis herpetiformis • Dapsone What physical exam sign excludes the diagnosis of a • Absence of forehead central facial paresis? furrows Tx (pharmacological): • alpha blockers (phentolamine, pheochromocytoma phenoxybenzamine) before beta-blockers In what order should adrenergic • alpha before beta blockers; if beta blockers blockers be given in given first, there will be unopposed alpha pheochromocytoma? Why? receptor stimulation, resulting in hypertension Tx (pharmacological): aortic • afterload reduction w/ CCBs or ACE regurgitation inhibitors Tx: heat stroke • Induction of evaporative cooling to reverse hyperthermia What is the initial effect of radioactive • Initial thyrotoxicosis due to dying iodine treatment on thyroid levels in the follicular cells; can exacerbate the hyperthyroid patient? hyperthyroid state What are the two ways in which • (1) Asymmetric polyarthritis (associated with Gonoccocal septic arthritis may tenosynovitis and skin rash) (2) isolated present? purulent arthritis Diagnostic • Serum osmolality < 270 Urine osmolaltiy > Serum osmolality criteria: SIADH Urine sodium > 20 mEq/L Absence of hypovolemia Normal renal, (5) adrenal and thyroid function How is toxic epidermal necrolysis distinguished • TEN > 30% of body Stevens from Stevens Johnson syndrome? John up to 10% of body Clinical presentation: vitreous hemorrhage • Sudden loss of vision Onset of (2) floaters

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Terms / Facts What is the most common etiology of vitreous • Diabetic hemorrhage? retinopathy What is the most feared complication • Spread of infection into the mediastinum, of a retropharyngeal abscess? leading to acute necrotizing mediastinitis Describe the G6PD levels in patients with G6PD deficiency • G6PD levels are suffering a hemolytic episode. often normal What is the first line medical treatment for idiopathic benign • intracranial hypertension? Acetazolamide What organism is commonly responsible for nosocomial • P. pneumonia in intubated patients? aeruginosa What nasal cytology finding is characteristic of allergic • nasal rhinitis? eosinophilia What is the appropriate first-line diagnostic test if the cause of • Nasal rhinitis is not clear? cytology Definition: • asymptomatic elevation of monoclonal protein detected on MGUS protein electrophoresis How is MGUS distinguished • Absence of MM sx: renal insufficiency, from multiple myeloma? hypercalcemia, anemia and lytic bone lesions Definition: sympathetic • Damage of one eye (the sympathetic eye) after a opthalmia penetrating injury to the other eye Mechanism: • Injury to eye → unveiling of previously "hidden sympathetic opthalmia antigens" → immunologic response in sympathetic eye What event usually precedes the development of HUS? • Diarrheal illness Tx: solitary brain metastasis • surgical resection followed by whole brain radiation What are the earliest side effects of • Hallucinations Dizziness levodopa/carbidopa therapy in PD? (4) Headache Agitation Tx: torsades de pointes (2) • remove offending agent IV magnesium sulfate What CBC finding is the presenting sign in HIV in about • 10% of cases? Thrombocytopenia What is the most specific test available for GERD? • 24 hour pH recording What imaging modality is the gold standard for avascular necrosis of the • hip? MRI What breathing maneuver is used on a ventilator to • End-inspiratory hold determine the lung compliance? maneuver Clinical presentation: • follicular conjunctivitis pannus (neovascularization) Trachoma (2) in the cornea In what patient populations is FSGS the most • African Americans Obese common cause of nephrotic syndrome in adults? patients Heroin users HIV (4) patients Pathophysiology: isolated • decreased elasticity of the arterial wall with aging → ↑ systolic hypertension systolic BP w/o change to diastolic pressure What cytochemical test is used to detect acute • Alpha-naphthyl esterase monocytic leukemia? (positive) What is the treatment of choice for iron deficiency in • IV iron (iron dialysis patients? dextran) What is the first-line therapy for reactive arthritis? • NSAIDs What is the most common cause of blood-tinged sputum in • acute young patients? bronchitis True or false: fever is usually present in acute bronchitis • false; usually afebrile !

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