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291 Cards in this Set
- Front
- Back
What does "irregularly irregular" mean on an ECG?
|
Irregular RR intervals
|
|
Irregularly irregular rhythm without p-waves prior to each QRS
|
Atrial fibrillation
|
|
Etiologies of A-Fib
(10) |
PIRATES:
Pulmonary (COPD, PE), Pheochromocytoma, Pericarditis; Ischemic heart dz & HTN; Rheumatic heart dz Anemia; Thyrotoxicosis; Ethanol & cocaine; Sepsis |
|
Signs/symptoms of A-Fib
(5) |
A FL PT:
Asymptomatic patient; Fatigue (most common); Light headedness, syncope; Palpitations, skipped beats; Tachypnea, dyspnea |
|
Complication of A-Fib
|
diffuse Embolization
(often to brain, leading to TIA or stroke) |
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One of two possible Drugs given to A-Fib to control rate in an emergent situation
|
IV Calcium channel blocker:
Diltiazem (or) IV Beta-blocker: Metoprolol |
|
Drugs given to A-Fib to control rate in a non-emergent situation
(2) |
oral Beta-blocker:
Atenolol (and) oral Calcium channel blockers: Verapamil or Diltiazem |
|
what are the (2) ways to cardiovert an A-Fib rhythm?
when should you not cardiovert? what would the Tx be then? |
Medical: Amiodarone
Electrical: start @ 100 J Do not cardiovert if patient is in A-Fib > 24 hours. Tx: Warfarin for 3-4 weeks before cardioversion |
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If cardioversion from A-Fib to sinus rhythm does not occur, what should patient be treated with?
|
Long-term anticoagulants
DOC: Warfarin (1st) Aspirin (2nd) |
|
Dx:
when the heart is unable to pump sufficient amounts of blood to meet the O2 requirement of the body causing blood to backup |
Congestive Heart Failure
(CHF) |
|
What are the systolic dysfunctions of CHF?
(EF, Preload, LVEDP, contractility) |
Ejection Fraction < 40%
leading to Inc preload & LVEDP, which leads to Dec contractility and Inc cardiac hypertrophy |
|
What causes CHF exacerbation in previously stable patients?
(10) |
FAILURE:
Forgot medication; Arrhythmia, Anemia; Ischemia, Infection; Lifestyle (Inc sodium); Upregulation (Inc cardiac output--pregnancy or hyperthyroidism); Renal failure w/ fluid overload; Emboli (pulmonary); Endocarditis |
|
What are the diastolic dysfunctions of CHF?
(compliance, contraction, recoil, LVEDP, CO, EF) |
Decreased compliance w/ normal contractile function
(ventricle either cant relax or fill properly) leading to Inc stiffness, Dec recoil & coencentric hypertrophy. LVEDP is Inc, CO is nml, EF is nml to high |
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Which type of CHF dysfunction--systolic or diastolic has a normal ejection fraction and is more common in women?
|
dyastolic
|
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What related heart conditions are seen in the systolic dysfunction of CHF that deals w/ decreased contractility?
(4) |
Ischemia(most common);
Dilated Cardiomyopathy; Hypertensive burnout; Valvular dz |
|
What related conditions are seen in the systolic dysfunction of CHF that deals w/ Inc afterload?
(3) |
Hypertension;
Aortic stenosis; Aortic regurg |
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What related conditions are seen in the diastolic dysfunction of CHF that deals w/ abnormal active relaxation?
(2) |
Ischemia;
Hypertrophic cardiomyopathy (from disorders causing LVH) |
|
What related conditions are seen in the diastolic dysfunction of CHF that deals w/ abnormal passive filling?
(2) |
Restrictive cardiomyopathy;
Concentric hypertrophy from HTN |
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What are the early signs of Left-sided CHF?
(2) |
Dyspnea on exertion;
Dec exercise tolerance |
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What are the late sx of Left-sided CHF?
(8) |
PORNS DD ****:
Paroxysmal Nocturnal Dyspnea; Orthopnea; Rales & crackles; Nocturia; S-3 gallop; Diaphoresis; Displaced PMI (laterally); Tachycardia |
|
What are the early signs of Right-sided CHF?
(6) |
A Juicy CHERry:
Anorexia JVD* Cyanosis Hepatomegaly Edema in periphery RUQ pain |
|
What are the late sx of Right-sided CHF?
(2) |
abnormal Hepatojugular reflex;
Ascites |
|
What force causes the pulmonary congestion in diastolic dysfunction?
|
Increased hydrostatic pressure
|
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what (3) ways can CHF be diagnosed by a CXR?
|
Enlargement of cardiac silhouette;
Pulmonary vascular congestion; Kerley-B lines |
|
(3) lab methods of diagnosing CHF
|
CXR;
Echocardiogram (function of ventricles); Basic Natriuretic Peptide (BNP elevation) |
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AHA staging guidelines for CHF (stages A-D)
|
A: at risk but w/o structural heart disorder
B: no sx, w/ structural disorder C: prior or current sx & structure disorder D: end-stage dz |
|
NY Heart Assoc Functional Classes of Heart Failure (I-IV)
[measures pt activity] |
I: No limitation
II: slight limitation III: Sx w/ minimal effort, ok at rest IV: Sx at rest |
|
SOB while lying flat
|
Orthopnea
|
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What drug classes are good versus CHF? Which ones are only helpful if patient has a diastolic dysfunction?
|
Systolic or Diastolic dysfunction:
ACEIs/ARBs Beta-blockers diuretics Diastolic dysfunction only: Calcium channel blockers Nitroglycerin |
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What diuretics are used for mild CHF and (2 for) significant CHF?
|
Mild:
Thiazides Significant CHF: Loop diuretics Spirolactone |
|
What is the difference in the signs/sx of people w/ right CHF and cirrhosis?
(2) |
Same sx, except right CHF patients have trouble lying flat & have JVD
|
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what are the (5) Tx for Acute Pulmonary Edema & Paroxysmal Nocturnal Dyspnea?
|
NOMAD:
Nitroglycerin Oxygen Morphine Aspirin Diuretic |
|
What is the rule for prescribing beta-blockers for CHF?
|
never give during active CHF--add beta-blockers once the patient is diuresed to dry weight and on stable doses of other medications
|
|
Describe (2) types of Malignant HTN
(+ BP limits) |
Hypertensive URGENCY:
systolic >200 or diastolic >110 WITHOUT evidence of end-organ damage Hypertensive EMERGENCY: Severe HTN w/ evidence of end-organ damage (encephalopathy, renal failure, CHF, etc) |
|
what is important to remember about treating a hypertensive emergency?
(2) |
1) Immediate therapy is needed
2) IV drip w/ Nitroprusside or Nitroglyerin, but do not lower BP by more then 1/4 at first, or patient can have a stroke |
|
DOC for HTN w/o any comorbid dz
|
Thiazide
|
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DOC for HTN w/ CHF
(3) |
ACEI / ARBs
B-blocker, K-sparing diuretic |
|
DOC for HTN w/ MI
(2) |
B-blocker & ACEI
|
|
DOC for HTN w/ osteoporosis
|
Thiazide
(dec. calcium excretion) |
|
DOC for HTN w/ BPH
|
Terazosin
(Alpha-blocker) |
|
DOC for HTN w/ pregnancy
|
alpha-methyldopa
|
|
(3) contraindications for Beta-blockers
|
COPD
Diabetes HyperK |
|
(3) contraindications for ACEI
|
Pregnancy
Renal artery stenosis Renal Failure (creatinine >1.5) |
|
contraindication of all diuretics
|
Gout
|
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(2) hypersteroidism syndromes that cause HTN w/ hyperK
|
Cushing's
Conn's |
|
endocrine system abnormality that can lead to HTN due to episiodic autonomic bursts of epinepherine
|
Pheochomocytoma
|
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congenital cause of HTN that leads to HTN in arms and low BP in legs
|
Coartation of the Aorta
|
|
renal artery stenosis that causes HTN in:
1) older men 2) younger women |
1) atherosclerosis
2) fibromuscular dysplasia |
|
valvular problem that causes HTN w/ a wide PP due to Inc SV
|
Aortic Regurg
|
|
congenital problem that causes HTN w/ a wide PP due to Inc SV
|
Patent Ductus Arteriosus
|
|
(3) drug classes that cause HTN
What metal poisoning? |
Oral contraceptives
Corticosteroids Amphetamines Lead poisoning |
|
(5) deadly causes of chest pain
|
TAPUM:
Tension pneumothorax Aortic Dissection PE Unstable Angina MI |
|
how is the maximum HR determined?
|
220-patient's age = Max HR
|
|
(6) Major risk factors for CAD
which is most prevetable? which is the greatest risk? |
Diabetes (greatest)
Smoking (most preventable) HTN Hypercholesterolemia Family Hx Age |
|
Chest pain that has an established character, timing and duration; pain is transient, reproducable and predictable.
What is cause? What is Tx? (2) |
Stable Angina
Reduced coronary blood flow through fixed athrosclerotic plaque in vessel of heart rest & nitroglyerin |
|
exertional substernal (precordial) chest pressure and pain radiating to left arm, jaw or back.
N/V, diaphoresis, dyspnea, HTN and tachycardia can accompany it. Name the types |
Angina:
Stable Unstable Variant (Prinzmetal's) |
|
Angina type that is also considered an Acute Coronary Syndrome (ACS).
What (3) factors must it have for diagnosis? |
Unstable Angina
1) New-onset 2) angina that changes or accelerates in pattern, location or severity 3) Occurs at REST |
|
Similar characteristics of stable angina, but due to vasospasm instead of atherosclerosis.
(2) Tx? |
Variant (Prinzmetal's) Angina
Nitrates & Calcium Channel blockers |
|
what (2) groups of patients may not show the classic signs pain seen in stable angina?
Why? |
Elderly & diabetics
(b/c: neuropathies) |
|
What does the EKG look like for the (3) angina types?
|
Stable & Unstable:
- ST Depression - T-wave Inversion Variant: - ST elevation |
|
62-yo smoker w/ 3 episodes of severe heavy chest pain in the morning. Each lasted 3 - 5 minutes, but he has no pain now. He has never had this before.
What is it? |
Unstable Angina
|
|
62-yo man w/ frequent episodes of chest pain on and off for 8 months. He says the pain wakes him from sleep at night.
What is it? |
Variant (Prinzmetal's) Angina
|
|
what is the alternative to an exercise Stress Test if the patient cannot get on a treadmill?
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IV Dobutamine is given to stimulate myocardial function
|
|
What is the criteria for a "positive" Stress Test?
(5) |
either:
- ST elevation - ST depression >1 mm in multiple leads - Dec BP - failure to go more than 2 minutes - failure to complete for reason other then cardiac symptoms (i.e. arthritis) |
|
what does Myocardial Perfusion Imaging detect?
(3) |
- Myocardial perfusion
- Ventricular volume - Ejection Fraction |
|
An ultrasound of the heart revealing abnormal wall motion due to ischemia or infarction. It also assesses left ventricular function and EF
|
Echocardiography
|
|
(5) uses for a cardiac catherization
|
1) MI / Unstable angina: stent or angiography
2) Valvular disease: valvuloplasty 3) Arrhythmias: mapping bypass tracts 4) Myocardial dz Bx: glycogen storage dz or cardiomyopathies 5) Congenital heart dz identification: angiography & closure of defects |
|
(4) serum markers for MI
|
Myoglobin
Troponin T/I CK Lactate Dehydrogenase |
|
How is the right heart accessed in a cardiac catherization? (2)
Left heart? (2) |
Right:
Femoral or Internal Jugular Left: Femoral or Radial artery (from right heart) |
|
what is the wave morphology changes sequence in a MI ECG?
(6) |
1. peaked T-waves
2. T-wave inversion 3. ST elevation 4. Q-waves 5. ST normalization 6. T-waves return upright |
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which cardiac enzyme is the most sensitive and specific for acute MI?
|
Troponin-I/T
|
|
which cardiac enzyme remains increased (peaked) the longest?
|
LDH
|
|
what does ST depression mean?
|
ST goes in the opposite direction of the QRS
|
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what does a Q-wave on an EKG in the presence of an infarction indicate?
|
Transmural infarction
(extends through full thickness of the myocardial wall) |
|
Time of onset for the (4) serum markers for MI
|
Myoglobin (1-4 hrs)
Troponin-I/T (3-12) CK-MB (3-12) LDH (6-12) |
|
which cardiac enzyme has the shortest duration?
Longest? |
Myoglobin (1 day)
Troponin-I/T (7-10 days) |
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ST elevation in II, III & aVF
|
Inferior wall MI
|
|
ST depression in II, III & aVF
|
Cor Pulmonale
|
|
ST elevation in V1, V2, V3
|
Anterior/septal MI
|
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ST elevation in V4, V5, V6
|
Lateral wall MI
|
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ST depression in V1, V2
|
Posterior wall MI
|
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difference b/t unstable angina & non-ST elevation MI?
(2) |
non-ST elevation MI has:
1. more severe lack of Oxygen (more severe myocardial damage) 2. Enzyme leakage (Unstable angina has none) |
|
Tx for Unstable angina & MI
(6) |
MONA has HEP B:
Morphine Oxygen Nitrates Aspirin HEParin Beta-blockers |
|
primary Tx (2) for the acute MI w/in 6 hours of infarct
(name 4 drugs) |
Throbolytics:
- tPA + Heparin (DOC) - Urokinase - strptokinase - Alteplase |
|
At what level should LDL be in person w/ MI history?
What is given to lower it? |
less then 100
statins |
|
When are throbolytics indicated in MI?
(3) |
- patients < 80 yo
- within 6-12 hrs of chest pain - evidence of infarct on ECG |
|
Contra-indications of Throbolytics
(9) |
Having Some Breaks A Blood Clot In Small Pieces:
- Hx of intracranial bleed - stroke < 1 year - BP > 180/110 - active internal bleed - bleeding disorder - CPR - Intracranial tumor - suspected aortic dissection - Peptic ulcer |
|
drug class that is used to break up clots
|
throbolytics
|
|
drug that prevents future clots from forming
|
heparin
|
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Tx of choice for MI if there is a high risk of ST elevation (cardiogenic shock) or it has been 3 hours since initial symptoms presented?
|
PTCA
(Percutaneous Transluminal Coronary Angioplasty) |
|
which throbolytic is highly immunogenic and cannot be used in the same patient twice in a 6 month period?
|
streptokinase
|
|
what should be given 48 hours post infarct if tPA was used?
|
heparin
|
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drug class that is excellent for late & long-term therapy for acute MI to decrease afterload and prevent remodeling?
|
ACEi
|
|
how many seconds & boxes is a normal PR interval?
|
0.2 ms
5 small boxes |
|
define:
Q-wave When is it pathologic? |
when initial part of ventricular depolarization is downward
Pathologic: greater then 1 small box |
|
normal time & boxes for QRS interval?
|
< 0.12 ms
3 small boxes |
|
normal sinus rate
|
60 - 100 bpm
|
|
define:
Junctional rhythm |
rhythm originating in the AV node & causing narrow QRS w/o P-waves
|
|
no p-waves;
all complexes are wide; no changes in height (amplitude) w/ each complex; > 100bpm |
Ventricular tachycardia
|
|
wide QRS complexes that vary in amplitude
(2 names) |
Ventricular Fibrillation
Torsades de Pointes |
|
normal sinus rhythm w/ PR interval > 0.2 ms (> 5 small boxes)
|
First-degree AV block
|
|
PR interval elongates from beat to beat until it becomes so long that a beat drops
|
Second-degree AV block, type 1
(Wenckebach) |
|
PR interval is fixed but every so often there is a P-wave w/o a QRS
|
Second-degree AV block, type 2
(Mobitz) |
|
no relationship b/t P-waves and QRS complexes
|
Third-degree AV block
|
|
QRS > 0.12 (> 3 small boxes)
RSR' in V1 & V2; deep S-wave in lateral leads (I, aVL, V5 & V6) |
RBBB
|
|
QRS > 0.12 (> 3 small boxes);
RSR' in V5 & V6; diffuse ST elevation |
LBBB
|
|
Different shapes to 3 or more P-waves;
normal rhythm (what is it called if it is tachycardic?) |
Wandering pacemaker
MFAT: Multifocal Atrial Tachycardia |
|
short PR interval;
slurring delta wave connecting P-wave to QRS complex |
Wolff-Parkinson-White syndrome
|
|
diffuse ST elevation that slopes in a concave manner back to baseline + diffuse PR segment depression in all leads except PR elevation in aVR
|
Pericarditis
|
|
Tx of wandering pacemaker & MFAT?
(1 drug / 1 "other") |
Verapamil (Ca channel block)
& Tx underlying condition |
|
what Tx breaks SVT (superventricular tachy) in > 90%?
|
Adenosine
(failure to break r/o SVT) |
|
Tx for V-tach w/ hypotension or no pulse
|
Emergency defibrillation @
200 - 360 J |
|
Tx of asymptomatic V-tach
(2) |
Amiodarone
Lidocaine |
|
Tx of V-Fib
|
Emergent electroshock @
200 - 360 J |
|
58-yo man discharged from hospital after MI 2 weeks ago presents w/ fever, chest pain & malaise. EKG shows diffuse ST-T wave changes.
What is Dx? What is Tx? |
Dressler's syndrome
NSAIDs |
|
Medication orders w/ dischsrge of an ACS (post-MI) patient?
(5) |
easy AS ABC:
- Aspirin (indefinitely) - Statin to lower LDL < 100 - ACE-inh (if EF <40%) - Beta-blocker (indefinitely) - Clopidogrel for 1 - 12 mo depending on stent placement |
|
Dx:
fever, pericarditis & possible pericardial or pleural effusions post cardiac surgery |
Dressler's syndrome
|
|
how do you distinguish Paroxysmal Noctournal Dyspnea from asthma?
|
no improvement w/ bronchodilators
|
|
SVT w/ AV block & yellow skin
|
Digoxin toxicity
|
|
Etiology of Dilated Cardiomyopathy
(6) |
TIMED:
- Toxic (EtOH, heavy metals) - Infectious / Ischemic - Metabolic / Mechanical (arrthymia, valve dz) - Endocrine - Drugs |
|
what is the Reversible & Irreversible(2) toxic causes of Dilated Cardiomyopathy?
|
Reversible:
prolonged EtOH use Irreversible: Cocaine; heavy metal toxicity |
|
what is the Reversible & Irreversible(2) endocrine causes of Dilated Cardiomyopathy?
|
Reversible:
Thyroid disease (hypo or hyper) Irreversible: Acromegaly; Pheochromocytoma |
|
Reversible metabolic causes of Dilated Cardiomyopathy?
(4) |
HypoC;
HypoP; Thiamine deficiency (wet beri-beri); Selenium deficiency |
|
Infections that cause Dilated Cardiomyopathy
(3) |
HIV;
Coxsackie virus; Chagas disease |
|
Drugs that cause Dilated Cardiomyopathy
(2) |
Doxorubicin (Adriamycin);
AZT |
|
Signs/Sx of Dilated Cardiomyopathy
|
RAMS:
R & L Heart failure; A-fib; Mitral regurg; S-3 Gallop |
|
Diastolic or Systolic Dz Cardiomyopathy:
1. Dilated 2. Restrictive 3. Hypertrophic |
Systolic:
Dilated Diastolic: Restrictive & Hypertrophic |
|
Diagnostic results of Dilated cardiomyopathy
- auscultation - EKG (3) - CXR (2) - Echo (2) |
Auscultation: S-3;
EKG: Vent Hypertrophy, BBB &/or A-fib; CXR: Inc heart size; pulm congestion Echo: low EF, large ventricles |
|
Tx Dilated Cardiomyopathy
(3) |
- stop any toxic agents
- anticoagulation w/ coumadin (even w/o evidence of thrombus) - heart transplant |
|
Right or left ventricular enlargement w/ loss of contractile function causing CHF, arrythymia, or throbus formation.
|
Dilated Cardiomyopathy
|
|
Scarring & infiltration of the myocardium causing decreased right or left ventricular filling
|
Restrictive Cardiomyopathy
|
|
Etiology of Restrictive Cardiomyopathy
(7) |
ACHES:
Amyloidosis; Carcinoid heart dz / Congenital; Hemochromatosis; Endomyocardial fibrosis Sarcoidosis / Scleroderma |
|
Dx:
Pulmonary HTN (right CHF); S-4 gallop; Low QRS voltage on EKG; Exercise intolerance; Diastolic dz |
Restrictive Cardiomyopathy
|
|
(5) tests used to assist in the Dx of Restrictive Cardiomyopathy
|
Aucsultation;
EKG; CXR; Echo; Endomyocardial Bx* |
|
Increase in the size of the interventricular septum causing narrowing of the LV outflow tract leading to anterior mitral valve outflow obstruction
|
Hypertrophic Cardiomyopathy
|
|
another name for Hypertrophic Cardiomyopathy
|
IHSS
Idiopathic Hypertrophic Subaortic Stenosis |
|
(3) causes of paradoxical splitting of S-2
|
Hypertrophic cardiomyopathy (IHSS);
Aortic stenosis; LBBB |
|
murmur that decrease with squatting (and increases when returning to standing position)
|
Hypertrophic CM
(IHSS) |
|
etiology of Hypertrophic Cardiomyopathy
|
50% idiopathic
50% familial (autosomal dominant, w/ variable penetrance) |
|
Dx:
Angina (at rest or exercise); Syncope; Arrhythmias; CHF |
Hypertrophic Cardiomyopathy
|
|
sudden death from Hypertrophic CM is usually due to what?
|
Arrhythmias
|
|
25-yo man becomes severly dyspneic & collapses while running laps, His father died suddenly at an early age.
|
Hypertrophic CM (IHSS)
|
|
Diagnostic results to Dx Hypertrophic CM
- Auscultation (2) - EKG (4) - Echo (2) |
Auscultation - Systolic ejection murmur;
Paradoxical splitting of S2; EKG - LVH, PVCs, A-fib, ST & Q abnormalities; Echo - septal hypertrophy, LVH w/ small LV |
|
Tx for Hypertrophic CM
(3) |
- No exercise
- Beta-blocker - implantable cardiac defibrillator |
|
Most common infectious cause of Myocarditis
|
Coxsackie B
|
|
(4) systemic diseases that causes Myocarditis
|
KISS:
- Kawasaki's - Inflammatory conditions - SLE - Sarcoidosis |
|
(4) Parasites that cause Myocarditis
|
Trypanosoma Cruzi (Chagas);
Toxoplasmosis; Trichinella; Echinococcus |
|
(5) Bacterial causes of Myocarditis
|
Group A beta-hemolytic Strep (rheumatic fever);
Corynebacterium; Meningococcus; Lyme (B. burgdorferi); Trichinella |
|
(8) viral causes of myocarditis
|
Coxsackie A or B;
Echovirus; EBV: HIV; HBV CMV; Influenza; Adenovirus |
|
(3) drugs that cause pericarditis
|
Hydralazine;
Isoniazid; Procainamide |
|
Etiology of Pericarditis
(6) |
Bacterial, viral or fungal infections;
Serositis from: RA; SLE; Scleroderma; Uremia; post-MI (Dressler's syndrome) |
|
Tx for pericarditis if:
- infection - pain/inflammation - Dressler's - Recurrent cases |
- Tx infection w/ Abx;
- NSAIDs to relieve pain & reduce inflammation; - Steroids for Dressler's; - Pericardectomy only w/ recurrent cases |
|
Transient fall in BP > 10 mmHg during inspiration
|
Pulsus Paradoxus
|
|
Physiologic result of rapid accumulation of fluid in the pericardial sac; impairs cardiac filling & reduces cardiac output
|
Pericardial Tamponade
|
|
Etiology of Pericardial Tamponade
(3) |
- Pericarditis
- Trauma - Aortic dissection or ventricular rupture into pericardium |
|
Beck's triad of the pericardial tamponade
(4) other signs/Sx |
Beck's triad:
- Hypotension - Muffled heart sounds - JVD Other Sx: Dyspnea; Tachycardia; Pulsus Paradoxus* narrow Pulse Pressure |
|
Tx for Pericardial Tamponade for:
1. unstable 2. stable 3. both |
Unstable: Immediate Pericardiocentesis;
Stable: Pericardial window Both: Infuse fluids to expand volume |
|
Failure of venous pressure to fall during inspiration
|
Kussmaul's sign
|
|
If pericardiocentesis has clots, what is likely source of blood?
|
Right Ventricle
|
|
Patient has chest pain w/ inspiration that radiates to the left trapezial ridge;
Pain is relieved by sitting up and leaning forward; does not respond to nitroglycerine |
Pericarditis
|
|
additional signs/Sx for Constrictive pericarditis (versus pericarditis)
(4) |
- JVD
- Kussmaul's sign - peripheral edema - LV failure |
|
Heart valve dz almost always due to Rheumatic Fever
|
mitral stenosis
|
|
Murmur type:
Dyspnea on Exertion; Cough, rales; signs of RV failure; RV precordial thrust; Hoarse voice (from enlarged LA on recurrent laryngeal nerve) |
Mitral Stenosis
|
|
Diagnostic results for Mitral Stenosis
- Auscultation - CXR - EKG |
Auscultation: mid-diastolic opening snap;
CXR: large Left atrium & Kerely B lines EKG: LA enlargement; RV hypertrophy; A-fib |
|
Tx for mitral stenosis w/ each grade (I-IV)
What should always be avoided w/ mitral stenosis tx? |
Grade:
I: Diuretics; B-Blockers; Anticoagulants; Digitalis II: Drugs from I + Balloon valvuloplasty (if drugs dont work) III/IV: Balloon Valvuloplasty Avoid: Inotropic Agents! |
|
Acute etiology of Mitral Regurgitation
(2) |
MI w/ papillary muscle rupture;
Endocarditis |
|
Chronic etiology of Mitral Regurgitation
(3) |
Rheumatic fever;
Mitral Prolapse; LV dilation |
|
Diagnostic tests for Mitral Regurgitation
- Auscultation - EKG - Echo |
Auscultation: Loud, holosystolic apical murmur radiating to axilla
EKG: large LA Echo: valve problem |
|
Tx for Mitral Regurgitation
(6) |
ACEinh;
Diuretics; Vasodilators; Digitalis; Endocarditis prophylaxis; Surgery if severe |
|
Most common valvular disorder
|
Mitral prolapse
|
|
Asymptomatic murmur w/ genetic predisopositon, seen most commonly in women
|
Mitral Prolapse
|
|
What murmur is seen in Marfan's syndrome?
|
Mitral prolapse
|
|
Tx for mitral prolapse?
|
not necessary to tx unless symptomatic
|
|
Mean survival rate for patients w/ Aortic Stenosis and:
1. Angina 2. Syncope 3. Heart failure |
1. 5 years
2. 2 - 3 years 3. 1 - 2 years |
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Etiology of Aortic Stenosis
(2) |
- Calcific dz w/ age
- Bicuspid valve (around age 40) |
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Conditions w/ a wide Pulse Pressure
(6) |
WAH-HAH-ide pulse pressure:
Wet beri-beri Aortic Regurgitation; Hyperthyroidism; Hypertension; Anemia; Hypertrophic Subaortic Stenosis (IHSS) |
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WHat (2) valve disorders result in severe decompensation to CHF due to the absence of hemodynamic compensation.
How is it treated? |
Mitral Regurg
Aortic Regurg Tx: Emergent surgery |
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Classic triad of Sx for Aortic Stenosis
(4) other signs |
SAD:
- Syncope; - Angina; - Dyspna on Exertion Others: - Forceful apex beat - narrow Pulse Pressure - Paradoxical S2 split - heard in carotids |
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Diagnostic test results for Aortic Stenosis
- Auscultation - EKG - Echo - CXR |
Auscultation: Loud systolic crescendo-decrescendo murmur;
EKG: LV strain CXR: calcifications on valve Echo: diseased valve |
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What is the EKG LV strain pattern seen in aortic stenosis?
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ST depression & T-wave inversion in I, aVL, V5 & V6
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Tx for aortic stenosis
(2) |
- avoid Afterload reducers (ACEinh & beta-blockers)
- Valve replacement |
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(3) main etiologies for Aortic Regurgitation
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Aortic root dilatation;
Valvular dz; Proximal Aortic root dissection |
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(3) causes of Aortic root dilatation thereby causing Aortic Regurg
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Marfan's;
Idiopathic (but inc w/ HTN); Collagen vascular dz |
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(2) causes of Valvular dz thereby causing Aortic Regurg
|
Rheumatic heart dz;
Endocarditis |
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(6) causes of proximal Aortic root dissection thereby causing Aortic Regurg
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"C 3 SHET":
Cystic medial necrosis (Marfans); 3rd trimester pregnancy; Syphilis; HTN; Ehlers-Danlos; Turner's syndrome |
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Names of the 7 unique signs of Aortic regurg
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1. Water-Hammer pulse
2. Traube's sign 3. Corrigan's pulse 4. Quincke's sign 5. de Musset's sign 6. Muller's sign 7. Duroziez's sign |
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Aortic regurg sign:
wide pulse pressure presenting w/forceful arterial pulse upswing w/ rapid falloff |
Water-Hammer pulse
|
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Aortic regurg sign:
pistol-shot bruit over femoral pulse |
Traube's sign
|
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Aortic regurg sign:
unusually large carotid pulsations |
Corrigan's pulse
|
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Aortic regurg sign:
pulsatile blanching & reddening of fingernails upon light pressure |
Quincke's sign
|
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Aortic regurg sign:
head bobbing caused by carotid pulsation |
de Musset's sign
|
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Aortic regurg sign:
pulsatile bobbing of the uvula |
Muller's sign
|
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Aortic regurg sign:
to-&-fro murmur over femoral artery (heard best w/ mild pressure applied to artery) |
Duroziez's sign
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Murmur presentation:
dyspnea, orthopnea, paroxysmal noctournal dyspnea, angina, LV failure, wide pulse pressure |
Aortic regurg
|
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Murmur presentation:
starts asymptomatic, then dyspnea, angina, syncope, heart failure |
Aortic stenosis
|
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Murmur presentation:
mostly asymptomatic, atypical chest pain, SOB, fatigue |
Mitral Prolapse
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Murmur presentation:
dyspnea, fatigue, weakness, cough, A-fib, systemic emboli |
Mitral Regurg
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Murmur presentation:
DOE, rales, cough, hemoptysis, systemic emboli, RV precordial thrust, RV failure, Hoarse voice |
Mitral stenosis
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How do you diagnose LVH from a ECG?
(2) |
1. S-wave in V1 + R-wave in V5 or V6 > 7 large boxes (35 small)
2. R-wave in V5 or V6 > 25 small boxes OR R-wave in lead aVL > 11 small boxes |
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Diagnostic tests for Aortic Regurg
- Auscultation (3) - EKG |
Auscultation:
1. Holosystolic, blowing decrescendo diastolic murmur 2. Apical diastolic rumble (mitral stenosis w/o snap) 3. Midsystolic flow murmur at base EKG: LVH Echo: regurgitant valve |
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Tx for Aortic regurg
(3) |
Tx LV heart failure;
Endocarditis prophylaxis; Valve replacement |
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Etiology of Tricuspid stenosis
(3) |
Rheumatic heart dz;
Congenital; Carcinoid |
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Murmur presentation:
peripheral edema, JVD, hepatomegaly, ascites, jaundice (2) |
Tricuspid stenosis
or Tricuspid Regurg |
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Diagnostic results for Tricuspid stenosis:
- auscultation - echo Tx? |
Dx:
Auscultation: diastolic, rumbling low-pitched heard w/ inspiration Echo: diseased valve Tx: surgical repair |
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Dx:
Patient w/ DVT has a stroke. He has a fixed S2 split |
Atrial-septal defect
(w/ right-to-left emboli) |
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Etiology of Tricuspid Regurg
(4) |
Increased pulmonary artery Pressure (from L-CHF or Mitral stenosis/regurg);
R-CHF; Right papillary muscle rupture w/ MI; Tricuspid valve lesions (rheumatic heart or bacterial endocarditis) |
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(3) causes of a holosystolic murmur
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Mitral Regurg;
Tricuspid regurg; Ventricular Septal Defect |
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Number 1 cause of death in CHF patients
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Arrhythmia
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Diagnostic results for Tricuspid Regurg
- Auscultation - EKG - Echo |
Auscultation: Holosystolic murmur increasing w/ inspiration
EKG: RV enlargement; A-fib Echo: diseased valve |
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Tx for Tricuspid Regurg
(3) |
Tx heart failure;
Diuresis; Surgical repair of valve |
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What is done first if a patient has hyperK and peaked T-waves?
Why? |
give Calcium
to stabilize cardiac membrane |
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Causes of prolonged QT
(8) |
QT WIDTH:
QT: Prolonged QT syndrome W: WPW I: Infarction D: Drugs T: Torsades de pointes H: HypoK, HypoC, Hypomagnesium |
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Causes short QT
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HyperC
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Causes of Torsades de Pointes
(7) |
POINTES:
Phenothiazines Other meds (TCAs) Intracranial bleed No known cause (idiopathic) Type 1 Anti-arrhthymics Electrolyte abnormalities Syndrome of prolonged QT |
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Murmur:
Diastolic apical rumble & opening snap |
Mitral stenosis
|
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Murmur:
Late systolic murmur w/ midsystolic click What is confirming test? |
Mitral Prolapse
Valsalva - click starts earlier, murmur prolonged |
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Murmur:
High-pitched apical blowing holosystolic murmur where does it radiate? |
Mitral Regurg
radiates to axilla |
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Murmur:
Diastolic rumble louder w/ inspiration |
Tricuspid stenosis
|
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Murmur:
High-pitched blowing holosystolic murmur heard better w/ inspiration Where is it heard? Where are pulsations seen? |
Tricuspid Regurg
- heard @ left sternal border - Jugular pulsations |
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Name sign:
Peripheral pulses that are weak & late compared to heart sounds What murmur? |
Pulsus Parvus et Tardus
Aortic Stenosis |
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Murmur:
midsystolic crescendo-decrescendo murmur Where does it radiate? (2) What is also heard? |
Aortic stenosis
radiates to: Carotids & Apex - S4 also heard |
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Name sign:
Double-peaked arterial pulse what murmur? |
Pulsus Bisferiens
Aortic regurg |
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Murmur:
Blowing early diastolic, apical diastolic rumble, midsystolic flow murmurs |
Aortic Regurg
|
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Murmur:
Systolic murmur at apex & left sternal boarder not transmitted to carotids How is it heard better? |
IHSS
heard better w/ standing after squat |
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When do you hear the "flow murmur" (murmur heard w/ any high flow state)?
What is differential dx? (5) |
Midsystolic:
Aortic Regurg A-S defect (fixed split S2) Anemia Adolescence Pregnancy |
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What can be given to a patient to temporarily slow a rapid supraventricular rhythm in order for you to be able to identify it?
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Adenosine
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What drugs should not be given to someone w/ Wolff-Parkinson-White syndrome?
(4) What is the DOC? |
ABCD:
Adenosine Beta-blockers Calcium channel blockers Digoxin DOC: Procainamide |
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Causes of Mobitz I
(3) Causes of Mobitz II (2) |
Mobitz I:
Inferior wall MI Digitalis toxicity Inc Vagal tone Mobitz II: Inferior or septal wall MI Conduction system disease |
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Tx for Mobitz I & II
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Both:
Atropine & temporary pacing (Mobitz II should have pacemaker) |
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Causes of third-degree heart block
(3) |
Digitalis toxicity
Inferior wall MI Conduction system disease |
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Causes of Bradycardia
(6) |
if R-R is longer then "One INCH"
Overmedication; Inferior MI / Inc intracranial Pressure; Normal variant (athletes); Carotid sinus hypersensitivity; Hypoparathyroidism |
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Tx for bradycardia
(3) |
Atropine
pacing pressors for hypotension |
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a 24-yo woman w/ preclampsia Tx w/ IV drip of magnesium complains of difficulty breathing & has diminished reflexes. Next step?
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Stop magnesium & give IV calcium
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equation for Mean Arterial Pressure
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MAP = (2dBP + sBP)/3
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heart medication that can cause cyanide toxicity
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Nitroprusside
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Tx for Hypertensive emergency due to pheochromocytoma
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Phentolamine
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(2) possible Tx for a preclampsia-related hypertensive emergency
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Hydralazine
or Magnesium |
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difference b/t Type A & Type B Aortic Dissections
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Type A:
involves the ascending aorta & can extend into the descending aorta Type B: descending aorta only |
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Debakey Classification of Aortic Dissection Types I-III
Which is most common? |
I: Ascending plus part of distal aorta (most common)
II: Ascending only III: Descending only |
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What is infected on the aorta when the aortic dissection is due to syphilis?
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Vasa Vasorum
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Etiology of Aortic Dissection
(7) |
PATC3H:
Pregnancy (3rd trimester); Aortic Coarctation (Turners or idiopathic); Trauma; Congenital heart dz / CT dz (Marfans & E-D syndromes) / Cocaine; HTN |
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Dx:
Severe tearing chest pain that radiates to the back, HTN, possible unequal pulses distally, possible aortic regurg murmur |
Aortic Dissection
|
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(3) tests to confirm Dx of aortic dissection
|
CXR - wide mediastinum
CT w/ contrast Angiogram (gold standard) |
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Drug Tx for Aortic dissection to stabilize BP
What is the next step for Type A vs. Type B? |
Rx: Beta-blocker + nitroprusside to keep BP < 120
Type A: Immediate surgery Type B: medical stabilization |
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When a patient has VHD or previous endocarditis, what (3) procedure types must they obtain endocarditis prophylaxis medications?
|
Dental procedures
Urologic procedures GI procedures |
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Dx:
acute onset of fever, chills & rigors; new cardiac murmur, possible associated meningitis or pneumonia |
Acute Bacterial Endocarditis
(ABE) |
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Infection of healthy heart valves by high-virulence organisms
MCC? Px if not treated? |
ABE
S. Aureus Px: fatal if not Tx w/i 6 weeks |
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Dx:
seeding of previously damaged heart valves by rheumatic fever, mitral prolapse, etc by low-virulence organisms MCC? What valve is affected the most? |
Subacute Bacterial Endocarditis
Strep Viridans Mitral valve |
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What valve is most commonly affected w/ IV drug users?
What bug? |
Tricuspid
S. Aureus |
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what endocarditis bug is associated w/ colonic neoplasms?
|
Strep Bovis
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Dx:
gradual onset of fever, sweats, weakness, anorexia, new murmur, splenomegaly, Osler's nodes, splinter hemorrhages, Janeway lesions, Roth spots |
Subacute Bacterial Endocarditis (SBE)
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Name sign:
Tender violaceous subcutaneous nodules on fingers & toes |
Osler's nodes
(SBE) |
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Name sign:
fine linear hemorrhages in the middle of nailbeds |
Splinter Hemorrhages
|
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Name sign:
multiple hemorrhagic nontender macules or nodules on palms & soles |
Janeway Lesions
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Name sign:
retinal hemorrhages w/ clear central areas seen on fundoscopy (w/ new murmur) |
Roth's spots
(SBE) |
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What is considered Major criteria in the Duke's criteria for endocarditis?
(2) |
1. Two positive blood cultures
2. Echo showing vegetations |
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What are the (6) Minor criteria in the Duke's criteria for endocarditis?
|
1. Fever
2. Predisposing heart abnormality 3. Arterial emboli (Janeway) 4. Osler nodes or Roth's spots 5. positive blood culture not meeting major criteria 6. Echo suspicious of endocarditis, but not meeting major criteria |
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For the Duke's criteria of Endocarditis, what are the (3) ways to dx w/ major and minor signs?
|
1. (2) major criteria
2. (1) major + (3) minor 3. (5) minor criteria |
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Tx for endocarditis that cultures:
1. Strep 2. Staph 3. MRSA |
1. Ceftriaxone or Penicillin G (4 weeks)
2. Nafcillin (4 weeks) 3. Vancomycin (4 weeks) |
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What is the Tx for patients w/ Valular abnormalities if they are having dental procedures, GI or GU surgery?
(2) |
Prophylactic:
Amoxicillin or Clarithromycin |
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Valvular dysfunction requiring surgery is common w/ which type of organism?
|
Fungi
(Candida or Aspergillus) |
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Endocarditis type:
due to cancer seeding heart valves during metastasis what can it lead to? |
Marantic endocarditis
leads to cerebral infarcts |
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Endocarditis type:
may be due to autoantibody damage of valves by SLE |
Libman-Sacks endocarditis
|
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MC valve affected by RHD
|
Mitral
|
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Cause of Rheumatic fever?
What does it lead to? |
Group A Strep
leads to Rheumatic Heart Disease (RHD) - immune complex deposits on valves |
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Major criteria (JONES criteria) for Dx Rheumatic fever
(5) |
JCNES:
Joints (arthritis) Carditis (myo-, endo- or peri-) Nodules (sub-Q) Erythema marginatum rash Sydenham's chorea (face, tongue, upper limb) |
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Minor criteria for Dx Rheumatic fever
(5) |
Fever
Prolonged PR interval Elevated ESR Arthralgias Recent Strep infection |
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Tx for Rheumatic fever
(for strep, arthritis, carditis) |
Penicillin for strep;
ASA for arthritis; Steroids for carditis |
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Etiologies of Syncope
(7) |
SVNCOPE:
Situational (valsalva, tight collar); Vasovagal response (common faint); Neurogenic; Cardiac; Orthostatic hypotension; Psychiatric (faking it); Everything else (idiopathic) |
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At what level is HDL cardioprotective?
|
> 60
|
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What "type" is all isolated hypercholesterolemia?
|
Type IIa
|
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What transports cholesterol from the gut to the bloodstream?
|
Chylomicrons
|
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What is left over after lipoprotein lipase liberates FFA from chylomicrons for use in tissues?
|
Chylomicron remnants
|
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What is secreted from the liver and carries endogenous cholesterol?
|
VLDL
|
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What is metabolized from VLDL?
|
Intermediate-Density Lipoproteins
(IDL) |
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What is metabolized from IDL & carries cholesterol in the bloodstream to the tissues?
|
LDL
|
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What takes up free cholesterol secreted by the tissues and transports it to the liver?
|
HDL
|
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What is the name for the (3) Type IIa Isolated Hypercholesterolemias?
What is abnormal with all of them? |
Familial Hypercholesterolemia;
Familial defective apo-B100; Polygenic Hypercholesterolemia High LDL (total cholesterol from 240 - 500) |
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What are the (3) isolated Hypertriglyceridemias & each "Type"?
What is elevated w/ each? |
1. Familial Hypertriglyeridemia
Type IV - high VLDL 2. Familial Lipoprotein Lipase deficiency 3. Familial apo-CII deficiency (both Type I & V - high chylomicrons) |
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At what level is HDL cardioprotective?
|
> 60
|
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What "type" is all isolated hypercholesterolemia?
|
Type IIa
|
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What transports cholesterol from the gut to the bloodstream?
|
Chylomicrons
|
|
What is left over after lipoprotein lipase liberates FFA from chylomicrons for use in tissues?
|
Chylomicron remnants
|
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What is secreted from the liver and carries endogenous cholesterol?
|
VLDL
|
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What is metabolized from VLDL?
|
Intermediate-Density Lipoproteins
(IDL) |
|
What is metabolized from IDL & carries cholesterol in the bloodstream to the tissues?
|
LDL
|
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What takes up free cholesterol secreted by the tissues and transports it to the liver?
|
HDL
|
|
What is the name for the (3) Type IIa Isolated Hypercholesterolemias?
What is abnormal with all of them? |
Familial Hypercholesterolemia;
Familial defective apo-B100; Polygenic Hypercholesterolemia High LDL (total cholesterol from 240 - 500) |
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What are the (3) isolated Hypertriglyceridemias & each "Type"?
What is lelvated w/ each? |
1. Familial Hypertriglyeridemia
Type IV - high VLDL 2. Familial Lipoprotein Lipase deficiency 3. Familial apo-CII deficiency (both Type I & V - high chylomicrons) |
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Class of drugs that that reduce LDL by binding bile acids in the gut.
name (2) drugs |
Bile Acid Sequestrants
Cholestyramine Colestipol |
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which drug class is best for reducing triglycerides in VLDL & chylomicrons?
|
Fibrinates
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