COMLEX LEVEL 2 Complete (Original)

First line treatment for Impetigo

Leukocytosis w/ left shift indicates?

Dicloxacillin

Followed by Vanc if Beta-lactamase resistant

- Excess neutrophils ... essential a bacterial infection

Treatment:

Hot tub folliculitis

Impetigo by strep

Contact dermatitis

impetigo, abscess and folliculitis by staph

Fluoroquinolon, Ciprofloxacin

Cephalexin

Topical steroid

TMP-SMX

Difference between HIB and Influenzae

What's the pnuemococcal vaccine for?

HIB

- Cause lower respiratory infection

- HIB vaccine reduce incidence since 1990s

Influenzae

- high fever, runny nose, sore throat, muscle pains, headache, coughing, and feeling tired.

- Yearly vaccine

- Treat w/ neuraminidase inhibitors (oseltamivir and zanamivir) and M2 protein inhibitors (adamantane derivatives).

Pneumoccocal vaccine

- Protects against S. Pneumoniae

Media

1) Chocolate agar

2) Thayer-Martin

3) Eaton agar

4) Charcoal yeast

1) H. Influenzae

2) N. Gonorrhea

3) Mycoplasma

4) Legionella

Stains

1) PAS

2) India ink

3) Silver Stain

1) Whipple diseae

2) C. neoformans

3) Fungi (e.g., Pneumocystis), Legionella,

Helicobacter pylori

___ antibiotics have better coverage than any other class

List them

Beta-Lactam

Penicillin, Cephalosporins, carbapenems, aztreonam

Which bacteria are covered by Amoxicillin

HELPS

H --> H. influenzae

E --> E. Coli

L --> Listeria

P --> Proteus

S --> Salmonella

Piperacillin, ticarcillin, azlocillin, mezlocillin

Cover what kind of bacteria

What are they useful for

Gram (-)

• Cholecystitis and ascending cholangitis

• Pyelonephritis

• Bacteremia

-All stuff that can climb up a tract

• Hospital-acquired and ventilator-associated pneumonia

• Neutropenia and fever

Ceftriaxone, Cefotaxime, Ceftazidime

- What class are these?

What is ceftriaxonde first line for?

Avoid ceftriaxone in ____ pt. Why?

3rd gen cephalosporin

- Meningitis

- Community-acquired pneumonia (in combination with macrolides)

- Gonorrhea

- Lyme involving the heart or brain

Avoid ceftriaxone in neonates because of impaired biliary metabolism.

Best therapy for community-acquired pneumonia, including penicillinresistant pneumococcus

Use ___ for cystitis and pyelonephritis.

____ can be used as a single

agent for diverticulitis and does not need metronidazole.

Fluoroquinolones (Ciprofloxacin, Gemifloxacin, Levofloxacin, Moxifloxacin)

* Macrolides and doxycycline also used

Ciprofloxacin

Moxifloxacin

Side effect of quinolones

Bone growth abnormalities in children and pregnant woman

Tendonitis and tendon rupture

Treatment for cystitis and pneumocystis treatment/prophylaxis

Side effects?

Trimethoprim/Sulfamethoxazole

Rash

hemolysis in G6PD

Bone marrow suppression (folate antagonist)

What do all these bugs have in common together?(E. coli, Klebsiella, Proteus, Pseudomonas, Enterobacter, Citrobacter)

Treat them w/ (memorize this list)

All gram (-) and can cause infections of the bowel (peritonitis, diverticulitis); urinary tract (pyelonephritis); and liver (cholecystitis, cholangitis).

• Quinolones

• Aminoglycosides

• Carbapenems

• Piperacillin, ticarcillin

• Aztreonam

• Cephalosporins

Pt w/ fever, headache, neck stiffness (nuchal rigidity), and photophobia.

Most likely organism

Best initial test

Rash shaped like a target

Rash moves from arms/legs to trunk

Meningitis

S. Pneumonia (60%)

LP

- Unless there's possibility of space occupying lesion (Papilledema, Seizures, Focal neurological abnormalities, Confusion interfering with the neurological examination)

-In the above case, treat w/ empiric antibiotics first than do a CT

- TB will have the highest protein concentration (FYI)

Lyme disease

Rocky mountain spotted fever (Rickettsia)

Thousands of neutrophils on CSF. Treat w/

If you find increase PMN in CSF, this means? What about increase lymphocytes CSF?

Add __ if immunocompromised, elder or neonates for Listeria.

___ meningitis requires respiratory isolation.

- Give details about these precaution

Most common causes of neonatal meningitis

ceftriaxone, vancomycin, and steroids

PMN--> indicate bacteria infection

Lymphocytes --> indicate fungal or TB infection

ampicillin

neisseria meningitis

- Give rifampin to close contacts (people in the same household or healthcare worker that intubate pt) (people who work go or go to school w/ pt will not need it unless they are the pt's roommate)

S. Agalactiae (GBS), than E. Coli than listeria

Acute onset of fever and confusion. Must consider ____

Most likely cause

First initial test

Most accurate test

What do you use for acyclovir-resistant form

Encephalitis

HSV

CT (because of the presence of confusion)

PCR of CSF (better than brain biopsy)

- Tzanck prep --> best initial on genital lesions

-Viral culture --> Most accurate for genital lesions

Foscarnet (has more renal toxicity than acyclovir though)

Most sensitive physical finding for otitis media

Most accurate diagnostic test

best initial therapy

Most common cause of otitis?

immobile typmanic membrane

tympanocentesis

amoxicillin (add clavulanate if no response)

S. Pnuemoniae or Haemophilus influenzae

first-line therapy for both otitis and sinusitis

Amoxicillin/clavulanic acid

doxycycline

trimethoprim/sulfamethoxazole

Pt w/ pain on swallowing, enlarged lymph node, exudate on pharynx, fever, no cough

90% of cases are due to ____

- But can also be caused by

Best treatment

Why is treatment important

Pharyngitis

S. pharyngitis (Group A Beta-hemolytic)

- EBV or S. Pyogenes

*If EBV but you give amoxicillin accidentalyl for S. pyogenes, pt may present w/ rash

Amoxicillin or cephalexin (if penicillin allergic)

To prevent development of rheumatic fever

• Arthralgias/myalgias

• Cough

• Fever

• Headache and sore throat

• Nausea, vomiting, or diarrhea, especially in children

What is treatment protocol for these pt

Influenza (The Flu)

<48hrs of symptoms --> treat w/ neuraminidase inhibitors (oseltamavir and zanamivir)

>48 hrs of symptoms --> treat symptomatically

Blood and WBC in stool... Think

• __: poultry

• __: most common cause, associated with GBS

• __:H7-hemolytic uremic syndrome (HUS)

• __: second most common association with HUS. Pt can present w/ seizures too

• __: shellfish and cruise ships

• __: shellfish, history of liver disease, skin lesions

• __: high affinity for iron, hemochromatosis, blood transfusions

• __: white and red cells in stool

Salmonella

Camplybacter

E. Coli 0157

Shigella

Vibrio parahaemolyticus

Vibrio vulnificus

Yersian

C. Diff

Hep B is dependent on Hep ___

Hep ___ is worst in pregnancy

Hep ____ is transferred by sex, blood and perinatal

Hep __ is associated w/ IVDU

What abnormalities would u see on lab values w/ acute hepatitis

Hep ___ disease activity is assessed w/ PCR for RNA levels

C

E

- Typically found in E. Asian woman

B, C, D

C

increase direct bilirubin, ALT:AST (>2:1) and increase Alk Phos

C

Hep B panel

When would u see a positive e-antigen?

When would u see a neg core antibody w/ positive surface antibody

When is the only time you would see a positive surface antigen

What would show up first in Hep B infection

What is associated w/ the quantity of active viral replication

What is the best indicator that a mother will transmit Hep B to child

Acute or chronic infection

Pt who is vaccinated for Hep B

Acute or chronic infection

Surface antigen

E- Antigen

E- Antigen

What's the different physical exam finding between urethritis and cystitis?

What's treatment for urethritis

Both have dysuria with urinary frequency and burning but cystitis does not have urethral discharge like urethritis

Gonorrhea --> Ceftriaxone, Cefixime

Chlamydia --> Azithro, Doxycycline

• Lower abdominal tenderness / Pain

• Fever / Leukocytosis

• Cervical motion tenderness

What's your diagnosis

What's your first initial test

Inpatient vs outpatient treatment

PID

Exclude pregnancy

Inpatient: Cefoxitin or cefotetan combined with doxycycline

Outpatient: Ceftriaxone and doxycycline (possibly with metronidazole)

Painless ulcer

Painful ulcer

Lymph nodes tender and suppurating

Vesicles prior to ulcer and painful

Also list treatment for each

Syphilis

- Single dose of penicillin or Doxycycline if penicillin allergic

- Usually multiple bumps

Chancroid (Haemophilus ducreyl)

- Single dose Azithro (1gram PO)

- Usually single or multiple bumps

Lymphogranuloma venereum

- Doxycycline

Herpes simplex

-Acyclovir, valacyclovir, famciclovir Foscarnet for ovir-resistant herpes

What are the presentation of different type of syphilis and their treatment

Primary

- Painless genital ulcer and adenopathy

- Treat w/ IM penicillin (oral doxy if penicillin allergic)

Secondary

-Rash on palms and sole, condylomata lata

- Same treatment as primary syphilis

Tertiary

- Neurosyphilis (menigovascular stroke, tabes dorsalis, general paresis and argyll robertson pupils). Aortitis and gummas of skin and bones

- Treat w/ IV penicillin (desensitize to penicillin if penicillin allergic or pregnant woman)

Treatment for

Condylomata acuminata

Pediculosis

Scabies

- How does this spread?

Genital warts

- Cryotherapy w/ liquid nitrogen, surgery.... Podophyllin or imiquimod

Crabs

- Permethrin

Scabies

- Permethrin

- Close skin to skin contact

Best initial therapy for pyelonephritis

Presentation for cystitis

- How many WBC are you looking for on urinalysis

Treatment for cystitis

Ceftriaxone

- Use ampicillin and gentamicin until culture results are known

Suprapubic pain w/ mild fever

- 10 WBC

Nitrofurantoin, TMP/SMX, Cipro (try to reserve it though)

- Nitro for 3 days for uncomplicated cystitis/ Nitro 7 days if there's an anatomic abnormality

Most common bug for IVDU endocarditis

What do you find on presentation?

Best diagnostic test

If culture is neg but highly suspect endocarditis, treat w/

Treatment for endocarditis

- Strep

- Staph sensitive and resistant

-Enterococci

Prophylaxis for endocarditis is treated w/

- what are the features that indicate prophylaxis

Staph A.

Fever w/ new onset murmur (endocarditis almost always occurs w/ abnormal valve)

Blood culture and TEE (look for vegetations).... Don't do EKG

Vanco and gentamycin

- Treat w/ ceftriaxone for HACEK group (most common cause of culture-neg endocarditis)

-Coxiella and bartonella most common bugs for culture-neg endocarditis

-Ceftriaxone 4 weeks

- sensitive (oxacillin, nafcillin or cefazolin) / Resistant (Vanc) / ADD RIFAMPIN IF PROSTETIC VALVE W/ STAPH

- Ampicillin and gentamicin

Amoxicillin prior to procedure

-Significant cardiac defect and risk of bacteremia (dental work or respiratory tract surgery)

Lyme disease

Found in what region

Common presentations

Treatment

Caused by the ____, which is commonly carried by ___ on the white-tailed deer and white-footed mice

Northeast (rocky mountain)

-Rash (Erythema migrans "bull's eye)

-Joint pain (usually knee)

-Menigitis, encephalitis and cranial nerve palsy (Bell's, which is 7th cranial nerve)

-Transient AV block

Rash, joint paint and bell's palsy--> treat w/ doxy and amoxicillin

Cardiac and neurologic manifestations --> treat w/ IV ceftriaxone

spirochete (borrelia burgdorferi)

Ixodes ticks

HIV

Initial, confirmation and test for infected infants

When do you start treatment

What do you start treatment w/

What's the best test to assess treatment effectiveness

ELISA, confirme w/ Western, PCR or viral culture for infants

CD4 <350 or viral load >100,000

emtricitabine, tenofovir, and efavirenz (Atripla is the combination of the 3)

PCR-RNA for viral load. Not CD4 because CD4 changes lag behind viral load testing

Adverse effects of HIV Drugs

Zidovudine

Abacavir (HLA B5701)

Tenofovir

Anemia

Hypersensitivity, SJS

Renal insufficiency

Antiretroviral during pregnancy. When should you start treatment

-Patient on antiretrovirals at the time of pregnancy

-Not on antiretrovirals, CD4 low or viral load high

-Not on antiretrovirals, CD4 high and viral load low

Which antiretroviral should be avoided during pregnancy

Which drug should be given intrapartum and for 6 wks afterward to avoid transmission

When should u do a C-section

Right away and continue for all 3 trimester

- Continue same medications, except switch efavirenz to a protease inhibitor

- Initiate antiretrovirals immediately; continue after delivery

- Antiretrovirals; immediately stop them in the mother after delivery

Efavirenz (teratogenic)

Zidovudine

CD4 < 350, viral load high (>1000)

Blood and WBC in stool... Think

• Salmonella: poultry

• Campylobacter: most common cause, associated with GBS

• E. coli 0157:H7-hemolytic uremic syndrome (HUS)

• Shigella: second most common association with HUS

• Vibrio parahaemolyticus: shellfish and cruise ships

• Vibrio vulnificus: shellfish, history of liver disease, skin lesions

• Yersinia: high affinity for iron, hemochromatosis, blood transfusions

• Clostridium difficile: white and red cells in stool

What is the most common cause of osteomyelitis?

In those w/ sickle cell anemia

Diabetics and drug users

Staph

Salmonella

Pseudomonas

What is management for people w/ dog, cat or human bites

Amoxicillin/clavulanate should be given prophylactically

Tetantus vaccination booster if >5 yrs since last injection

What do these tell you on urinalysis?

-Leukocyte esterase test

- Nitrite test

___ is a vesicular eruption of the tonsillar region, soft palate, or posterior pharynx typically occuring in children 3-10 y.o.. It is most commonly as a result of infection by ____

Bacterial UTI

Gram negative bacterial UTI

Herpangina

- Coxsackie A virus

___ is localized anaphylaxis with a "wheal and flare."

Angioedema is swelling of ____

- Could be due to ____ or _____

-Treatment?

___ is sudden swelling of the superficial layer of the skin

Urticaria

Face, tongue, eyes, airway

- Recent start of ACE(-) or C1 esterase deficiency

-Ensure airway first. Acute therapy (FFP or Ecallanatide). Long term (androgen therapy).

.....GCT does not help in angioedema!

Urticaria

Pt presents w/ these symptoms. What is it?

• Watery eyes, sneezing, itchy nose, and itchy eyes

• Inflamed, boggy nasal mucosa

• Nasal polyps

How would there turbinates look like?

What is first line treatment?

Allergic rhinitis

• Pale or violaceous turbinates

Intranasal steroids

Pt present w/ recurrent sinupulmonary infection. Differential includes

Pt w/o AIDs presents w/ infections w/ PCP, Varicella and candida

Anaphylaxis to blood transfusion

Recurrent skin infection w/ staph

Immunodeficiency combined w/ thrombocytopenia and eczema

Lymph nodes w/ purulent material leaking out? What's the disease and best test

CVID, X-linked (Bruton) agammaglobulinemia, SCID and IgA deficiency

SCID

IgA deficiency

Hyper IgE syndrome

Wiskott-Aldrich syndrome

Chronic granulomatous disease

- Nitroblue tetrzolium test

Individuals w/ CVID are at increased risk for

lymphoma

MI extremely rare in woman before age ____.

___ may improve LDL but does not help in CAD in woman

Worst risk factor for CAD?

Most common risk factor for CAD?

What age in man and woman do u start to worry about CAD

What are considered family risk factors

50

Estrogen replacement

DBM

HTN

45

55

1st degree relatives only. If family w/ CAD who are elderly, they don't count as family risk factor (most common wrong answer for risk factor assessment)

Physical exam finding of those w/ ischemic chest pain

Infarct symptoms

Pleuritic (changes w/ respiration), pain changes w/ POSITION, pain changes w/ touch of chest wall (tenderness)

Sharp / knife-life pain

Pain worse w/ lying flat, better when sitting up, young <40

Sudden-onset of SOB, tachycardia and hypoxia?

- What's the most accurate test

Pericarditis

PE

- Spiral CT or V/Q Scan

Stress testing is the answer

when __ and ___

What nuclear test are useful in assessing chest pain?

the etiology of chest

pain is uncertain and the

EKG is not diagnostic

Thallium and sestamibi

Ischemia gives ___

wall motion or thallium

uptake between rest and

exercise. Infarction is

___

Most accurate test of detecting CAD?

___is to evaluate stable

patients with chest pain whose diagnoses are not clear.

reversible

irreversible or "fixed."

Angiography

Exercise tolerance testing

Chronic angina, what drugs lower mortality?

Low ejection fraction / systolic dysfunction. Best drug to lower mortality

What drug increase mortality in CAD

Recent angioplasty w/ stenting. What drug do u give

pt w/ CAD, what is LDL goal

ASA, B-Blocker and NitroGlycerin

ACE-I/ARB

Ca++ channel blockers

clopidogrel

<100

Pt intolerant to both ASA and clopidogrel. Which drug can u give

Hydralazine should be used in association with ___ to dilate the coronary arteries so that blood is not "stolen" away from coronary perfusion when afterload is decreased with the use of hydralazine

Ticlopidine

nitrates

Pt on statin meds should be monitored for what?

___ w/ statins can increase risk of myositis

Liver dysfunction. Routinely monitor AST and ALT

Fibrates (such as gemfibrozil)

Adverse effects of lipid lowering meds

Statins

Niacin

fibric acid derivatives

Cholestyramine

Ezetimibe

Elevations of transaminases (liver function tests), myositis

Elevation in glucose and uric acid level, pruritus

Increased risk of myositis when combined with statins

Flatus and abdominal cramping

Well tolerated and nearly useless

Use CCBs (verapamil/diltiazem) in CAD only with

Adverse Effects of CCBs

• Severe asthma precluding the use of beta blockers

• Prinzmetal variant angina

• Cocaine-induced chest pain (beta blockers thought to be contraindicated)

• Edema

• Constipation (verapamil most often)

• Heart block (rare)

Indications for a CABG

Are artery or vein graph better?

___ is the best in acute coronary syndromes, particularly with ST segment elevation

• Three vessels with at least 70% stenosis in each vessel

• Left main coronary artery occlusion

• Two-vessel disease in a patient with diabetes

• Persistent symptoms despite maximal medical therapy

Artery graph (last 10 yrs)

Vein graph (last 5 years)

PCI (angioplasty)

What is the S4 sound

What is the S3 sound

What is pulsus pardoxus and what is it associated w/

What is Kussmaul sign

Increase in wedge pressure is an indication of

Atrial pumping into a stiff ventricle

CHF

Decrease in BP >10mmHg on inspiration --> Pericardial tamponade

Inc in jugulovenous pressure on inhalation --> associated w/ constrictive pericarditis

pulmonary HTN

Leads V2-V4

Leads II, III, AVF

Leads V1, V2

Which is associated w/ worst mortality

Which leads are read backwards?

anterior wall

Inferior wall

Posterior wall

*present w/ reciprocal ECG changes

*Posterior descending from RCA

V2-V4 (anterior wall)

V1, V2 (therefore, ST depression is actually an infarct)

In acute coronary syndrome, what drug decreases mortality?

After drugs what should u do?

When does CK-MB and troponin show up? How long until levels go down?

ASA. Morphine, O2, and Nitro should be given but they do not decrease mortality.

- B-blocker --> lower mortality but does not matter when you give it

- ACE-I --> lower mortality in those w/ EF <40%

- Statin --> Lowers mortality in those w/ LDL >100

Thrombolytics or angioplasty and move them to ICU

- Door to balloon time --> 90 mins

-Door to needle --> 30 mins

- Preferred to do angioplasty but if facility doesn't have it than give thrombolytics

CK-MB and Troponin don't appear until 4hrs. CK-MK (1-2days) Troponin (10-14days)

Q waves

Cannon A waves

Old infarcts

3rd degree AV block (atrial systole against closed tricuspid valve)

How do you decrease stent placement complications?

Contraindications to stent placement?

- Place a stent that is drug-eluting (inhibits local T-cell response). This reduces rates of restenosis

Any bleeding, recent surgery (<2 wks), HTN (>180/110)

When do you us Ca++ Channel blocker in heart disease?

Cocaine-induced pain or prinzmetal/vasospasctic variant angina (don't use b-blocker --> lead to unrestricted alpha stimulation which may further vasoconstrict coronary vessels)

Drugs used for stable angina

Drugs used for unstable angina / Non-ST elevation MI

ST elevation MI

ASA, B-Blocker and Nitrates

Drugs above and Hep (non-ST elevation MI) and GPIIb/IIIa (Non-St elevation MI and about to undergo PCI and stenting)

Drugs above except for GPIIB/IIIa. Use thrombolytics if PCI is not available

RCA supplies

- R. Ventricle, AV node and inferior wall --> do not give nitro (will worsen MI)

*Nitro will decrease preload in inferior wall MI, which is preload dependent because it's not acting like a pump anymore. Good idea to give these pt fluids to increase preload

Murmur at apex and radiate to axilla

Pt w/ Turner's present w/ what cardiac defect?

MR

Coarctation of aorta

- also aortic stenosis due to bicuspid aortic valve

Step up in O2 from RA to RV --> you should think of

septal rupture, post MI

Several days post MI --> sudden loss of pulse

What do you need to consider for pts before discharge

What drugs do you discharge them home on?

Pt, post-MI, present w/ erectile dysfunction. Most likely cause?

Tamponade/free wall rupture --> Emergency ECHO followed by pericardiocentesis

- Do a stress test

- ASA, B-blocker, ACE-I and statin

-Anxiety, however B-blocker can cause some erectile dysfunction

*Post MI, pt can reengage in physical activity including sex right away

IWMI in history, clear lungs, tachycardia, hypotension with nitroglycerin

New murmur, rales/congestion

New murmur, increase in oxygen saturation on entering the right ventricle

RV infarct

Valve rupture

Septal rupture

Stress determines the need for ____. That determines the need for ____

Angiography

Revascularization, such as angioplasty and bypass surgery

*If pt are symptomatic --> Skip stress test and go straight to angiography

*Don't do angiography on infarcted heart (no point, tissue already dead)

Most likely diagnosis for dyspnea

1) Sudden onset, clear lungs

2) Sudden onset, wheezing, increased expiratory phase

3) Slower, fever, sputum, unilateral rales/rhonchi

4) Decreased breath sounds unilaterally, tracheal deviation

5) Circumoral numbness, caffeine use, history of anxiety

6) Pallor, gradual over days to weeks

7) Pulsus paradoxus, decreased heart sounds, JVD

8) Palpitations, syncope

9) Dullness to percussion at bases

10) Recent anesthetic use, brown blood not improved with oxygen, clear lungs on auscultation, cyanosis

11) Burning building or car, wood- Stove in winter, suicide attempt

1) PE

2) Asthma

3) pneumonia

4) pneumo

5) Panic attack

6) Anemia

7) Tamponade

8) Arrhythmia of almost any kind

9) Pleural effusion

10)methemoglobinemia

11) CO poisoning

Most important test in CHF

ECHO

*CHF is a clinical diagnosis. Should be able to identify it w/o labs or imaging. Most common cause of SOB

What should you order in acute shortness of breath in whom the etiology of the dyspnea is not clear and you cannot wait for an echo to be done.

BNP

- Normal BNP excludes CHF and pulmonary edema

Pharm treatment for systolic dysfunction CHF

Which of these drugs show mortality benefits

Pharm treatment for diastolic CHF w/ preserved EF

1) ACE-I or ARB

2)B-Blocker

- Only metoprolol, bisoprolol and carvedilol

- Metoprolol and bisoprolol specific B1 antagonist

- Carvedilol non-specific beta and a-1 antagonist

3) Spironolactone

- Only effective in CHF stage III and IV

- Switch to eplerenone if side effect of gynecomastia

4) Diuretics

- Give loop

5) Digoxin

- Used to control symptoms but no mortality benefit

ACE-I, B-Blocker, Spironolactone, hydralazine&nitrate, and implantable defibrillator

Beta-blocker and diuretics (don't use diuretics in HOCM)

When do you give

1) implantable defibrillator

2) Biventricular pacemaker

1) ischemic cardiomyopathy w/ EF <35%

2) Dilated cardiomyopathy w/ EF <35% and a wide QRS complex

*arrhthymia and sudden death are the most common cause of mortality in those w/ CHF

What's the most severe form of CHF

___ is ordered w/ the etiology of SOB is not clear

How do u distinguish between systolic or diasystolic CHF?

Engorged pulmonary veins indicate

Pulmonary Edema

BNP

ECHO

Pulmonary congestion (blood is backing up in the pulmonary system w/ often blood flow greater in the cephalad region because of pooling of pulmonary fluid in the base)

What is the best initial step for management of acute pulmonary edema

Loop diuretics -- remove large volume of fluid from vascular space --> reduces preload

- Afterward you can give them O2 and do an ECHO

Increase intensity w/ inhalation

Increase intensity w/ exhalation

Valvular heart disease

- Best initial test

- Most accurate

right side of the heart (triscupid or pulmonary valve)

Left side of the heart (Mitral or aortic valve)

- except for MVP and HOCM

-ECHO (TEE)

-Cath (can look into the chamber size and pressure gradient difference)

All forms of valvular heart disease will benefit from

___ is dilated w/ a balloon

Regurgitant respond best to

Rheuamtic fever can cause any valve dysfunction but the most common is __

diuretics

Mitral stenosis

Vasodilator therapy (ACEi/ARBs, nefedipine or hydralazine) --> all decrease venous return

Mitral stenosis

What are some unique presentation findings of mitral stenosis

Balloon valvuloplasty is not routinely done for ___

1) Dysphagia --> LA pressing on esophagus

2)Hoarseness --> LA pressing on largyneal nerve

3) A. Fib --> due to enlarge L. Atrium

4) Hemoptysis

AS --> because calcification doesn't improve much w/ a balloon

Diastolic murmur w/ opening snap

Systolic crescendo decrescendo.. Where does it radiate

Pansystolic that radiates to axilla

Diastolic, decrescendo murmur

More blood return increases all murmurs except ____

___ increases return

___ decreases return

Mitral stenosis

AS .... radiate to carotid A.

Mitral regurg

Aortic regurg --> heard best at L. LOWER STERNAL BORDER

MVP and HOCM

squatting / handgrip --> increase afterload and blood in the heart

valsalva / standing

Heart dilation will most likely result in what valve disorder

Mitral regurgitation or aortic regurg

What are some unique physical findings in aortic regurg

1) wide pulse pressure

2) Wide bounding pulse

3) Head bobbing

For MVP

____, which decrease venous return to the heart, will worsen MVP. Anything that increases left ventricular chamber size, such as___, will improve or diminish the murmur of MVP.

Valsalva and standing

squatting or handgrip

*MVP is essentially the opposite of what you would think intuitively... Don't forget this for the exam

*MVP is so common that it is at times considered a normal variant. Also rarely symptomatic

Cardiomyopathy

Present w/ ?

best initial test

Treat all of them w/ ?

edema, rales and JVD

ECHO

Diuretics (except for HOCM)

Hypertrophic cardiomyopathy

__ are the "best initial therapy" for both HOCM and ordinary HCM.

Diuretics & ACEi may help in ___, but they are contraindicated in___

___ should be used in any HOCM patient with syncope.

Beta blockers

HCM / HOCM

Implantable defibrillators

What are causes of restrictive cardiomyopathies

____improves HOCM

because the heart is

larger (more full), which

decreases the obstruction.

sarcodosis

amyloid

hemochromatosis

endomyocardial fibrosis

sceleroderma

Handgrip

Most common infection related to pericarditis?

Connective tissue disorder related to pericarditis

Pt presents w/

Viral (coxsackie B) followed by staph and strep

SLE, Wegener granulomatosis, Goodpasture, RA, polyarteritis nodosa, etc...

Pleuritic chest pain (worse when lying flat and better w/ sitting up). ST elevation in all leads and pulsus paradoxis

Hypotension, tachycardia, JVD and clear lungs

-Also w/ pulsus paradoxus

What would u see on EKG

what would u find on CATH

Pericardial tamponade

Electrical alternans, ST elevation in all leads, PR depression

Equalization of pressures in diastole

What causes constrictive pericarditis

Associated physical exam findings

Best initial test

Best treatment

Sufficient calcification and fibrosis that chronically prevents filling of the right side of the heart

Kussmaul sign

Knock--> Ventricular expansion hits a hard pericardium leading to a "knocking" sound

CXR --> shows calcification

Diuretics to relieve symptoms and surgical remove the pericardium

- Give NSAIDs for viral pericarditis

- Give CST for autoimmune pericarditis

____pain is worse when walking down hills, because of leaning back.

Spinal stenosis

Best initial test of PAD

Treatment

ABI (If <0.9 than considered positive for PAD)

-Not intuitive

ASA, smoking cessation and cilostazol (Phosphodiesterase 3-inhibitor)

What are key physical exam findings for aortic dissections

Best initial test

Most accurate test

Best initial treatment

Screening recommendations

- pain going back to scapula and difference in BP between the arms

CXR

Spiral CT angiography of the chest

-If ascending dissection that need to treat surgical right away before it ascends to the aortic valve

-If descending and pt stable, than give B-blocker first. Cont to control BP w/ nitroprusside

*Use short acting beta blocker (esmolol)

U/S Men >65 w/ smoking history (no screening for woman or those w/ non-smoker history)

What is eisenmenger syndrome

What is peripartum cardiomyopathy

Development of R. to L. shunt due to severe pulmonary HTN (there must be a ventricular septal defect for this to occur)

AB develops against the myocardium after delivery. Subsequent pregnancy will provoke large antibody against myocardium again... This is the most serious cardiac problem related to pregnancy

Someone presents w/ NS w/ tachycardia and no p-waves seen on ECG. What is the diagnosis

How do you treat?

SVT

Adenosine if pt is stable

Sync Cardioversion if pt is unstable

What is the NYHA classification of heart failure

Class I --> No limitation of physical activity, no symptoms on exertion

Class II --> slight limitations on physical activity and symptoms of heart failure with strenuous physical activity.

Class III --> symptoms such as angina, shortness of breath and palpitations, with minimal physical exertion.

Class IV --> symptoms of heart failure, even at rest.

Prolactin deficiency leads to

LH &FSH deficiency

Inhibits lactation at birth

Women --> amenorheic, decrease libido

Men --> no testosterone or sperm, decrease libido, erectile dysfunction

Describe Kallman syndrome

Decrease FHS and LH from decrease GnRH

Anosmia (can't smell)

Renal agenesis (50% of people)

Panhypopituitarism

___ is common secondary to hypothyroidism and isolated glucocorticoid underproduction.Potassium levels remain normal because aldosterone is not affected and aldosterone excretes potassium.

Hyponatremia

The two products of posterior pituitary are

___ deficiency is called central diabetes insipidius

What can cause nephrogenic DI

What effect does SIADH have on volume and electrolytei What about on urine?

How can you tell the difference between nephogenic and central DI?

ADH and oxytocin

ADH

any damage to the kidneys. Hypercalcemia and hypokalemia. Lithium will do damage to the kidneys as well

-Volume depletion and hypernatremia

-Decrease urine osmolality and sodium concentration

Vasopressin challenge

- Central DI will concentrate urine

- Nepho DI will not concentrate urine

What are some presentation of acromegaly

What is co-secreted w/ growth hormone

Best initial test for acromegaly?

• Increased hat, ring, and shoe size

• Carpal tunnel syndrome and obstructive sleep apnea from soft tissues enlarging

• Body odor from sweat gland hypertrophy

• Coarsening facial features and teeth widening from jaw growth

• Deep voice and macroglossia (big tongue)

• Colonic polyps and skin tags

• Arthralgias from joints growing out of alignment

• Hypertension for unclear reasons in 50%

• Cardiomegaly and CHF

Prolactin

IGF-1 Levels

What are some causes of hyperprolactinemia

Effects of hyperprlactinemia in men

Always exclude ___ in woman w/ high prolactin level

After prolactin levels are found to be high. What test do your run?

How do you treat it?

-Acromegaly (prolactin is co-secreted w/ GH)

-Hypothyrodism (high TRH stimulates prolactin secretion)

-Drugs such as verapamil

Erectile dysfunction and decrease libido

Pregnancy

Thyroid function test, pregnancy test, BUN/Creatinine

Give DA (Cabergoline is better tolerated than bromocriptine)

- Transphenoidal surgery if they do not respond to meds

In hypothyroidisms, all bodily processes are slowed down except for ___

What drug can cause hypothyrodism

When should you order antithyroid peroxidase/antthyroglobulin antibody and when should you start treatment

Is diarrhea associated w/ hyper or hypo thyroidism?

Menstrual flow

Amiodarone

If TSH is more than double normal and T4 normal --> treat

If TSH is elevated but less than double normal and T4 normal --> order Antibody test

Hyperthyroidism

What's the TSH level, RAIU, Confirmatory test and treatment for each of the following

1) Grave's Disease

2) Subacute Thyroiditis

3) Painless "Silent" Thyroiditis

4) Exogenous thyroid hormone use

5) Pituitary adenoma

1) Grave's Disease

- Low / Increase / AB test / Radioactive iodine

2) Subacute Thyroiditis

- Low / Decrease / Tenderness / ASA

3) Painless "Silent" Thyroiditis

- Low / Decrease / None / None

4) Exogenous thyroid hormone use

- Low / Decrease / History & Involuted gland / Stop use

5) Pituitary adenoma

- HIGH / Not done / MRI of the head / Surgery