10-25-2007, 07:45 PM
Cardio:
** Depressed CO + elevated PCWP+elevated SVR=> left ventricular failure. Cardio shock
Hypovolemia shock=> decreased PCWP + decreased CO
Pulmon shock => normal or lower PCWP,
** ST elevation in II, III, and aVF =>acute inferior wall myocardial infarction. occlusion of either the right coronary artery or the left circumflex artery. Left anterior descending artery occlusion causes anterior wall myocardial infarction.
# Pericarditis will have diffuse ST elevation in all leads
# Atrial fibrillation is a common complication of hyperthyroidism. Tx: beta-blocker like propranolol.
# early complications of an acute anterior wall Ml: Papillary muscle dysfunction=> Sudden onset of shortness of breath (SOB), bibasilar rales, an apical pansystolic murmur (PSM) radiating to the axilla(mitral regurgitation ). Ventricular septal rupture has similar features but the murmur is heard at the left sternal border and would not radiate to the axilla.
Pericardial tamponade-- not have any murmurs
# late complication of an acute anterior wall MI: Left ventricular aneurysm=>Precordia double apical beat, additional S3 or S4 and sometimes a murmur of mitral regurgitation is present due to papillary muscle dysfunction. Chest x-ray usually shows a characteristic prominence of the left border of the heart. The EKG shows persistent ST elevation.
# Free-wall rupture is an early mechanical complication of Ml. It does not produce a murmur and it presents with cardiogenic shock.
# Rupture of chordae tendinae is not a complication of Ml and it usually occurs secondary to trauma or infective endocarditis
# sick sinus node syndrome -- the best treatment is placement of a permanent pacemaker.
sick sinus syndrome refers to a clinical syndrome in which sinus node dysfunction produces symptomatic bradyarrhythmias, including sinus bradycardia, sinoatrial block and sinus arrest either singly or in combination. Symptoms may range from syncope, dizziness, confusion, and congestive heart failure.
# malignant hypertension-- high blood pressure (>/= 200/140 mmHg) + papilledema.
The pathologic change responsible for end-organ damage in malignant hypertension is fibrinoid necrosis of small arterioles.
# Amiodarone is a class 3 anti-arrhythmic agent, which has now been shown to be very effective in terminating both atrial and ventricular arrhythmias. However, administration of this drug has been known to cause lipoid accumulation in lung parenchyma lead to fibrosis. In a patient with compromised lung function, use of amiodarone can potentiate the lung injury and its use should be with held.
# Atrial fibrillation due to macro re entry circuits-- characterized by irregular undulation base line, No discrete P wave and QRS irregularly spaced.
Tx: hemodynamically unstabl-- electrical cardioversion
Stable w acute process -- either cardioversion or rate control
Stable w chronic process -- rate control along with anticoagulation
Electrical cardioversion should not be performed without 3-4 weeks of anticoagulation in chronic atrial fibrillation (>48hours), as the risk of embolization is high. Cardioversion can be either electrical or chemical. chemical cardioversion the best drugs would be class III agents (amiodarone, sotalol, ibutilide etc.)
For rate control -- either IV diltiazem or beta-blockers (IV metoprolol). Digoxin is a good agent for patients with heart failure (systolic dysfunction)
# recurrent VT, first thing to do after stabilizing the patient is to search for underlying cause, eg: Measure serum electrolytes if pt use digoxin, furosemide ïƒ decreased K
# third degree AV block-- atria and ventricles beat independently. Tx: permanent pacemaker
# Electromechanical dissociation is typical for pulmonary thromboembolism and pericardial tamponade.
# Increased automaticity is a frequent cause of arrhythmia in patients with glycoside intoxication.
# Reentrant ventricular arrhythmia (ventricular fibrillation) is the most common cause of
death in acute myocardial infarction.
# exertional angina + hypertension -- ST depression. best initial treatment-- beta-block, Calcium antagonists if beta-blockers are contraindicated or poorly tolerated.
# vasovagal syncope= neurocardiogenic syncope=> prodrome (lightheadedness, weakness, and blurred vision), provocation by an emotional situation, and rapid recovery of consciousness. frequently recurrent. Diag: upright tilt table testing
# The most common cause of aortic dissection is systemic HTN. “ sudden excruciating chest pain radiates to back. an early diastolic decrescendo murmur at the right or left sternal border. Chest x-ray -- a widened superior mediastinum. normal EKG. Diag: Transesophageal echocardiography
# Renal artery stenosis is a common cause of resistant hypertension in a patient with advanced atherosclerosis.
# diagnosis and follow-up of abdominal aortic aneurysms is an abdominal ultrasound
# The primary mechanism responsible for the effect of nitroglycerin in patients with anginal pain is dilation of veins (capacitance vessels). Increased venous capacitance and venous pooling of the blood lead to significant decrease in ventricular preload and decrease in heart size. As the result of these changes, oxygen requirement of the heart greatly reduces.
# aortic stenosis and hypertrophic cardiomyopathy produce a midsystolic (ejection systolic murmurs) murmur;
For aortic stenosis -- murmur at right second intercostal space, radiates to the carotids, Valsalva maneuver attenuates murmur
For HCM-- murmur at the lower left sternal border and it does not radiate to carotids, Valsalva maneuver accentuates murmur
# Myxomatous valvular degeneration is the most frequent cause of mitral valve prolapse
# Elderly patients are particularly sensitive to fluid loss, and even mild hypovolemia may predispose them to orthostatic syncope, especially upon getting up in the morning. BUN/creatinine ratio is a useful indicator of dehydration.
# Aortic regurgitation-- high-pitched, blowing, early diastolic decrescendo murmur heard best in the left third intercostal space. collapsing (water-hammer) pulse
Pulmonary regurgitation-- early diastolic, decrescendo, high-pitched, blowing, best heard along the left sternal border
The murmur of mitral stenosis is a mid-diastolic rumble and it is best heard at the apex.
The murmur of tricuspid stenosis is a mid-diastolic rumble and is best heard along the left lower sternal border.
The murmur of the aortic stenosis is ejection systolic and best heard at right 2nd intercostal space.
The murmur of tricuspid regurgiation is pansystolic
#Elevated liver enzymes and myopathy are well-known side effects of statins, the popular lipid-lowering drugs. They inhibit HMG-CoA reductase, a rate-limiting enzyme in the synthesis of cholesterol that converts HMG-CoA to mevalonate. It is important to know that mevalonate is used not only for the synthesis of cholesterol, but also for the production of several other products including dolichol and CoQ10. Reduced CoQ10 production has been implicated in the pathogenesis of statin-induced myopathy
# right ventricular infarctionïƒ Decreased compliance of right ventricleïƒ right ventricle dilatedïƒ tricuspid regurgitation(pansystolic murmur at the left lower sternal border) , Diastolic dysfunction of R ventricleïƒ R heart failure(jugular venous distension, KussmaulDs sign, hepatomegaly, and hypotension in the presence of clear lung fields)
# The hallmark finding mitral stenosis is elevated left atrioventricular pressure gradient that ultimately leads to left atrial enlargement.
# evaluate aortic stenosis “ Echocardiography
# Aspirin, beta-blockers, ACE inhibitors and spiranolactone improve survival in patients with heart failure, while digoxin and loop diuretics does not provide any survival benefit.
# It is better to keep Bp < 130/80 mmHg to slow end-organ damage in patients with diabetes and chronic renal failure.
# Amiodarone is an excellent drug for stable ventricular tachycardia and maintaining normal sinus rhythm following a ventricular arrhythmia
# Torsades de pointes”caused by 1st “ Quinidine, then procainamide, tricyclics and disopyramide. EKG -- varying QRS morphology with prolonged QT
Torsades can caused by hypokalemia, hypomagnesemia and hypocalcemia, acute ischemia and bradycardia. mitral valve prolapse, amyloidosis and acute myocarditis.
Tx: magnesium
# Jervell-Lange-Nielson syndrome=> congenital QT prolongation syndromes + congenital deafness. autosomal recessive. Cause torsades de pointesïƒ syncopal episodes and sudden death. Tx: beta-blocker like propranolol.
# Restrictive cardiomyopathy is characterized by severe diastolic dysfunction due to a stiff ventricular wall. Chest x-ray shows only mild enlargement of the cardiac silhouette. Echocardiography usually shows a symmetrically thickened ventricle wall, normal or slightly reduced left ventricle size and normal or near normal systolic function.
# Dilated cardiomyopathy is characterized by impaired systolic function of left and right ventricle leading to progressive cardiac enlargement. Chest x-ray shows marked or moderate enlargement of cardiac silhouette. Echocardiography shows systolic dysfunction and left ventricular dilatation with normal thickness of the ventricular wall.
# Hypertrophic cardiomyopathy is characterized by asymmetric left ventricular hypertrophy. In HCM, a harsh systolic murmur best heard at the left sternal border is also present. Chest x-ray shows mild enlargement of cardiac silhouette. Echocardiography shows vigorous systolic function, asymmetric septal hypertrophy and in some cases systolic anterior motion of the mitral valve. Due to the hypertrophy of the left ventricular wall, there is diastolic dysfunction.
# Dipyridamole and adenosine are coronary vasodilators. Infusion of these substances in patients without coronary artery disease, increases coronary blood flow three to five times above the baseline levels. However, in patients with coronary artery disease, the diseased vessels distal to the obstruction are already maximally dilated, and their ability to increase myocardial perfusion is limited; therefore, redistribution of coronary blood flow to non-diseased areas occurs, and the perfusion of diseased segments diminishes. This phenomenon demonstrated by dipyridamole is called coronary steal and is used to diagnose ischemic heart disease. Dipyridamole can be used during myocardial perfusion scanning to reveal the areas of restricted myocardial perfusion.
# prevention of recurrent attacks of rheumatic fever with antibiotic prophylaxis may slow down the progression of mitral stenosis in adolescents.
# The drugs that slow the AV conduction (digoxin and verapamil) are contraindicated in patients with atrial fibrillation and Wolff-Parkinson-White syndrome because they can increase the conduction of impulses through the accessory pathway, thus leading to malignant arrhythmias and hypotension.
# Procainamide or disopyramide are for Atrial fibrillation in the context of WPW syndrome.
# chemical cardioversion for atrial flutter is ibutilide
Either calcium channel blockers (verapamil or diltiazem) or beta-blockers can be used for rate control in acute/chronic atrial flutter
Atrial flutter with unstable hemodynamics is best treated with cardioversion
# ST segment depression, T wave inversion and first degree AV block can occur at therapeutic levels of digoxin. Atrial tachycardia along with variable degree of AV block is the most important EKG finding of digitalis toxicity
# In a post-MI hypertensive patient, beta-blockers and ACE inhibitors are preferred over diuretics and calcium channel blockers. Beta blockers decrease myocardial oxygen demand by reducing heart rate and contractility. ACE inhibitors improve prognosis in post-MI patients with subnormal EF by decreasing ventricular remodeling,
# Any patient who presents with sudden onset of chest pain, SOB, and has evidence of hypoxia and the new onset right bundle branch block should be considered as having a pulmonary embolism
# Marfan™s syndrome-- aneurysms of the ascending aorta
In aldut, Atherosclerosis-- aneurysm of the descending aorta
In yang, of blunt injuries to the chest-- aneurysm of the descending aorta
CT scans or angiograms are diagnostic
# high risk to develop infective endocarditis include: 1. All prosthetic heart valves. 2. Any history of previous bacterial endocarditis. 3. Complex cyanotic congenital heart disease and surgically- constructed systemic pulmonary shunts.
Patients with artificial pacemakers and defibrillators do not require prophylaxis for infective endocarditis.
# Absolute indications for dialysis
1. Fluid overload not responsive to medical treatment.
2. Hyperkalemia not responsive to medical management.
3. Uremic pericarditis.
4. Refractory metabolic acidosis.
Contraindications:
1. Debilitating chronic disease.
2. Severe irreversible dementia.
# isolated systolic hypertension”1st low-dose thiazide diuretic
# Antihypertensive management should be the first step in patients with aortic dissection with hypertension, then Transesophageal echocardiogram
# a difference of more than 30 mmHg in the blood pressure readings between two arms-- aortic dissection
# Cutaneous flushing and intensive generalized pruritis are well-known side effects of high-dose niacin therapy caused by drug-induced release of histamine and prostaglandins=> peripheral vasodilatation. can be reduced by low-dose aspirin
# Age-dependant idiopathic sclerocalcific changes are the most frequent cause of isolated aortic stenosis in elderly patients. Cause Exertional syncope.
# In a patient with an Ml who develops a cold leg, one has to get an ECHO to rule out a
thrombus in the left ventricle.
# A detailed medical history and physical examination is the most effective way to screen a low risk population for the presence of underlying cardiac disease.
# alcoholism-- thrombocytopenia, macrocytosis, and elevated transaminases, dilated cardiomyopathy”heart failure.
# Mobitztype 2 block is characterized by a fixed PR interval with an occasional dropped beat in a 2:1,3:1,4:1 pattern. The QRS is usually wide. Tx: permanent pacemaker
# Type I Mobitz or Wenckebach AV block is characterized by a narrow QRS, progressive increase in PR interval until a ventricular beat is dropped
# Stress testing with imaging is indicated when the patient has complete left bundle branch block, an idioventricular rhythm, Wolff-Parkinson-White syndrome, and ST depression of greater than 1 mm at rest.
Dobutamine stress echo is indicated in patients who can™t do sufficient exercise,
Coronary angiogram is indicated in patients who have abnormal stress testing
exercise EKG testing should be the initial test of choice for stable angina when there is an intermediate pretest probability of coronary heart disease that is based on patient™s age, sex and symptoms.
# Sepsis is the most common cause adult ARDS
# hypertrophic obstructive cardiomyopathy -- systolic anterior motion of mitral valve leaflet that causes mitral regurgitation.
# Mitral annulus calcification due to aging occurs in elderly, is a degenerative process and it may lead to severe mitral regurgitation.
# Mitral valve prolapse is the most common cause for isolated mitral regurgitation in North America.
# An atrial premature beat results from the premature activation of the atria that originates from a site other than the SA node. EKG shows an early P wave. Tobacco and alcohol are reversible risk factors for the development of atrial premature beats.
# Think of cocaine intoxication in a young patient presenting with chest pain/myocardial infarction or stroke. Features of cocaine intoxication are cocaine bugs, agitation, decreased appetite, dilated pupils, elevated or decreased blood pressure, tachycardia or bradycardia, and sweating.
# The earliest EKG finding in acute Ml is peaked (hyperacute) T waves, followed by ST elevation, followed by the inversion of T waves, followed by the appearance of Q waves.
Peaked T ïƒ ST elevationïƒ inversion Tïƒ Q waves
# Nitrates are contraindicated when a patient is continuously or intermittently taking sildenafil. It is recommended not to use nitrates within 24 hours of the last dose of sildenafil. The reason for the dangerous interaction between nitrates and sildenafil is that both induce nitric oxide mediated vasodilatation. In such settings nitrates may cause syncope, Ml, or sudden death when a patient has an acute coronary syndrome.
# ventricular tachycardia “ widen QRS. The best treatment w no hemodynamic compromise ïƒ either lidocaine or amiodarone. Unstable ïƒ cardioversion
# Carotid massage is useful for supraventricular tachycardia
# Dressler™s syndrome, an autoimmune pericarditis, is a late complication of acute Ml that usually develops between the second and tenth weeks post Ml.
# Norepinephrine is a powerful vasoconstrictor and can lead to decreased blood supply to both the lower and upper extremity cause Bluish discoloration and cool fingers
# septic shock both right atrial pressures and pulmonary capillary wedge pressure are low.
# Treatment with IV heparin, aspirin, beta-blocker, and nitroglycerin is indicated unstable angina and non-Q wave infarcts
# thrombolytic therapy indicate 1) MI w ST elevation greater than 1 mm in two contiguous leads after sublingual nitroglycerin administration to rule out coronary vasospasm. 2) new left bundle branch block
# Thrombolytic therapy, with tissue plasminogen activator, requires co-administration of heparin and aspirin for additional benefit. Streptokinase do not need co-administration of heparin because it may produce allergy.
Thiazide diuretics are the initial antihypertensive of choice in patients with osteoporosis. Thiazide diuretics decrease urinary calcium excretion
# Chaga™s disease caused by Trypanosoma cruzi. megacolon or mega-esophagus, cardiomegaly -- >cardiomyopathy, conduction abnormalities
** Decreased tolerance to glucose is a well-known side effect of thiazide diuretic therapyïƒ hyperglycemia. Also increased LDL cholesterol & triglycerides. hyponatremia, hypokalemia and hypercalcemia
# Presence of hypotension, pulsus paradoxus, and pulseless electrical activity in a
patient with a recent acute Ml should make you think of free ventricular wall ruptureïƒ acute cardiac tamponade
Free wall rupture usually occurs in the first week after Ml. Risk factors include advanced age, large Q wave infarct, a history of HTN, and no prior history of angina pectoris.
# Papillary muscle rupture -- occurs in the first week after an acute Ml. lead to acute mitral regurgitation and a pansystolic murmur
# Premature atrial beats never require any treatment and are completely benign
# Digoxin is particularly used in patients with heart failure (systolic dysfunction) and atrial fibrillation/flutter. It increases the AV nodal refractoriness and thereby slows the ventricular rate in atrial fibrillation and flutter.
# In all ST elevation Ml, reperfusion therapy with thrombolytics or PTCA(Percutaneous Coronary Interventions (previously called Angioplasty, Percutaneous Transluminal Coronary [PTCA], or Balloon Angioplasty) with or without stenting must be performed as soon as possible.
PCI is the reperfusion therapy of choice as it has a better outcome than thrombolysis.
Contraindications to thrombolytics include active bleeding, history of a hemorrhagic stroke anytime or a cerebrovascular accident within the last year, drug allergy or systolic BP greater than 175 mmHg.
Concurrent administration of glycoprotein llb/llla inhibitors has shown promising results with improved coronary reperfusion, early ST segment resolution, and reduction of the incidence of recurrent ischemia and infarction. The role of GP llb/llla inhibitors in primary PCI(PTCA) is not certain. At some centers it is used routinely while at others, it is given under special circumstances like the finding of residual thrombus.
# Constrictive pericarditis-- decreased cardiac output (fatigue, muscle wasting etc) and /or signs and symptoms of venous overload like elevated JVP, dyspnea, ascites, positive Kussmaul's sign, pedal edema, tender hepatomegaly etc. Sharp 'x' and y descent on central venous tracing is characteristic of constrictive pericarditis as is the presence of pericardial knock. Tuberculosis is the most common cause of constrictive pericarditis
# Calcium channel blockers are the drugs of choice for Variant anginaïƒ rest chest pain w transient ST elevation during the episode of chest pain which usually returns to baseline as the pain resolves. Cardiac enzymes are usually negative. Caused by coronary vasospasm
# situational syncope related to micturition caused by autonomic dysregulation
# The EKG findings in pericardial tamponade include sinus tachycardia, low voltage QRS complexes, and electrical alternans. Electrical alternans is characterized by alternating amplitudes of QRS complexes
# Mobitz type I heart block is characterized by a narrow QRS, progressive increase in PR interval until a ventricular beat is dropped,. In type II block -- dropped QRS complex with normal PR interval. In third degree AV block -- atria and ventricles beat independently
# Even though IV beta-blockers improve mortality in acute Ml, they are contraindicated in the presence of pulmonary edema. Other absolute contraindications to their use include asthma, hypotension, severe bradycardia and heart block greater than first degree.
# CK-MB fraction has a high specificity for an acute Ml (slightly lower than cardiac troponins). It begins to rise within 4-6 hours after Ml and returns to baseline within 48-72 hours. It™s high specificity and rapid return to the baseline makes it the biomarker of choice for the diagnosis of a recurrent Ml.
# Cardiac troponins T and cardiac troponins I are proteins that control the interaction of actin and myosin. They are more specific than all the other biomarkers of cardiac injury being used for the diagnosis of Ml. They begin to rise 4-6 hours after an Ml, and remain elevated for 10 days. They have now become the primary biochemical tests used for the diagnosis of acute Ml. They have also replaced LDH for the retrospective diagnosis of Ml.
# Acute transmural infarct => Q-waves + ST elevation
# The diagnosis of ventricular septal rupture (The diagnosis of ventricular septal rupture can be made if there is evidence of left to right shunting on Swan-Ganz catheter readings )can be made if there is evidence of left to right shunting on Swan-Ganz catheter readings
# Aspirin, ACE inhibitors, and beta-blockers have been shown to reduce mortality in
the setting of acute Ml.
# Alpha-blockers(Doxazosin) are preferred in patients with BPH and an unfavorable metabolic profile (dyslipidemia, glucose intolerance).
# Mitral valve prolapse is the most common cause of mitral regurgitation in USA. papillary muscle dysfunction or infarction as the next most common cause
#Beta blockers are used to treat chest pain, palpitations, and autonomic symptoms of MVP.
# The first line medication for HTN in the general population is either a thiazide diuretic or beta-blocker. Non-selective beta-blockers are contraindicated in asthmatics especially if they are steroid dependent or on continuous albuterol.
# ACE inhibitors, like enalapril, are the 1st line drugs for diabetics with hypertension. These are usually 2nd line drugs for the general population.
# Generally, we can say that prophylaxis is recommended for high-risk conditions and is optional for moderate risk conditions.
Conditions put a patient at high risk to develop infective endocarditis include:
1. All prosthetic heart valves.
2. Any history of previous bacterial endocarditis.
3. Complex cyanotic congenital heart disease and surgically constructed systemic pulmonary shunts.
Conditions, which put a patient at moderate risk to develop infective endocarditis includes:
1. Congenital cardiac malformations not falling into the high or negligible risk categories (such as PDA, VSD, ostium primum ASD, bicuspid aortic valve and coarctation).
2. Acquired valvular heart disease (such as rheumatic heart disease, valvular stenosis and regurgitation).
3. MVP with regurgitation and/or myxomatous leaflets.
4. Hypertrophic cardiomyopathy.
a moderate-risk cardiac condition and now the decision about the need and choice of antibiotic regimen will depend on the type of procedure.
For dental procedures with bleeding, antibiotic prophylaxis is recommended both in high-risk and moderate-risk patients. For dental procedures which are unlikely to cause bleeding, prophylaxis is not recommended.
For respiratory procedures like rigid bronchoscopy and operations involving mucosa, antibiotic prophylaxis is recommended both in high-risk and moderate-risk patients. For flexible bronchoscopy, prophylaxis is optional in high-risk patients and not recommended in moderate-risk patients. For endotracheal intubation, prophylaxis is not recommended
For gastrointestinal procedures like sclerotherapy of varices, gastrointestinal surgery involving mucosa, biliary tract surgery, esophageal stricture dilatation and ERCP in the presence of obstruction, antibiotic prophylaxis is recommended in high-risk patients and optional in moderate risk patients. For endoscopy and TEE, prophylaxis is optional in high-risk patients and not recommended in moderate-risk patients
For genitourinary tract procedures like prostatic surgery, cystoscopy and urethral dilatation, antibiotic prophylaxis is recommended both in high-risk and moderate-risk patients. For urethral catheterization, uterine D&C, therapeutic abortion, sterilization or insertion or removal of IUD, prophylaxis is recommended only when an infection is present. For vaginal delivery and vaginal hysterectomy, prophylaxis is optional in the high-risk patient. For cesarian section, prophylaxis is not recommended.
# supraventricular tachycardia-- HR of >140/min, regular, loss of P waves and narrow QRS complex. Tx: unstableïƒ cardioversion. Stableïƒ vagal maneuvers initially, If these fail -- > IV adenosine push
# Prolonged, tachysystolic atrial fibrillation causes significant left ventricular (LV) dilation and a depressed ejection fraction. Tx: Controlling the rhythm or rate
# Hyperkalemia and pregnancy are contraindications to the use of ACE inhibitors
# Beta-blockers can worsen severe peripheral vascular disease while helping for blood pressure.
# Jugular venous distention (JVD) and RBBB indicate right heart strain
# Think of PE in a postoperative patient with JVD and new onset RBBB
# Hypertrophic cardiomyopathy has an autosomal dominant mode of inheritance.
# Screening should be done in all first-degree relatives of the patients of hypertrophic cardiomyopathy and the most effective way of screening these people is echocardiography. Detailed history and examination is the screening method used for young athletes
# Diastolic and continuous murmurs as well as loud systolic murmurs revealed on cardiac auscultation should always be investigated using transthoracic Doppler echocardiography. Midsystolic soft murmurs (grade l-ll/IV) in an asymptomatic young patient are usually benign and need no further work-up.
# Hyperkalemia present in this patient may be due to the combination of enalapril, digoxin, and spironolactone. Furosemide causes hypokalemia.
# Hyponatremia is a bad prognostic factor in patients with heart failure. It indicates the presence of severe heart failure and a high level of neurohumoral activation
# The early third heart sound, that is also called pericardial knock and the inspiratory increase in the jugular venous pressure (KussmaulDs sign), are important physical findings of constrictive pericarditis. KussmaulDs sign is also present in right sided heart failure, severe tricuspid regurgitation, right ventricular infarction and cardiac tamponade.
# Water hammer or collapsing pulse and pistol shot femoral pulses are diagnostic clues to aortic regurgitation
Tapping apex beat and malar flush are important physical findings of mitral stenosis. Pulsus paradoxus is defined as greater than 10-mmHg fall of the systolic blood pressure during inspiration
# Pulsus paradoxus and hypotension point toward the diagnosis of pericardial tamponade
# A pansystolic murmur at the left sternal border is usually seen in tricuspid regurgitation
# Calcium channel blockers have good peripheral vasodilating properties that can help to diminish the symptoms of intermittent claudication. They are also metabolically neutral, not affecting plasma lipid profile.
# Infective endocarditis prophylaxis and repeated regular follow-ups are recommended for all patients of aortic stenosis even if they are asymptomatic.
# Isolated premature ventricular arrhythmias generally do not require any medical
treatment; observation is usually the treatment of choice
# Transmural infarcts-- ST segment elevation followed by the development of Q waves and elevation of cardiac enzymes
# Subendocardial infarcts are characterized by ST segment depressions that are not followed by the development of Q waves and elevation of cardiac enzymes.
# All patients with unstable angina(either ST depression, T wave inversion, or many times no changes) should be hospitalized and treated with aspirin, IV heparin, and IV nitroglycerin. Once the patient is free of chest pain, an angiography can be performed non-emergently.
# Chronic oral contraceptive use is a common cause of secondary hypertension caused by an estrogen-mediated increase in the synthesis of angiotensinogen in the liver
# Coxsackie-B virus is a common cause of acute pericarditis.
# A history of recent upper respiratory tract infection followed by sudden onset of cardiac failure in an otherwise healthy patient is suggestive of dilated cardiomyopathy, most likely secondary to acute viral myocarditis(Coxsackie B infection). The diagnosis is made by echocardiogram, which typically shows dilated ventricles with diffuse hypokinesia resulting in low ejection fraction (systolic dysfunction). Viral myocarditis can cause dilated cardiomyopathy by direct viral damage, as well as sequel of humoral or cellular immune responses to persistent viral infection.
Concentric hypertrophy of the heart is seen following chronic pressure overload, as in valvular aortic stenosis or untreated hypertension
Eccentric hypertrophy of the heart is seen following chronic volume overload, as seen in valvular regurgitation
# Isolated systolic hypertension (ISH) is important cause of hypertension in elderly patients caused by decreased elasticity of the arterial wall. Tx: Always treat isolated systolic hypertension. “ Hydrochlorothiazide
# Diuretics, nitrates, ACEi and digitalis be avoided in HCM especially when an outflow gradient is present. hypertrophic cardiomyopathyïƒ Beta-blockers are usually the first line of medication.
# Dressier syndrome typically occurs two-to-four weeks after an Ml and presents with a low-grade fever, malaise and pleuritic chest pain. ECG will reveal 'non specific1 ST elevations and there may be a pericardial effusion. NSAIDs are the agents of choice.
# Lidocaine increased risk of asystole
# Valsalva maneuver and standing after squatting are two maneuvers that decrease left ventricle volume thus increasing the gradient and intensifying the associated systolic murmur. handgrip increases the systemic arterial resistance and thus decreases the gradient and associated systolic murmur. Phenylephrine also decreases the murmur by increasing systemic arterial pressure. Leg elevation increases the left ventricular volume and thus decreases the gradient and the associated murmur.
# Whenever a patient of chronic aortic regurgitation develops symptoms of LV dysfunction, he should undergo aortic valve replacement after his congestive symptoms are relieved by intense medical treatment with digoxin, diuretics, and vasodilators (ACE inhibitors).
Acute aortic regurgitation is an emergency and requires emergent surgery. Sodium nitroprusside or inotropes like dopamine or dobutamine are used to stabilize this condition before emergent surgery can take place.
#I.V atropine is the drug of first choice in patients with symptomatic bradycardia (Choice B). Transcutaneous pacing is the next step after atropine. If the patient has severe bradycardia with hypotension then epinephrine is the drug of choice
Adenosine is used for supraventricular tachycardia
# If average alcohol intake is greater than 2 drinks/day, risk of development of hypertension increases by 1.5-2 times compared to the general population and the risk increases substantially if the average alcohol intake is greater than 5 drinks/day. On the other hand moderation of alcohol intake to 1-2 drinks per days also has been shown to have a cardioprotective effect ïƒ decrease blood pressure
# Thrombolytic therapy is indicated when the chest pain is suggestive of Ml and there is ST segment elevation greater than 1 mm in two contiguous leads after sublingual nitroglycerin administration to rule out coronary vasospasm. Another indication for thrombolytic therapy is a new or presumably new left bundle branch block. Thrombolytic therapy is not indicated for an Ml with ST segment depression and it is also not indicated for unstable angina.
Thrombolytic therapy with tissue plasminogen activator requires co-administration of heparin and aspirin for greater benefit. Tissue plasminogen activator is slightly more effective than streptokinase but it has a slightly more risk of intracranial bleeding. For streptokinase, co-administration of heparin is not required.
# Treatment with IV heparin, aspirin, and IV nitroglycerin is indicated in cases of unstable angina and non-Q wave infarcts
# Manage a patient with ST segment elevation Ml with immediate angiography and PTCA when thrombolytic are contraindicated. Even if the patient has no contraindications forthrombolytic therapy and a catheterization laboratory is available in the hospital, or within 30 min of the hospital, PTCA with stent placement has been shown to have better outcomes than thrombolytic therapy in acute ST elevation Ml.
# Severe systolic dysfunction and increased left ventricle size are features of dilated cardiomyopathy.
Supernormal ejection fraction is present in hypertrophic cardiomyopathy as is dynamic outflow obstruction. Diastolic dysfunction is present in HCM, due to the stiff, hypertrophied ventricle wall.
# ejection fraction (EF) normal = 55-65%
# Digoxin slows the ventricular response rate in atrial fibrillation by slowing down AV conduction and thus increasing the diastolic filling. It also has a beneficial effect in patients of systolic dysfunction due to its positive inotropic effect. Thus any patient who has atrial fibrillation and heart failure will benefit from digoxin; it should be considered over before beta-blockers or calcium channel blockers.
# Beta-blockers are preferred over the digoxin or calcium channel blockers in patients with coronary artery disease. Calcium channel blockers are not the best drugs for patients with heart failure due to their negative inotropic effect.
# IV dobutamine is used when a patient is in cardiogenic shock.
# Mitral valve prolapse-- systolic click, The click occurs earlier with standing and Valsalva maneuver and it disappears with squatting and handgrip
#Cutaneous flushing and intensive generalized pruritis are well-known side effects of high-dose niacin therapy (high dose is required to treat lipid abnormalities). These effects are explained by niacin-induced peripheral vasodilatation. The mechanism involved in this reaction is believed to be drug-induced release of histamine and prostaglandins. can be reduced by low-dose aspirin
# In a patient with an Ml who develops a cold leg, one has to get an ECHO to rule out a
thrombus in the left ventricle.
# exercise EKG testing should be the initial test of choice for stable angina
# Presence of complete RBBB (or) ST depression at rest of less than 1 mm are not contraindications to perform stress testing. Stress testing with imaging is indicated when the patient has complete left bundle branch block, an idioventricular rhythm, Wolff-Parkinson-White syndrome, and ST depression of greater than 1 mm at rest.
# Dobutamine stress echo is indicated in patients who canDt do sufficient exercise.
# in hypertrophic cardiomyopathy it is the systolic anterior motion of mitral valve leaflet that causes mitral regurgitation Coronary angiogram is indicated in patients who have abnormal stress testing
# Aortic stenosis may present with syncope, angina, or dyspnea (SAD) on exertion
ENT
4 allergic rhinitis -- pale bluish mucosa, dark, puffy eyelids
5 Otitis externa is always painful and tender; pain without tenderness suggests middle rather than an external infection
6 Juvenile angiofibroma-- triad of nasal obstruction, nasopharyngeal mass, and recurrent epistaxis. headache, conductive hearing loss, and diplopia secondary to erosion into cranial cavity and pressure on optic chiasm. CTscan of the head and the face is confirmatory
7 nasal polyps are recurrent episodes of rhinitis, chronic nasal obstruction, altered taste sensation, diminished sense of smell and persistent postnasal drip
8 Manner -- recurrent episodes of rotational vertigo, sensorineural hearing loss and tinnitus.
9 Serous otitis media”aids pt with hearing difficulty, dull tympanic membrane which is sluggish to air insufflation and presence of air fluid levels in the middle ear. Caused by auditory tube dysfunction arising from HIV lymphadenopathy or obstructing lymphomas
10 Peritonsillar abscess presents with unilateral sore throat, neck pain, referred
earache, dysphagia, swollen tonsils, drooling, and trismus -- Streptococcus pyogenes
1 Furosemide, a loop diuretic can cause ototoxicity”hearing loss, tinnitus and dysequilibrium
2 Cavernous Sinus Thrombosis is the most common, late complication of infection of the central face or para nasal sinuses.-- dysfunction of the CN III, IV, V, and VI are present. Lateral gaze palsy (CN VI dysfunction), ptosis, mydriasis (CN III dysfunction), absent corneal reflex (CN V dysfunction), CT is the definitive procedure for diagnosis. The mainstay of treatment is early and aggressive antibiotic administration. Anticoagulants and corticosteroids may also be used as adjunctive therapy, Patients present with severe headache, followed by fever and periorbital edemea.
3 Viral rhinitis-- Nasal examination shows an erythematous mucosa, Allergic rhinitis-- clear nasal discharge and nasal mucosa is pale or bluish.
4 Juvenile angiofibroma is a vascular tumor -- the most common benign tumor of nasopharynx The triad of nasal obstruction, nasopharyngeal mass, and recurrent epistaxis in a young male is highly suggestive of juvenile angiofibroma. Juvenile angiofibroma can be managed with medical or surgical therapy depending on the stage of tumor, examination there is a grayish-red mass in the posterior nasopharynx.
5 Typical symptoms of nasal polyps are recurrent episodes of rhinitis, chronic nasal obstruction, altered taste sensation, diminished sense of smell and persistent postnasal drip
6 meniere™s syndrom-- recurrent episodes of rotational vertigo, sensorineural hearing loss and tinnitus. Benign positional vertigo-- not usually associated with hearing loss or tinnitus. Acute labyrinthitis-- follows a viral infection or mumps, ear ache, vertigo
7 Serous otitis media is the most common middle ear pathology in acquired immuno deficiency syndrome. It presents with hearing difficulty, dull tympanic membrane which is sluggish to air insufflation and presence of air fluid levels in the middle ear. It is due to the auditory tube dysfunction arising from HIV lymphadenopathy or obstructing lymphomas.
8 Chronic otitis media usually presents with purulent aural discharge. Tympanic membrane appears thickened with calcific patches and perforation
9 Otosclerosis is an osseous dyscrasia limited to the temporal bone. It causes symptomatic hearing loss + tinnitus tinnitus by third decade of life. Otoscopic examination --usually normal, 10% of patients demonstrate a Schwartz sign, characterized by a reddish-blue hue over promontory and oval window niche areas, secondary to rich vascular supply associated with immature and audiometry shows conductive hearing loss and loss of stapedial reflex, It is inherited in an autosomal dominant pattern with incomplete penetrance. Treatment consists of oral sodium fiuoride
10 peritonsillar abscess -- unilateral sore throat, neck pain, referred earache, and dysphagia, trismus, pooling of saliva, and a muffled voice. associated with prominent cervical lymphadenitis and deviation of uvula. tonsils are swollen-- Streptococcus pyogenes is the most commonly associated organism-- Treatment consists of Iv antibiotics and needle aspiration of the abscess. Failure to obtain pus is an indication for surgical incision and more formal exploration
Retropharyngeal abscess also presents with neck pain, sore throat, and dysphagia. These patients have posterior pharyngeal edema, nuchal rigidity, cervical adenopathy, fever, and drooling of saliva. Tonsils are normal
11 Presbyopia is the loss of accommodative capacity that occurs with ageing. Usually patients notice inability to focus objects at normal reading distance and complain of having to hold books at arms length to read. It is corrected with convex lenses In Hyperopia light rays fall behind the retina, Myopia or shortsightedness -- light rays are focused in front of the retina. It is corrected using concave lenses
12 quinine is being used for treating cramps in dialysis patients. Vancomycin can cause nephrotoxicity and the red man syndrome (due to histamine release from mast cells)
13 Tinnitus can sometimes occur in patients taking aspirin, quinine, and even in patients who are depressed -- It can cause disruption of sleep, concentration and depression. Tricyclic anti¬depressants have been found to be effective for this condition.
14 Glomus tumor arises in the middle ear or in the jugular bulb. They present with pulsatile tinnitus and hearing loss
15 Presbyacusis-- high frequency hearing loss in both ears associated with difficulty in speech discrimination
16 Petrous apicitis presents with a triad of retro orbital pain, lateral rectus palsy, and otorrhea.
17 Orbital cellulitis is manifested by abrupt onset of fever, proptosis, restriction of extra
ocular movements, and swollen red eyelids. “ cause Staphylococcus aureus, Streptococcus pneumoniae, and Hemophilus influenza
18 Malignant otitis externa is an infection of external ear -- caused by pseudomonas aeruginosa and occurs in patients who suffer from coexisting diseases such as diabetes mellitus, malnutrition, leukemia, and other debilitating diseases. foul smelling discharge, deep otalgia, granulations in ear canal and involvement of cranial nerves VII, IX-XII. X-rays should be done in all cases of suspected malignant otitis externa to look for the degree of damage to the body tissues X-rays should be done in all cases of suspected malignant otitis externa to look for the degree of damage to the body tissues
19 Cholesteatoma is an epithelial cyst that contains desquamated keratin-- repeated infections or progressive conductive hearing loss, drainage and granulation tissue that are unresponsive to antibiotic treatment, characterized by marginal tympanic membrane perforation or sometimes it may present as ear canal filled with mucous, pus and granulation tissue. Cholesteatomas destroy bones and therefore, any bony structure in or around the middle ear and mastoid cavity can be eroded “CT. Therapy consists of surgical removal Therapy consists of surgical removal
20 Tympanic sclerosis is common sequelae of chronic otitis media. It presents as thickening and calcification of the tympanic membrane. Hearing loss is rare Tympanic sclerosis is common sequelae of chronic otitis media. It presents as thickening and calcification of the tympanic membrane. Hearing loss is rare
21 Central Retinal Vein Occlusion (CRVO) presents with sudden, painless, unilateral loss of vision. disk swelling, venous dilation and tortuosity, retinal hemorrhages and cotton wool spots. -> emergent ophthalmologist referral emergent ophthalmologist referral
22 Acute angle closure glaucoma is characterized by sudden onset of symptoms such as blurred vision, severe eye pain, nausea and vomiting. Examination reveals a red eye with hazy cornea and a fixed dilated pupil
23 Optic neuritis also presents with sudden unilateral loss of vision but is associated with severe pain. Fundoscopy may reveal swollen optic disc and central scotoma. They will also have pupillary abnormalities pallor of the optic disc, cherry red fovea and boxcar segmentation of blood in the retinal veins.
24 Central retinal artery occlusion is also characterized by sudden painless loss of vision in one eye.-- pallor of the optic disc, cherry red fovea and boxcar segmentation of blood in the retinal veins.
25 In patients with asthma and nasal polyps, aspirin is contraindicated as it may lead to severe bronchospasm (aspirin triad or SamterDs triad).
26 Eustachian tube dysfunction is a common cause of conductive hearing loss in children. Symptoms follow the onset of upper respiratory tract infection or allergic rhinitis - aural fullness, popping noise while swallowing or yawning, intermittent ear pain, and hearing loss. Otoscopy reveals retraction and decreased mobility of the tympanic membrane. Hallmark of eustachian tube dysfunction is a middle ear effusion. treated with auto insufflations and oral and nasal decongestants
27 Leukoplakia -- whitish patch or plaque, granular appearance ->hard to remove caused by chronic irritation to the oral mucosa due to smoking, alcohol, or ill-fitting dentures and Vitamin A and B deficiencies and syphilis. risk of transformation into squamous cell carcinoma. incisional biopsy or exfoliative cytologic examination should always be done.
28 Hairy leukoplakia is a white, painless lesion - found in AIDS patient on the lateral aspect of tongue. It is caused by Epstein Barr Virus (EBV).
29 Lichen planus is characterized by polygonal, violaceous, papular eruption covered by fine scales. These lesions when involving oral mucosa have higher incidence of malignant transformation.
30 Keith-Wagener classification -- stages of hypertensive retinopathy
Slight AV nicking “ grade 1
Copper wiring, AV depression with humping ends “g 2 G2g
Silver wiring, flame shaped hemorrhages, exudates “g3 333
Flame shaped hemorrhages, exudates and papilledema “ g 4
31 Mastoiditis is the most common complication of the otitis media, pain behind the ear, and fever. Examination reveals erythema, edema, and tenderness over mastoid area( behind ear ). protruded auricle. CT imaging may be used to confirm the clinical diagnosis. It demonstrates fluid filled middle ear and demineralization of mastoid trabeculae. Intravenous antibiotics are the immediate treatment of choice
32 Treatment of choice for streptococcal pharyngitis is single injection of IM Benzathine penicillin G
33 IV crystalline penicillin G is used in cases of bacterial meningitis, endocarditis, and neurosyphilis
34 Bullous myringitis presents with painful vesicles on the tympanic membrane. It is associated with mycoplasma or viral respiratory Infection
35 Diabetic Retinopathy -- micro aneurysms, hemorrhages, exudates, and retinal edema. pre proliferative retinopathy with cotton wool spots. malignant retinopathy-- proliferative retinopathy consisting newly formed vessels -> leading cause of blindness in USA.
Tx- Argon Laser photocoagulation
36 Retinal detachment - retina hanging in the vitreous.
37 Open angle glaucoma-- gradual loss of peripheral vision resulting in tunnel vision. cupping of optic disc
38 Cigarette smoking increases the risk of macular degeneration
39 H. Influenzae and Group A Streptococcus are the most common causes of
epiglottitis
40 Gonococcal conjunctivitis - copious purulent eye discharge with swollen eyelids and chemosis, occurs 2-3 days after birth. Tx ->A single intramuscular dose of ceftriaxone
41 Neonatal chlamydial conjunctivitis presents with mild hyperemia with scant mucoid eye discharge not purulent. It occurs about 5-14 days after birth
42 Chemical conjunctivitis is the most common cause of conjunctivitis occurring within the first 24 hours after birth. A history of silver nitrate eye drops instillation is usually present
43 Sialolithiasis presents as post-prandial pain and swelling. calculus formation within the ductal system of salivary gland is most common in submandibular gland followed by sublingual and parotid gland. x-ray of the involved salivary gland is diagnostic. Treatment consists of dilation and incision of the involved duetto remove the calculus.
GenitaUrine
============
1 Membranoproliferative glomerulonephritis, type 2 -- Dense intramembranous deposits that stain for C3, caused by IgG antibodies (termed C3 nephritic factor) directed against C3 convertase of the alternative complement pathway. These antibodies reacting with C3 convertase lead to persistent complement activation and kidney damage
2 immune complex-mediated glomerulopathies that include SLE, post-streptococcal glomerulonephritis
3 anti-GMB antibody “ good pasture ˜ syndrom. idiopathic crescentic glomerulonephritis.-- Cell-mediated injury
4 collapsing focal and segmental glomerulosclerosis is the most common form of
glomerulopathy associated with HIV. Typical presentation includes nephritic range proteinuria, azotemia, and normal sized kidneys
5 HIV + hepatitis B -> membranous glomerulonephritis
6 Cardiovascular disease is the most common cause of death in dialysis patients and in renal transplant patients
7 interstitial nephritis are caused by drugs such as cephalosporins, penicillins, sulfonamides, sulfonamide containing diuretics, NSAIDDs, Rifampin, phenytoin, and allopurinol. Discontinuing the offending drug is the treatment of drug-induced interstitial nephritis
Clinical features include fever, rash and arthralgias. Other features are peripheral eosinophilia, hematuria, sterile pyuria and eosinophiluria. WBC casts may be present in the urine
8 sickle cell trait in a young black male - > painless episode hematuria. Caused by apillar ischemia. Papillar necrosis can occur with massive hematuria
9 analgesic nephropathy “ headache + painless hematuria. results from papillary ischemia induced by analgesic-mediated vasoconstriction of medullary blood vessels (vasa recta). ->Papillary necrosis
10 several years of analgesic abuse induce pailess hematuria characterized by chronic tubuiointerstitial damage
11 Any patient with recurrent sinusitis, cavitary lung lesions, pulmonary hemorrhages and
glomerulonephritis will most likely have WegenerDs glomerulonephritis. Both hematuria and hemoptysis are seen in cases of GoodpastureDs syndrome and WegenerD s granulomatosis. In WegenerDs granulomatosis
12 hepatitis B infection-- membranous glomerulonephritis, but HBsAg carriers-- membranoproliferative glomerulonephritis
13 Child or adolescent presenting with priapism suspect sickle cell disease and leukemia
14 Fluoxetine does lead to sexual dysfunction, resulting in impotence, decreased libido and ejaculatory problems,
15 Priapism with Trazadone.
16 All patients with chronic renal failure and hematocrit < 30% (or hemoglobin <10g/dl_) are candidates for recombinant erythropoietin therapy after iron deficiency has been ruled out. Erythropoietin is also indicated in all the hemodialysis patients who have symptoms attributed in part to anemia
most common side effects of erythropoietin therapy are:
a. Worsening of hypertension or induced hypertension “ Tx: fluid removal (by dialysis) and use of anti¬hypertensive drugs (beta blockers and vasodilators are preferred).
b. Headaches
c. Flu like syndrome
d. red cell aplasia
17 recurrent renal stones need 24hr urine is collected to find any underlying metabolic disorder. A detailed metabolic evaluation is not needed when a patient presents with their first renal stone
18 Finasteride acts on epithelium. alpha-1 blockers act on smooth muscles of
prostate and bladder base
19 Finasteride is 5-alpha reductase inhibitor and it inhibits the conversion of testosterone to dihydrotestosterone. It acts on the epithelial components of the prostate gland and produces improvement of symptoms as well as reduction in the size of the gland. BPH w collagen predominance respond neither to finasteride nor to alpha-1 blockers
19 epididymitis characterized by fever, painful enlargement of testes, and irritative voiding symptoms usually w UTI, in younger patients is usually caused by sexually transmitted organisms such as C. trachomatis or N. gonorrhea. In older men it is usually non-sexually transmitted and is caused by gram-negative rods
20 Peritoneal dialysis is an alternative to hemodialysis when vascular access is not possible; when there is bleeding tendency; when there is hemodynamic instability; or when a patient is having hypothermia
21 Indications for dialysis includes uremic symptoms such as pericarditis, encephalopathy, coagulopathy, and fluid overload unresponsive to diuresis, hyperkalemia not amenable to standard therapy, and pH less than 7.20 (acidosis
22 All patients with irritative or obstructive voiding symptoms should have their urinalysis and serum creatinine done. Patients with elevated serum creatinine levels should have ultrasound of kidney, ureter and bladder done
23 Glomerular hyperfiltration is believed to be the earliest renal abnormality present in patients with diabetes mellitus. It creates intraglomerular hypertension leading to progressive glomerular damage and renal function loss. diabetic nephropathy =>Thickening of the glomerular basement membrane is the first change that can be quantitated -> mesangial expansion -> Nodular sclerosis
24 acyclovir- Nephrotoxicity.= > Crystalluria with renal tubular obstruction & acute renal failure
25 Fibromuscular dysplasia can present with diastolic hypertension in children. Bruit or venous hum may be heard at the costovertebral angle. Angiogram will reveal "string of beads" sign
26 Alport™s syndrome -recurrent episodes of hematuria with proteinuria
sensorineural deafness and family history of renal failure. Electron microscopy --thinned and thickened capillary loops with splitting of GBM
27 In a patient with flank pain, fevers, chills and white blood cells in the urine, think
pyelonephritis. Urine and blood cultures should be obtained prior to obtaining
antibiotics.
28 medullary cystic kidney- in adults with recurrent UTI or renal stones ( x-ray shows nephrocalcinosis and contrast filled cysts demonstrated by IVP. AD. is not associated with renal failure or hypertension. whereas the juvenile form also known as nephronophthisis is autosomal recessive.
29 Alpha-blockers are used for the treatment of benign prostatic hyperplasia. Phenoxybenzamine is a non- selective alpha-blocker. Prazosin, Terazosin and Doxazosin are all selective alpha-1 blockers recommended for the treatment of BPH. They produce side effects like orthostatic hypotension, headache, dizziness, retrograde ejaculation and rhinitis
30 Tamsulosin is a new drug and it blocks only alpha-1 receptors that are present in prostate and bladder base used for the treatment of benign prostatic hyperplasia
31 Cystinuria is an inherited disease causing recurrent renal stone formation. impaired amino acid transport by the brush borders of renal tubular and intestinal epithelial cells. Urinalysis - hexagonal crystals. Urinary cyanide nitroprusside test, detects elevated cystine level, helps to confirm the diagnosis
32 cryoglobulinemia includes palpable purpura, glomerulonephritis(proteinuria and hematuria) along with high titers of rheumatoid factor, non-specific systemic symptoms, arthralgias, hepatosplenomegaly, peripheral neuropathy, and hypocomplementemia. Most of these patients have evidence of Hepatitis C.
33 nephrotic syndrome- proteinuria in excess of 3.5g/day, hypoalbuminemia and edema, -ïƒ 1. Accelerated atherogenesis may occur due to increased levels of LDL. 2. Microcytic hypochromic anemia may be due to loss of transferring. 3 immunoglobulins may be lost in urine resulting in hypogammaglobulinemia. 4 cholecalciferol-binding protein may be lost in urine with resulting deficiency of vitamin D and hypocalcemia. Hypocalcemia may result in secondary hyperparathyroidism
***Patients with nephrotic syndrome are at increased risk for developing
hypercholesterolemia, hypertriglyceridemia, and hypercoagulable state
34 In hyperkalemia, removal of K+ from the body can be achieved with dialysis, cation
exchange resins or diuretics. Kayexalate or sodium polystyrene sulfonate is a cation-exchange resin, which acts in Gl tract by promoting the exchange of Na+ for K+, and thereby increasing the excretion of K+.
35 Sodium bicarbonate, insulin plus glucose drip and beta agonist decrease the extra cellular concentration of potassium by driving the potassium into the cell, however they do not remove potassium from the body.
36 prostatodynia are afebrile and have irritative voiding symptoms urinary hesitancy and interruption of flow, increased urinary frequency and urgency ). Physical examination is unremarkable and urinalysis is normal
37 chronic diarrhea may develop renal stones composed of calcium oxalate. Fat malabsorption result in increased absorption of oxalic acid. This is because unabsorbed fatty acids chelates calcium and thus oxalic acid is free for absorption
38 Calcium phosphate stones are common in primary hyperparathyroidism and renal tubular acidosis (RTA)
39 Struvite stones are formed when urine is alkaline because of infection with urease producing bacteria like Proteus
40 dysuria, urinary frequency, suprapubic discomfort along with urinary findings of bacteriuria and pyuria establish the diagnosis of acute cystitis. Oral trimethoprim-sulfamethoxazole is the preferred empiric treatment for acute uncomplicated cystitis
41 Uric acid stones are radiolucent; however, they are seen on USG and CT scan. Treatment of uric acid stones includes hydration, alkalinization of urine, and use of low purine diet with/without allopurinol if hyperuricosuria is present. alkali nization of urine to pH > 6.5 with oral sodium bicarbonate or sodium citrate is indicated.
42 Hydrochlorothiazide decreases urinary calcium excretion and is used in management of recurrent hypercalciuric renal stones
43 Renal vein thrombosis is an important complication of nephrotic syndrome, most common with membranous glomerulonephritis
44 amyloidosis are renal amyloid deposits that show apple-green birefringence under polarized light after staining with Congo red. history of rheumatoid arthritis (that predisposes to amyloidosis), enlarged kidneys w proteinuria, and hepatomegaly Crescent formation revealed on light microscopy is characteristic for rapidly progressive glomerulonephritis
45. Linear immunoglobulin deposits on immunofluorescence microscopy are typical for anti-glomerular basement membrane disease (e.g., GoodpastureDs syndrome)
46 Granular immunoglobulin deposits revealed on immunofluorescence microscopy -- usually present during immune complex glomerulonephritis (e.g., lupus nephritis or poststreptococcal glomerulonephritis).
47 The two initial tests, which are recommended in all the patients with possible benign
prostatic hyperplasia, are serum creatinine and urinalysis.
48 Transient proteinuria is a common cause of isolated proteinuria and can occur during stress or any febrile illness
49 When an old patient comes with irritative voiding symptoms and cultures are negative, nonbacterial prostatitis ->bladder cancer must be ruled out by urinary cytology and cystoscopy. Oral erythromycin is used to treat nonbacterial prostatitis, as it may be caused by Mycoplasma or Ureaplasma. Oral trimethoprim-sulfamethoxazole is used to treat chronic bacterial prostatitis
49 Hypertensive nephrosclerosis-- Arteriosclerotic lesions of afferent and efferent renal arterioles and glomerular capillary tufts -> Nephrosclerosis is characterized by hypertrophy and intimal medial fibrosis of renal arterioles; whereas, glomerulosclerosis is characterized by progressive loss of glomerular capillary surface area with glomerular and peritubular fibrosis. The kidneys are generally small and microscopic hematuria and proteinuria occurs due to glomerular lesions.
50 diabetes mellitus
1. Within first year of diabetes mellitus - Glomerular hyperperfusion and renal hypertrophy with increase in glomerular filtration rate.
2. First five years of diabetes mellitus - Glomerular basement membrane thickening, glomerular hypertrophy, and mesangial volume expansion with glomerular filtration rate returning to normal.
3. Within 5-10 years of diabetes mellitus- Microalbuminuria, which later progresses to overt nephropathy.
51 Analgesic abuse nephropathy is primarily a tubulointerstitial disease characterized by focal glomerulosclerosis.
52 hematuria with irritative or voiding symptoms, suprapubic pain should alarm the physician for the possibility of bladder cancer
53 a patient with acute pyelonephritis does not respond to 72 hr treatment with appropriate antibiotics, urological imaging with CT scan or ultrasound must be performed to exclude obstruction, renal, perirenal abscess, or some other complication
54 Calcium gluconate is the treatment of choice for hyperkalemic patients with significant EKG abnormalities
55 Kayexalate is a cation exchange resin used in case of chronic hyperkalemia
56 The duration of diabetes should be longer (10-15 years) to cause nephropathy. Hypercalcemia is usually not caused by HTN related renal failure
57 Any elderly patient with bone pain, renal failure, and hypercalcemia has multiple myeloma until proven otherwise
58 Papillary necrosis and chronic tubulointerstitial nephritis is the most common pathology seen in analgesic nephropathy. Patients with chronic analgesic abuse are more likely to develop premature aging, atherosclerotic vascular disease, and urinary tract cancer
59 BPH -weak urinary stream, urgency, frequency, and sensation of
incomplete voiding, it starts in the center of prostrate. treatment with alpha-blockers is usually the first choice
60 uremic coagulopathy -- platelet dysfunction. desmopressin (DDAVP), cryoprecipitate, and conjugated estrogens has been used to correct the coagulopathy in uremic patients.
61 nafcillin cause acute allergic interstitial nephritis -> a Type 4 hypersensitivity reaction. The triad of fever, petechial rash, and peripheral eosinophilia in an azotemic patient is highly suggestive of allergic interstitial nephritis. eosinophiluria (positive Hansel stain).
62 Acute tubular necrosis-- Muddy brown granular casts are characteristic
63 The nephrotic syndrome is a hypercoagulable condition, which manifests as venous or arterial thrombosis and even pulmonary embolism. Renal vein thrombosis is the most frequent manifestation. Other complications of nephrotic syndrome include: protein malnutrition, iron-resistant microcytic hypochromic anemia, increased susceptibility to infection, and vitamin D deficiency.
64 Imaging studies should be performed in all children under the age of 10 years with UTI, in all male children with UTI, and in all prepubertal non-sexually active females with UTI. Imaging studies are performed to find any underlying structural abnormality predisposing to UTI. The most common one in this age group is vesico-ureteral reflux. Voiding cystoureterogram is usually done for this purpose but it is performed only after the acute illness is over
65 Struvite stones almost always occur in the presence of alkaline urine that is
persistently infected with urease producing bacteria
**66 Cholesterol embolization, usually follows surgical or interventional manipulation of the arterial tree. Renal failure, livedo reticularis, systemic eosinophilia, and low complement level should make you think of cholesterol embolism
67 1)WBC casts are definite evidence that urinary WBCs originate in the kidney and are seen in cases of interstitial nephritis, pyelonephritis, etc.
2)RBC casts are indicative of glomerular disease or vasculitis.
3) Hyaline casts are composed almost entirely of protein and they pass unchanged along the urinary tract. They may be seen in asymptomatic individuals and in patients with pre-renal azotemia.
4) Fatty casts are seen in conditions causing nephrotic syndrome.
5) Broad casts arise in the dilated tubules of enlarged nephrons that have undergone compensatory hypertrophy in response to reduced renal mass; thus, they are seen in chronic renal
** Depressed CO + elevated PCWP+elevated SVR=> left ventricular failure. Cardio shock
Hypovolemia shock=> decreased PCWP + decreased CO
Pulmon shock => normal or lower PCWP,
** ST elevation in II, III, and aVF =>acute inferior wall myocardial infarction. occlusion of either the right coronary artery or the left circumflex artery. Left anterior descending artery occlusion causes anterior wall myocardial infarction.
# Pericarditis will have diffuse ST elevation in all leads
# Atrial fibrillation is a common complication of hyperthyroidism. Tx: beta-blocker like propranolol.
# early complications of an acute anterior wall Ml: Papillary muscle dysfunction=> Sudden onset of shortness of breath (SOB), bibasilar rales, an apical pansystolic murmur (PSM) radiating to the axilla(mitral regurgitation ). Ventricular septal rupture has similar features but the murmur is heard at the left sternal border and would not radiate to the axilla.
Pericardial tamponade-- not have any murmurs
# late complication of an acute anterior wall MI: Left ventricular aneurysm=>Precordia double apical beat, additional S3 or S4 and sometimes a murmur of mitral regurgitation is present due to papillary muscle dysfunction. Chest x-ray usually shows a characteristic prominence of the left border of the heart. The EKG shows persistent ST elevation.
# Free-wall rupture is an early mechanical complication of Ml. It does not produce a murmur and it presents with cardiogenic shock.
# Rupture of chordae tendinae is not a complication of Ml and it usually occurs secondary to trauma or infective endocarditis
# sick sinus node syndrome -- the best treatment is placement of a permanent pacemaker.
sick sinus syndrome refers to a clinical syndrome in which sinus node dysfunction produces symptomatic bradyarrhythmias, including sinus bradycardia, sinoatrial block and sinus arrest either singly or in combination. Symptoms may range from syncope, dizziness, confusion, and congestive heart failure.
# malignant hypertension-- high blood pressure (>/= 200/140 mmHg) + papilledema.
The pathologic change responsible for end-organ damage in malignant hypertension is fibrinoid necrosis of small arterioles.
# Amiodarone is a class 3 anti-arrhythmic agent, which has now been shown to be very effective in terminating both atrial and ventricular arrhythmias. However, administration of this drug has been known to cause lipoid accumulation in lung parenchyma lead to fibrosis. In a patient with compromised lung function, use of amiodarone can potentiate the lung injury and its use should be with held.
# Atrial fibrillation due to macro re entry circuits-- characterized by irregular undulation base line, No discrete P wave and QRS irregularly spaced.
Tx: hemodynamically unstabl-- electrical cardioversion
Stable w acute process -- either cardioversion or rate control
Stable w chronic process -- rate control along with anticoagulation
Electrical cardioversion should not be performed without 3-4 weeks of anticoagulation in chronic atrial fibrillation (>48hours), as the risk of embolization is high. Cardioversion can be either electrical or chemical. chemical cardioversion the best drugs would be class III agents (amiodarone, sotalol, ibutilide etc.)
For rate control -- either IV diltiazem or beta-blockers (IV metoprolol). Digoxin is a good agent for patients with heart failure (systolic dysfunction)
# recurrent VT, first thing to do after stabilizing the patient is to search for underlying cause, eg: Measure serum electrolytes if pt use digoxin, furosemide ïƒ decreased K
# third degree AV block-- atria and ventricles beat independently. Tx: permanent pacemaker
# Electromechanical dissociation is typical for pulmonary thromboembolism and pericardial tamponade.
# Increased automaticity is a frequent cause of arrhythmia in patients with glycoside intoxication.
# Reentrant ventricular arrhythmia (ventricular fibrillation) is the most common cause of
death in acute myocardial infarction.
# exertional angina + hypertension -- ST depression. best initial treatment-- beta-block, Calcium antagonists if beta-blockers are contraindicated or poorly tolerated.
# vasovagal syncope= neurocardiogenic syncope=> prodrome (lightheadedness, weakness, and blurred vision), provocation by an emotional situation, and rapid recovery of consciousness. frequently recurrent. Diag: upright tilt table testing
# The most common cause of aortic dissection is systemic HTN. “ sudden excruciating chest pain radiates to back. an early diastolic decrescendo murmur at the right or left sternal border. Chest x-ray -- a widened superior mediastinum. normal EKG. Diag: Transesophageal echocardiography
# Renal artery stenosis is a common cause of resistant hypertension in a patient with advanced atherosclerosis.
# diagnosis and follow-up of abdominal aortic aneurysms is an abdominal ultrasound
# The primary mechanism responsible for the effect of nitroglycerin in patients with anginal pain is dilation of veins (capacitance vessels). Increased venous capacitance and venous pooling of the blood lead to significant decrease in ventricular preload and decrease in heart size. As the result of these changes, oxygen requirement of the heart greatly reduces.
# aortic stenosis and hypertrophic cardiomyopathy produce a midsystolic (ejection systolic murmurs) murmur;
For aortic stenosis -- murmur at right second intercostal space, radiates to the carotids, Valsalva maneuver attenuates murmur
For HCM-- murmur at the lower left sternal border and it does not radiate to carotids, Valsalva maneuver accentuates murmur
# Myxomatous valvular degeneration is the most frequent cause of mitral valve prolapse
# Elderly patients are particularly sensitive to fluid loss, and even mild hypovolemia may predispose them to orthostatic syncope, especially upon getting up in the morning. BUN/creatinine ratio is a useful indicator of dehydration.
# Aortic regurgitation-- high-pitched, blowing, early diastolic decrescendo murmur heard best in the left third intercostal space. collapsing (water-hammer) pulse
Pulmonary regurgitation-- early diastolic, decrescendo, high-pitched, blowing, best heard along the left sternal border
The murmur of mitral stenosis is a mid-diastolic rumble and it is best heard at the apex.
The murmur of tricuspid stenosis is a mid-diastolic rumble and is best heard along the left lower sternal border.
The murmur of the aortic stenosis is ejection systolic and best heard at right 2nd intercostal space.
The murmur of tricuspid regurgiation is pansystolic
#Elevated liver enzymes and myopathy are well-known side effects of statins, the popular lipid-lowering drugs. They inhibit HMG-CoA reductase, a rate-limiting enzyme in the synthesis of cholesterol that converts HMG-CoA to mevalonate. It is important to know that mevalonate is used not only for the synthesis of cholesterol, but also for the production of several other products including dolichol and CoQ10. Reduced CoQ10 production has been implicated in the pathogenesis of statin-induced myopathy
# right ventricular infarctionïƒ Decreased compliance of right ventricleïƒ right ventricle dilatedïƒ tricuspid regurgitation(pansystolic murmur at the left lower sternal border) , Diastolic dysfunction of R ventricleïƒ R heart failure(jugular venous distension, KussmaulDs sign, hepatomegaly, and hypotension in the presence of clear lung fields)
# The hallmark finding mitral stenosis is elevated left atrioventricular pressure gradient that ultimately leads to left atrial enlargement.
# evaluate aortic stenosis “ Echocardiography
# Aspirin, beta-blockers, ACE inhibitors and spiranolactone improve survival in patients with heart failure, while digoxin and loop diuretics does not provide any survival benefit.
# It is better to keep Bp < 130/80 mmHg to slow end-organ damage in patients with diabetes and chronic renal failure.
# Amiodarone is an excellent drug for stable ventricular tachycardia and maintaining normal sinus rhythm following a ventricular arrhythmia
# Torsades de pointes”caused by 1st “ Quinidine, then procainamide, tricyclics and disopyramide. EKG -- varying QRS morphology with prolonged QT
Torsades can caused by hypokalemia, hypomagnesemia and hypocalcemia, acute ischemia and bradycardia. mitral valve prolapse, amyloidosis and acute myocarditis.
Tx: magnesium
# Jervell-Lange-Nielson syndrome=> congenital QT prolongation syndromes + congenital deafness. autosomal recessive. Cause torsades de pointesïƒ syncopal episodes and sudden death. Tx: beta-blocker like propranolol.
# Restrictive cardiomyopathy is characterized by severe diastolic dysfunction due to a stiff ventricular wall. Chest x-ray shows only mild enlargement of the cardiac silhouette. Echocardiography usually shows a symmetrically thickened ventricle wall, normal or slightly reduced left ventricle size and normal or near normal systolic function.
# Dilated cardiomyopathy is characterized by impaired systolic function of left and right ventricle leading to progressive cardiac enlargement. Chest x-ray shows marked or moderate enlargement of cardiac silhouette. Echocardiography shows systolic dysfunction and left ventricular dilatation with normal thickness of the ventricular wall.
# Hypertrophic cardiomyopathy is characterized by asymmetric left ventricular hypertrophy. In HCM, a harsh systolic murmur best heard at the left sternal border is also present. Chest x-ray shows mild enlargement of cardiac silhouette. Echocardiography shows vigorous systolic function, asymmetric septal hypertrophy and in some cases systolic anterior motion of the mitral valve. Due to the hypertrophy of the left ventricular wall, there is diastolic dysfunction.
# Dipyridamole and adenosine are coronary vasodilators. Infusion of these substances in patients without coronary artery disease, increases coronary blood flow three to five times above the baseline levels. However, in patients with coronary artery disease, the diseased vessels distal to the obstruction are already maximally dilated, and their ability to increase myocardial perfusion is limited; therefore, redistribution of coronary blood flow to non-diseased areas occurs, and the perfusion of diseased segments diminishes. This phenomenon demonstrated by dipyridamole is called coronary steal and is used to diagnose ischemic heart disease. Dipyridamole can be used during myocardial perfusion scanning to reveal the areas of restricted myocardial perfusion.
# prevention of recurrent attacks of rheumatic fever with antibiotic prophylaxis may slow down the progression of mitral stenosis in adolescents.
# The drugs that slow the AV conduction (digoxin and verapamil) are contraindicated in patients with atrial fibrillation and Wolff-Parkinson-White syndrome because they can increase the conduction of impulses through the accessory pathway, thus leading to malignant arrhythmias and hypotension.
# Procainamide or disopyramide are for Atrial fibrillation in the context of WPW syndrome.
# chemical cardioversion for atrial flutter is ibutilide
Either calcium channel blockers (verapamil or diltiazem) or beta-blockers can be used for rate control in acute/chronic atrial flutter
Atrial flutter with unstable hemodynamics is best treated with cardioversion
# ST segment depression, T wave inversion and first degree AV block can occur at therapeutic levels of digoxin. Atrial tachycardia along with variable degree of AV block is the most important EKG finding of digitalis toxicity
# In a post-MI hypertensive patient, beta-blockers and ACE inhibitors are preferred over diuretics and calcium channel blockers. Beta blockers decrease myocardial oxygen demand by reducing heart rate and contractility. ACE inhibitors improve prognosis in post-MI patients with subnormal EF by decreasing ventricular remodeling,
# Any patient who presents with sudden onset of chest pain, SOB, and has evidence of hypoxia and the new onset right bundle branch block should be considered as having a pulmonary embolism
# Marfan™s syndrome-- aneurysms of the ascending aorta
In aldut, Atherosclerosis-- aneurysm of the descending aorta
In yang, of blunt injuries to the chest-- aneurysm of the descending aorta
CT scans or angiograms are diagnostic
# high risk to develop infective endocarditis include: 1. All prosthetic heart valves. 2. Any history of previous bacterial endocarditis. 3. Complex cyanotic congenital heart disease and surgically- constructed systemic pulmonary shunts.
Patients with artificial pacemakers and defibrillators do not require prophylaxis for infective endocarditis.
# Absolute indications for dialysis
1. Fluid overload not responsive to medical treatment.
2. Hyperkalemia not responsive to medical management.
3. Uremic pericarditis.
4. Refractory metabolic acidosis.
Contraindications:
1. Debilitating chronic disease.
2. Severe irreversible dementia.
# isolated systolic hypertension”1st low-dose thiazide diuretic
# Antihypertensive management should be the first step in patients with aortic dissection with hypertension, then Transesophageal echocardiogram
# a difference of more than 30 mmHg in the blood pressure readings between two arms-- aortic dissection
# Cutaneous flushing and intensive generalized pruritis are well-known side effects of high-dose niacin therapy caused by drug-induced release of histamine and prostaglandins=> peripheral vasodilatation. can be reduced by low-dose aspirin
# Age-dependant idiopathic sclerocalcific changes are the most frequent cause of isolated aortic stenosis in elderly patients. Cause Exertional syncope.
# In a patient with an Ml who develops a cold leg, one has to get an ECHO to rule out a
thrombus in the left ventricle.
# A detailed medical history and physical examination is the most effective way to screen a low risk population for the presence of underlying cardiac disease.
# alcoholism-- thrombocytopenia, macrocytosis, and elevated transaminases, dilated cardiomyopathy”heart failure.
# Mobitztype 2 block is characterized by a fixed PR interval with an occasional dropped beat in a 2:1,3:1,4:1 pattern. The QRS is usually wide. Tx: permanent pacemaker
# Type I Mobitz or Wenckebach AV block is characterized by a narrow QRS, progressive increase in PR interval until a ventricular beat is dropped
# Stress testing with imaging is indicated when the patient has complete left bundle branch block, an idioventricular rhythm, Wolff-Parkinson-White syndrome, and ST depression of greater than 1 mm at rest.
Dobutamine stress echo is indicated in patients who can™t do sufficient exercise,
Coronary angiogram is indicated in patients who have abnormal stress testing
exercise EKG testing should be the initial test of choice for stable angina when there is an intermediate pretest probability of coronary heart disease that is based on patient™s age, sex and symptoms.
# Sepsis is the most common cause adult ARDS
# hypertrophic obstructive cardiomyopathy -- systolic anterior motion of mitral valve leaflet that causes mitral regurgitation.
# Mitral annulus calcification due to aging occurs in elderly, is a degenerative process and it may lead to severe mitral regurgitation.
# Mitral valve prolapse is the most common cause for isolated mitral regurgitation in North America.
# An atrial premature beat results from the premature activation of the atria that originates from a site other than the SA node. EKG shows an early P wave. Tobacco and alcohol are reversible risk factors for the development of atrial premature beats.
# Think of cocaine intoxication in a young patient presenting with chest pain/myocardial infarction or stroke. Features of cocaine intoxication are cocaine bugs, agitation, decreased appetite, dilated pupils, elevated or decreased blood pressure, tachycardia or bradycardia, and sweating.
# The earliest EKG finding in acute Ml is peaked (hyperacute) T waves, followed by ST elevation, followed by the inversion of T waves, followed by the appearance of Q waves.
Peaked T ïƒ ST elevationïƒ inversion Tïƒ Q waves
# Nitrates are contraindicated when a patient is continuously or intermittently taking sildenafil. It is recommended not to use nitrates within 24 hours of the last dose of sildenafil. The reason for the dangerous interaction between nitrates and sildenafil is that both induce nitric oxide mediated vasodilatation. In such settings nitrates may cause syncope, Ml, or sudden death when a patient has an acute coronary syndrome.
# ventricular tachycardia “ widen QRS. The best treatment w no hemodynamic compromise ïƒ either lidocaine or amiodarone. Unstable ïƒ cardioversion
# Carotid massage is useful for supraventricular tachycardia
# Dressler™s syndrome, an autoimmune pericarditis, is a late complication of acute Ml that usually develops between the second and tenth weeks post Ml.
# Norepinephrine is a powerful vasoconstrictor and can lead to decreased blood supply to both the lower and upper extremity cause Bluish discoloration and cool fingers
# septic shock both right atrial pressures and pulmonary capillary wedge pressure are low.
# Treatment with IV heparin, aspirin, beta-blocker, and nitroglycerin is indicated unstable angina and non-Q wave infarcts
# thrombolytic therapy indicate 1) MI w ST elevation greater than 1 mm in two contiguous leads after sublingual nitroglycerin administration to rule out coronary vasospasm. 2) new left bundle branch block
# Thrombolytic therapy, with tissue plasminogen activator, requires co-administration of heparin and aspirin for additional benefit. Streptokinase do not need co-administration of heparin because it may produce allergy.
Thiazide diuretics are the initial antihypertensive of choice in patients with osteoporosis. Thiazide diuretics decrease urinary calcium excretion
# Chaga™s disease caused by Trypanosoma cruzi. megacolon or mega-esophagus, cardiomegaly -- >cardiomyopathy, conduction abnormalities
** Decreased tolerance to glucose is a well-known side effect of thiazide diuretic therapyïƒ hyperglycemia. Also increased LDL cholesterol & triglycerides. hyponatremia, hypokalemia and hypercalcemia
# Presence of hypotension, pulsus paradoxus, and pulseless electrical activity in a
patient with a recent acute Ml should make you think of free ventricular wall ruptureïƒ acute cardiac tamponade
Free wall rupture usually occurs in the first week after Ml. Risk factors include advanced age, large Q wave infarct, a history of HTN, and no prior history of angina pectoris.
# Papillary muscle rupture -- occurs in the first week after an acute Ml. lead to acute mitral regurgitation and a pansystolic murmur
# Premature atrial beats never require any treatment and are completely benign
# Digoxin is particularly used in patients with heart failure (systolic dysfunction) and atrial fibrillation/flutter. It increases the AV nodal refractoriness and thereby slows the ventricular rate in atrial fibrillation and flutter.
# In all ST elevation Ml, reperfusion therapy with thrombolytics or PTCA(Percutaneous Coronary Interventions (previously called Angioplasty, Percutaneous Transluminal Coronary [PTCA], or Balloon Angioplasty) with or without stenting must be performed as soon as possible.
PCI is the reperfusion therapy of choice as it has a better outcome than thrombolysis.
Contraindications to thrombolytics include active bleeding, history of a hemorrhagic stroke anytime or a cerebrovascular accident within the last year, drug allergy or systolic BP greater than 175 mmHg.
Concurrent administration of glycoprotein llb/llla inhibitors has shown promising results with improved coronary reperfusion, early ST segment resolution, and reduction of the incidence of recurrent ischemia and infarction. The role of GP llb/llla inhibitors in primary PCI(PTCA) is not certain. At some centers it is used routinely while at others, it is given under special circumstances like the finding of residual thrombus.
# Constrictive pericarditis-- decreased cardiac output (fatigue, muscle wasting etc) and /or signs and symptoms of venous overload like elevated JVP, dyspnea, ascites, positive Kussmaul's sign, pedal edema, tender hepatomegaly etc. Sharp 'x' and y descent on central venous tracing is characteristic of constrictive pericarditis as is the presence of pericardial knock. Tuberculosis is the most common cause of constrictive pericarditis
# Calcium channel blockers are the drugs of choice for Variant anginaïƒ rest chest pain w transient ST elevation during the episode of chest pain which usually returns to baseline as the pain resolves. Cardiac enzymes are usually negative. Caused by coronary vasospasm
# situational syncope related to micturition caused by autonomic dysregulation
# The EKG findings in pericardial tamponade include sinus tachycardia, low voltage QRS complexes, and electrical alternans. Electrical alternans is characterized by alternating amplitudes of QRS complexes
# Mobitz type I heart block is characterized by a narrow QRS, progressive increase in PR interval until a ventricular beat is dropped,. In type II block -- dropped QRS complex with normal PR interval. In third degree AV block -- atria and ventricles beat independently
# Even though IV beta-blockers improve mortality in acute Ml, they are contraindicated in the presence of pulmonary edema. Other absolute contraindications to their use include asthma, hypotension, severe bradycardia and heart block greater than first degree.
# CK-MB fraction has a high specificity for an acute Ml (slightly lower than cardiac troponins). It begins to rise within 4-6 hours after Ml and returns to baseline within 48-72 hours. It™s high specificity and rapid return to the baseline makes it the biomarker of choice for the diagnosis of a recurrent Ml.
# Cardiac troponins T and cardiac troponins I are proteins that control the interaction of actin and myosin. They are more specific than all the other biomarkers of cardiac injury being used for the diagnosis of Ml. They begin to rise 4-6 hours after an Ml, and remain elevated for 10 days. They have now become the primary biochemical tests used for the diagnosis of acute Ml. They have also replaced LDH for the retrospective diagnosis of Ml.
# Acute transmural infarct => Q-waves + ST elevation
# The diagnosis of ventricular septal rupture (The diagnosis of ventricular septal rupture can be made if there is evidence of left to right shunting on Swan-Ganz catheter readings )can be made if there is evidence of left to right shunting on Swan-Ganz catheter readings
# Aspirin, ACE inhibitors, and beta-blockers have been shown to reduce mortality in
the setting of acute Ml.
# Alpha-blockers(Doxazosin) are preferred in patients with BPH and an unfavorable metabolic profile (dyslipidemia, glucose intolerance).
# Mitral valve prolapse is the most common cause of mitral regurgitation in USA. papillary muscle dysfunction or infarction as the next most common cause
#Beta blockers are used to treat chest pain, palpitations, and autonomic symptoms of MVP.
# The first line medication for HTN in the general population is either a thiazide diuretic or beta-blocker. Non-selective beta-blockers are contraindicated in asthmatics especially if they are steroid dependent or on continuous albuterol.
# ACE inhibitors, like enalapril, are the 1st line drugs for diabetics with hypertension. These are usually 2nd line drugs for the general population.
# Generally, we can say that prophylaxis is recommended for high-risk conditions and is optional for moderate risk conditions.
Conditions put a patient at high risk to develop infective endocarditis include:
1. All prosthetic heart valves.
2. Any history of previous bacterial endocarditis.
3. Complex cyanotic congenital heart disease and surgically constructed systemic pulmonary shunts.
Conditions, which put a patient at moderate risk to develop infective endocarditis includes:
1. Congenital cardiac malformations not falling into the high or negligible risk categories (such as PDA, VSD, ostium primum ASD, bicuspid aortic valve and coarctation).
2. Acquired valvular heart disease (such as rheumatic heart disease, valvular stenosis and regurgitation).
3. MVP with regurgitation and/or myxomatous leaflets.
4. Hypertrophic cardiomyopathy.
a moderate-risk cardiac condition and now the decision about the need and choice of antibiotic regimen will depend on the type of procedure.
For dental procedures with bleeding, antibiotic prophylaxis is recommended both in high-risk and moderate-risk patients. For dental procedures which are unlikely to cause bleeding, prophylaxis is not recommended.
For respiratory procedures like rigid bronchoscopy and operations involving mucosa, antibiotic prophylaxis is recommended both in high-risk and moderate-risk patients. For flexible bronchoscopy, prophylaxis is optional in high-risk patients and not recommended in moderate-risk patients. For endotracheal intubation, prophylaxis is not recommended
For gastrointestinal procedures like sclerotherapy of varices, gastrointestinal surgery involving mucosa, biliary tract surgery, esophageal stricture dilatation and ERCP in the presence of obstruction, antibiotic prophylaxis is recommended in high-risk patients and optional in moderate risk patients. For endoscopy and TEE, prophylaxis is optional in high-risk patients and not recommended in moderate-risk patients
For genitourinary tract procedures like prostatic surgery, cystoscopy and urethral dilatation, antibiotic prophylaxis is recommended both in high-risk and moderate-risk patients. For urethral catheterization, uterine D&C, therapeutic abortion, sterilization or insertion or removal of IUD, prophylaxis is recommended only when an infection is present. For vaginal delivery and vaginal hysterectomy, prophylaxis is optional in the high-risk patient. For cesarian section, prophylaxis is not recommended.
# supraventricular tachycardia-- HR of >140/min, regular, loss of P waves and narrow QRS complex. Tx: unstableïƒ cardioversion. Stableïƒ vagal maneuvers initially, If these fail -- > IV adenosine push
# Prolonged, tachysystolic atrial fibrillation causes significant left ventricular (LV) dilation and a depressed ejection fraction. Tx: Controlling the rhythm or rate
# Hyperkalemia and pregnancy are contraindications to the use of ACE inhibitors
# Beta-blockers can worsen severe peripheral vascular disease while helping for blood pressure.
# Jugular venous distention (JVD) and RBBB indicate right heart strain
# Think of PE in a postoperative patient with JVD and new onset RBBB
# Hypertrophic cardiomyopathy has an autosomal dominant mode of inheritance.
# Screening should be done in all first-degree relatives of the patients of hypertrophic cardiomyopathy and the most effective way of screening these people is echocardiography. Detailed history and examination is the screening method used for young athletes
# Diastolic and continuous murmurs as well as loud systolic murmurs revealed on cardiac auscultation should always be investigated using transthoracic Doppler echocardiography. Midsystolic soft murmurs (grade l-ll/IV) in an asymptomatic young patient are usually benign and need no further work-up.
# Hyperkalemia present in this patient may be due to the combination of enalapril, digoxin, and spironolactone. Furosemide causes hypokalemia.
# Hyponatremia is a bad prognostic factor in patients with heart failure. It indicates the presence of severe heart failure and a high level of neurohumoral activation
# The early third heart sound, that is also called pericardial knock and the inspiratory increase in the jugular venous pressure (KussmaulDs sign), are important physical findings of constrictive pericarditis. KussmaulDs sign is also present in right sided heart failure, severe tricuspid regurgitation, right ventricular infarction and cardiac tamponade.
# Water hammer or collapsing pulse and pistol shot femoral pulses are diagnostic clues to aortic regurgitation
Tapping apex beat and malar flush are important physical findings of mitral stenosis. Pulsus paradoxus is defined as greater than 10-mmHg fall of the systolic blood pressure during inspiration
# Pulsus paradoxus and hypotension point toward the diagnosis of pericardial tamponade
# A pansystolic murmur at the left sternal border is usually seen in tricuspid regurgitation
# Calcium channel blockers have good peripheral vasodilating properties that can help to diminish the symptoms of intermittent claudication. They are also metabolically neutral, not affecting plasma lipid profile.
# Infective endocarditis prophylaxis and repeated regular follow-ups are recommended for all patients of aortic stenosis even if they are asymptomatic.
# Isolated premature ventricular arrhythmias generally do not require any medical
treatment; observation is usually the treatment of choice
# Transmural infarcts-- ST segment elevation followed by the development of Q waves and elevation of cardiac enzymes
# Subendocardial infarcts are characterized by ST segment depressions that are not followed by the development of Q waves and elevation of cardiac enzymes.
# All patients with unstable angina(either ST depression, T wave inversion, or many times no changes) should be hospitalized and treated with aspirin, IV heparin, and IV nitroglycerin. Once the patient is free of chest pain, an angiography can be performed non-emergently.
# Chronic oral contraceptive use is a common cause of secondary hypertension caused by an estrogen-mediated increase in the synthesis of angiotensinogen in the liver
# Coxsackie-B virus is a common cause of acute pericarditis.
# A history of recent upper respiratory tract infection followed by sudden onset of cardiac failure in an otherwise healthy patient is suggestive of dilated cardiomyopathy, most likely secondary to acute viral myocarditis(Coxsackie B infection). The diagnosis is made by echocardiogram, which typically shows dilated ventricles with diffuse hypokinesia resulting in low ejection fraction (systolic dysfunction). Viral myocarditis can cause dilated cardiomyopathy by direct viral damage, as well as sequel of humoral or cellular immune responses to persistent viral infection.
Concentric hypertrophy of the heart is seen following chronic pressure overload, as in valvular aortic stenosis or untreated hypertension
Eccentric hypertrophy of the heart is seen following chronic volume overload, as seen in valvular regurgitation
# Isolated systolic hypertension (ISH) is important cause of hypertension in elderly patients caused by decreased elasticity of the arterial wall. Tx: Always treat isolated systolic hypertension. “ Hydrochlorothiazide
# Diuretics, nitrates, ACEi and digitalis be avoided in HCM especially when an outflow gradient is present. hypertrophic cardiomyopathyïƒ Beta-blockers are usually the first line of medication.
# Dressier syndrome typically occurs two-to-four weeks after an Ml and presents with a low-grade fever, malaise and pleuritic chest pain. ECG will reveal 'non specific1 ST elevations and there may be a pericardial effusion. NSAIDs are the agents of choice.
# Lidocaine increased risk of asystole
# Valsalva maneuver and standing after squatting are two maneuvers that decrease left ventricle volume thus increasing the gradient and intensifying the associated systolic murmur. handgrip increases the systemic arterial resistance and thus decreases the gradient and associated systolic murmur. Phenylephrine also decreases the murmur by increasing systemic arterial pressure. Leg elevation increases the left ventricular volume and thus decreases the gradient and the associated murmur.
# Whenever a patient of chronic aortic regurgitation develops symptoms of LV dysfunction, he should undergo aortic valve replacement after his congestive symptoms are relieved by intense medical treatment with digoxin, diuretics, and vasodilators (ACE inhibitors).
Acute aortic regurgitation is an emergency and requires emergent surgery. Sodium nitroprusside or inotropes like dopamine or dobutamine are used to stabilize this condition before emergent surgery can take place.
#I.V atropine is the drug of first choice in patients with symptomatic bradycardia (Choice B). Transcutaneous pacing is the next step after atropine. If the patient has severe bradycardia with hypotension then epinephrine is the drug of choice
Adenosine is used for supraventricular tachycardia
# If average alcohol intake is greater than 2 drinks/day, risk of development of hypertension increases by 1.5-2 times compared to the general population and the risk increases substantially if the average alcohol intake is greater than 5 drinks/day. On the other hand moderation of alcohol intake to 1-2 drinks per days also has been shown to have a cardioprotective effect ïƒ decrease blood pressure
# Thrombolytic therapy is indicated when the chest pain is suggestive of Ml and there is ST segment elevation greater than 1 mm in two contiguous leads after sublingual nitroglycerin administration to rule out coronary vasospasm. Another indication for thrombolytic therapy is a new or presumably new left bundle branch block. Thrombolytic therapy is not indicated for an Ml with ST segment depression and it is also not indicated for unstable angina.
Thrombolytic therapy with tissue plasminogen activator requires co-administration of heparin and aspirin for greater benefit. Tissue plasminogen activator is slightly more effective than streptokinase but it has a slightly more risk of intracranial bleeding. For streptokinase, co-administration of heparin is not required.
# Treatment with IV heparin, aspirin, and IV nitroglycerin is indicated in cases of unstable angina and non-Q wave infarcts
# Manage a patient with ST segment elevation Ml with immediate angiography and PTCA when thrombolytic are contraindicated. Even if the patient has no contraindications forthrombolytic therapy and a catheterization laboratory is available in the hospital, or within 30 min of the hospital, PTCA with stent placement has been shown to have better outcomes than thrombolytic therapy in acute ST elevation Ml.
# Severe systolic dysfunction and increased left ventricle size are features of dilated cardiomyopathy.
Supernormal ejection fraction is present in hypertrophic cardiomyopathy as is dynamic outflow obstruction. Diastolic dysfunction is present in HCM, due to the stiff, hypertrophied ventricle wall.
# ejection fraction (EF) normal = 55-65%
# Digoxin slows the ventricular response rate in atrial fibrillation by slowing down AV conduction and thus increasing the diastolic filling. It also has a beneficial effect in patients of systolic dysfunction due to its positive inotropic effect. Thus any patient who has atrial fibrillation and heart failure will benefit from digoxin; it should be considered over before beta-blockers or calcium channel blockers.
# Beta-blockers are preferred over the digoxin or calcium channel blockers in patients with coronary artery disease. Calcium channel blockers are not the best drugs for patients with heart failure due to their negative inotropic effect.
# IV dobutamine is used when a patient is in cardiogenic shock.
# Mitral valve prolapse-- systolic click, The click occurs earlier with standing and Valsalva maneuver and it disappears with squatting and handgrip
#Cutaneous flushing and intensive generalized pruritis are well-known side effects of high-dose niacin therapy (high dose is required to treat lipid abnormalities). These effects are explained by niacin-induced peripheral vasodilatation. The mechanism involved in this reaction is believed to be drug-induced release of histamine and prostaglandins. can be reduced by low-dose aspirin
# In a patient with an Ml who develops a cold leg, one has to get an ECHO to rule out a
thrombus in the left ventricle.
# exercise EKG testing should be the initial test of choice for stable angina
# Presence of complete RBBB (or) ST depression at rest of less than 1 mm are not contraindications to perform stress testing. Stress testing with imaging is indicated when the patient has complete left bundle branch block, an idioventricular rhythm, Wolff-Parkinson-White syndrome, and ST depression of greater than 1 mm at rest.
# Dobutamine stress echo is indicated in patients who canDt do sufficient exercise.
# in hypertrophic cardiomyopathy it is the systolic anterior motion of mitral valve leaflet that causes mitral regurgitation Coronary angiogram is indicated in patients who have abnormal stress testing
# Aortic stenosis may present with syncope, angina, or dyspnea (SAD) on exertion
ENT
4 allergic rhinitis -- pale bluish mucosa, dark, puffy eyelids
5 Otitis externa is always painful and tender; pain without tenderness suggests middle rather than an external infection
6 Juvenile angiofibroma-- triad of nasal obstruction, nasopharyngeal mass, and recurrent epistaxis. headache, conductive hearing loss, and diplopia secondary to erosion into cranial cavity and pressure on optic chiasm. CTscan of the head and the face is confirmatory
7 nasal polyps are recurrent episodes of rhinitis, chronic nasal obstruction, altered taste sensation, diminished sense of smell and persistent postnasal drip
8 Manner -- recurrent episodes of rotational vertigo, sensorineural hearing loss and tinnitus.
9 Serous otitis media”aids pt with hearing difficulty, dull tympanic membrane which is sluggish to air insufflation and presence of air fluid levels in the middle ear. Caused by auditory tube dysfunction arising from HIV lymphadenopathy or obstructing lymphomas
10 Peritonsillar abscess presents with unilateral sore throat, neck pain, referred
earache, dysphagia, swollen tonsils, drooling, and trismus -- Streptococcus pyogenes
1 Furosemide, a loop diuretic can cause ototoxicity”hearing loss, tinnitus and dysequilibrium
2 Cavernous Sinus Thrombosis is the most common, late complication of infection of the central face or para nasal sinuses.-- dysfunction of the CN III, IV, V, and VI are present. Lateral gaze palsy (CN VI dysfunction), ptosis, mydriasis (CN III dysfunction), absent corneal reflex (CN V dysfunction), CT is the definitive procedure for diagnosis. The mainstay of treatment is early and aggressive antibiotic administration. Anticoagulants and corticosteroids may also be used as adjunctive therapy, Patients present with severe headache, followed by fever and periorbital edemea.
3 Viral rhinitis-- Nasal examination shows an erythematous mucosa, Allergic rhinitis-- clear nasal discharge and nasal mucosa is pale or bluish.
4 Juvenile angiofibroma is a vascular tumor -- the most common benign tumor of nasopharynx The triad of nasal obstruction, nasopharyngeal mass, and recurrent epistaxis in a young male is highly suggestive of juvenile angiofibroma. Juvenile angiofibroma can be managed with medical or surgical therapy depending on the stage of tumor, examination there is a grayish-red mass in the posterior nasopharynx.
5 Typical symptoms of nasal polyps are recurrent episodes of rhinitis, chronic nasal obstruction, altered taste sensation, diminished sense of smell and persistent postnasal drip
6 meniere™s syndrom-- recurrent episodes of rotational vertigo, sensorineural hearing loss and tinnitus. Benign positional vertigo-- not usually associated with hearing loss or tinnitus. Acute labyrinthitis-- follows a viral infection or mumps, ear ache, vertigo
7 Serous otitis media is the most common middle ear pathology in acquired immuno deficiency syndrome. It presents with hearing difficulty, dull tympanic membrane which is sluggish to air insufflation and presence of air fluid levels in the middle ear. It is due to the auditory tube dysfunction arising from HIV lymphadenopathy or obstructing lymphomas.
8 Chronic otitis media usually presents with purulent aural discharge. Tympanic membrane appears thickened with calcific patches and perforation
9 Otosclerosis is an osseous dyscrasia limited to the temporal bone. It causes symptomatic hearing loss + tinnitus tinnitus by third decade of life. Otoscopic examination --usually normal, 10% of patients demonstrate a Schwartz sign, characterized by a reddish-blue hue over promontory and oval window niche areas, secondary to rich vascular supply associated with immature and audiometry shows conductive hearing loss and loss of stapedial reflex, It is inherited in an autosomal dominant pattern with incomplete penetrance. Treatment consists of oral sodium fiuoride
10 peritonsillar abscess -- unilateral sore throat, neck pain, referred earache, and dysphagia, trismus, pooling of saliva, and a muffled voice. associated with prominent cervical lymphadenitis and deviation of uvula. tonsils are swollen-- Streptococcus pyogenes is the most commonly associated organism-- Treatment consists of Iv antibiotics and needle aspiration of the abscess. Failure to obtain pus is an indication for surgical incision and more formal exploration
Retropharyngeal abscess also presents with neck pain, sore throat, and dysphagia. These patients have posterior pharyngeal edema, nuchal rigidity, cervical adenopathy, fever, and drooling of saliva. Tonsils are normal
11 Presbyopia is the loss of accommodative capacity that occurs with ageing. Usually patients notice inability to focus objects at normal reading distance and complain of having to hold books at arms length to read. It is corrected with convex lenses In Hyperopia light rays fall behind the retina, Myopia or shortsightedness -- light rays are focused in front of the retina. It is corrected using concave lenses
12 quinine is being used for treating cramps in dialysis patients. Vancomycin can cause nephrotoxicity and the red man syndrome (due to histamine release from mast cells)
13 Tinnitus can sometimes occur in patients taking aspirin, quinine, and even in patients who are depressed -- It can cause disruption of sleep, concentration and depression. Tricyclic anti¬depressants have been found to be effective for this condition.
14 Glomus tumor arises in the middle ear or in the jugular bulb. They present with pulsatile tinnitus and hearing loss
15 Presbyacusis-- high frequency hearing loss in both ears associated with difficulty in speech discrimination
16 Petrous apicitis presents with a triad of retro orbital pain, lateral rectus palsy, and otorrhea.
17 Orbital cellulitis is manifested by abrupt onset of fever, proptosis, restriction of extra
ocular movements, and swollen red eyelids. “ cause Staphylococcus aureus, Streptococcus pneumoniae, and Hemophilus influenza
18 Malignant otitis externa is an infection of external ear -- caused by pseudomonas aeruginosa and occurs in patients who suffer from coexisting diseases such as diabetes mellitus, malnutrition, leukemia, and other debilitating diseases. foul smelling discharge, deep otalgia, granulations in ear canal and involvement of cranial nerves VII, IX-XII. X-rays should be done in all cases of suspected malignant otitis externa to look for the degree of damage to the body tissues X-rays should be done in all cases of suspected malignant otitis externa to look for the degree of damage to the body tissues
19 Cholesteatoma is an epithelial cyst that contains desquamated keratin-- repeated infections or progressive conductive hearing loss, drainage and granulation tissue that are unresponsive to antibiotic treatment, characterized by marginal tympanic membrane perforation or sometimes it may present as ear canal filled with mucous, pus and granulation tissue. Cholesteatomas destroy bones and therefore, any bony structure in or around the middle ear and mastoid cavity can be eroded “CT. Therapy consists of surgical removal Therapy consists of surgical removal
20 Tympanic sclerosis is common sequelae of chronic otitis media. It presents as thickening and calcification of the tympanic membrane. Hearing loss is rare Tympanic sclerosis is common sequelae of chronic otitis media. It presents as thickening and calcification of the tympanic membrane. Hearing loss is rare
21 Central Retinal Vein Occlusion (CRVO) presents with sudden, painless, unilateral loss of vision. disk swelling, venous dilation and tortuosity, retinal hemorrhages and cotton wool spots. -> emergent ophthalmologist referral emergent ophthalmologist referral
22 Acute angle closure glaucoma is characterized by sudden onset of symptoms such as blurred vision, severe eye pain, nausea and vomiting. Examination reveals a red eye with hazy cornea and a fixed dilated pupil
23 Optic neuritis also presents with sudden unilateral loss of vision but is associated with severe pain. Fundoscopy may reveal swollen optic disc and central scotoma. They will also have pupillary abnormalities pallor of the optic disc, cherry red fovea and boxcar segmentation of blood in the retinal veins.
24 Central retinal artery occlusion is also characterized by sudden painless loss of vision in one eye.-- pallor of the optic disc, cherry red fovea and boxcar segmentation of blood in the retinal veins.
25 In patients with asthma and nasal polyps, aspirin is contraindicated as it may lead to severe bronchospasm (aspirin triad or SamterDs triad).
26 Eustachian tube dysfunction is a common cause of conductive hearing loss in children. Symptoms follow the onset of upper respiratory tract infection or allergic rhinitis - aural fullness, popping noise while swallowing or yawning, intermittent ear pain, and hearing loss. Otoscopy reveals retraction and decreased mobility of the tympanic membrane. Hallmark of eustachian tube dysfunction is a middle ear effusion. treated with auto insufflations and oral and nasal decongestants
27 Leukoplakia -- whitish patch or plaque, granular appearance ->hard to remove caused by chronic irritation to the oral mucosa due to smoking, alcohol, or ill-fitting dentures and Vitamin A and B deficiencies and syphilis. risk of transformation into squamous cell carcinoma. incisional biopsy or exfoliative cytologic examination should always be done.
28 Hairy leukoplakia is a white, painless lesion - found in AIDS patient on the lateral aspect of tongue. It is caused by Epstein Barr Virus (EBV).
29 Lichen planus is characterized by polygonal, violaceous, papular eruption covered by fine scales. These lesions when involving oral mucosa have higher incidence of malignant transformation.
30 Keith-Wagener classification -- stages of hypertensive retinopathy
Slight AV nicking “ grade 1
Copper wiring, AV depression with humping ends “g 2 G2g
Silver wiring, flame shaped hemorrhages, exudates “g3 333
Flame shaped hemorrhages, exudates and papilledema “ g 4
31 Mastoiditis is the most common complication of the otitis media, pain behind the ear, and fever. Examination reveals erythema, edema, and tenderness over mastoid area( behind ear ). protruded auricle. CT imaging may be used to confirm the clinical diagnosis. It demonstrates fluid filled middle ear and demineralization of mastoid trabeculae. Intravenous antibiotics are the immediate treatment of choice
32 Treatment of choice for streptococcal pharyngitis is single injection of IM Benzathine penicillin G
33 IV crystalline penicillin G is used in cases of bacterial meningitis, endocarditis, and neurosyphilis
34 Bullous myringitis presents with painful vesicles on the tympanic membrane. It is associated with mycoplasma or viral respiratory Infection
35 Diabetic Retinopathy -- micro aneurysms, hemorrhages, exudates, and retinal edema. pre proliferative retinopathy with cotton wool spots. malignant retinopathy-- proliferative retinopathy consisting newly formed vessels -> leading cause of blindness in USA.
Tx- Argon Laser photocoagulation
36 Retinal detachment - retina hanging in the vitreous.
37 Open angle glaucoma-- gradual loss of peripheral vision resulting in tunnel vision. cupping of optic disc
38 Cigarette smoking increases the risk of macular degeneration
39 H. Influenzae and Group A Streptococcus are the most common causes of
epiglottitis
40 Gonococcal conjunctivitis - copious purulent eye discharge with swollen eyelids and chemosis, occurs 2-3 days after birth. Tx ->A single intramuscular dose of ceftriaxone
41 Neonatal chlamydial conjunctivitis presents with mild hyperemia with scant mucoid eye discharge not purulent. It occurs about 5-14 days after birth
42 Chemical conjunctivitis is the most common cause of conjunctivitis occurring within the first 24 hours after birth. A history of silver nitrate eye drops instillation is usually present
43 Sialolithiasis presents as post-prandial pain and swelling. calculus formation within the ductal system of salivary gland is most common in submandibular gland followed by sublingual and parotid gland. x-ray of the involved salivary gland is diagnostic. Treatment consists of dilation and incision of the involved duetto remove the calculus.
GenitaUrine
============
1 Membranoproliferative glomerulonephritis, type 2 -- Dense intramembranous deposits that stain for C3, caused by IgG antibodies (termed C3 nephritic factor) directed against C3 convertase of the alternative complement pathway. These antibodies reacting with C3 convertase lead to persistent complement activation and kidney damage
2 immune complex-mediated glomerulopathies that include SLE, post-streptococcal glomerulonephritis
3 anti-GMB antibody “ good pasture ˜ syndrom. idiopathic crescentic glomerulonephritis.-- Cell-mediated injury
4 collapsing focal and segmental glomerulosclerosis is the most common form of
glomerulopathy associated with HIV. Typical presentation includes nephritic range proteinuria, azotemia, and normal sized kidneys
5 HIV + hepatitis B -> membranous glomerulonephritis
6 Cardiovascular disease is the most common cause of death in dialysis patients and in renal transplant patients
7 interstitial nephritis are caused by drugs such as cephalosporins, penicillins, sulfonamides, sulfonamide containing diuretics, NSAIDDs, Rifampin, phenytoin, and allopurinol. Discontinuing the offending drug is the treatment of drug-induced interstitial nephritis
Clinical features include fever, rash and arthralgias. Other features are peripheral eosinophilia, hematuria, sterile pyuria and eosinophiluria. WBC casts may be present in the urine
8 sickle cell trait in a young black male - > painless episode hematuria. Caused by apillar ischemia. Papillar necrosis can occur with massive hematuria
9 analgesic nephropathy “ headache + painless hematuria. results from papillary ischemia induced by analgesic-mediated vasoconstriction of medullary blood vessels (vasa recta). ->Papillary necrosis
10 several years of analgesic abuse induce pailess hematuria characterized by chronic tubuiointerstitial damage
11 Any patient with recurrent sinusitis, cavitary lung lesions, pulmonary hemorrhages and
glomerulonephritis will most likely have WegenerDs glomerulonephritis. Both hematuria and hemoptysis are seen in cases of GoodpastureDs syndrome and WegenerD s granulomatosis. In WegenerDs granulomatosis
12 hepatitis B infection-- membranous glomerulonephritis, but HBsAg carriers-- membranoproliferative glomerulonephritis
13 Child or adolescent presenting with priapism suspect sickle cell disease and leukemia
14 Fluoxetine does lead to sexual dysfunction, resulting in impotence, decreased libido and ejaculatory problems,
15 Priapism with Trazadone.
16 All patients with chronic renal failure and hematocrit < 30% (or hemoglobin <10g/dl_) are candidates for recombinant erythropoietin therapy after iron deficiency has been ruled out. Erythropoietin is also indicated in all the hemodialysis patients who have symptoms attributed in part to anemia
most common side effects of erythropoietin therapy are:
a. Worsening of hypertension or induced hypertension “ Tx: fluid removal (by dialysis) and use of anti¬hypertensive drugs (beta blockers and vasodilators are preferred).
b. Headaches
c. Flu like syndrome
d. red cell aplasia
17 recurrent renal stones need 24hr urine is collected to find any underlying metabolic disorder. A detailed metabolic evaluation is not needed when a patient presents with their first renal stone
18 Finasteride acts on epithelium. alpha-1 blockers act on smooth muscles of
prostate and bladder base
19 Finasteride is 5-alpha reductase inhibitor and it inhibits the conversion of testosterone to dihydrotestosterone. It acts on the epithelial components of the prostate gland and produces improvement of symptoms as well as reduction in the size of the gland. BPH w collagen predominance respond neither to finasteride nor to alpha-1 blockers
19 epididymitis characterized by fever, painful enlargement of testes, and irritative voiding symptoms usually w UTI, in younger patients is usually caused by sexually transmitted organisms such as C. trachomatis or N. gonorrhea. In older men it is usually non-sexually transmitted and is caused by gram-negative rods
20 Peritoneal dialysis is an alternative to hemodialysis when vascular access is not possible; when there is bleeding tendency; when there is hemodynamic instability; or when a patient is having hypothermia
21 Indications for dialysis includes uremic symptoms such as pericarditis, encephalopathy, coagulopathy, and fluid overload unresponsive to diuresis, hyperkalemia not amenable to standard therapy, and pH less than 7.20 (acidosis
22 All patients with irritative or obstructive voiding symptoms should have their urinalysis and serum creatinine done. Patients with elevated serum creatinine levels should have ultrasound of kidney, ureter and bladder done
23 Glomerular hyperfiltration is believed to be the earliest renal abnormality present in patients with diabetes mellitus. It creates intraglomerular hypertension leading to progressive glomerular damage and renal function loss. diabetic nephropathy =>Thickening of the glomerular basement membrane is the first change that can be quantitated -> mesangial expansion -> Nodular sclerosis
24 acyclovir- Nephrotoxicity.= > Crystalluria with renal tubular obstruction & acute renal failure
25 Fibromuscular dysplasia can present with diastolic hypertension in children. Bruit or venous hum may be heard at the costovertebral angle. Angiogram will reveal "string of beads" sign
26 Alport™s syndrome -recurrent episodes of hematuria with proteinuria
sensorineural deafness and family history of renal failure. Electron microscopy --thinned and thickened capillary loops with splitting of GBM
27 In a patient with flank pain, fevers, chills and white blood cells in the urine, think
pyelonephritis. Urine and blood cultures should be obtained prior to obtaining
antibiotics.
28 medullary cystic kidney- in adults with recurrent UTI or renal stones ( x-ray shows nephrocalcinosis and contrast filled cysts demonstrated by IVP. AD. is not associated with renal failure or hypertension. whereas the juvenile form also known as nephronophthisis is autosomal recessive.
29 Alpha-blockers are used for the treatment of benign prostatic hyperplasia. Phenoxybenzamine is a non- selective alpha-blocker. Prazosin, Terazosin and Doxazosin are all selective alpha-1 blockers recommended for the treatment of BPH. They produce side effects like orthostatic hypotension, headache, dizziness, retrograde ejaculation and rhinitis
30 Tamsulosin is a new drug and it blocks only alpha-1 receptors that are present in prostate and bladder base used for the treatment of benign prostatic hyperplasia
31 Cystinuria is an inherited disease causing recurrent renal stone formation. impaired amino acid transport by the brush borders of renal tubular and intestinal epithelial cells. Urinalysis - hexagonal crystals. Urinary cyanide nitroprusside test, detects elevated cystine level, helps to confirm the diagnosis
32 cryoglobulinemia includes palpable purpura, glomerulonephritis(proteinuria and hematuria) along with high titers of rheumatoid factor, non-specific systemic symptoms, arthralgias, hepatosplenomegaly, peripheral neuropathy, and hypocomplementemia. Most of these patients have evidence of Hepatitis C.
33 nephrotic syndrome- proteinuria in excess of 3.5g/day, hypoalbuminemia and edema, -ïƒ 1. Accelerated atherogenesis may occur due to increased levels of LDL. 2. Microcytic hypochromic anemia may be due to loss of transferring. 3 immunoglobulins may be lost in urine resulting in hypogammaglobulinemia. 4 cholecalciferol-binding protein may be lost in urine with resulting deficiency of vitamin D and hypocalcemia. Hypocalcemia may result in secondary hyperparathyroidism
***Patients with nephrotic syndrome are at increased risk for developing
hypercholesterolemia, hypertriglyceridemia, and hypercoagulable state
34 In hyperkalemia, removal of K+ from the body can be achieved with dialysis, cation
exchange resins or diuretics. Kayexalate or sodium polystyrene sulfonate is a cation-exchange resin, which acts in Gl tract by promoting the exchange of Na+ for K+, and thereby increasing the excretion of K+.
35 Sodium bicarbonate, insulin plus glucose drip and beta agonist decrease the extra cellular concentration of potassium by driving the potassium into the cell, however they do not remove potassium from the body.
36 prostatodynia are afebrile and have irritative voiding symptoms urinary hesitancy and interruption of flow, increased urinary frequency and urgency ). Physical examination is unremarkable and urinalysis is normal
37 chronic diarrhea may develop renal stones composed of calcium oxalate. Fat malabsorption result in increased absorption of oxalic acid. This is because unabsorbed fatty acids chelates calcium and thus oxalic acid is free for absorption
38 Calcium phosphate stones are common in primary hyperparathyroidism and renal tubular acidosis (RTA)
39 Struvite stones are formed when urine is alkaline because of infection with urease producing bacteria like Proteus
40 dysuria, urinary frequency, suprapubic discomfort along with urinary findings of bacteriuria and pyuria establish the diagnosis of acute cystitis. Oral trimethoprim-sulfamethoxazole is the preferred empiric treatment for acute uncomplicated cystitis
41 Uric acid stones are radiolucent; however, they are seen on USG and CT scan. Treatment of uric acid stones includes hydration, alkalinization of urine, and use of low purine diet with/without allopurinol if hyperuricosuria is present. alkali nization of urine to pH > 6.5 with oral sodium bicarbonate or sodium citrate is indicated.
42 Hydrochlorothiazide decreases urinary calcium excretion and is used in management of recurrent hypercalciuric renal stones
43 Renal vein thrombosis is an important complication of nephrotic syndrome, most common with membranous glomerulonephritis
44 amyloidosis are renal amyloid deposits that show apple-green birefringence under polarized light after staining with Congo red. history of rheumatoid arthritis (that predisposes to amyloidosis), enlarged kidneys w proteinuria, and hepatomegaly Crescent formation revealed on light microscopy is characteristic for rapidly progressive glomerulonephritis
45. Linear immunoglobulin deposits on immunofluorescence microscopy are typical for anti-glomerular basement membrane disease (e.g., GoodpastureDs syndrome)
46 Granular immunoglobulin deposits revealed on immunofluorescence microscopy -- usually present during immune complex glomerulonephritis (e.g., lupus nephritis or poststreptococcal glomerulonephritis).
47 The two initial tests, which are recommended in all the patients with possible benign
prostatic hyperplasia, are serum creatinine and urinalysis.
48 Transient proteinuria is a common cause of isolated proteinuria and can occur during stress or any febrile illness
49 When an old patient comes with irritative voiding symptoms and cultures are negative, nonbacterial prostatitis ->bladder cancer must be ruled out by urinary cytology and cystoscopy. Oral erythromycin is used to treat nonbacterial prostatitis, as it may be caused by Mycoplasma or Ureaplasma. Oral trimethoprim-sulfamethoxazole is used to treat chronic bacterial prostatitis
49 Hypertensive nephrosclerosis-- Arteriosclerotic lesions of afferent and efferent renal arterioles and glomerular capillary tufts -> Nephrosclerosis is characterized by hypertrophy and intimal medial fibrosis of renal arterioles; whereas, glomerulosclerosis is characterized by progressive loss of glomerular capillary surface area with glomerular and peritubular fibrosis. The kidneys are generally small and microscopic hematuria and proteinuria occurs due to glomerular lesions.
50 diabetes mellitus
1. Within first year of diabetes mellitus - Glomerular hyperperfusion and renal hypertrophy with increase in glomerular filtration rate.
2. First five years of diabetes mellitus - Glomerular basement membrane thickening, glomerular hypertrophy, and mesangial volume expansion with glomerular filtration rate returning to normal.
3. Within 5-10 years of diabetes mellitus- Microalbuminuria, which later progresses to overt nephropathy.
51 Analgesic abuse nephropathy is primarily a tubulointerstitial disease characterized by focal glomerulosclerosis.
52 hematuria with irritative or voiding symptoms, suprapubic pain should alarm the physician for the possibility of bladder cancer
53 a patient with acute pyelonephritis does not respond to 72 hr treatment with appropriate antibiotics, urological imaging with CT scan or ultrasound must be performed to exclude obstruction, renal, perirenal abscess, or some other complication
54 Calcium gluconate is the treatment of choice for hyperkalemic patients with significant EKG abnormalities
55 Kayexalate is a cation exchange resin used in case of chronic hyperkalemia
56 The duration of diabetes should be longer (10-15 years) to cause nephropathy. Hypercalcemia is usually not caused by HTN related renal failure
57 Any elderly patient with bone pain, renal failure, and hypercalcemia has multiple myeloma until proven otherwise
58 Papillary necrosis and chronic tubulointerstitial nephritis is the most common pathology seen in analgesic nephropathy. Patients with chronic analgesic abuse are more likely to develop premature aging, atherosclerotic vascular disease, and urinary tract cancer
59 BPH -weak urinary stream, urgency, frequency, and sensation of
incomplete voiding, it starts in the center of prostrate. treatment with alpha-blockers is usually the first choice
60 uremic coagulopathy -- platelet dysfunction. desmopressin (DDAVP), cryoprecipitate, and conjugated estrogens has been used to correct the coagulopathy in uremic patients.
61 nafcillin cause acute allergic interstitial nephritis -> a Type 4 hypersensitivity reaction. The triad of fever, petechial rash, and peripheral eosinophilia in an azotemic patient is highly suggestive of allergic interstitial nephritis. eosinophiluria (positive Hansel stain).
62 Acute tubular necrosis-- Muddy brown granular casts are characteristic
63 The nephrotic syndrome is a hypercoagulable condition, which manifests as venous or arterial thrombosis and even pulmonary embolism. Renal vein thrombosis is the most frequent manifestation. Other complications of nephrotic syndrome include: protein malnutrition, iron-resistant microcytic hypochromic anemia, increased susceptibility to infection, and vitamin D deficiency.
64 Imaging studies should be performed in all children under the age of 10 years with UTI, in all male children with UTI, and in all prepubertal non-sexually active females with UTI. Imaging studies are performed to find any underlying structural abnormality predisposing to UTI. The most common one in this age group is vesico-ureteral reflux. Voiding cystoureterogram is usually done for this purpose but it is performed only after the acute illness is over
65 Struvite stones almost always occur in the presence of alkaline urine that is
persistently infected with urease producing bacteria
**66 Cholesterol embolization, usually follows surgical or interventional manipulation of the arterial tree. Renal failure, livedo reticularis, systemic eosinophilia, and low complement level should make you think of cholesterol embolism
67 1)WBC casts are definite evidence that urinary WBCs originate in the kidney and are seen in cases of interstitial nephritis, pyelonephritis, etc.
2)RBC casts are indicative of glomerular disease or vasculitis.
3) Hyaline casts are composed almost entirely of protein and they pass unchanged along the urinary tract. They may be seen in asymptomatic individuals and in patients with pre-renal azotemia.
4) Fatty casts are seen in conditions causing nephrotic syndrome.
5) Broad casts arise in the dilated tubules of enlarged nephrons that have undergone compensatory hypertrophy in response to reduced renal mass; thus, they are seen in chronic renal