1.
90% of orbital cellulitis cases are due to spread from where?: ethmoid sinus
2.
A new aortic regurgitation murmur in a pt with acute CP is highly suggestive of what?: PROXIMAL AORTIC DISSECTION!
3.
administerting b-blockers in an MI does what?: decreases the incidence of v.fib which has a significant impact on long-term mortality
4.
An aortic diameter of > __ cm is an AAA?: >3 cm! (most are true aneuryms and involve the infrarenal aorta).
5.
asymmetric pulses will occur only if which artery is involved in a dissection?: the subclavian artery!
6.
before administering NTG, what should you ask the pt?: ask about use of viagara or other phosphodiesterase inhibitors before administering NTG
7.
common findings with a PE?: ssx are sudden only 1/2 the time
-SOB = m/c complaint
-tachypnea = m/c finding
-cxr: hampton's hump: wedge-shaped density indicating infarcted lung
-westermark's sign: decr vessel markings distal to embolus
8.
describe acute glomerulonephritis!: inflammation of the glomeruli. may be the 1 process as in post strep glomerulonephritis or 2 with lupus, systemic vasculitis.
ssx: DARK urine, hematuria, edema, HTN
Dx: RBC casts! proteinuria, hematuria renal biopsy is definitive
tx: abx if poststrep, control BP, supportive care, steroids used to treat underlying systemic dz
9.
Describe ATN: m/c hospital-acquired arf DUE TO
-RENAL ischemia: SURGERY, TRAUMA, SEPSIS
-nephrotoxic agents: aminoglycosides, radiocontrast agents (!) --- give n-acetylcysteine to help prevent it!
-pigments: myoglobin, hemoglobin
dx: loss of urinary concentrating ability, urine osmolality = serum osmolality, muddy brown casts, and renal tubular casts
administer crystalloid, mannitol and alkalinize urine if pigment induced
10.
Describe interstitial nephritis!: think medications! think wbc casts on UA.
it's a interstitial inflammation, m/c in response to medication. m/c (pcn, diuretics, anticoagulants, NSAIDs)
ssx: fever + rash
dx: elevated BUN/cr, renal biopsy, wbcs, and wbc casts on ua
tx: d/c agent, steroids if significant renal impairment
11.
Dx of syncope-: all pts need an ECG. can use echo to check for cardiovascular dz - at risk: .45, hx of ventricular dysrhythmias, hx of CHF, abnl ECG, syncope in supine position, exertional syncope, syncope w/CP
12.
ECG findings suggestive of an MI?: -hyperacute T waves (earliest finding!)
-ST segment elevation
-reciprocol ST segment depression
-T-wave inversions in regional distribution
-new LBBB
13.
Gold standard for dx-ing aortic dissection?: aortography, but largely supplanted by CT angiography
14.
how do you dx aaa?: suspect if pt is >50 with hypotension, flank pain and abdominal pain
-Abd xray
-U/S 100% sensitive!!!
-CT (highly sensitive)
15.
how do you dx cholangitis?: -leukocytosis
-incr bilirubin
-incr alk phos
-OBTAIN BLOOD CULTURES TO R/O EARLY SEPSIS
-U/S or CT
-ERCP is dx and therapeutic (drainage)
16.
how do you dx HUS?: anemia and thrombocytopenia
PT+ PTT NORMAL
renal failure
peripheral smear: schistocytes**
17.
how do you dx postrenal arf?: renal ultrasound
UA is often normal
18.
how do you dx pre-renal ARF?: BUN/CR > 10:1
-evidence of increased renal Na conservation
-increased urine osmolality
-UA: normal with occ hyaline casts
-no evidence of obstruction
19.
How do you treat orbital cellulitis?: CT of orbits
blood cultures (esp if febrile)
gram stain
broad spectrum IV abx
20.
how do you tx a DVT?: -immediate anticoagulation w/LMW heparin (requires dose adjustment in renal failure)
-long term anticoagulation: warfarin, 1st dose in ED
-thrombolysis is NOT more effective than heparin for preventing PE, but may accelerate clot lysis and REDUCE COMPLICATIONS OF VENOUS INSUFFICIENCY in massive thrombosis***
21.
how do you tx a hypertensive urgency?: -tx any secondary causes
-begin ORAL antihypertensive agents w/goal of lowering over 24-48 hours
22.
how do you tx a PE?: immediate anticoag with heparin. thrombolysis if a massive PE. embolectomy. IVC filter to those with CI to anticoagulation
23.
how do you tx acute arterial thromboembolism?: immediate heparin!
surgical embolectomy
24.
how do you tx cholangitis?: IV abx
25.
how do you tx hypertensive emergencies?: oral agents are a NONO!
drug of choice is: sodium nitroprusside! -- arteriolar and venodilator!
it's also a cerebral vasodilator (so you want to be careful in stroke syndromes!)
it dilates normal coronary arteries > diseased > coronary steal!
-cyanide is a metabolite so long term use is LIMITED.
C/I in pregnancy
26.
how do you tx stable angina?: alleviating the increased O2 demand (resting or blood transfusion) OR by increasing the blood supply through vasodilators LIKE nitroglycerin
27.
how does an aortic dissection occur?: -disruption of the intima of the aortic wall -> blood travels (dissects) into media and then creates a false lumen
28.
How does orbital cellulitis look different periorbital cellulitis?: -worse pain/decreased/restriction with EOM***
-visual changes or diplopia
-fever/toxic looking
-incr IOP
29.
how to you tx HUS?: -tx complications of ARF
-rehydration
-PRBC transfusion if Hgb <6 mg/dL
-platelet transfusion only if there's significant bleeding
30.
how to you tx pre-renal ARF?: -tx underlying cause
-d/c offending agent - NSAIDs, ACE inhibitors
-dialyze as needed
-correct e- imbalance
31.
if the pt has CP and stroke ssx, what are you thinking?: AORTIC DISSECTION
32.
in acs, how soon should you give beta blockers?: give as early as possible. it blocks the sympathetic stimulation, reducing HR. decr myocardial O2 consumption, decr incidence of v.fib
33.
M/C cause of venous insufficiency?: DVT! (also: TRAUMA, varicose veins, pelvic vein obstruction, av FISTULA
34.
nitroglycerin causes what sort of dilation?: more venous > arterial
35.
primary cause of ARF?: hypovolemia!
36.
rupture of an AAA is linked to how much mortality?: 80-90%
37.
ssx of HUS:: prodrome of fever, vomiting, abd pain, and diarrhea (often bloody)
-onset of pallor with petechial or purpural rash
-decr UO
hx of abd pain and diarrhea are COMMON!!!
38.
The m/c aneursym site is:: abdominal aorta. common in the peripheral arteries : popliteal arter aneurysm
39.
the m/c reason for acute interstitial nephritis is...: response to medication!
40.
the m/c site of acute arterial embolism?: bifurcation of common femoral artery
41.
the vast majority of pts with aortic dissections have what sort of pain?: pain in their chest, neck or back. 90%!! ripping and tearing pain. abrupt and maximal at onset.
42.
triad of AAA?: hypotension, pulsatile abdominal mass, abdominal pain!
43.
tx accelerated htn, htnive encephalopathy, ARF: sodium nitroprusside, labetalol, nicardipene (decreases cerebral vasospasm, therefore it's a good agent for stroke syndromes)
44.
tx for an aortic dissection?: -After resuscitation is to decrease SHEARING FORCES by reducing the BP, start with IV B-blockers!!.
ADD IV nitroprusside
AVOID nifedipine
45.
tx for PID?: outpt: ceftriaxone (3rd gen) 250 mg IM + doxy 100 mg po BID x 14 days
inpt:
1) cefotetan or cefoxitin + doxy
2) clindamycin + gentamycin
46.
tx of AAA?: surgical intervention (no such thing as a stable rupture)
-fluid and blood resuscitation (to SBP 90-100 mm Hg)
-thoractomy w/cross clamping of aorta if there's a really severe cardiac arrest or hemodynamic compromise!
47.
tx of aortic dissection: esomolol or labetalol (first!)
sodium nitroprusside
48.
tx of catecholamine crisis: benzo, labetalol, phentolmine
49.
tx of eclampsia: magnesium, labetalol, nicardipine, hydralazine
50.
tx of MI: nitroglycerin, labetalol
51.
tx of postrenal arf: relieve the obstruction!!! correct electrolyte imbalances! dialyze as needed!
52.
tx of pulm edema: nitroglycerin, sodium nitroprusside, fenoldopam (improves renal function acutely)
53.
upon exam, what will you see with AAA?: -vital signs may be normal!
-abdominal tenderness, distension or pulsatile mass
-evidence for retroperitoneal hematoma!
periumbilical ecchymosis (cullen's sign)
flank ecchymosis (grey-turner's sign)
54.
what aortic diameter in AAA is most likely to rupture?: >5 cm!!!
55.
what are the causes of intrinsic ARF?: -glomerulonephritis
-acute interstitial nephritis
-acute tubular necrosis
-vascular dz (vasculitis, eeclampsia, malig HTN)
56.
What are the causes of pre-renal ARF?: Hypovolemia (hemorrhage, v/diarrhea, diuretics
Volume redistribution (3rd space, sepsis, hypoalbumin state)
Decr effective CO (MI, valvular dz, cardiomyopaty)
Meds that limit glomerular perfusion (ACE inhibitor or prostaglandin (NSAID) use
57.
what are the complications of an AAA?: -rupture
-atheroembolism : microemboli from atherosclerotic aneuryms which lodge in distal small vessels...blue toe syndrome (classic!)
58.
what are the indications for thrombolysis in PE?: clinical evidence of a MASSIVE PE. (hypotension, cardiac arrest, evidence of R heart strain)
59.
What are the most common causes of PID?: neisseria gonorrhoeae
chlamydia trachomatis
60.
what are the possible causes of postrenal ARF?: 1) urethral obstruction: phimosis or stricture
2) bladder obstruction: BPH, stones, clot, tumor, neurogenic bladder, posterior urethral valve
3) intrarenal/ureteral obstruction: kidney stone, crystalline precipitation, tumor, iatrogenic, papillary necrosis
61.
what are the short term high risk factors for death in pts with US angina?: rest pain >20 min
CHF or pulm edema
rest pain w/ECG changes
CP with new or worsening MR murmur
CP with hypotension
62.
what are the symptoms of an acute arterial thromboembolsim?: pain, pallor, paresthesias, pulselessness, paralysis
63.
what causes venous insufficiency?: chronic elevation of venous pressure which compromises the integrity of valves in the deep and perforating veins in the leg
64.
what does tx of aortic dissections depend on?: Location has important implications!!! proximal (ascending) dissections are managed surgically. distal dissections are typically managed MEDICALLY. **
65.
What is a hypertensive urgency?: a persistent and marked elevation of BP in a pt at risk for end-organ damage, but WITHOUT acute organ injury
66.
what is ARF?: sudden decline in kidney fn marked by the accumulation of nitrogenous waste products, disturbances of fluid, and metabolic disturb.t
67.
what is cholangitis?: acute bacterial infxn of the biliary tree commonly occurs because of obstruction from gallstones
68.
what is d-dimer all about?: order if you suspect pt might have a DVT
-it measures fibrin breakdown product. it indicates presence of a clot WITHIN past 72 hours*
-elevates levels often seen in sepsis, pregnancy, trauma, MI, liver dz, cancer
69.
what is definitive cardiac testing?: definitive: cardiac catheterization
70.
what is gold standard for DVTs?: venography
71.
what is reperfusion therapy?: it's either PCI (percutaneous coronary intervention) vs thrombolytic therapy
PCI consists of catheterization w/angioplasty + stent placement.
thrombolytics bind plasminogen, which then degrades fibrin, "busting clots"///primary risk is bleeding. give alteplase, reteplase, or tenecteplase.
72.
what is stable angina?: when a fixed coronary plaque PREVENTS sufficient blood supply through the coronary artery at times of INCREASED O2 demand...results in ischemic ssx
73.
what is syncope and how is it different from a seizure?: transient LOC and postural tone w/ subsequent spontaneous recovery. transient cerebral hypoperfusion. POST-ICTAL PD IS NOTABLY ABSENT!!
74.
what is unstable angina?: new-onset angina, angina with incr frequency/duration, angina with minimal exertion/rest
75.
What should be done with the pt has a STEMI?: 1) ASA given on arrival
2) ECG interpreted within 10 min
3) if STEMI:
door to needle (fibrinolytics) <30 min
and
door to catheterization <90 min
4) beta blockers within 24 hours
76.
what should you suspect if the pt is on ACE inhibitors and is in ARF?: suspect bilateral renal artery stenosis!
77.
what sort of hx will a pt w/HUS possibly have?: hx of abdominal pain and diarrhea!!
78.
What's a hypertensive emergency?: HTN with evidence for acute-end-organ dysfunction
types: MI, pulm edema, acute aortic dissection, HTN encephalopathy, eclampsia, ARF, uncontrolled bleeding
79.
what's an MI?: either NSTEMI or STEMI. myocardial cell death and necrosis diagnosed by a rise and fall of cardiac enzymes or by pathologic findings of prior MI (insufficient O2 supply!)
80.
what's charcot's triad and reynold's pentad?: both for cholangitis
charcot's triad: jaundice, RUQ pain, fever/chills
reynold's pentad: charcots + AMS + shock
81.
what's clopidogrel?: plavix - irreversibly inhibits platelet aggregation via adenosine diphosphate receptor antagonism. onset = hours! give to those with aspirin allergy!
82.
what's HUS?: microangiopathic hemolytic anemia, thrombocytopenia, acute renal failure
common in peds
m/c seen following infxn with e. coli serotype 0157:H7
83.
what's the best treatment for acute decompensated heart failure?: provide supplemental O2
afterload reduction with nitrates and diuretics
84.
what's the goal in treating hypertensive emergencies?: reduce MAP by 25% in 30-60 minutes or reduction of diastolic pressure to about 110 mm Hg.
if more than >25%, pt is at risk for end-organ ischemia due to relative hypotension!!!
normal range is 60-160 for the MAP
(for aortic dissection, a lower MAP is necessary to eliminate shear forces.
85.
what's the m/c cause of ARF in the ICU? (hospital acquired): ATN (with muddy brown cast)
86.
what's the m/c cause of heart failure in the US?: ischemic heart disease
87.
What's the M/C location of AAA rupture??: retroperitoneum
88.
what's the most common predisposing risk factor to an aortic dissection?: uncontrolled HTN
89.
what's the most cost-effective tx to pts with ACS?: aspirin, it independently REDUCES mortality. it irreversibly inhibits platelet cyclooxygenase activity therefore inhibiting the formation of thromboxane A2. onset = minutes. caution with PUD!
90.
what's the number one cause of death in the US?: CORONARY HEART DISEASE!
91.
When do AAA's become symptomatic? what sort of ssx?: Most are asymptomatic, unless expanding or ruptured*
-Acute pain in abdomen, back or flank
-N/V
-syncope or near syncope
92.
when do the serum markers rise in the eval of ACS?: myoglobin rises in 1-2 hr (early rise but poor specificity)
CK-MB rises in 3-4 hr (not as sens or spec as troponin)
troponin rises in 3-6 hr (most sens but delayed rise)
93.
when do you decide to reperfuse?: 1-2 mm ST elevation in regional distribution or new LBBB
94.
when is PCI generally preferred?: do it in the setting of STEMI if:
-transfer to a PCI facility can be done within 2 hours. goal is always <90 minutes.
-presentation >3 hr after onset of ssx
-uncertain dx
-complications (CHF, unstable)
-CI to thrombolytics
95.
Who do pts with severe UA have a prognosis similar to?: to those with mild NSETMI
96.
who do you not use clopidogrel or ticlodipine (plavix or ticlid)?: dont use in pts who require a surgical intervention (CABG) within the next 5 days
97.
who would you consider an IVF filter in?: those with a DVT
-C/I to or complication of anticoagulation (bleeding or HIT)
-propagation of DVT despite adequate anticoagulation w/warfarin and heparin
-presence of DVT despite adequate antocag with warfarin and heparin
-presence of free-floating nonadherent thrombus >5 cm
-massive clot burden
98.
why is nicardipene great?: it's a calcium channel blocker, decreases peripheral vascular resistance, and decr cerebral vasospasm (GREAT FOR STROKE SYNDROMES!)
99.
xray with aortic dissection?: widened mediastinum
loss of aortic knob
pleural capping
aortic shadow extending >5 mm from aortic calcification
