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Clin Med Exam 3 - arrhythmia meds, HF meds, myocarditis/pericarditis, lipids, peripheral vascular, HF, DM
Terms in this set (178)
SP is a 64 yo female who presents with a chief complaint of palpitations. PMH: HTN, MI 2 weeks ago, allergy to procaine (Novocain). She is pale, diaphoretic, BP 95/70, pulse 145 bpm and diagnosis is sustained ventricular tachycardia. Which medication would be effective in terminating the arrhythmia?
Lidocaine (Class 1b)
RD, a 68 year old male patient reports to the clinic with a re-entrant arrhythmia and you suspect one of his medications as the cause. Which med has the highest risk of being the cause?
Flecainide (Class Ic)
JH a female patient with a h/o exercise induced angina presents 24 hrs post-CABG with new onset a-fib with a ventricular response rate of 142 bpm. Which medication would be a good choice to start in this patient to control the ventricular response rate?
Metoprolol (Class II)
GV, a female patient with a congenital long QT interval requires chronic treatment with an anti-arrhythmic to maintain NSR. You are concerned about torsades developing. Which medication would be a better choice in this patient?
Amiodarone (Class III)
JK, 66 yo male patient presents to the clinic with dyspnea and intermittent palpitations and is diagnosed with new onset paroxysmal a-fib, a pulse of 154 bpm and EF 30%. PMH: HTN, DM, HF. Which would be a good rate controller to initiate in this patient?
Digoxin (Class IV)
DOC for termination of VT and prevention of VF after conversion in setting of acute ischemia
best drug to use for rapid conversion of AFib and aflutter of less than three months duration
best drug for acute treatment of PSVT
DOC for arrhythmias in pts w/ HF
DOC in AFib w/ no identifiable cause
Class DOC in exercise induced arrhythmias and in patients w/ long QT syndrome
Class II - MEP
severe SE of amiodarone
interstitial pneumonitis, pulmonary fibrosis
which class of arrhythmia drugs should NOT be used in cases of Wolff-parkinson-white syndrome
Class IV - Nondihydropyridine CCBs - Diltiazem and Verapamil
Which antiarrythmia drug has black box warning of increased mortality
Dronedarone (Class III- K channel blocker)
Which Class I drug causes CNS effects
Mexiletine (Class Ib)
which drug should NOT be used if pt has an allergy to ester-type anesthetics, such as novocaine?
Pracainamide (Class Ia)
CD is a 62 year old male patient with a past medical h/o HTN, CAD, dyslipidemia. He presents to the clinic today during his first follow-up visit after his recent MI and is newly diagnosed with HF. It is true that drug therapy can....
prolong his survival
CD, our newly diagnosed HF patient, has no symptoms of dyspnea or edema. His current medications are aspirin, metoprolol succinate (b-blocker), simvastatin. Vitals are HR 67 bpm, BP 138/80. PMH: HTN, CAD, Dyslipidemia, MI What is our next step?
initiate enalapril (ACE-I)
CD presents to the clinic today complaining of a dry cough that keeps him awake at night. Medications are aspirin, metoprolol succinate, simvastatin, furosemide (diuretic), enalapril, digoxin, docusate. He has also been taking some cough and cold products with no relief. Which medications should be discontinued/initiated?
discontinue enalapril(ACEi) and initiate valsartan(ARB)
CD presents for a clinic visit 6 months later and states he had several near syncopal episodes. Current medications are aspirin, metoprolol succinate, simvastatin, enalapril, furosemide, docusate. Vitals are HR 48 bpm, BP 108/78. How should you alter his medication regimen?
decrease dose of metoprolol succinate
CD presents for his clinic visit now showing initial signs of edema. You decide to initiate a diuretic to control fluid volume and start him on furosemide, a loop diuretic. What should you monitor labs for
Hypokalemia and Hyponatremia
CD presents for a clinic visit 2 years after his HF diagnosis. Today he complains of dyspnea at rest, increased fatigue, and use of 3 pillows to sleep. Vitals are HR 62 bpm, BP 105/78, EF 30%. Current meds are aspirin, metoprolol succinate, simvastatin, enalapril, furosemide, docusate. What is our next step?
CD calls your office to state he has gained 6 pounds (~3 kg) in the last two days, is having trouble breathing while watching TV, wheezing at night, his ankles are too swollen to get his shoes on and he just feels miserable. What should you do?
admit to hospital
which drug is recommended for all HF patients w/ reduced EF?
SE of ACEi
dry, hacking cough
functional renal insufficiency
SE of ARNi
Loop diuretics take effect in
ascending limb of Loop of Henle
potassium sparing diuretics take effect in
thiazide diuretics take effect in
distal convoluted tubule
when is dioxin used in HF patients?
to control symptoms of fatigue, dyspnea, and exercise tolerance in symptomatic patients w/ EF <40%
which drugs are selective for epicardial coronary vasculature
vasodilators - organic nitrates
which HF drug is a potential alternative for ACE-i, specifically for AA patients
BiDil - organic nitrate vasodilator
For stable, symptomatic HF patients on highest tolerable dose of beta blockers, what med would be appropriate to use
Drugs used for acute/severe HF should be
vasoactive and positive inotropic
Pt w/ HF has not responded to dobutamine, dopamine, IV vasodilators. which drug would be best to use
Bipyridines (inamrinone or milrinione)
which acute HF drug class is contraindicated in cardiogenic shock or a SBP of <90mmHg
which drugs should be AVOIDED in HF?
Sildenafil, vardenafil, tadalafil
First line drugs for HF patients
ACEi and BB (Both class IA recommended)
A Syndrome caused by cardiac dysfunction, generally resulting in myocardial dysfunction and loss is called?
Ejection fraction set by the gov't for systolic HF?
Lowest ejection fraction compatible with life?
5% - assuming RV is in really good shape
Pt has new onset of pulmonary edema, and you suspect HF. you order an ECHO which shows significant E to A ratio and ejection fraction <30%. dx?
mixed HF (Systolic and Diastolic HF)
87 yo pt presents w/ loud S3 murmur. what should you suspect
HFrEF / systolic HF
MC infectious disease cause of HF
Chagas dz (Trypanosoma Cruzi)
Which HF is most likely to improve if you fix the underlying cause?
Alcohol induced cardiomyopathy
MC Medicare diagnosis that hospitals bill for
Typical symptoms of HF
Paroxymal nocturnal dyspnea
SOB on exertion
SOB at rest
Which Med doesn't improve mortality in HF pts?
Which of the following drug classes has the largest reduction in mortality for HF?
What scoring system to determine if pt needs to be on a statin or not?
38 yr old with viral cardiomyopathy, EF 30%, persistent asthma, requires BB, BEST choice of medication?
MCC of HF in US
Breathing pattern a/w decompensated HF?
Pt wants an ECHO because they think they are getting better, should you do one?
No, only Repeat if an event or treatment would significantly affect cardiac function or significant change in clinical status
BiDil is most likely to benefit which population?
Which food causes digoxin toxicitiy?
Pt VERY allergic to Sulfa, which loop diuretic can you give?
pt has terrible Gout and needs an ARB, which one to use?
Metformin causes ____________ vitamin deficiency?
Statin myopathy after trying 2 different statins, what lab should you get?
25-hydroxyl Vitamin D
Which of the following is LEAST likely to cause harm in a patient systolic HF w/ EF <30%?
Diabetes Med, NSAID
What should you NOT recommend to pts w/ sleep apnea and HF
Adaptive servo ventilation (ASV)
You notice your HF patient is doing very well on their ACEi and BB. they state they feel great. How should you manage their treatment
continue to increase meds - even if they look great!
Should you restrict fluids in HF patient?
which drug has been shown to be better than placebo in treating diastolic HF
Considered, the largest lipoprotein molecule, which lipid is made mostly of exogenous TG and synthesized in wall of small intestine?
which lipid transports endogenous TG to fat and muscle cells
which lipid is rich in cholesterol and returns from body tissues to liver
which lipid is the main carrier of cholesterol and circulates until removed by the receptor-mediated or non-receptor medicated pathyways
which lipid is rich in surface phospholipids, excreted by the liver, and inhibits cellular uptake of LDL
what is the rate limiting factor keeping LDLs from being circulated
reflects density of LDL particle
small, dense LDL =
atherogenic LDL = bad
You are consulting pt on their hyperlipidemia status. TG levels are over 2000. you also note cream-colored blood vessels in the fundus. what is this finding called?
which lipoproteins are measured? which ones are calculated?
TC, TG, VLDL, HDL = measured
LDL = calculated from Freidwald equation
what is the first step in overall management of hyperlipidemia
largest and most controversial change presented in the ATP IV guidelines is
recommendations for the medial management of hyperlipidemia
populations who should be evaluated for statin therapy
1. pts w/ clinical ASCVD
2. 40-75 yo w/ DM, no ASCVD, LDL-C 70-189
3. primary elevations of LDL-C >190
4. 40-75 yo, no ASCVD, no DM, LDL-C 70-189, 10 year risk of >7.5%
High intensity statins would work best on what group of individuals
1. <=75 yo w/ ASCVD
2. pts w/ LDL >190
3. pts 40-75, no ASCVD, no DM, LDL 70-189, 10 year risk >7.5%
Moderate intensity statins would work best on what group of individuals
1. >75 w/ clinical ASCVD
2. pts who can't tolerate high intensity
3. pts 40-75 yo, no ASCVD, no DM, LDL 70-189, 10 year risk of 7.5%
4. pts 40-75yo w/ DM and LDL 70-189
low intensity statins are indicated for what group of patients
pts who cannot tolerate high or moderate intensity statins
50 yo pt has LDL of 100 and 10 year risk of 10%. Pt has no history of ASCVD or DM. What group of statins would be most appropirate
Pt's LDL is 200. what statin therapy should they be on
60 yo patient w/ DM has LDL of 120. what statin therapy should they be put on
Pt has homozygotic Familial hypercholesterolemia. what is a common prognosis ? how do you treat
atherosclerosis/ MI in childhood - death by age 20
tx - paresis, liver trasplant, stem cell transplant
pt has heterozygotic familial hypercholesterolemia. what is a common prognosis if left untreated? how do you treat
premature mortality from CAD by age 40 if left untreated
tx - statins
Which gene is associated w/ familial hypercholesterolemia
56 yo male with 30 pack year smoking history presents w/ pain claudication in R foot. Pt states it gets better once they sit down. On exam you note diminished dorsals pedis pulse and cooler temperature in R foot. Pulses in left foot are 2+, temperature is not as cool as you find in the R foot. what should you suspect and how would you diagnose? when would treatment be necessary?
Peripheral Arterial Disease
tx - lifestyle mods first
if ABI is 0.8-0.9, treat risk factors
if ABI is 0.8- <0.5, refer to vascular specialist
Calf claudication is hallmark for
Percutaneous revascularization is best for
short focal stenosis of large arteries
surgical revascularization is best for
longer areas of stenosis or obstructive lesions distal to the origin of the iliac arteries
Pt has Ankle -Brachial Index of 1.0. how should you treat?
no treatment - this is considered normal
Pt has Ankle -Brachial Index of 0.82. how should you treat?
Treat risk factors
Pt has Ankle -Brachial Index of 0.6. how should you treat?
refer to vasular specialist
pt presents w/ sudden onset pain and tingling in R foot. You note decreased PMS in lower R extremity and it is also very cold compared to the left. Pt does not have a h/o claudication. what should you suspect and how would you treat
Acute Limb ischemia - arterial embolism
tx - heparin
if sxs lasting >14 days, surgical thromboemolectomy
70 yo male presents w/ severe abdominal pain and syncope. Pt has h/o hypertension and is a 30 pack year smoker. On exam you note a painless, pulsatile mass below the umbilicus, distal to the real arteries. The mass is approximately 6cm in diameter. what should you suspect and how would you treat this patient?
Surgery - Percutaneous endovascular aneurism repair (EVAR) - this is used in patients w/ multiple comorbidities, which this patient has.
55 yo pt w/ h/o HTN presents w/ sudden onset of severe chest pain with abdominal pain. EMS notes syncopal episodes and possible stroke. How should you confirm dx and how would you treat
MR or CT angiography to confirm Type A Aortic dissection - this is FATAL - need emergent surgical repair
55 yo pt w/ h/o HTN and bicuspid aortic valve presents w/ acute onset of chest pain, tachypnea, tachycardia. Pt notes his R foot feels numb and tingly. You note decreased pulses in R lower extremity and no sensation to sharp/dull. what should you suspect and how would you treat
Type B aortic dissection
treat medically - the 1 year survival rate is higher than surgery
surgery is indicated if there is compromise of blood flow to the legs, kidneys, or other viscera
45 yo male with 30 pack year history presents w/ claudication of the feet bilaterally. on exam you note superficial thrombophlebitis. What should you suspect and how would you treat
tx - complete tobacco abstinence
pt presents w/ recurrent episodes of pallor followed by cyanosis, then by erythema in the fingers. This event is brought on by cold temperatures and stress. what should you suspect and how would you treat
avoid cold temperatures and dress warmly
CCBs - reduce frequency and severity of episodes
male pt presents w/ temporal HA, jaw claudication, fever, and chest pain. You note pale and edematous fundi on retinal exam. what should you suspect and how would you confirm
Giant Cell Arteritis
confirm diagnosis by biopsy
Endothelial damage - surgery or trauma
venous stasis - prolonged bedrest
hypercoagulable state - cancer
Pt has Well's score of 2. what is their risk of venous thromboembolic disease?
risk of PE is much higher if clots are where?
proximal calf veins
Pt living in nursing home presents w/ tenderness and warmth in proximal calf. you also note a palpable tender cord and dilated superficial veins in this same leg. what testing should you do to confirm and how should you treat initially?
D-dimer to rule out DVT
can do D-dimer, Wells score, u/s
Contrast venography = gold standard (but it's invasive)
tx - LMWH
pt has DVT. you have already treated them initially w/ LMWH. what is your next step in treatment?
Oral warfarin or a Direct Xa inhibitor (Eliquis)
how long should you treat a low risk pt for DVT?
how long should you treat a high risk patient or active cancer pt for DVT?
Pt presents / dilated, elongated, tortuous veins in her lower R extremity. you also note brownish pigmentation and thinking of the skin above the ankle. what should you suspect and how would you treat
tx - graduated support hose
endovenous ablation- do Duplex u/s to plan procedure
Pt presents w/ thin, shiny, atrophic skin w/ brown pigmentation in lower extremities. Pt notes pruritus and discomfort when standing. Pt states this has progressively gotten worse the past few months. what should you suspect and how would you treat
Chronic Venous insufficiency
anticoagulants - heparin
what is the best treatment for venous stasis ulcers?
treat the edema - if the edema doesn't go away, you can't treat the ulcer. must find out the underlying cause
Pt w/ Buerger's presents w/ induction and redness bilaterally on lower extremities. you note tenderness along the course of the great saphenous vein. what should you suspect
infectious myocarditis is commonly caused by
viruses - Coxsackial, echovirus
drug induced and toxin myocarditis is considered___. what are some things that cause this
Chemotherapeutic agents, catecholamines, radiation, cocaine, hypersensitivity reactions
Pt presents w/ SOB and chest pain one week after acute febrile illness. On exam you note friction rub, rales, orthopnea, and increased JVP. ECG shows sinus tach and AV block. what should you suspect and what treatment should you avoid
Myocarditis - possibly a/w Lyme Disease bc of AV block
50 yo AA male presents w/ orthopnea and SOB. you note S3 gallop and elevated JVP on exam. ECG shows LBBB. EF 30%. what should you suspect and how would you treat
tx - ACEi, BB (standard HF therapy)
refer for AICD
20 yo runner presents w/ syncope after exertion and SOB. on exam you note S4 murmur that decreases when she crouches down and increases when she stands up. ECG is normal. what should you suspect, how should you confirm and what would you see? how would you treat
ECHO is diagnostic - would see left ventricular hypertrophy, asymmetric septal hypertrophy
tx - BB or CCB
50 yo male presents w/ SOB, fatigue, and edema in the lower extremities. pt has ongoing case of amyloidosis. On exam you note Kussamaul sign and elevated JVP. ECHO shows small, thickened LV w/ bright myocardium, and rapid early diastolic filling w/ biatrial enlargement. what should you suspect and how would you confirm? how would you treat?
myocardial biopsy is confirmatory
treat underlying cause - treat amyloidosis
diuretics if you are careful - go slow
65 yo female pt presents w/ angina and SOB while planning her daughter's wedding. Pt states she feels like this when she is really stressed. EKG shows diffuse ST elevation, and deep anterior T wave inversion. CXR is normal. what should you suspect and how would you treat
tx - similar to MI (ASA, BB, ACEi)
MC viral cause of pericarditis
inflammation causes the pericardium to go from transparent and glistening to
dull, opaque, "sandy" sac
Hemorrhagic pericarditis is most likely to occur in cases of
metastatic tumor or TB
causes of acute pericarditis
Myocardial infarction, meds
pt presents w/ persistent pleuritic chest pain, SOB, and fever. Pt states the pain is worse when they breathe in but gets better when they lean forward. You note pericardial rub on exam. what should you suspect and how would you treat?
Viral tx - NSAIDS, Colchicine
post MI tx - ASA DOC
Pt presents w/ SOB, pulses paradoxus, and muffled heart sounds. ECG shows decreased voltage and electrical altering. CXR shows flask-like appearance. What should you suspect and what is the most sensitive test to confirm?
ECHO = most sensitive test for effusion
Pt presents w/ cough, dysphagia, and hiccups. On exam you note increased JVP, pulses paradoxus and distant heart sounds. what should ou suspect and how would you treat
pericardial tamponade - medical emergency
tx - pericardiocentesis
pt presents w/ SOB, elevated JVP, Kussmaul's sign, and you note a pericardial "knock" on auscultation. CXR shows pericardial calcification and CT shows 5mm thickening. what should you suspect and how would you treat?
tx - initially, diuresis
most sensitive and specific antibody test for T1DM
glutamic acid decarboxylase (GAD65)
earliest pathophysiologic finding in T2 DM
Female pt has h/o obesity, BP of 140/90, FPG 120, TG 155, HDL 40. What should you suspect
"The Insulin Resistance Syndrome"
Pt presents w/ polyuria, polydipsia, weight loss, and fatigue. Random glucose is 220. what is the dx
Acanthosis nigricans is a sign associated w/
Type 2 DM
Diagnostic Criteria for Prediabetes
IFG/FPG >/= 100-125
IGT/2hr PG >/= 140-199
confirm w/ glucose testing
Diagnostic Criteria for Diabetes
2hr PG >/=200
random glucose >/= 200 + symptoms
In what conditions would Fructosamine levels be measured instead of A1C?
in pts w/ hemoglobinopathies such as thalassemia and sickle cell dz
When should you immediately refer to ophthalmology
pt w/ T2 DM
what is the base of therapy for prediabetic patients
what is the first lifestyle modification you should consider in patients w/ T1 or T2 DM
weight loss - dietary motivation is paramount
How often should pt w/ T1 DM check their BG?
occasional 2hr post-prandial
how often should pt w/ T2 DM check their BG
before some meals
2hrs after some meals
A1C goal should be
tailored to individual patient's health status and comorbidities
#1 cause of blindness in US
when should pt w/ T1DM begin eye exams
within 5 years after diagnosis
when should pt w/ T2 DM begin eye exams
at time of diagnosis
what should be done at each regular visit for diabetic patients
Diabetic foot exam
first line treatments for peripheral neuropathy
MCC renal failure in US
morning spot urine looks at the ratio of
leading COD in people w/ DM
Pt w/ DM presents w/ tachycardia, sweating, nausea, hunger. Pt is awake and alert. what is happening w/ this patient and how should you treat
give them soda or glucose tablet to increase BG
Pt w/ DM presents w/ confusion and stupor, and then went unconscious. BG is 20. How should you treat
Pt w/ DM presents w/ confusion and irritability. BG is 50. how should you treat
give either Glucagon IM/SubQ or Gvoke subQ
what should you do after injecting patient w/ glucagon
turn patient on side because it can cause NV
#1 cause of DKA
Pt presents to ED w/ BG of 500. Labs show decreased potassium, decreased CO2, elevated BUN. what should you suspect , how should you initiate treatment
start potassium, but then give them insulin bc insulin causes hypokalemia.
once serum glucose reaches 200, give 5% dextrose w/ 0,45% NaCl
overall mortality rate for what condition is >10x that of DKA? Which type of DM is it associated with
Hyperosmolar hyperglycemic state
a/w T2 DM
first line med for treatment of DM
CI: impaired renal function - can cause lactic acidosis
Not recommended in patients w/ eGFR 30-45
also CI if pt has had contrast dye w/in 24 hours
Metabolized in kidney
Can cause B12 deficiency
SGLT 2 Inhibitors
MOA: reduces reabsorption of filtered glucose and renal threshold for glucose
CI: renal impairment (eGFR<45), ERSD, dialysis
AE: risk of lower limb amputations
how would you dose a patient for GLP-I Agonists/Analogs
start w/ low dose, can increase to higher dose in 1 month if tolerated
Contraindications for DPP-IV inhibitor
T1 DM or DKA
-meds in this class
MOA: increase insulin release from pancreas, reduces pancreatic glucagon secretion
metabolism: hepatic, renal excretion
CI: Ketoacidosis, T1 DM
Don't use if pt is not making insulin! (pancreatic poop out)
when should you use Nateglinide (glinidies)?
as a PCP in mild DM - use 3x/day with meals bc glucose dependent
MOA: decreases insulin resistance by making muscle and adipose cells more sensitive to insulin
Efficacy: takes 6 weeks for maximum effort - since it's working at the cellular level
SE: weight gain, edema, hypoglycemia
CI: abnormal liver function or Class III and IV HF
MOA: blocks the enzymes that digest starches
SE: flatulence or abdominal discomfort
metabolism: expected by kidney
CI: DKA, IBD and other intestinal absorption/ digestion disorders
what should you keep in mind when giving insulin to pts who also have CKD
may have to back off dose because insulin is 60% metabolized by the kidney
SE of insulin
injection site hypertrophy
standard concentration for insulin
U-100 (100 units of insulin per mL) = each vial has 1000 units
what is the set maximum dose for insulin
there isn't one
a higher concentration of insulin can
reduce the volume of insulin injected in someone w/ high insulin requirements
which type of insulin is injected and absorbed in the blood stream, usually used at mealtime?
Lispro(Humalog) is an example
what type of insulin is used in diabetic emergencies such as DKA
Short acting - Human R "Regular"
given IV - acts in same fashion as endogenous insulin
For what patient would you use pre-mix insulin
Type 2 DM only
insulin regimens for T1 DM
multiple daily injections
insulin regimens for T2 DM
basal insulin (used as add on to non-insulin therapy)
multiple daily injections
twice daily injections
how to calculate daily injection for diabetic pt (for multiple daily injections)
Step 1: Calculate TDD of insulin (pt weight x dose)
Step 2: 50% of TDD
Step 3: 50% of TDD/ 3 (or however many meals)
how to calculate Pre-mix insulin dosing - for Type 2 only
Step 1: calculate TDD
Step 2: 60% TDD for pre-breakfast, 40% TDD for pre-supper
main side effect for insulin
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