Internal Medicine COMAT Review
Wide, fixed, and split S2
ASD
"Cannon A-Waves" post-MI
AV-dissociation... either V-fib or 3rd degree heart block.
Timeframe for acute vs chronic arthritis
Acute <6 weeks Chronic >6 weeks
What antibiotics are appropriate for patients with neutropenic fever?
Antibiotics used in neutropenic fever need to treat for pseudomonas (since it can be lethal in septic patients if left untreated)--> ceftazadime, cefepime, piperacillin-tazobactam, meropenem, imipenem.
Definition of metabolic syndrome
Any three of the following five: 1. Fasting plasma glucose > 100 mg/dL (or on medical therapy for hyperglycemia) 2. BP ≥ 130/85 mmHg (or on medical therapy for hypertension) 3. Triglycerides ≥ 150 mg/dL (or on medical therapy for hypertriglyceridemia) 4. High density lipoprotein (HDL) cholesterol < 40 mg/dL for men, < 50 mg/dL for women (or on medical therapy for low HDL cholesterol) 5. Abdominal obesity (waist circumference > 40" for men, > 35" for women)
Systolic ejection murmur: cres/decresc, louder w/squatting, softer w/valsalva & parvus et tardus
Aortic stenosis (note: parvus et tardus= when palpated pulse is later and weaker than expected)
Most common cause of death post-MI
Arrhythmias, v-fib.
Arterial Blood Gas (ABG) in a PE patient
Arterial blood gases (ABGs) in pulmonary thromboembolism usually reveal an acute respiratory alkalosis secondary to hyperventilation.
Discharge Medications after heart attack
Aspirin (+ clopidogrel for 9-12 months if stent is placed)
Regular rhythm w/a atrial rate of 250-300 bpm and a ventricular rate of 125-150 bpm. EKG has a saw-tooth appearance
Atrial flutter
Antibiotic of choice for uncomplicated pneumonia
Azithromycin
Medications that have been shown to decrease mortality in systolic heart failure
-ACE inhibitors -ARBs (angiotensin receptor blockers) -Beta blockers -Aldosterone blockers -Hydralazine & nitrates
Centor Criteria for Strep Throat
4 criteria= fever, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough. Score of 0/1= no test. Score of 2= RADT (rapid antigen detection test) Score of 3/4= not test. Score of 0/1= no treatment Score of 2= Penicillin V if positive RADT Score of 3/4= Emperic Penicillin V
What's a supraventricular tachycardia?
tachycardia that originates at or above the AV node Note: the patient often will experience a sudden onset of palpitations/dizziness.
Where is aortic regurgitation auscultated?
It's an early DIASTOLIC murmur heard in the 2nd LEFT-upper sternal border.
Indications for CABG
L main disease 3 vessel disease (or 2 vessel disease + DM) >70% occlusion Pain despite maximum medical treatment Post-infarction angina
Anterior infarct
LAD Leads V1-4
Rhonchi
Low-pitched, continuous sounds often described as similar to a snoring sound. Generated by narrowing of larger airways due to mucus from bronchitis or narrowing from asthma or COPD
Treatment of NSTEMI
MONA-B Morphine Oxygen Nitrates Aspirin/clopidogrel B-blocker Also: do CORONARY ANGIOGRAPHY within 48 hrs to determine need for intervention
Holosystolic murmur that radiates to axilla with LAE (left atrial enlargement)
Mitral regurgitation
Rumbling diastolic murmur w/an opening snap, LAE, & A-fib
Mitral stenosis
Late systolic murmur w/click Louder w/valsalva & handgrip; softer w/squatting
Mitral valve prolapse
*** "Varrying PR interval with 3 or more morphologically distinct P waves in the same lead."*** Seen in an old person with chronic lung disease in pending respiratory failure
Multifocal atrial tachycardia.
A young, healthy patient comes in with chest pain...if vague w/hx of viral infection & murmur, diagnosis=
Myocarditis
Treatment of Dressler's Syndrome
NSAIDs and aspirin.
What is neutropenic fever
Neutropenic fever= temperature greater than 38.3 C (101 F) & an absolute neutrophil count less than 500.
Appearance of EKG in a-fib
No p-waves appreciated Irregularly irregular Irregular R-R interval
vesicular breath sounds
Normal breath sounds in the lung, characterized by a long inspiratory phase followed by a short expiratory phase
Difference in sounds between COPD and pulmonary edema/interstitial lung disease.
Wheezing or rhonchi= more suggestive of COPD Crackles= more suggestive of pulmonary edema or interstitial lung disease.
What do you do if you hear decreased breath sounds upon auscultation?
When you hear decreased breath sounds, percuss out the lungs. Dullness to percussion in an area of decreased breath sounds suggests pleural effusion, whereas hyperresonance suggests pneumothorax.
Short PR interval followed by QRS <120 ms w/a slurred initial deflection representing early ventricular activation (via bundle of Kent)
Wolff-Parkinson-White syndrome.
A young, healthy patient comes in with chest pain... if worse w/palpation, diagnosis=
costochondritis
Treatment of right ventricular infarct
Vigorous fluid resuscitation.
Indications for ordering an echocardiogram
1. Patient is symptomatic w/murmur. 2. Pt has continuous murmur. 3. Pt has diastolic murmur 4. Pt has murmur w/intensity >3/6.
4 groups of ppl most likely to benefit from statin therapy
1. current ASCVD (atherosclerotic vascular dz) 2. LDL cholesterol > 190 3. Diabetes (type 1 or 2) ages 40-75 4. Estimated 10-year ASCVD risk by pooled cohort equations >7.5%
Goal of treating hypertensive urgency
BP reduction of 25% in the first few hours to day in order to avoid reducing the BP too quickly.
In which conditions can pulsus paradoxus be seen?
Cardiac tamponade Pericarditis Chronic sleep apnea Croup Obstructive lung disease (eg: asthma, COPD).
Causes of orthostatic hypotension
Causes of orthostatic hypotension can include medications, hypovolemia, cardiac insufficiency, and diabetic neuropathy.
Treatment of Prinzemetal's angina
CCB or nitrates. (note: beta blockers, especially nonselective, are contraindicated in Prinzemetal's angina bc blockade of beta receptors, which mediate vasodilation, allows unopposed alpha receptor-mediated coronary vasoconstriction to occur & can sometimes worsen vasospastic angina)
Most common cause of an S3 heart sound
CHF
When would you give a patient an ACI-inhibitor?
CHF or LV-dysfunction.
What are "cannon A waves"
Cannon atrial waves are sometimes seen in the jugular vein in certain arrhythmias. When the atria & ventricles contract simultaneously, the blood will be pushed against the AV valve and the large pressure waves runs up the vein. *associated w/heart block...especially third degree (complete) heart block. (it can also be seen in pulmonary HTN...and sometimes in ventricular tachy bc of inherent AV dissociation of the arrhythmia)
Multifocal Atrial Tachycardia
Cardiac arrhythmia caused by multiple sites of competing atrial activity; characterized by an irregular atrial rate >100 beats/min. **varrying PR interval with *3 or more morphologically distinct P waves in the same lead***
Next best test in chest pain patient after EKG
Cardiac enzymes... (Myoglobin, CKMB, troponin I) if elevated--> NSTEMI!! (check enzymes q 8hrs X3)
When is a stress test considered positive
Chest pain is reproduced, ST segment depression, or hypotension.
Lateral infarct
Circumflex artery Leads I, aVL, V4-6
Bronchial breath sounds
Compared to vesicular breath sounds, bronchial breath sounds have a louder, shorter inspiratory phase and louder, prolonged expiratory phase. This is a normal finding when heard over the trachea. However, when bronchial breath sounds are heard in a location other than the trachea, it is suggestive of pulmonary consolidation (meaning the alveoli are full of something other than air such as pus, water, or blood).
Cannon a-waves on physical exam plus ECG showing regular P-P interval & regular R-R interval
Complete (3rd degree) heart block.
If a stress test is positive when working up unstable angina, what's the NEXT step?
Coronary angiography
Well's Criteria
Criteria for diagnosing a DVT: A point each for (1) localized tenderness, (2) asymmetric pitting edema, and (3) asymmetric calf swelling
Common associations w/Waterhouse-Friderichsen syndrome (hemorrhage of adrenal glands & septic shock from N meningitidis)
DIC & petechial rash.
What's a major differentiating factor between TTP/HUS and DIC?
DIC is associated with an increase in both PT and PTT (not TTP/HUS), and bleeding usually occurs at venipuncture sites.
5-10 weeks post MI w/pleuritic chest pain & low grade temp?
Dressler's syndrome==> autoimmune pericarditis
Best 1st test when a patient comes in w/chest pain
EKG
Diagnosis of Prinzmetal's angina is done with...
Ergonovine stimulation test. (ergonovine stimulates coronary vessels spasm...note: it can also be used in OBGYN to deliver the placenta & stop bleeding after childbirth by causing vasoconstriction of the blood vessels in the uterus).
Work up for unstable angina
Exercise EKG (avoid CCB & b-blockers before) Can't do EKG stress test if old LBBB, baseline ST elevation, or on digoxin...do exercise echo instead. If patient can't exercise- do chemical stress w/dobutamine or adenosine. MUGA= nuclear medicine test: shows perfusion of areas of heart (avoid caffeine or theophylline before). **positive if: 1. chest pain is reproduced 2. ST depression 3. Hypotension
Characteristics common to both TTP and HUS
Fever, anemia, & acute renal failure. Both can present with elevated LDH, indirect bilirubin, and schistocytes on peripheral smear (consistent with MAHA- microangiopathic hemolytic anemia).
For persistent neutropenic fevers, after giving broad spectrum antibiotics that cover for pseudomonas, what should be added?
For persistenet neutropenic fevers, add a broad spectrum anti-fungal agent (like amphotericin B).
When do you give clopidogrel in addition to aspirin for discharge after an MI?
Give Clopidogrel for 9-12 months if a stent was placed. Clopidogrel= antiplatelet (irreversibly binds to P2Y12 adenosine diphosphate receptors, reducing platelet activation & aggregation)
Difference in heart architecture in HCOM vs aortic stenosis
HCOM= asymmetric hypertrophy, usually of the interventricular septum. Aortic stenosis= concentric hypertrophy.
Systolic ejection murmur louder with valsalva, softer w/squatting or handgrip
HOCM (hypertrophic cardiomyopathy)
What are some differentiating factors btwn TTP and HUS
HUS is often associated with a prodromal bloody diarrhea TTP often is associated with neurological deficits
Radiographic signs seen occasionally in PE
Hampton hump (shallow wedge-shaped opacity in the periphery of the lung w/its base against the pleural surface). Westermark sign=sign that represents a focus of oligemia (leading to collapse of vessel) seen distal to a PE. It's due to a combo of dilation of the pulmonary arteries proximal to the embolus & collapse of the distal vasculature creating the appearance of a sharp cut off on CXR.
causes of a mid-systolic non-radiating murmur
High output states (anemia, fever, thyrotoxicosis, pregnancy). Aortic stenosis (ejecting systolic murmur that radiates to carotids). Aortic sclerosis (valve thickening w/o outflow obstruction). Pulmonic stenosis Hypertrophic cardiomyopathy (consider in younger patients).
Wheezes
High-pitched whistling sound during breathing when air flows through a narrowed airway, most commonly heard in asthmatics.
Hallmark metabolic disturbance of refeeding syndrome
Hypophosphatemia
Symptoms of right ventricular infarct
Hypotension, tachycardia, clear lungs, JVD, and NO pulsus paradoxus... DON'T give nitro!!
ECG leads representing the lateral myocardial wall
I, AVL, V5, & V6
ECG leads representing the inferior portion of the heart
II, III, and aVF (right coronary artery)
mechanism of reduced BP during normal inspiration
Normally during inspiration, systolic BP decreases (<10 mmHg) & pulse rate goes up slightly bc inspiration makes intra-thoracic pressure more negative relative to atmospheric pressure, which increases venous return so more blood goes into the right side of the heart. Also, since the intra-thoracic BP becomes more negative (aka decreases), more blood goes into the compliant pulmonary vasculature & flow is reduced to the left side of the heart. The slight decrease in left-heart filling during inspiration reduces stroke volume, which manifests as a decrease in systolic BP...this decreased BP leads to a faster heart rate via the baroreceptor reflex.
Standard treatment for NSTEMI
PCI w/stenting.
Continuous machine-like mumur
PDA
Criteria used to decide whether to admit patients with community-acquired pneumonia
PORT (pneumonia severity index score) & CURB-65: C=confusion U=blood Urea nitrogen >19 R=Respiratory rate (>30 breaths/minute) B=Blood Pressure (systolic <90 or diastolic <60) age>65 w/CURB-65, consider hospitalization w/score of 1/2; urgent hospitalization if score score 3-4
New systolic murmur 5-7 days status post-MI=
Papillary muscle rupture.
A young, healthy patient comes in with chest pain...if it gets worse w/inspiration, better leaning forwards, friction rub, & diffuse ST elevation, diagnosis=
Pericarditis
Common presentation of acute lymphoblastic leukemia (ALL)
Presents in a younger child (2-5 years old) with fever (due to neutropenia), pallor & fatigue due to anemia, & petechiae (due to thrombocytopenia).
Another name for angioplasty...
Primary
A young, healthy patient comes in with chest pain...if it occurs at rest, worse at night, few CAD risk factors & migraine headaches, with transient ST elevation during episodes...diagnosis=
Prinzmetals' angina
What is pulsus paradoxus
Pulsus paradoxus= an abnormal drop in systolic BP (>10 mm Hg) upon inspiration
Roth spots
Retinal hemorrhages w/pale centers...usually seen in bacterial endocarditis
In an acute inferior wall myocardial infarction, occlusion of which coronary artery is usually implicated?
Right coronary artery
Inferior infarct
Right coronary artery Leads II, III, & aVF
Right ventricular infarct
Right coronary artery Leads--> V4 on R-sided EKG= 100% specific
*Virchow's Triad
Risk for DVT Triad= 1. Stasis 2. Vascular Injury 3. Hypercoagulability
What are S3 heart sounds
S3 results from increased atrial pressure leading to increased flow rates, as seen in congestive heart failure, which is the most common cause of an S3 heart sound.
Changes in EKG suggesting a STEMI
ST elevation 2mm or new LBBB
Why can TSH be helpful in diagnosing heart failure
Severe hypothyroidism can cause CHF. Hyperthyroidism can cause high output HF.
Bloody lumbar puncture is associated with...
Subarachnoid hemorrhage & herpes encephalopathy.
Crackles
Synonymous with rales. A discontinuous sound heard more often during inhalation caused by airway opening. The sounds are often divided into dry or moist, with the dryness being caused by disease processes such as fibrosis and the moistness or wetness being secondary to heart failure or pneumonia.
Which cardiac enzyme lasts the longest in blood strem
Troponin I
Diagnosis of a patient presenting with chest pain that has no ST elevation & normal cardiac enzymes X 3
Unstable angina
ECG leads representing anterior wall
V1-4 (LAD)
Acute severe hypotension post-MI?
Ventricular free wall rupture.
Holosystolic mumur with late diastolic rumble in children
Ventricular septal defect
"Step up" in O2 concentration from RA-> RV post-MI?
Ventricular septal rupture.
Three or more consecutive beast with a QRS<120 ms at a rate of 120 beats per minute
Ventricular tachycardia
Persistent ST elevation ~1 month post-MI + systolic MR murmur?
Ventricular wall aneurysm
Treatment of a STEMI
emergency reperfusion- go to cath lab or thrombolytics if no contraindications
First cardiac enzyme to elevate in an NSTEMI
myoglobin (peaks in 2 hrs, normal by 24 hrs). **that's why this is the best biomarker to use to see if there's a repeat STEMI
When should you consider immediate diagnostic coronary angiography?
order immediate diagnostic coronary angiography for a STEMI or new-onset Left BBB
