EMED PAEA 2

Normal BP

120/80

Stage 1 HTN

140/90

stage 2 HTN

160/100

dx of cardiomyopathy

echo

Which is the most likely mechanism responsible for retinal hemorrhages and neurologic complications in a patient with infective endocarditis?

embolization of vegetations

heart failure - health maintenance

fluid and sodium restriction

dx of septic arthritis

joint aspiration and analysis

exacerabates coronary vasospasm

metoprolol

Aortic dissection dx

multiplanar CT scan

Long term treatment of patients with osteoarthritis should include?

muscle strengthening exercises - increase stability, slow viscous destructive cycle of trauma, cartilage destruction unstable joint

A 49-year-old female presents complaining of several episodes of chest pain recently. Initial ECG in the ED shows no acute changes. Two hours later while the patient was having pain, repeat ECG revealed ST segment elevation in leads II, III and avf. Cardiac catheterization shows no significant obstruction of the coronary arteries. Which of the following is the treatment of choice in this patient?

nifedipine (Procardia) - prophylactic treatment with CCB for coronary vasospasm

Bony and cartilaginous enlargement of distal Interphalangeal joint is commonly seen in which of the following medical conditions?

osteoarthritis - heberdens nodes are commonly seen in primary osteoarthritis

tx of ganglion cyst

pain control, NSAIDs, cyst aspiration, corticosteroid injection, surgical excision

acute hot, swollen, and tender joint(s) with restriction of movement - dx

septic arthritis

Which of the following is the most common cause of infective endocarditis in an IV drug user?

staphylococcus aureus - more than 60% of cases of IVDA endocarditis

tx of endocarditis

tx: airway stabilization, afterload reduction, intra-aortic balloon, antibiotics

Peripheral arterial disease - tx

Angioplasty and stenting**, lifestyle changes

Health maintenance in IVDA infective endocarditis

proper oral hygiene

Coronary vasospasm tx

- coronary arteriogram to determine whether fixed stenotic lesions are present. - avoid triggers such as cigarette smoking and cocaine - Nitroglycerin - calcium channel blockers (Nifidipine, Diltiazem or Amlodipine)

dx studies for hip pain

- radiographic imaging including AP and lat views of hip and pelvis - MRI is highly sensitive for occult fractures

Which of the following is the earliest symptom for the pt with LV failure?

Dyspnea on exertion

Syncopal events, palpitations, SOB, sudden death, improves with squatting and leg lift, worsens with valsalva - dx

HOCM

pain worsened by coughing, Valsalva maneuver, or sitting and is relieved by lying in supine position, positive straight leg raise test - dx

L4-L5 or L5-S1 herniated disc

A 57 year-old male recently on a high protein diet presents with an exquisitely tender, erythematous, warm right great toe. Which of the following is the treatment of choice for this patient?

Non-steroidal antiinflammatory agents - tx of choice for acute gouty attacks

Chest pain secondary to cocaine use - tx

Benzos

acute tx of gout

NSAID (indomethacin)

tx of OA

NSAIDs

tx of reactive arthritis

NSAIDs

tx of ankylosing spondylitis

NSAIDs and refer to rheum

Aortic dissection tx

Urgent surgical intervention, lower BP with labetalol or esmolol

Type II aortic dissection

ascending aorta

22 yo male received a stab wound in the chest 1 hr ago. The diagnosis of pericardial tamponade is strongly supported by the presence of...?

Distended neck veins

hypotension, muffled heart sounds, JVD, Pulsus paradoxus - DX

Pericardial tamponade

A 45-year-old male presents to the ED c/o sudden onset of tearing chest pain radiating to his back. On exam the pt is hypertensive and his peripheral pulses are diminished. ECG shows no acute ST-T wave changes. Which of the following is the diagnostic study of choice in this patient?

CT scan

Which of the following can optimize quality of life and is a definitive treatment for a patient with refractory heart failure?

Cardiac transplantation - effective with 80-90% survival rates in 1 year; improves quality of life

Type III aortic dissection

descending aorta distal to left subclavian artery

HOCM dx

echo

Acute pericarditis tx

NSAIDs** and ASA; colchicine in all refractory cases

67 year-old female presents with progressive pain in her left knee that is worse with activity and relieved with rest. She notes stiffness of the knee that last about 20 minutes after activity is resumed. She exercises regularly. No known drug allergies. On physical exam she is 5' 5", 225 pounds. Her left knee exam reveals mild effusion without erythema or warmth. Radiographs of the left knee reveal medial joint space narrowing and subchondral bone sclerosis. Her sodium is 138 mEq/L, potassium 4.3 mEq/L, bicarbonate 24 mEq/L, chloride 104 mEq/L, BUN 23 mg/dl and creatinine 1.8 mg/dl. Which of the following medications is most appropriate for this patient's worsening pain?

Acetaminophen - 1st line pharmacotherapy for osteoarthritis

Which of the following risk factors is the most predictive for the development of osteoarthritis?

Age - most significant RF - prevalence and severity increases with age - weight bearing joints

Which of the following medications is the treatment of choice for patients with chronic gout to prevent recurrence of symptoms during its quiescent phase?

Allopurinol (Zyloprim) - best drug to lower serum urate in overproducers, stone formers, and patients with advanced renal failure; xanthine oxidase inhibitor that is used to prevent the formation of uric acid

Eliciting a history from a pt presenting with dyspnea due to early heart failure, the severity of the dyspnea should be quantified by ?

Amount of activity that precipitates it

60 year old male complains of progressive fatigue and dyspnea. On exam his lungs are clear to auscultation BL, heart with RRR without S3 S4 or murmur and extremities show 1+ edema BL. CXR reveals cardiomegaly. ECG shows low voltage and echo shows EF of 55% with small, thickened LV that has rapid early filling with diastolic dysfunction. Which of the following is the likely etiology of this patient's cardiomyopathy?

Amyloidosis - MCC of restrictive cardiomyopathy - associated with small thickened LV that has rapid early filing with diastolic dysfunction

Which of the following is the most helpful in establishing the diagnosis of gout?

Analysis of synovial fluid with polarized light - although sedimentation rate, CRP and uric acid levels may be elevated, the most SPECIFIC diagnostic test for gout is negatively birefrienement needlelike crystals in leukocytes from synovial fluid

- Severe persistent chest pain, sudden onset, radiates down the back or into anterior chest. - Syncope, hemiplegia, or paralysis of lower extremities - Intestinal ischemia or renal insufficiency - Peripheral pulses diminished or unequal. - diastolic murmur, valvular regurgitation, heart failure and cardiac tamponade DX?

Aortic dissection

A 60 year-old male with hypertension is brought to the emergency department 30 minutes after the sudden onset of severe chest pain that radiates to his back and arms. His blood pressure is 180/80 mmHg in his left arm; no blood pressure reading can be obtained from the right arm. ECG shows sinus tachycardia with left ventricular hypertrophy. A high pitched decrescendo diastolic murmur is heard along the left mid-sternal border. Which of the following is the most likely diagnosis?

Aortic dissection

A 60-year-old male is brought to the ED complaining of severe onset of chest pain and intrascapular pain. The patient states that the pain feels as though something is "ripping and tearing". The patient appears shocky, the skin is cool and clammy. The patient has an impaired sensorium. Physical examination reveals a loud diastolic murmur and variation in blood pressure between the right and left arm. Based upon this presentation what is the most likely diagnosis?

Aortic dissection

According to the American college of cardiology/AHA classification of heart failure, which of the following patients fits the stage B classification system?

Asymptomatic patient with structural disease - stage B - initial stage in which medication therapy other than just ACE inhibitors are recommended

Which of the following laboratory studies would be elevated in a pt with symptomatic heart failure?

BNP - expressed in the ventricles

In addition to Verapamil, which of the following medications is considered the treatment of choice in patients with hypertrophic cardiomyopathy?

Beta blockers - tx with BB and CCB - these agents improve symptoms esp dyspnea and chest pain - slow the HR, prolongs diastole and allows for passive ventricular filling

When instituting diuretic therapy for a patient with heart failure, which of the following is considered the treatment of choice as a first line therapy in a failing kidney due to improved sodium clearance?

Bumetanide (Bumex) - loop diuretics remain active in severe renal insufficiency and are the most effective type of diuretics used in the management of heart failure symptoms. These agents have a rapid onset and result in natriuresis due to activity in the ascending limb in the Loop of Henle

A 35 year-old female who was a back seat passenger in a vehicle which was involved in a head-on collision is brought to the ED. She is able to tell you that she is having difficulty moving both of her legs and is experiencing bilateral leg pain as well. She is embarrassed because she has "wet myself." Physical examination reveals markedly diminished sensory and motor function of both legs and decreased rectal sphincter tone. Which of the following is the most likely diagnosis?

Cauda equina syndrome - massive central disc protrusion that causes variable degrees of paralysis; bowel and bladder function may be impaired with saddle anesthesia; SURGICAL EMERGENCY

43 year-old male with a history of a right medial meniscectomy and a strong family history of osteoarthritis presents to the clinic for a routine physical exam. He states he is very active and runs 20-25 miles a week and competes routinely in 5 km races. He is 5' 10" and 160 lbs, BP is 128/76 and P 72. His physical examination is unremarkable. Which of the following would you recommend to this patient to delay the onset of osteoarthritis?

Consider swimming or biking instead of running - promotes excellent joint motion and muscle strength

Which of the following conditions would cause a positive Kussmauls sign on physical exam?

Constrictive pericarditis - increase (rather than the normal decrease) of the CVP during inspiration - often caused by severe R sided heart failure and frequently found in pts. with constrictive pericarditis or RV infarction

A 29 year-old male presents with complaint of substernal chest pain for 12 hours. The patient states that the pain radiates to his shoulders and is relieved with sitting forward. The patient admits to recent upper respiratory symptoms. On examination vital signs are BP 126/68, HR 86, RR 20, temp 100.3 degrees F. There is no JVD noted. Heart exam reveals regular rate and rhythm with no S3 or S4. There is a friction rub noted. Lungs are clear to auscultation. EKG shows diffuse ST segment elevation. What is the treatment of choice in this patient?

Indomethacin (Indocin) - treatment of choice in acute pericarditis - NSAID

A 45 year-old male presents with an acute onset of asymmetric arthritis of the lower extremities. Further history reveals an episode of urethritis two weeks ago. Physical exam reveals a swollen tender right knee and left ankle and vesicles on his palms and soles. Which of the following is the initial treatment of choice in this patient?

Indomethacin - formerly known as Reiters syndrome - term has been used to refer to spondyloarhtropathies following and enteric or urogenital infection

A 45-year-old male presents with sudden onset of pain in his right great toe. The metatarsophalangeal joint is inflamed and aspiration of joint fluid reveals negatively birefringent crystals under polarized light microscopy. Which of the following is the preferred treatment for this patient?

Indomethacin - oral NSAIDS such as indomethacin, usually provide relief of gout within 24 hours with complete resolution of the attack within 48-72 hours

28 year old female, 3 months postpartum, complains of gradually increasing dyspnea on exertion. She also complains of near syncope last week. She denies chronic medical problems or hospitalizations. Denies tobacco, alcohol or illicit drug use. Cardiovascular exam is noteworthy of a laterally displaced apical impulse, a S3 and a systolic murmur best heard in the left axilla. Which is the most likely diagnosis?

Dilated cardiomyopathy - complicated 1 in 3,000 pregnancies and can present from last month of pregnancy to 5 months post-partum. Signs and symptoms of congestive heart failure are typical on presentation. The mitral insufficiency is the result of the dilation of the annulus.

A 50 year old male with history of alcohol abuse presents with complaint of worsening dyspnea. Physical exam reveals bibasilar rales, elevated JVP, S3 and lower extremity edema. Chest x-ray reveals pulmonary congestion and cardiomegaly. ECG shows frequent ventricular ectopy. Echo shows LV dilatation and an ejection fraction of 30%. Which of the following is the likely diagnosis in this patient?

Dilated cardiomyopathy - often causes by chronic alcohol use. Characterized by signs and symptoms of left sided heart failure. A dilated LV and decreased ejection fraction

A 36 year old patient with cardiomyopathy secondary to viral myocarditis develops fatigue, increasing dyspnea, and lower extremity edema over the past 3 days. He denies fever. A CXR shows no significant increase in heart size, but reveals prominence of the superior pulmonary vessels. Based on these clinical findings which of the following is the most likely diagnosis?

Heart failure - cardiomyopathy + decreased functional reserve

A 23-year-old male presents with syncope. On physical examination you note a medium pitched, mid systolic murmur that decreases with squatting and increases with straining. Which of the following is the most likely diagnosis?

Hypertrophic cardiomyopathy - characterized by a medium-pitched, midsystolic murmur that decreases with squatting and increases with straining

Which of the following is the pathophysiologic process of a transudative pleural effusion?

Increased fluid production due to increased hydrostatic pressure - transudative pleural effusion occurs in the setting of normal capillary integrity and suggests the absence of a pleural disease - chronic heart failure = 90% of transudates

When performing a pre-participation sports physical in the adolescent population, a murmur with which of the following qualities indicated a risk for sudden death during exercise?

Increases with valsava maneuver - HCM is a known cause of sudden death during or just after physical exertion - murmur associated with HCM is worsened by conditions causing reduced ventricular volume such as valsalva, sudden standing, tachycardia

A 27 year-old male presents with gradually worsening low back pain and stiffness for the past two years. His symptoms are worse upon awakening and gradually improve throughout the day. Lumbosacral flexion is less than 50%. Lumbosacral spine films show erosions in the joint line of both sacroiliac joints. HLA-B27 test is positive. Which of the following is the most appropriate first-line medication for this patient?

Indomethacin (Indocin) - NSAIDS are mainstay of tx for Ankylosing spondylitis (AS)

criteria used to dx endocarditis

DUKE Criteria: microorganisms on culture or histologic exam of vegetation that has embolized or in abscess clinical criteria - 2 major or 1 major & 3 minor or 5 minor major = positive blood culture on 2 separate cultures, evidence on echo, new valvular regurg minor = predisposition (heart condition, IV drug use), fever, vascular phenomena (arterial emboli, pulm conjunctival hemorrhages, janeway lesions), immunologic phenomena (glomerulonephritis, osler nodes, roth spots, and rheumatoid fever), microbiology ( + blood culture not meeting major criteria)

dx of MAT

EKG reveals three or more P-wave morphologies often associated with palpitations and severe COPD. Rate between 100-140 beats/min

Which of the following would provide the most specific information regarding the functional status of a patient with chronic heart failure?

Echocardiogram - EF (indicator of LV function)

fever, chills, n/v, fatigue, malaise, heart murmurs (regurgitant), petechiae, splinter or subungal hemorrhages of nails, osler nodes (on pads of fingers, small, tender), janeway lesions (small hemorrhagic plaques on palms or soles), digital clubbing - dx

Endocarditis

A patient presents with acute pain in his knee. The pain occurred abruptly and there was no preceding trauma. The knee is red and hot. Aspiration of the joint revealed negatively birefringent needle-shaped crystals with an increase in white cells but no bacteria on Gram stain. Which of the following is the most likely diagnosis?

Gout - affects the great toe, knees, wrists and elbows almost commonly - monosodium urate crystals appear negatively birefringement under polarized light

A 26 year old male presents with increased dyspnea with exercise. He has noted a decrease in his exercise tolerance over the past several months. He denies chest pain or skipped heart beats. Echocardiogram reveals left ventricular hypertrophy with asymmetric septal hypertrophy. Ejection fraction is 65%. Which of the following is most likely presenting history or physical exam findings?

He has an older brother with the same dx - hypertrophic cardiomyopathy can be genetic and present in 25% of first degree relatives

A 65 year-old male presents with back pain two days after he was shoveling snow. The patient complains of pain in his low back that radiates into his buttocks, posterior thigh and calf, and the bottom of his foot. There is associated numbness of his lateral and plantar surface of his foot. Which of the following disc herniations is most likely to be affected?

L5-S1 - the S1 nerve root impingement is most likely to occur from the herniation of the L5-S1 disc space. The S1 disc affects Achilles reflex. The gastrocnemius and soleus muscles and the abductor hallicus and gluteus maximus muscles

56 year old male s/p MI is noted to have LVH and EF of 38%. Which of the following medications should be prescribed to prevent the development of heart failure symptoms?

Lisinopril (Zestril) - ACE inhibitors markedly improve survival and are recommended for prevention of symptoms in pts. at risk for heart failure

A 16 yr old male presents with complaint of syncope after basketball practice today. Physical exam reveals a systolic murmur along the left sternal border that increases with valsava. An ECG reveals LVH. Echo shows asymmetric left ventricular hypertrophy with a hypercontractile LV. Which of the following is the initial medication of choice in this patient?

Metoprolol - BB is the initial drug of choice in a symptomatic pt with hypertrophic cardiomyopathy

Which of the following physical exam findings will be associated with hypertrophic cardiomyopathy?

Murmur will decrease with deep breathing - reduces LV volume (ex-standing), narrows the LV outflow and increases the degree of obstruction. Increase in LV volume occurs with squatting which will expand the outflow tract and reduce the pressure gradient decreasing the murmur

53 yo patient presents with severe pain at the base of the thumb and no other finger involvement. The pain is worse with acitivty and last a short period of time following rest. There is no specific history of trauma to the thumb but the patient admits working with her hands as a typist. Which of the following is the most likely?

Osteoarthritis - base of the thumb typically involved ** also the DIP of the other fingers

Intraarticular injection of hyaluronic acid has been approved for treatment of pts. with which of the following conditions?

Osteoarthritis of the knee- for tx of osteoarthritis of the knee that has failed other therapies. Onset of action is slower than injected glucocorticoids but sustained length of activity outlasting glucocorticoid

Which of the following is a common x-ray finding seen in osteoarthritis

Osteophyte formation - and joint space narrowing seen in osteoarthritis

26 yo pt is brought to the ED after a head on collision. The pt complains of chest pain, dyspnea and cough. Examination reveals the patient to be tachypneic and tachycardic with a narrow pulse pressure. JVD is noted. ECG reveals nonspecific T wave changes and electrical alternans. Which of the following is most appropriate management for this patient?

Pericardiocentesis

Which of the following is a systemic manifestation of infective endocarditis?

Petechiae - petechiae, splinter hemorrhages, janeway lesions, and oslers nodes are systemic manifestations of patietns who have infective endocarditis

In congestive heart failure the mechanism responsible for the production of an S3 gallop is?

Rapid ventricular filling during early diastole

Examination of the heart in chronic heart failure frequently reveals?

S3 - occurs as a result of LV becoming stiff and interfering with blood entering the LV during filling - as the LV loses compliance there is impaired filling which results in less blood entering the LV, increased LV filling pressures, and LV failure

A 41 year-old male with a history of intravenous drug abuse presents to your office with acute, nontraumatic right knee pain, chills, and sweats starting 2 days ago. On physical examination, his temperature is 102.9 degrees F. The right knee is erythematous, edematous and tender to palpation and range of motion. Plain knee x-ray reveals soft tissue swelling. Which of the following is most likely the diagnosis?

Septic arthritis - IV drug abuse places this pt at even greater risk

A 32 year-old male presents with an acute onset of pain and swelling to his left ankle. On physical examination the ankle is warm, swollen and erythematous. Evaluation of the synovial fluid reveals only leukocytosis with a low glucose. Which of the following is the most likely diagnosis?

Septic arthritis - leukocytosis and a low synovial glucose are indicative of septic arthritis; due to bacterial cause and gram stain would identify

A 28 year-old female, who has experienced occasional painful migratory arthralgias, complains now of a tender, swollen, and hot left ankle. The joint was aspirated and the synovial fluid showed 55,000 WBCs, 75% polymorphonuclear lymphocytes, low glucose level, and no crystals. Which of the following would be the most likely diagnosis?

Septic arthritis - presents with a large number of WBCs predominantly polymorphonuclear and with glucose levels much lower than serum levels

The most important preventative medicine recommendation for patients with osteoarthritis is which of the following?

Start an exercise program

SVT tx

TX= vagal maneuvers such as valsalva and carotid massages > if that fails, Adenosine > if that fails, synchronized cardioversion

57 yo male with hx of HTN presents with acute gouty arthritis. Which of the following anti-hypertensive classes should be avoided in this patient?

Thiazide diuretics - common causes of increased urate levels causing gout attacks

Which of the following is a cause of high output heart failure?

Thyrotoxicosis - HOHF occurs in pts. with reduced systemic vascular resistance - thyrotoxicosis, anemia, pregnancy, Beri Beri, Pagets dz. Normal pump function, not adequate to meet the high metabolic demands

29 yo female with hx of IVDA presents with ongoing fevers for 3 weeks. Complains of fatigue, worsening dyspnea on exertion and arthralgias. Physical exam reveals a BP of 130/60 mmHg, HR 90 regular RR 18 unlabored. Petechiae are noted beneath her fingernails. Fundoscopic exam reveals exudative lesions in the retina. Heart examination shows regular rate and rhythm, grade II-III/VI systolic murmur noted with no S3 or S4. Lungs are CTABL and extremities without edema. Which of the following is the diagnostic study of choice in this patient?

Transesophageal Echocardiogram - diagnostic study of choice for infective endocarditis

A 72 year old male with new dx of congestive heart failure and atrial fibrillation develops episodes of hemodynamic compromise secondary to increased ventricular rate. A decision to perform elective cardioversion is made and the patient is anticoagulated with heparin. Which test should be ordered to assess for atrial or ventricular mural thrombi?

Transesophageal echocardiogram

Tx of MAT

Treatment of the underlying lung disease is the most effective treatment > Verapamil 240-480 mg daily in divided doses

dx of HTN

Two to three blood pressure readings each at three or more separate appointments will be taken before diagnosing someone with high blood pressure.

Afib with heart failure - tx

Warfarin

A 74 year old pt presents with signs and symptoms of heart failure. EKG shows the patient to be in atrial fibrillation at a rate of 80 bpm. BP is 120/76. The patient denies complaint of palpitations, chest pain or syncope. Which of the following is the most important long term therapy in this patient?

Warfarin - increased risk for stroke, so treated with anticoagulation with warfarin to an INR of 2.0-3.0

long term tx of gout

allopurinol, probenacid

Type I aortic dissection

ascending aorta, aortic arch, and descending aorta

What is revealed on echo of HOCM

asymmetric LVH, systolic anterior motion of the atrial valve, early closing followed by reopening of the aortic valve, a small and hypercontractile LV, and a delayed relaxation and filling of the LV during diastole.

tx of chronic and acute gout

colchicine

Coronary vasospasm - dx

coronary angio

78 yo male with hx of coronary artery dz s/p CABG and ischemic cardiomyopathy presents with complaint of progressive dyspnea and orthopnea. He also complains of lower extremity edema. The patient denies fever, chest pain or cough. On physical examination, vs are bp 120/68 HR 75 and regular RR 22 and afebrile. You note S3 heart sound, JVD and 2+ lower extremity edema. The patient is admitted and treated. Upon discharge from the hospital the pt should be educated to monitor which of the following at home?

daily weights