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ACEI when do you give across the board even w/o HTN?
DM or Renal failure patients
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What heart murmur can you feel the thrill in a murmur?
4/6 or higher murmur
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Which CCB are contraindicated in renal failure, and why?
Dihydropyridine calcium channel blockers can worsen proteinuria in patients with nephropathy.
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What are secondary causes of Reynaud's?
Arthrosclerosis, collagen vascular disease, autoimmune disorders, use of vibrating hand tools, piano playing, typing, frost bite, tobacco use, ergotamine, BB use.
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Treatment for Reynaud's can include?
Dihydropyridine CCB. ACEI.
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What increases risk for varicose veins?
Leg crossing, heaving lifting, constricting clothes, pregnancy
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What vessel is most affected in varicose veins?
Great Saphenous Vein
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Treatment for varicose veins?
Weight loss, leg elevation, jobst stockings medium to heavy wt, laser tx or sclerotherapy
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Complication of varicose veins can include?
Superficial thrombophlebitis. Dilation of varicose vein can lead to secondary changes of LE including chronic limb edema, skin Hyperpigmentation due to chronic venous insufficiency
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Virchow's triad of clot formation?
Stasis, injury to vascular intima, and abnormal coagulation
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What is thrombophlebitis? Benign condition?
Clot plus inflammation of vein. Half are benign, but half also will have DVT in addition. Therefore automatically assume DVT and do work up.
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What are the risk factors for thrombophlebitis?
Local trauma, prolonged travel or rest, varicose veins, estrogen hormone supplement, late stage pregnancy and up to 6 weeks postpartum
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How is thrombophlebitis treated?
Conservatively if no risks for DVT. If high risk for DVT, start SQ LMWH and consider coumadin
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What is the work-up for DVT?
Compressions duplex ultrasound of venous system, d-dimer, including other clotting factors, Factor V Leiden, antiphospholipid antibodies etc
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What are the physical assessment findings of DVT?
Unilateral extremity Edema- most specific finding, Tenderness will be noted in 75% of patients, Leg pain, leg heaviness or ache, 33% will have positive homan's sign.
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What is the mortality rate of DVT?
20-40% due to PE risk
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What are the presentation signs of a Pulmonary Embolus?
SOB, friction rug, pleuritic chest pain, louder S2, tachypnea, tachycardia, (rarely see hemoptysis, cyanosis, or LOC)
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What is the INR goal for mechanical valve? Coagulopathy? And everything else?
Mechanical heart valve: 2.5-3.5. Coagulopathy: 3.0 to 4.0. Everything else, 2.0 to 3.0 (i.e.: a. fib, tissue valve, valvular disease, DVT)
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What are some medications that cause a prolonged INR?
Many antibiotics including many oral antifungals, some Macrolides, ciprofloxacin, tetracycline, ETOH especially in liver disease, tagamet, omeprazole, tamoxifen
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What are some medications that cause a low INR?
Smoking, cholestyramine, trazodone, barbiturates,
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What are the risk factors for PVD?
DM, HTN, Smoking, hyperlipidemia
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What are some medications for symptomatic control of PAD?
Pentoxifylline and Cilostazol. Also Plavix and Warfarin
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Who does Pentoxifylline (Trental) and Cilostazol (Pletal)help PAD?
- Causes symptomatic relief?
- Trental decreases blood viscosity. Pletal decreases plt aggregation and causes vasodilation. Pletal is contraindicated in CHF pts
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What is peripheral arterial occlusive disease?
An acute embolic, thrombotic, or traumatic event causing acute limb ischemia.
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What are the signs of acute PAOD? The six Ps.
Pain, Paresthesias are most common. Pallor, pulselessness, poikilotheramy (variations in limb temperature), paralysis. Will note blanching of foot on elevation
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What is a pathologic split S2 and how is it differentiated from physiologic split S2?
Physiologic- benign- split INcreases on INspiration. Many adults less than age 30 have it. Pathologic split S2 is not noted to change with inspiration or narrows or closes with inspiration.
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Where is any Split of S2 heard, and why?
Heard in pulmonic region. Because it comes from the pulmonic valve
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What can be the cause of a pathologic split S2?
Often heard in uncorrected septal defect, or also conditions that cause the delay of the aortic valve closure such as LBBB
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What heart sounds are heard with the bell of stethoscope?
S3 and S4, because they are low pitched sounds
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What is it called when a heart value fails to open adequately?
Stenosis
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What is it called when a heart value fails to close adequately?
Incompetent. Incompetent valves cause regurgitant murmurs
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What is a mid to late systolic click followed by a short systolic murmur?
Mitral Valve Prolapse
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What is a crescendo decrescendo murmur heard throughout most of systole?
Aortic stenosis.
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What is a Holosystolic murmur?
Mitral regurgitation
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What murmur radiates to axilla?
Mitral regurg
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Which is always considered a pathologic murmur, systolic or diastolic?
Diastolic (AR, and MS)
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What is an early diastolic murmur?
Aortic Regurg
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What is a mid to late diastolic murmur?
Mitral stenosis
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What grade murmur has a palpable thrill?
Grade IV, Grade V, and Grade IV
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What is a vibratory murmur called?
Still Murmur. Musical quality to it. Common benign murmur in childhood
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If the murmur is as loud as S1 or S2, what grade would it be?
Grade III are heard about as loud as the S1 and S2 sounds
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When is a systolic murmur considered benign vs. pathologic?
Benign with negative symptoms, lower grade less than Grade III, no radiation to neck or axilla, S1 and S2 are still intact, no thrill noted, PMI normal, softens or disappears with standing
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When is a systolic murmur pathologic?
Abnormal history, Grade IV or higher. Radiates beyond precordium to neck, axilla. S1 and S2 are obliterated, thrill felt, PMI displaced, increased intensity upon standing
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What finding on cardiac auscultation would note Hypertrophic cardiomyopathy?
Grade II mid systolic murmur that increases in intensity from supine to standing
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What grades are there in hypertensive retinopathy, which grades indicate irreversible damage to retina?
Grades 1 to 4. 3 and 4 are permanent damage.
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What is progression of damage of retinal arteries?
1 Narrowing, 2 then AV nicking, 3 then soft exudates and hemorrhages, 4 finally papilledema.
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What grade of hypertensive retinopathy starts the sensation of visual change?
Grade 3 changes are noted along with narrowing, AV nicking, striate hemorrhages and soft exudates
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What provides the most blood pressure reduction with TLC changes?
Weight reduction in the overweight person will lower SBP 5 to 20mm Hg, DASH diet will drop SBP 8-14 mmHg
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How does thiazide diuretic work to lower B/P?
Cause low volume sodium depletion that lowers PVR.
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What are the complications of using thiazide diuretics and what labs need to be monitored?
Can cause dyslipidemia, hyperglycemia. Don't give if Gout. Need to monitor for depletion of K, Na, Mg,
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When are thiazide diuretics ineffective in renal impairment?
GFR less than 30. Switch to loop diuretic
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What is the positive side effect of thiazide diuretic?
It is calcium sparing, therefore good for osteoporosis. Also it is indicated for kidney stones
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How do Beta blockers work to lower B/P?
Block beta adrenergic receptor sites and blunt the catecholamine response. Lower HR and lower the SV, but do not alter PVR.
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Cautionary points about Beta blockers and alpha-beta blockers?
Caution in COPD, asthma, and heart block. Taper over 2 weeks if want to d/c BB.
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How do Alpha- Beta blockers work to lower B/P?
They block adrenergic A1, B1, B2 receptor sites and blunt catecholamine response. They lower HR, Lower SV, and lower PVR
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How do ACE inhibitors and ARBS work to lower B/P?
They work on angiotensin II. Either minimizing the production (ACE) or blocking its action (ARB). They lower PVR
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Cautionary points about ACE and ARB?
Contraindicated in Bilateral Renal Artery stenosis (a rare occurrence).They are Renal-protective, but need to adjust dose in renal insufficiency.
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What are the side effects of using ACE and ARBs and what labs need to be monitored?
Modest hyperkalemic risk, especially with dehydrated. ACE can induce cough, ARB as alternative
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How do Calcium Channel blockers work to lower B/P?
Cause vasodilation, lower PVR. The most potent BP lowering class. Reduce CV mortality, proteinuria, and Diabetic nephropathy progression (independent of ACE use).
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What are the side effects of using CCBs?
Ankle edema especially with the DHP class (d/t vasodilating effect). NonDHP caution with BetaBlocker use or with Heart block, heart failure, or renal or hepatic failure
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What is the concern with abrupt withdraw of clonidine?
It can cause rebound hypertension
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What is the required amount of fasting state prior to drawing a lipid profile?
12 hour fast. Triglycerides are the most affected if nonfasting
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What should LDL be if CHD or risk equivalent?
LDL should be less than 100
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What is the AHA optimum lipid level of HDL for women?
Goal is greater than 50
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What is the AHA optimum lipid level of LDL for women?
Goal is Less than 100
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What is the AHA optimum lipid level of Triglycerides for women?
Goal is less than 150
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What labs should be checked periodically while on Statins?
Get AST prior to starting and then 8 weeks after any dose adjustment
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Which cholesterol drugs should the person not take grapefruit juice?
Statins and grapefruit juice NOT allowed
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What cholesterol drug classes have the best LDL lowering ability?
Statins, Bile Acid Sequestrants, and Ezetimibe (Zetia)
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What cholesterol drug classes have the best Triglyceride lowering ability?
Niacin, Fibrates, Fish Oil, and statins to some degree
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What are some causes of secondary hypertriglyceridemia?
Excessive ETOH, Poorly controlled DM, Untreated or undertreated hypothyroidism
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Physical findings in Left Ventricular Heart Failure?
Lung= Left. Crackles, cough, decreased breath sounds, dullness to percussion, PND, orthopnea
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Physical findings in Right Ventricular Heart Failure?
JVD, Liver Enlargement, Spleen Enlargement, anorexia, Nausea, abdominal pain, lower extremity edema
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Osler nodes and Janeway lesions can be found in?
Infective endocarditis. Osler nodes are painful purple spots on finger and toes. Janeway lesions are red spots on palms and soles
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When should screening for lipids begin?
Every 5 years at age 20, then every 2-3 years at 40. Yearly if elevated lipids
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Total intake of cholesterol should be less than?
200 mg /day
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Total intake of total fat should be less than?
25-35% of calories should be from fat per day
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Total intake of saturated fat should be less than?
Less than 7% of calories should be from saturated fat
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Total intake of monounsaturated fat should be less than?
Less than 20% of calories should be from monounsaturated fat
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Total intake of polyunsaturated fat should be less than?
Less than 10% of calories should be from polyunsaturated fat
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Total intake of carbohydrates should be?
50-60% of calories should be from complex carbohydrates
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Total intake of protein should be?
15% of calories should be from protein
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What antihypertensive is contraindicated in heart failure?
Calcium Channel blockers
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What are symptoms of heart failure?
Nocturnal cough that wakes pt, JVD, S3, displaced PMI
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What are the cardinal signs of Aortic Stenosis?
Dyspnea, Syncope, Angina with harsh holosystolic murmur crescendo-decrescendo heard at the 2nd Right ICS
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What is the main cause of new onset heart failure?
Long standing poorly controlled HTN
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What size should a B/P cuff be?
It should cover 80% of the upper arm
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When does the troponin elevate and when does CK-MB elevated in MI?
Troponin elevates in first 12 hours and stays up for 200 hours, CK-mb elevates in 6-12 hours, and normal by 60 hours
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What are the 3 goals of HF treatment?
Reduce preload, reduce afterload, inhibit renin and sympathetic nervous system effects
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What Medications are given in HF treatment?
ACE/ARB, Diuretic and Beta blocker
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