Podcast
Questions and Answers
A patient with known COPD presents with acute respiratory distress. Blood gas analysis reveals a pH of 7.20, pCO2 of 65 mmHg, and HCO3- of 28 mEq/L. Which of the following acid-base disturbances is MOST likely?
A patient with known COPD presents with acute respiratory distress. Blood gas analysis reveals a pH of 7.20, pCO2 of 65 mmHg, and HCO3- of 28 mEq/L. Which of the following acid-base disturbances is MOST likely?
- Respiratory alkalosis
- Metabolic acidosis
- Respiratory acidosis (correct)
- Metabolic alkalosis
A patient is diagnosed with primary hyperaldosteronism. Which set of lab findings would be expected?
A patient is diagnosed with primary hyperaldosteronism. Which set of lab findings would be expected?
- Decreased PAC, elevated PRA, PAC/PRA ratio < 20
- Elevated PAC, decreased PRA, PAC/PRA ratio < 20
- Elevated PAC, decreased PRA, PAC/PRA ratio > 20 (correct)
- Elevated PAC, elevated PRA, PAC/PRA ratio > 20
In a patient with suspected Cushing's syndrome, which of the following diagnostic tests has the HIGHEST sensitivity for initial screening?
In a patient with suspected Cushing's syndrome, which of the following diagnostic tests has the HIGHEST sensitivity for initial screening?
- Serum ACTH level
- Low-dose dexamethasone suppression test
- Midnight salivary cortisol
- Urine free cortisol (correct)
A patient presents with clinical features of hyperthyroidism. Lab results show a low TSH and elevated free T4. Which of the following, if also present, would MOST strongly suggest the diagnosis of Graves' disease?
A patient presents with clinical features of hyperthyroidism. Lab results show a low TSH and elevated free T4. Which of the following, if also present, would MOST strongly suggest the diagnosis of Graves' disease?
A patient with a history of alcohol abuse is admitted with suspected acute kidney injury (AKI). Which urinary cast is MOST indicative of acute tubular necrosis (ATN) in this patient?
A patient with a history of alcohol abuse is admitted with suspected acute kidney injury (AKI). Which urinary cast is MOST indicative of acute tubular necrosis (ATN) in this patient?
Which scenario would warrant the MOST cautious approach to fluid resuscitation?
Which scenario would warrant the MOST cautious approach to fluid resuscitation?
A patient is being evaluated for renal artery stenosis. Which of the following findings would be the STRONGEST indication for renal artery stenting?
A patient is being evaluated for renal artery stenosis. Which of the following findings would be the STRONGEST indication for renal artery stenting?
A patient in the ICU develops severe hyponatremia (Na 118 mEq/L). Which of the following clinical manifestations would be MOST concerning and warrant immediate intervention?
A patient in the ICU develops severe hyponatremia (Na 118 mEq/L). Which of the following clinical manifestations would be MOST concerning and warrant immediate intervention?
A patient with ESRD on hemodialysis misses two dialysis sessions and presents to the ED with severe hyperkalemia. Which of the following is the MOST definitive treatment for this condition?
A patient with ESRD on hemodialysis misses two dialysis sessions and presents to the ED with severe hyperkalemia. Which of the following is the MOST definitive treatment for this condition?
A patient with a history of asthma is admitted for an acute exacerbation. After initial treatment, the patient's condition worsens. Which of the following assessment findings would MOST suggest impending respiratory failure?
A patient with a history of asthma is admitted for an acute exacerbation. After initial treatment, the patient's condition worsens. Which of the following assessment findings would MOST suggest impending respiratory failure?
A patient with known pulmonary hypertension is being treated with pulmonary vasodilators. Which of the following findings would be the MOST concerning indication of disease progression and right ventricular failure?
A patient with known pulmonary hypertension is being treated with pulmonary vasodilators. Which of the following findings would be the MOST concerning indication of disease progression and right ventricular failure?
A patient with a history of COPD presents with worsening dyspnea. Which of the following SpO2 targets is generally recommended during acute exacerbations?
A patient with a history of COPD presents with worsening dyspnea. Which of the following SpO2 targets is generally recommended during acute exacerbations?
A patient is diagnosed with diabetes insipidus (DI). Administration of desmopressin (synthetic ADH) would MOST likely result in which of the following changes?
A patient is diagnosed with diabetes insipidus (DI). Administration of desmopressin (synthetic ADH) would MOST likely result in which of the following changes?
A patient presents with signs and symptoms suggestive of adrenal insufficiency. Which of the following diagnostic tests is MOST appropriate for confirming primary adrenal insufficiency?
A patient presents with signs and symptoms suggestive of adrenal insufficiency. Which of the following diagnostic tests is MOST appropriate for confirming primary adrenal insufficiency?
A patient is undergoing evaluation for osteoporosis. Which of the following T-scores on a DXA scan would be diagnostic of osteoporosis?
A patient is undergoing evaluation for osteoporosis. Which of the following T-scores on a DXA scan would be diagnostic of osteoporosis?
A patient with type 2 diabetes mellitus presents with altered mental status, severe dehydration, hyperglycemia (glucose > 600 mg/dL), and an elevated serum osmolality (> 320 mOsm/kg). Which condition is MOST likely?
A patient with type 2 diabetes mellitus presents with altered mental status, severe dehydration, hyperglycemia (glucose > 600 mg/dL), and an elevated serum osmolality (> 320 mOsm/kg). Which condition is MOST likely?
A patient with a history of parathyroid adenoma resection presents with muscle cramps, perioral tingling, and a positive Chvostek's sign. Which abnormality is MOST likely?
A patient with a history of parathyroid adenoma resection presents with muscle cramps, perioral tingling, and a positive Chvostek's sign. Which abnormality is MOST likely?
Which of the following ECG characteristics is MOST suggestive of a first-degree AV block?
Which of the following ECG characteristics is MOST suggestive of a first-degree AV block?
After starting a patient on levothyroxine for hypothyroidism, what is the MOST appropriate interval to recheck the TSH level?
After starting a patient on levothyroxine for hypothyroidism, what is the MOST appropriate interval to recheck the TSH level?
A 68-year-old male with a history of hypertension and hyperlipidemia presents to the emergency department with palpitations. An ECG reveals an irregularly irregular rhythm with absent P waves and fibrillatory waves best seen in lead V1. Which of the following is the MOST appropriate next step in managing this patient's rhythm abnormality, assuming he is hemodynamically stable?
A 68-year-old male with a history of hypertension and hyperlipidemia presents to the emergency department with palpitations. An ECG reveals an irregularly irregular rhythm with absent P waves and fibrillatory waves best seen in lead V1. Which of the following is the MOST appropriate next step in managing this patient's rhythm abnormality, assuming he is hemodynamically stable?
A 72-year-old woman is admitted to the hospital for increasing shortness of breath. Her ECG shows a rapid, regular atrial rate of 300 bpm with a variable ventricular response. The baseline undulates with a 'sawtooth' pattern. Which of the following is the MOST appropriate long-term strategy for managing this patient's underlying rhythm disorder?
A 72-year-old woman is admitted to the hospital for increasing shortness of breath. Her ECG shows a rapid, regular atrial rate of 300 bpm with a variable ventricular response. The baseline undulates with a 'sawtooth' pattern. Which of the following is the MOST appropriate long-term strategy for managing this patient's underlying rhythm disorder?
A 55-year-old male with no significant past medical history has an ECG performed as part of a routine physical exam. The ECG shows a PR interval of 0.24 seconds. All other parameters are normal. Which of the following is the MOST appropriate management approach for this patient's ECG finding?
A 55-year-old male with no significant past medical history has an ECG performed as part of a routine physical exam. The ECG shows a PR interval of 0.24 seconds. All other parameters are normal. Which of the following is the MOST appropriate management approach for this patient's ECG finding?
A 78-year-old man with a history of coronary artery disease and hypertension presents to the emergency room with dizziness and near-syncope. His ECG reveals a Mobitz Type I second-degree AV block (Wenckebach). Which of the following factors would MOST strongly suggest the need for permanent pacemaker implantation in this patient?
A 78-year-old man with a history of coronary artery disease and hypertension presents to the emergency room with dizziness and near-syncope. His ECG reveals a Mobitz Type I second-degree AV block (Wenckebach). Which of the following factors would MOST strongly suggest the need for permanent pacemaker implantation in this patient?
A 60-year-old woman with a history of hypertension and diabetes mellitus presents with sudden onset of dizziness and palpitations. Her ECG shows a ventricular rate of 45 bpm. There are P waves present at a rate of 80 bpm, but they bear no fixed relationship to the QRS complexes. The QRS complexes are narrow. What is the MOST likely underlying cause of this patient's arrhythmia?
A 60-year-old woman with a history of hypertension and diabetes mellitus presents with sudden onset of dizziness and palpitations. Her ECG shows a ventricular rate of 45 bpm. There are P waves present at a rate of 80 bpm, but they bear no fixed relationship to the QRS complexes. The QRS complexes are narrow. What is the MOST likely underlying cause of this patient's arrhythmia?
During a code blue situation, a patient's ECG suddenly shows a chaotic, irregular waveform with no discernible P waves, QRS complexes, or T waves. The patient is unresponsive, pulseless, and apneic. What is the MOST appropriate initial intervention?
During a code blue situation, a patient's ECG suddenly shows a chaotic, irregular waveform with no discernible P waves, QRS complexes, or T waves. The patient is unresponsive, pulseless, and apneic. What is the MOST appropriate initial intervention?
A 58-year-old male with a history of ischemic cardiomyopathy presents to the emergency department complaining of palpitations and lightheadedness. His ECG shows a wide-complex tachycardia at a rate of 180 bpm. The rhythm is regular, and there are no visible P waves. The patient's blood pressure is 80/60 mmHg. What is the MOST appropriate next step in management?
A 58-year-old male with a history of ischemic cardiomyopathy presents to the emergency department complaining of palpitations and lightheadedness. His ECG shows a wide-complex tachycardia at a rate of 180 bpm. The rhythm is regular, and there are no visible P waves. The patient's blood pressure is 80/60 mmHg. What is the MOST appropriate next step in management?
A 25-year-old patient presents with acute asthma exacerbation. After initial treatment with oxygen and bronchodilators, which finding would MOST strongly suggest the need for intubation and mechanical ventilation?
A 25-year-old patient presents with acute asthma exacerbation. After initial treatment with oxygen and bronchodilators, which finding would MOST strongly suggest the need for intubation and mechanical ventilation?
Which of the following is the MOST important initial step in the management of a patient with severe COPD exacerbation and suspected pneumonia?
Which of the following is the MOST important initial step in the management of a patient with severe COPD exacerbation and suspected pneumonia?
A patient with known asthma presents with acute dyspnea, wheezing, and a nonproductive cough. Which medication is MOST appropriate to administer FIRST?
A patient with known asthma presents with acute dyspnea, wheezing, and a nonproductive cough. Which medication is MOST appropriate to administer FIRST?
Which of the following diagnostic criteria is MOST specific to diagnose pulmonary hypertension?
Which of the following diagnostic criteria is MOST specific to diagnose pulmonary hypertension?
A 40-year-old obese male presents for evaluation of daytime somnolence, morning headaches, and reports from his partner of loud snoring and witnessed apneas during sleep. Polysomnography reveals an AHI of 35. Which of the following is the MOST appropriate initial management strategy?
A 40-year-old obese male presents for evaluation of daytime somnolence, morning headaches, and reports from his partner of loud snoring and witnessed apneas during sleep. Polysomnography reveals an AHI of 35. Which of the following is the MOST appropriate initial management strategy?
A patient presents with a longstanding history of diabetes insipidus. After administering a dose of desmopressin, which of the following changes would MOST strongly suggest effectiveness of the drug?
A patient presents with a longstanding history of diabetes insipidus. After administering a dose of desmopressin, which of the following changes would MOST strongly suggest effectiveness of the drug?
A patient exhibiting fatigue, weight loss, and persistent hypotension is suspected of having adrenal insufficiency. What confirmatory finding is MOST consistent with primary adrenal insufficiency versus secondary adrenal insufficiency?
A patient exhibiting fatigue, weight loss, and persistent hypotension is suspected of having adrenal insufficiency. What confirmatory finding is MOST consistent with primary adrenal insufficiency versus secondary adrenal insufficiency?
A 70-year-old female with a history of multiple fractures is undergoing a bone density scan. Which T-score range, as measured by dual-energy X-ray absorptiometry (DXA), aligns with the diagnostic criteria for osteoporosis?
A 70-year-old female with a history of multiple fractures is undergoing a bone density scan. Which T-score range, as measured by dual-energy X-ray absorptiometry (DXA), aligns with the diagnostic criteria for osteoporosis?
Which laboratory finding is MOST suggestive of hyperosmolar hyperglycemic state (HHS) over diabetic ketoacidosis (DKA)?
Which laboratory finding is MOST suggestive of hyperosmolar hyperglycemic state (HHS) over diabetic ketoacidosis (DKA)?
A patient with a history of primary hyperparathyroidism undergoes parathyroidectomy. Postoperatively, which sign or symptom is MOST suggestive of hypocalcemia?
A patient with a history of primary hyperparathyroidism undergoes parathyroidectomy. Postoperatively, which sign or symptom is MOST suggestive of hypocalcemia?
A patient presents with the following ECG findings: PR interval of 0.28 seconds, QRS duration of 0.08 seconds, heart rate of 70 bpm, regular rhythm. Which of the following is the MOST accurate interpretation?
A patient presents with the following ECG findings: PR interval of 0.28 seconds, QRS duration of 0.08 seconds, heart rate of 70 bpm, regular rhythm. Which of the following is the MOST accurate interpretation?
Following the initiation of thyroid hormone replacement therapy (levothyroxine) in a patient with newly diagnosed hypothyroidism, when is the MOST appropriate time to reassess thyroid-stimulating hormone (TSH) levels?
Following the initiation of thyroid hormone replacement therapy (levothyroxine) in a patient with newly diagnosed hypothyroidism, when is the MOST appropriate time to reassess thyroid-stimulating hormone (TSH) levels?
Which electrolyte imbalance is MOST likely to be associated with a flattened T wave and the presence of U waves on an ECG?
Which electrolyte imbalance is MOST likely to be associated with a flattened T wave and the presence of U waves on an ECG?
A patient with a history of alcohol abuse is admitted for altered mental status. Lab results show a sodium level of 120 mEq/L. Further workup reveals the patient is euvolemic with normal renal and thyroid function. Which of the following is the MOST likely cause of the patient's hyponatremia?
A patient with a history of alcohol abuse is admitted for altered mental status. Lab results show a sodium level of 120 mEq/L. Further workup reveals the patient is euvolemic with normal renal and thyroid function. Which of the following is the MOST likely cause of the patient's hyponatremia?
A patient with a history of chronic kidney disease presents with muscle weakness, paresthesias, and ECG changes showing peaked T waves. Which of the following is the MOST appropriate initial step in managing this patient's hyperkalemia, assuming the patient is hemodynamically stable?
A patient with a history of chronic kidney disease presents with muscle weakness, paresthesias, and ECG changes showing peaked T waves. Which of the following is the MOST appropriate initial step in managing this patient's hyperkalemia, assuming the patient is hemodynamically stable?
A patient with known heart failure presents with increased shortness of breath. Lab results show a sodium level of 148 mEq/L. Which of the following is the MOST likely cause of the patient's hypernatremia?
A patient with known heart failure presents with increased shortness of breath. Lab results show a sodium level of 148 mEq/L. Which of the following is the MOST likely cause of the patient's hypernatremia?
A patient with diabetic ketoacidosis (DKA) is being treated with intravenous fluids and insulin. The patient's anion gap is closing, but the serum glucose remains elevated at 250 mg/dL. Which of the following is the MOST appropriate next step in management?
A patient with diabetic ketoacidosis (DKA) is being treated with intravenous fluids and insulin. The patient's anion gap is closing, but the serum glucose remains elevated at 250 mg/dL. Which of the following is the MOST appropriate next step in management?
A patient with hyperparathyroidism develops symptomatic hypercalcemia with altered mental status. After initial hydration with intravenous normal saline, which of the following is the MOST appropriate next step in management?
A patient with hyperparathyroidism develops symptomatic hypercalcemia with altered mental status. After initial hydration with intravenous normal saline, which of the following is the MOST appropriate next step in management?
A patient with a history of rheumatoid arthritis presents with fatigue, weight loss, and orthostatic hypotension. Lab results show hyponatremia and hyperkalemia. Cosyntropin stimulation test reveals minimal increase in cortisol levels. Which of the following is the MOST likely underlying cause?
A patient with a history of rheumatoid arthritis presents with fatigue, weight loss, and orthostatic hypotension. Lab results show hyponatremia and hyperkalemia. Cosyntropin stimulation test reveals minimal increase in cortisol levels. Which of the following is the MOST likely underlying cause?
A patient with a history of heart failure presents with exertional dyspnea. An echocardiogram reveals an elevated mean pulmonary artery pressure. Right heart catheterization confirms pulmonary hypertension. Which of the following findings would MOST strongly suggest the presence of pulmonary arterial hypertension (PAH) as opposed to pulmonary hypertension secondary to left heart disease?
A patient with a history of heart failure presents with exertional dyspnea. An echocardiogram reveals an elevated mean pulmonary artery pressure. Right heart catheterization confirms pulmonary hypertension. Which of the following findings would MOST strongly suggest the presence of pulmonary arterial hypertension (PAH) as opposed to pulmonary hypertension secondary to left heart disease?
A patient with uncontrolled asthma is admitted for an acute exacerbation. Despite aggressive bronchodilator therapy and systemic corticosteroids, the patient's peak expiratory flow rate (PEFR) remains below 40% of baseline. Which of the following findings would MOST strongly suggest the need for intubation and mechanical ventilation?
A patient with uncontrolled asthma is admitted for an acute exacerbation. Despite aggressive bronchodilator therapy and systemic corticosteroids, the patient's peak expiratory flow rate (PEFR) remains below 40% of baseline. Which of the following findings would MOST strongly suggest the need for intubation and mechanical ventilation?
A patient with a history of COPD presents to the emergency department with worsening dyspnea, productive cough, and fever. Despite initial management with bronchodilators and oxygen, the patient's condition deteriorates. Which of the following arterial blood gas (ABG) findings would be MOST concerning for impending respiratory failure?
A patient with a history of COPD presents to the emergency department with worsening dyspnea, productive cough, and fever. Despite initial management with bronchodilators and oxygen, the patient's condition deteriorates. Which of the following arterial blood gas (ABG) findings would be MOST concerning for impending respiratory failure?
A patient is being evaluated for Cushing's syndrome. After an overnight dexamethasone suppression test, the morning cortisol level remains elevated. Which of the following additional tests is MOST useful in differentiating between pituitary Cushing's disease and ectopic ACTH production?
A patient is being evaluated for Cushing's syndrome. After an overnight dexamethasone suppression test, the morning cortisol level remains elevated. Which of the following additional tests is MOST useful in differentiating between pituitary Cushing's disease and ectopic ACTH production?
A patient presents with muscle weakness, fatigue, and frequent muscle cramps. Lab results reveal hypokalemia and metabolic alkalosis. Which of the following additional findings would MOST strongly suggest primary hyperaldosteronism as the underlying cause?
A patient presents with muscle weakness, fatigue, and frequent muscle cramps. Lab results reveal hypokalemia and metabolic alkalosis. Which of the following additional findings would MOST strongly suggest primary hyperaldosteronism as the underlying cause?
A patient with a history of diabetes insipidus is admitted for dehydration. After fluid resuscitation, the patient develops acute hyponatremia. Which of the following is the MOST likely cause of the patient's hyponatremia?
A patient with a history of diabetes insipidus is admitted for dehydration. After fluid resuscitation, the patient develops acute hyponatremia. Which of the following is the MOST likely cause of the patient's hyponatremia?
A patient with known osteoporosis sustains a hip fracture after a minor fall. Which of the following interventions is MOST effective in preventing future fractures in this patient, assuming no contraindications?
A patient with known osteoporosis sustains a hip fracture after a minor fall. Which of the following interventions is MOST effective in preventing future fractures in this patient, assuming no contraindications?
A patient presents with signs and symptoms of hyperthyroidism. Initial lab results show a low TSH and elevated free T4. Radioactive iodine uptake (RAIU) scan reveals diffusely increased uptake. Which of the following additional findings would MOST strongly suggest Graves' disease as the underlying cause?
A patient presents with signs and symptoms of hyperthyroidism. Initial lab results show a low TSH and elevated free T4. Radioactive iodine uptake (RAIU) scan reveals diffusely increased uptake. Which of the following additional findings would MOST strongly suggest Graves' disease as the underlying cause?
Which of the following is the MOST appropriate initial step in managing a patient presenting with hyperosmolar hyperglycemic state (HHS)?
Which of the following is the MOST appropriate initial step in managing a patient presenting with hyperosmolar hyperglycemic state (HHS)?
A patient with a history of chronic kidney disease (CKD) presents with fatigue, pruritus, and muscle cramps. Lab results show elevated serum creatinine, BUN, and phosphate levels. Which of the following findings would MOST strongly suggest the need for initiation of renal replacement therapy (dialysis)?
A patient with a history of chronic kidney disease (CKD) presents with fatigue, pruritus, and muscle cramps. Lab results show elevated serum creatinine, BUN, and phosphate levels. Which of the following findings would MOST strongly suggest the need for initiation of renal replacement therapy (dialysis)?
A patient is being evaluated for secondary hypertension. Which of the following clinical scenarios would warrant the STRONGEST consideration for primary aldosteronism?
A patient is being evaluated for secondary hypertension. Which of the following clinical scenarios would warrant the STRONGEST consideration for primary aldosteronism?
A patient with a history of parathyroid adenoma presents to the emergency department with severe dehydration and altered mental status. Lab results reveal a markedly elevated serum calcium level. After aggressive fluid resuscitation, which of the following is the MOST appropriate next step in management?
A patient with a history of parathyroid adenoma presents to the emergency department with severe dehydration and altered mental status. Lab results reveal a markedly elevated serum calcium level. After aggressive fluid resuscitation, which of the following is the MOST appropriate next step in management?
A patient with a history of poorly controlled type 2 diabetes mellitus presents with altered mental status, polyuria and polydipsia. Initial laboratory findings include a serum glucose level of 900 mg/dL, serum osmolality of 340 mOsm/kg, and an anion gap of 10 mEq/L. Which of the following is the MOST likely diagnosis?
A patient with a history of poorly controlled type 2 diabetes mellitus presents with altered mental status, polyuria and polydipsia. Initial laboratory findings include a serum glucose level of 900 mg/dL, serum osmolality of 340 mOsm/kg, and an anion gap of 10 mEq/L. Which of the following is the MOST likely diagnosis?
Flashcards
What are the key EKG features of Atrial Fibrillation (AFib)?
What are the key EKG features of Atrial Fibrillation (AFib)?
Irregularly irregular rhythm, absence of P waves, and presence of fibrillatory waves.
What are the key EKG features of Atrial Flutter?
What are the key EKG features of Atrial Flutter?
Sawtooth pattern, especially in the inferior leads (II, III, aVF).
What defines a 1st degree AV block on EKG?
What defines a 1st degree AV block on EKG?
Prolonged PR interval (>0.20 seconds or one large box).
What are the key EKG features of Mobitz Type I (Wenckebach) 2nd degree AV block?
What are the key EKG features of Mobitz Type I (Wenckebach) 2nd degree AV block?
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What defines Mobitz Type II 2nd degree AV block on EKG?
What defines Mobitz Type II 2nd degree AV block on EKG?
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What are the key EKG features of Ventricular Fibrillation (VFib)?
What are the key EKG features of Ventricular Fibrillation (VFib)?
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What defines Ventricular Tachycardia (VTach) on EKG?
What defines Ventricular Tachycardia (VTach) on EKG?
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What defines a Complete Heart Block (3rd degree AV block) on EKG?
What defines a Complete Heart Block (3rd degree AV block) on EKG?
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What is the key feature of ST depression?
What is the key feature of ST depression?
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What are the causes of ST elevation?
What are the causes of ST elevation?
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What artery supplies the inferior wall of the heart?
What artery supplies the inferior wall of the heart?
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What artery supplies the lateral wall of the heart?
What artery supplies the lateral wall of the heart?
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What artery supplies the anterior wall of the heart?
What artery supplies the anterior wall of the heart?
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What artery supplies the septal wall of the heart?
What artery supplies the septal wall of the heart?
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What causes asthma?
What causes asthma?
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What are the key clinical features of acute asthma exacerbations?
What are the key clinical features of acute asthma exacerbations?
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What's the most important acute management for asthma?
What's the most important acute management for asthma?
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What are the common risk factors for COPD?
What are the common risk factors for COPD?
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What are the clinical features of COPD?
What are the clinical features of COPD?
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What's the management of COPD?
What's the management of COPD?
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Study Notes
EKG Interpretation
- Identify Atrial Fibrillation (AFib) on a 12-lead EKG, characterized by irregular R-R intervals and absent P waves.
- Atrial flutter on a 12-lead EKG shows a "sawtooth" pattern, especially in leads II, III, and aVF.
- 1st degree AV block on a 12-lead EKG is identified by a prolonged PR interval (>0.20 seconds).
- Mobitz Type I second-degree AV block (Wenkebach) on a 12-lead EKG shows progressive PR interval lengthening followed by a dropped QRS complex.
- Mobitz Type II second-degree AV block on a 12-lead EKG is identified by consistent PR intervals with intermittent dropped QRS complexes.
- Ventricular fibrillation on a 12-lead EKG shows chaotic, irregular deflections without identifiable P waves, QRS complexes, or T waves.
- Ventricular tachycardia on a 12-lead EKG typically displays a series of wide QRS complexes at a rate greater than 100 bpm.
- Complete heart block (3rd degree) on a 12-lead EKG is indicated by the absence of a relationship between P waves and QRS complexes.
- Identify Non-ST-segment elevation myocardial infarction (NSTEMI) and ST-segment elevation myocardial infarction (STEMI) with regionality on a 12-lead EKG.
- Inferior leads II, III, and AVF are typically used to identify regionality.
ST Segment
- The ST segment represents the interval between ventricular depolarization and repolarization.
- ST-segment elevation may be caused by early repolarization, STEMI, pulmonary embolism, or pericarditis.
- ST-segment depression may signify NSTEMI, be a normal variant during tachycardia, or be associated with LBBB or hypertrophy.
Anatomical Relationship of ECG Leads
- Inferior leads (II, III, aVF) correlate with the right coronary artery (90%) and the left circumflex artery (10%).
- Lateral leads (I, aVL, V5, V6) correlate with the left circumflex artery (lead I & aVL), distal left anterior descending (LAD), left circumflex artery or right coronary artery (V5 & V6).
- Anterior leads (V3, V4) correlate with the distal left anterior descending (LAD) artery.
- Septal leads (V1, V2) correlate with the proximal left anterior descending (LAD) artery.
Pulmonology
- Diagnostics for asthma include assessments for adolescence and nonallergic asthma over 40 years old.
- T-helper type 2 cells cause bronchial hyperresponsiveness, bronchial inflammation, and endobronchial obstruction.
- Clinical features of asthma include wheezing, shortness of breath, and acute asthma exacerbations.
- Management of asthma includes inhaled corticosteroids (ICS) and formoterol.
- Acute management of asthma exacerbations includes assessing for bronchospasm, hypoxia, and altered mental status (AMS), as well as checking SpO2, ABG, viral panel, and CXR.
- Nebulized SABA (albuterol) is important for acute asthma management with an onset of action of 5 minutes.
- Other treatments include nebulized SAMA (ipratropium; onset of action ~15 minutes), steroids (within 4 hours), and IV magnesium.
- Severe/life-threatening asthma may require supplemental O2 and intubation.
- Diagnostics for COPD include considering a history of being over 40 years old, tobacco smoking, and air pollution; GOLD criteria can be used.
- Clinical features of COPD include cough and dyspnea, and symptoms may be asymptomatic until advanced stage.
- Management of COPD includes LABAs and LAMAs, smoking cessation, and pneumococcal and flu vaccines.
- Acute management of COPD exacerbation includes ruling out pneumonia, supplemental O2 (goal: 88-92%), bronchodilators (albuterol + ipratropium 4X daily), systemic steroids, and azithromycin.
- Consider NIPPV or HFNC and intubation if there are signs of impending respiratory failure.
- Diagnostics for OSA include assessing for excessive daytime sleepiness and risk factors (obesity, increased neck circumference >40 cm, smoking/alcohol before sleep), in hospital polysomnography (gold standard) and home sleep apnea testing, apnea events, AHI >5 with symptoms, AHI >15 without symptoms, mild (AHI 5-15) to severse (AHI >30).
- Clinical features of OSA include restless sleep with waking, gasping or choking, loud/irregular snoring w/ apneic episodes (3rd party reports), excessive daytime sleepiness (falls asleep while seated), morning headaches.
- Management of OSA includes nocturnal positive airway pressure (PAP), utilizing bilevel PAP (inspiratory and expiratory) or continuous PAP (CРАР, inspiratory only) to keep airways open.
- Pulmonary hypertension is diagnosed by an elevated mean pulmonary artery pressure > 20 mm Hg.
- The WHO system for pulmonary HTN includes: Group 1 (pulmonary arterial hypertension, often idiopathic), Group 2 (left heart disease, CHF, valvular heart disease), and Group 3 (chronic lung disease, COPD, OSA).
- Additional groups include Group 4 (pulmonary artery obstruction) and Group 5 (unclear multifactorial mechanism).
- Clinical features of pulmonary hypertension include dyspnea, chest pain, and fatigue, similar to COPD, CHF, PE, and OSA. TTE (echocardiography) measures arterial pressure, and right heart catheterization confirms but is not required.
- Medical therapies are only for PAH/Group 1, and it is necessary to treat underlying causes for other groups.
- Management includes PAH specialty center, calcium channel blockers (direct vasodilator), and pulmonary vasodilators.
- Possible pulmonary vasodilators include are IV prostacyclins,IV PDE-5 inhibitors -> inhaled NO and endothelin rc antagonist.
- Long term oxygen therapy is a treatment option, diuretics for volume overload.
Chest X-Ray Recognition
- Tension pneumothorax: tracheal or mediastinal deviation, abrupt radiolucency and decreased lung markings.
- Pulmonary hyperinflation (emphysema): characterized by subcutaneous emphysema with linear lucencies and mediastinal emphysema with air seen along the thoracic aorta.
- Enlarged cardiac silhouette: CTR > 0.5 (biventricular cardiomegaly).
- Pneumoperitoneum: free air under both diaphragms.
- Consolidation: filled with stuff
- Pulmonary edema: Kerley B lines, increased lung markings.
Renal/Fluids/Electrolytes
- Urinalysis involves checking color and turbidity for cloudiness indicative of infection, using a urine dipstick to test pH, blood, protein, glucose, ketones (DM), WBC, and nitrite (GN bacteria).
- Urine microscopy involves examining a centrifuged urine sample under a microscope to identify cells, casts, and crystals to diagnose UTI.
- Hyaline casts indicate dehydration or CKD, while granular/muddy brown casts suggest acute tubular necrosis (ATN).
- RBC casts indicate glomerulonephritis and hypertensive emergency, while WBC casts suggest infection (cystitis/pyelonephritis).
- Dysuria indicates lower UTI.
- Nocturia indicates CHF or bladder outlet obstruction (enlarged prostate).
- Polyuria indicates diabetes mellitus or insipidus.
- Oliguria/anuria: decreased or no urine output; AKI, shock, obstruction.
- Ketonuria indicates DKA, starvation ketoacidosis, or alcohol ketoacidosis.
- Proteinuria indicates DM, HTNsive kidney dz, glomerulonephritis.
- Bacteriuria needs > 100,000 units to be significant of UTI.
- Pyuria indicates UTI, glomerulonephritis, acute tubulointerstitial nephritis (AIN).
- Hematuria indicates UTI, kidney stones, BPH, or glomerulonephritis.
- Pre-renal AKI is the most common, caused by hypovolemia (GI losses, diuretics), or hypotension (sepsis).
- Intrinsic AKI is caused by damage to the vascular/tubular component of the nephron (35%), acute tubular necrosis (ischemia, nephrotoxic agents), or acute interstitial nephritis (iodine contrast).
- Postrenal AKI is from outflow obstruction like BPH and b/l stones, causing an increased pressure in renal tubules.
- Clinical features of AKI include asymptomatic presentation and decreased UOP.
- Diagnosis of AKI involves confirming elevated creatine levels, determining the mechanism based on history and physical, and obtaining labs.
- Management of AKI includes fluid trials for prerenal, relief of obstruction for postrenal, and holding nephrotoxic agents for intrinsic AKI.
- Etiologies of CKD include diabetic nephropathy (47%), hypertensive nephropathy (28%), and glomerulonephritis (7%).
- Clinical features of CKD include asymptomatic presentation in early stages and HTN, CHF, uremia, fatigue, pruritus, and pericarditis in later stages.
- Management of CKD includes renal replacement therapy/dialysis with hemodialysis or diffusion-mediated techniques.
- AV fistula is an anastomosis of artery to vein to pull arterial blood into dialyzer then pushed back cleaned blood into vein
- Indications for acute dialysis is acidemia, electrolyte or refractory hyperkalemia or hypercalcemia, intoxication, overload or refractory volume overload, uremia (encephalopathy, neuropathy, pericarditis).
- Compensation is on the opposite side of the problem, but in the same direction.
- Anion gap for metabolic acidosis
- Respiratory acidosis: pCO2 > 44 mmHg, hypoventilation, COPD
- Metabolic acidosis: HCO3 < 20 mEq/L, divided into normal vs elevated anion gap
- Respiratory alkalosis: pCO2 < 36 mmHg, hyperventilation, anxiety, pulmonary embolism
- Metabolic alkalosis: HCO3 > 28 mEq/L; vomiting, diuretics, laxatives
- Identify the scenario and find the problem (hypotensive, hypertensive, stable, high Na, hypoglycemia...)
- Resuscitation (unstable vitals) which includes trauma, sepsis, and severe dehydration.
- Maintenance: NPO before surgery Intubated patient, Mild illness without dehydration orElderly or kids who aren't eating.
Fluid Maintenance
- Resuscitation uses a bolus (500cc-1L at a time; if h/o CHF or elderly, 250-500) over 15-30 mins
- Maintenance: only if effectively NPO, 2 cc/kg/hr (100-150 cc/hr)
Electrolyte Disorders
- Clinical features of hyponatremia include nausea, confusion, coma, and seizures.
- Causes of hyponatremia include hypovolemia, CHF, and psychogenic polydipsia.
- Clinical features of hypernatremia include severe irritability and coma.
- Etiology of hypernatremia is inadequate fluid intake or diabetes insipidus.
- Hyperkalemia - Etiology: m.c.c. is AKI (due to reduced excretion); rhabdomyolysis (muscle cell lysis).
- Hyperkalemia Treatment - Rule out hemolyzed sample during phlebotomy.
- Hypercalcemia Clinical features: stones (nephrolithiasis), bones (arthralgias), thrones (polyuria), Groans (constipation, abdominal pain), psychiatric overtones (anxiety, depression, fatigue), cardiac arrhythmia (QT shortening).
Endocrinology
- Clinical Features of Primary Adrenal Insufficiency includes; Hypoaldosteronism → hypovolemic hypotension, hyperkalemia, metabolic acidosis & Hypocortisolism → fatigue, lethargy; GI complaints (e.g. nausea, vomiting); orthostatic hypotension.
- Clinical features of Acute adrenal crisis includes: Refractory hypotension, hypoglycemia, hyperkalemia, confusion, severe abdominal pain + N/V
- Dx; low AM cortisol, high ACTH in primary, low ACTH in 2 and 3
- 5 S's of adrenal crisis treatment are Salt (0.9% saline), Sugar (50% dextrose), Steroids (100 mg hydrocortisone IV once, then 200 mg over 24 hours) and Support (normal saline to correct hypotension and electrolyte abnormalities)
- Labs for diagnosis of hypopituitarism show Low AM cortisol, low ACTH, low FT4 and low FSH/LH/testosterone/estrogen. Diagnose with MRI brain to r/o pituitary adenoma, trauma, congenital
- Clinical Features for Cushing Syndrome includes:Obese, moon face, buffalo hump; muscle weakness, thin/wrinkled skin; hypertension, hypokalemia, cardiac hypertrophy, DM2 (insulin resistance).
- Clinical Features for Hyperaldosteronism includes: Drug-resistant hypertension, Hypokalemia (can cause muscle cramps, weakness) and Metabolic alkalosis.
- Hypothyroidism:check TSH, FT4, check when patient is not ill, ultrasound to assess goiter.
- hyperthyroidism includes: Anxiety, restlessness, insomnia, hyperreflexia, fine tremor.
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