1. Hazards Ratio: Measure of how much effect something actually had.

Value of
1.00 means there is nodifference between the two groups. A ratio 1 indicates a
protecti!e effect" and # 1 indicates adetrimental effect. $f the confidence inter!al
of the hazard ratio includes 1.00 %null !alue&" then theeffect wasn't statistically
significant. $f the inter!al doesn't include the !alue" the difference was significant.
(. )*) le!els: +eep 100 in pt w, +nown -H* ris+ e.ui!alent %-A*" M$" /V*" or
inpatient *M&. $f pt hasnone of these problems" can +eep below 100 if 011 R2"
130 if #4( R2. -onsider drug therapy onlyay 30 abo!e the threshold" unless # (
R2
3. $nitial *5- for newly diagnosed H67 is thiazide diuretic. -ommon side effect is
photosensiti!ity"leading to a rash in sun e8posed areas. R8 by stopping med" or
a!oid sun e8posure. 6hus" this is acommon side ef8 of meds in newly diagnosed
H67
9. :est R2 to modify to reduce ris+ of -A* is )*). H67 is also good but not as
good as )*). 5ther stuff helps too %e8ercise" stop smo+e" control *M&" but they
don't lower ris+ as much as )*) and H67
;. <econdary H67: -onsider it in a young patient w, high blood pressure. =0> of
secondary H67 is d,tunidentified cause. 5therwise" the M-- is reno!ascular
H67. )oo+ for abd or flan+ bruit in pt withreno!ascular H67. 5ther causes: pheo
%headaches" tachy&" -ushing's disease %edema&" ad!ancedrenal disease %edema&
0. Retinal abnormalities is a long term effect of H67" not seen early in disease
?. *M is the single most important predictor of ad!erse -V outcomes. <uch a good
predictor that *M isconsidered a -H* e.ui!alent. $n women" the prediction is
e!n more important.
@. 2or people with *M" +eep :/ 130,@;" !ersus 190,=0 in a healthy person
=. AAA: -utoff for surgery is # ; cm diameter. $f smaller" do periodic imaging.
Rapid growth can alsoneed surgery. :ig time R2 is smo+ing. 5ther R2 don't ha!e
as much impact as smo+ing cessationdoes.
10. Amlodipine side ef8: fluid retention and urticarial rash.
11. A-A$ side ef8: angioedema" urticaria. Rash is usually psoriatic" not
photosensiti!ity in nature. 7otethat AR: might also cause angioedema if a pt has
bad e8perience w. A-A$
1(. /aro8ysmal a fib: present w, A/$<5*$- palpitation possibly associated w,
symptoms. <ame -VA ris+as normal afib" so need warfarin. Aither rate or rhythm
control is effecti!e if asymptomatic. $f there aremar+ed or persistent symptoms
%palpitation" dizzy" dyspnea& rhythm control is better. Amiodarone isthe preferred
drug for rhythm control if pt also has some other structural heart
disease%cardiomyopathy" -H2" -A*&. 2lecainide can wor+ 57)B if pt has 75
structural heart disease. $t canlead to fatal arrhythmias if you gi!e it to pt w,
structural heart disease
13. $butilide: use for acute termination of a1fib
19. 2ibrinogen: associated w, increased -V ris+. # 3.93 is a double ris+. # (.? is high.
*rug therapy todecrease fibrinogen hasn't been shown to be pre!entati!e.
Howe!er" stopping further increase helps.Cithin statins" lo!astatin and
ator!astatin increase le!els" while pra!a and sim!a don't increase. 6hus if
someone is at a high le!el for fibrinogen" must thin+ about which statin to use if
pt also has high)*)
1;. 7onsusstained !entricular tachy: #43 consecuti!e !entricular beat w, rate # 1(0"
and the episodelasts 30 sec. $f you see this" pt most li+ely has structural heart
diease. A8. /rior M$ scarring"!entricular hypertrophy" mitral !al!e prolapse
%midsystolic clic+&. $f you pic+ up this rhythm on ADE"ne8t step is to get echo
and stress test to r,o ischemia.
10. -H2: A-A$ are the main therapy. $mpro!e sur!i!al and delay progression of
disease. $ndicated e!en if pt is asymptomatic. 5nly contraindications are poor
tolerance to drug" or renal failure or hyper+alemia.
1?. -H2: standard therapy is diuretic" A-A$" bb" digo8in" or spironolactone. A-A$ is
the best" and won'te8acerbate confusion in a pt. digo8in could worsen
confusion.$f A-A$ isn't well tolerated %angioedema&" then hydralazine and
isosorbide dinitrate is a commoncombination. <ide ef8 might include drug
induced lupus. Manifest as flu li+e symptoms %fe!er"malaise" myalgia" facial
rash&. )A*" splenomegaly can also happen. Antihistone antibody is mar+er
of drug induced lupus. R8 is to stop drug. Hydralazine is safe in pregnancy %as are
dopa" labetalol&
1@. -H2 as a cause of hypo7a. 6he decreased -5 and <:/ decreases perfusion / at
carotidbaroreceptor" so body stimulates A*H and rennin angiotensin despite
!olume o!erload. 6his causese!en more fluid retention" leading to hypo7a. Must
correct le!els gradually" not acutely. :est R8 iswater restriction.
1=. -H2: syndrome which results from impaired !entricular emptying %systolid& or
rela8ation %diastolic&.<ymptoms: fatigue" wea+ness %d,t reduced -5&" edema %d,t
fluid retention&. A8ertion e8acerbates allsymptoms. $ts's a syndrome" so it's a
clinical diagnosis based on H and /. /7*" orthopnea" raisedFV/" rales" <3" -Gr
findings %increased !ascular congestion or silhouette& are maHor criteria. *8 is
(maHor or 1 maHor I ( minor. Minor criteria: bilateral )A edema" hepatomegaly"
dyspnea on e8ertion"nocturnal cough&.
(0. *igo8in to8icity) 7,V" anore8ia" confusion" !isual disturb" cardiac abnormalities.
*rugs that can causeto8icity: !erapamil" .uinidine" amiodarone" spironolactone.
(1. Hypercholesteremia I hypertriglyceridemia %#(00&: *5- is a statin. . $f statin
isn't good alon"e addgemfibrozil or niacin.
((. )one a fib: a1fib which occurs w,o any other signs of clinical heart disease %r,o
-A*" 6H" /A" H67"*M" -H2&. Carfarin is not necessary" Hust aspirin is good
enough.
(3. Jnstable angina: no matter what" need a coronary angio A<A/ to loo+ at bloc+age
and see it'sse!erity. $f angio re!eals pt to be high ris+" consider percutaneous
coronary inter!ention %/-$& or -A:E. Remember that *M will increase rate of
progression a lot.A!aluating heart ischemia in pt w, prior -A:E" poor heart
function" or if there already e8ist baselineADE changes: use adenosine or
dipyramidole to induce ischemia and watch the technetium1==.%sestamibi&. <tress
echo should only be done if adenosine cant be used for some reason.
Remember that arthritis can also impair e8ercise. Adenosine can induce
bronchospasm" so if pt has -5/* or asthma" adenosine is contraindicated.Jse
dobutamine instead
(9. .5rthostatic Hypotension) d8 with fall or (0 <:/ or 10 *:/. -an happen after
standing up or e!eneating. *rop in :/ must happen within (1; min of standing.(
(;. M-- ortho hytpo: autonomic dysfunction or intra!ascular !olume depletion.
Autonomic dysfunction%*M neuropathy&. *rugs: antihyptrtensi!es" !asodilators" anti1
angina drugs.
(0. -a channel bloc+er: peripheral edema is common side ef8. 6he Kdipines are
common" but diltiazemcan also cause it
(?. .A8ercise stress test is 2<5M in pt w, angina symptoms..
(@. Ceight loss is the best non1drug way to decrease :/. :enefit in o!erall -V ris+ is
unclear butprobably helps.
(=. 5ther firstline drug for H67 besides A-A$ is b1bloc+er.
30. /ositi!e stress test: # 1 mm downsloping <6 depression. 7<5M is to do cardiac
cath to see wherethe lesions are" and to possibly to balloon stenting.
31. Right sided endocarditis: commonly see R sided in!ol!ement or septic pulmonary
emboli. <epticemboli manifests as scattered bilateral rales. /ulmonary infiltrates
on both sides. $V*J is the li+elycause. 5therwise" R sided disease is !ery
uncommon.
3(. -oumadin management: $f $7R # 3 but ;" Hust hold drug for a few days to get
le!el to therapeuritic. $f $7R # ; but =" stop drug and gi!e small dose of !it D
%11( mg&. $f # = but (0" higher dose of !it D. $f # (0" consider 22/. $f at anytime
pt is bleeding" gi!e 22/.
33. *rug interaction w, warfarin: Amiodarone increases warfarin action. $f need to
ha!e the two together"reduce warfarin by (;>.
39. MV/: M- !al!e abnormality in industrialized nations. Mid to late systolic clic+"
most easily heard o!er )V
3;. .Mitral regurg: holosystolic decrescendo murmur %can be (ndary to MV/& heard
in ape8" radiates toa8illa. $ncreases w, grip" decrease w, !alsal!a.
30. <ystolic # in )J sternal border: pulmonic stenosis.
3?. Mitral stenosis: low pitched diastolic rumble heard o!er the ape8 best when pt is
lying ) lat decubitis.6he narrowing of the !al!e leads to increased / in )A" which
bac+flows into increased / in pulmonary!asculature and R side of heart. M-- is
rheumatic fe!er. May present as hemoptysis. )A canenlarge" leading to ele!ation
of ) mainstem bronchus" and flattening of ) heart border.
3@. Mitral stenosis: opening snap with diastolic rumble. :est heard mid cla!icular on
) side between ;
th
and 0
th
ribs.
3=. M- congenital heart malformation: V<*. $f large enough" may be symptomatic.
Murmus is pansystolicmurmur at )) sternal border. <hould get an echo. V<* is
not congenitally cyanotic" only if its bigenough.
90. /olypharmacy: Jsing too many diuretics" a1bloc+er" or nitrates can induce ortho
hypo.
91. M-- perioperati!e mortality: cardiac death. Highest ris+s: unstable angina and
critical aortic stenosis.A8ercise angina and M$ 0 mo ago are also decently big
R2" but less than the other two.
9(. Amiodarone induced lung to8icity: M- presentation is as a chronic interstitial
pneumonitis. 7onprodcough" fe!er" pleuritic -/" focal or diffuse interstitial
opacity on -GR. R8 with d,c drug. $f really bad"consider steroids.
93. $npt facilityMetformin: higher chance of lactic acidosis %contraindicated& if renal
insufficiency" hepatic dysfunction"or -H2. 6hus" if pt goes to a procedure that
needs contrast %e8. -ardiac cath&" you must d,cmetformin a bit before the
procedure.
99. Acute M$: sinus bradycardia could happen after M$. 2<5M is $V atropine. $f that
doesn't wor+" thenmust inter!ene w, thrombolysis or /6-A %angio&. $n the
meantime" probably need to do trans!enouscardiac pacing while setting up the
thrombolysis . Remember that thrombolysis is contra in recent abdsurgery %(
w+s&.$f need to inter!ene in -A* in a pt with *M" -A:E is better than angio.
*M has higher chance of restenosis" so angio or balloon I stent isn't good
enough.Multifocal atrial tachy: # 3 / wa!es of different morphoLlogies. 7arrow
MR<" !ariable /R segment.M-- is hypo8ia and -5/*. 6hus" someone showing
this arrhythmia must first analyze their 5(status" since correction may eliminate
the arrhythmia. 5ther causes are hypoD and hypoMg. R8 isalways re!erse the
cause. $f the initial therapy doesn't wor+" try bb or !erapamil if bb is contra
%-5/*"asthma&. Acute heart failure: M-- are papillary m. rupture" infecti!e
endocarditis" chordae tendinae rupture"and chest wall trauma . A mitral regurg
ma+es you thin+ of ruptured chordae tendinae. *8 **8 for chrdae tendinae
rupture: $A" ischemia" MV rupture.Ahlers *anlos syndrome: mitral !al!e
degeneration can happen" leading to chordae rupture. /esplanus and scoliosis are
common findings. Foint hypoermobility" hypere8tensibility. Marfans can
alsocause rupture. Anticoagulation for mechanical !al!es: mechanical mitral and
aortic !al!es need $7R between (.;13.;.6orsades de pointes: loo+ for an ADE
showing a M6 inter!al prolongation" followed by some sort of clear arrhythmia.
2re.uent !ariation in MR< morphology is more li+ely torsades. R8 for torsades
withhemodynamic compromise is immediate defibrillation. 5nce pt is stable" then
gi!e Mg<59.Remember that the lab !alue for Mg is unreliable" so Hust gi!e it
regardless of le!els. $f Mg therapyfails" then do temporary trans!enous
pacema+er.
9;. <ynchronized cardio!ersion: for !1tach" a fib.
90. s,p M$" best to hold se8ual acti!ity for 0 wee+s after the e!ent. $f there were
complications because of the M$" need to further e!aluate.
9?. A1fib: 2irst line for rate control is -a channel bloc+er. *iltiazem is good.
/ropranolol is goodalternati!e if diltiazem is contra %significant -H2" cardiac
conduction system disease&.
9@. -ancer drugs w, -V side ef8: 1rubicin and mito8antrone. 6hese are cardioto8ic"
so should getbaseline radionuclide !entriculography %RVE& can detect early
to8icity. 6his can do nonin!asi!e serialmonitoring of cardiac function. Multiple
gated blood pool %MJEA& is also good. Acho isn't goodenough because can't do
serial e!als. Jsed more in +ids getting chemo" to a!oid radiation e8posure.
9=. A*$f someone presents with cardiac symptoms" but all the first line tests come
bac+ negati!e" consider doing continuous AD)E monitor for (9 h to e!aluate for
arrhythmias.<tress test with radioacti!e stuff: perfusion defect is a place where
blood flow is not the same aselsewhere. )ateral wall of )V is supplied by )
circumfle8" so defect there is li+ely this !essel.
;0. $n a pt with acute M$" -a channel bloc+ers may actually be harmful. 6hin+ about
this b,c often theymight be on the drug to control H67. $n contrast" bb" A-A$" and
statins can help pre!ent -A*.(
;1. nd
;(. degree AV bloc+: R8 with permanent cardiac pacema+er insertion. %a+a
trans!enous pacema+er&.6his helps pre!ent progression to 6ype $$$ bloc+.
Remmebr that 3
;3. rd
;9. degree bloc+ is a random" norelationship at all btw A and V beating on ADE.
;;. Acute M$ management: 2<5M include 5(" $V access and gi!e aspirin and nitro.
A-A$ aren't usedacutely but reduces mortality if ta+en for the wee+s after an M$.
bb helps w, decrease myocardialdemand and controls HR. -an gi!e after aspirin"
nitro" and morphine.
;0. Acute M$: sinus bradycardia could happen after M$. 2<5M is $V atropine. $f that
doesn't wor+" thenmust inter!ene w, thrombolysis or /6-A %angio&. $n the
meantime" probably need to do trans!enouscardiac pacing while setting up the
thrombolysis . Remember that thrombolysis is contra in recent abdsurgery %(
w+s&.
;?. $f need to inter!ene in -A* in a pt with *M" -A:E is better than angio. *M has
higher chance of restenosis" so angio or balloon I stent isn't good enough.
;@. Multifocal atrial tachy: # 3 / wa!es of different morphoLlogies. 7arrow MR<"
!ariable /R segment.M-- is hypo8ia and -5/*. 6hus" someone showing this
arrhythmia must first analyze their 5(status" since correction may eliminate the
arrhythmia. 5ther causes are hypoD and hypoMg. R8 isalways re!erse the cause.
$f the initial therapy doesn't wor+" try bb or !erapamil if bb is contra
%-5/*"asthma&.
;=. Acute heart failure: M-- are papillary m. rupture" infecti!e endocarditis" chordae
tendinae rupture"and chest wall trauma . A mitral regurg ma+es you thin+ of
ruptured chordae tendinae. *8 **8 for chrdae tendinae rupture: $A" ischemia"
MV rupture.
00. Ahlers *anlos syndrome: mitral !al!e degeneration can happen" leading to
chordae rupture. /esplanus and scoliosis are common findings. Foint
hypoermobility" hypere8tensibility. Marfans can alsocause rupture.
01. Anticoagulation for mechanical !al!es: mechanical mitral and aortic !al!es need
$7R between (.;13.;.
0(. 6orsades de pointes: loo+ for an ADE showing a M6 inter!al prolongation"
followed by some sort of clear arrhythmia. 2re.uent !ariation in MR<
morphology is more li+ely torsades. R8 for torsades withhemodynamic
compromise is immediate defibrillation. 5nce pt is stable" then gi!e
Mg<59.Remember that the lab !alue for Mg is unreliable" so Hust gi!e it
regardless of le!els. $f Mg therapyfails" then do temporary trans!enous pacema+er
03. .<ynchronized cardio!ersion: for !1tach" a fib.
09. s,p M$" best to hold se8ual acti!ity for 0 wee+s after the e!ent. $f there were
complications because of the M$" need to further e!aluate.
0;. A1fib: 2irst line for rate control is -a channel bloc+er. *iltiazem is good.
/ropranolol is goodalternati!e if diltiazem is contra %significant -H2" cardiac
conduction system disease&.
00. -ancer drugs w, -V side ef8: 1rubicin and mito8antrone. 6hese are cardioto8ic"
so should getbaseline radionuclide !entriculography %RVE& can detect early
to8icity. 6his can do nonin!asi!e serialmonitoring of cardiac function. Multiple
gated blood pool %MJEA& is also good. Acho isn't goodenough because can't do
serial e!als. Jsed more in +ids getting chemo" to a!oid radiation e8posure.
0?. A* $f someone presents with cardiac symptoms" but all the first line tests come
bac+ negati!e" consider doing continuous AD)E monitor for (9 h to e!aluate for
arrhythmias.
0@. <tress test with radioacti!e stuff: perfusion defect is a place where blood flow is
not the same aselsewhere. )ateral wall of )V is supplied by ) circumfle8" so
defect there is li+ely this !essel.
0=. $n a pt with acute M$" -a channel bloc+ers may actually be harmful. 6hin+ about
this b,c often theymight be on the drug to control H67. $n contrast" bb" A-A$" and
statins can help pre!ent -A*.(
?0. nd
?1. degree AV bloc+: R8 with permanent cardiac pacema+er insertion. %a+a
trans!enous pacema+er&.6his helps pre!ent progression to 6ype $$$ bloc+.
Remmebr that 3
?(. rd
?3. degree bloc+ is a random" norelationship at all btw A and V beating on ADE.
?9.
?;.
?0. Acute M$: $f ADE shows <6 segment ele!ation in ( contiguous leads" then
thrombolytics areindicated" and if pt presents within 1(1(9 h of symptoms. Must
gi!e 75 before getting the ADE.
??. -ontra for thrombolytics are acti!e bleed" any intracranial e!ent %bleed" ischemia"
neoplasm&" <:/ #1@0" or trauma. *on't confuse with <6 segment depression"
which is Hust ischemia.
?@. 2lash pulmonary edema: /resents w, acute onset of <5:. 7o pre!ious history
necessary.Hypertensi!e crisis can cause it" so loo+ for a !ery high :/. -GR loo+s
li+e lots of edema" and therewilll be diffuse crac+les. 2<5M in any flash pul
edema is gi!e 5( %5( sat will be low&" morphine" and$V furosemide %loop
diuretics&. $f the cause is H67 crisis" the preferred drug to gi!e is $V 75 or
nitroprusside.
?=. 5ther causes of flash pul edema: mitral stenosis or acute aortic,mitral regurg.
6hus" after someonehas an episode of this" get an echo. :b are
-576RA$7*$-A6A* in acute heart failure" can slowheart too much and lead to
death.
@0. -ardiogenic pulmonary edema: $nitial R8 is similar: 5(" morphine %reduces wor+
of breathing&" and aloop diuretic.
@1. -ardiogenic shoc+ complicated by hypotension: dopamine is a good choice.
@(. Acute pericarditis: can be infarct associated" and happen after an M$ %esp.
transmural&. 6heassociated -/ depends on position" and worsens w, deep
inspiration. ADE has diffuse <6 ele!ationw, /R depression. Rub is heard !oer )
sternal border %a scratchy sound&" which gets louder as ptleans forward. R8 is
7<A$*< %or anything for pain&. -holchicine for !iral pericarditis.
@3. .*ressler's syndrome: happens in M$ pt and after cardiac surgery. Jsually
de!elops wee+s,monthsafter M$ not days. /resents w, fe!er" leu+ocytosis"
pleuritic chest pain" and pericardial rub. 6hus" !erysimilar to pericarditis" but loo+
at the time course.
@9. M wa!es are indicati!e of old infarct %days old sometimes&
@;. Aortic stenosis: Area of aortic !al!e 1 cm( is considered se!ere stenosis. 5nset
of symptoms has abig effect on prognosis" so prompt inter!ention is important in
symptomatic aortic stenosis %syncope"angina" dyspnea&. R8 w, aortic !al!e
replacement will reduce mortality. :alloon !al!ulotomy has onlytransient
efficacy" and high procedural morbidity.
@0. -arotid artery dissection: presents w, unilateral headache I associated Horner's
syndrome %miosis"ptosis" and anhidrosis& on the affected side only. 6hus"
symptoms aren't bilateral. <ome causes aretrauma" -6 disease" smo+ing" seatbelts
in MVA. *8 is MRA. $f MRA fails" then catheter angio isdefiniti!e test. R8 is
with anticoagulation w, heparin or platelet agents. /t with this dissection is at
highris+ of de!eloping cerebral infarction.
@?. M-- of -H2 is ischemic heart disease. 6hus" if you diagnose a new case of -H2"
and are still tryingto loo+ for etiology" first r,o coronary lesions with a cardiac
stress test. 5ther causes of -H2 are H67"and !al!e or reno!ascular disease. :7/
is not useful in this case. :7/'s main purpose is todistinguish between
cardiogenic pulmonary edema from primary pulmonary conditions.
@@. Acute aortic dissection: Jsually presents in older male with long history of H67
and atherosclerosis.$n younger pt" thin+ -6 disease %Marfan" Ahler *anlos&"
inflammatory !asculitis" aortic !al!e problem"or cocaine. /resents w, sudden
onset of sharp tearing chest or bac+ pain. $f tear happens inascending aorta" pt
may de!elop acute aortic insufficiency" causing acute heart failure.
*issectioncould also e8tend into coronary !essels" leading to cardiac tamponade
or hemothora8. /A showsdifference in :/ between ( arms. -GR can show
mediastinal widening. 6AA is *8 of choice. 2<5M isto gi!e bb to lower <:/ and
)V contractility to 10011(0 mmHg and 00 bpm. $f bb is not enough tolower
:/" gi!e sodium nitroprusside. After this is achie!ed" go to surgery right away.
@=. <yncope w,o any apparent cause is most li+ely neurocardiogenic. /rodrome of
nausea"lightheadedness" pallor" and diaphoresis. /recipitating e!ents include
prolonged standing" e8ertion"!enipunture" or painful stimulus.
=0. Ventricular tachy !s. sus supra!entricular tachy: supra has regular" narrow MR<
comple8es.Ventricular tachy has wide MR< comple8es.
=1. A flutter is in a sawtooth pattern
=(. C/C syndrome: delta wa!e is a upstro+e of MR< that is slurred. $t may present
as <V6. $f !erapamilor bb are gi!en to C/C pt" ! fib may occur d,t increased
accessory pathway conduction.
=3. /ericardial effusion: can happen in response to pericarditis or any malignancy. $f
too much fluid getsout" and tamponade de!elops" presents as :ec+'s triad:
hypotension" muffled heart sounds" andele!ated FV/. <5: is present. *8 is echo
emergently and R8 is surgery. A.ual diastolic / on allchambers on cardiac cath is
aldo present. /ericardiocentesis is life sa!ing.
=9. -hest pain relie!ed by 75 is probably cardiogenic. Eet cardiac enzymes
=;. A1fib which is hemodynamically unstable: Must do synchronized cardio!ersion.
%in sync w, the Rwa!e&. $f pt is stable" then you can con!ert to normal w, drug
%amiodarone" sotalol&. 6hese agentsaren't for long term rate control. )ong term
rate control is with diltiazem or metoprolol.
=0. Asynchronized cardio!ersion is 65- for !entricular fibrillation
=?. Acute arterial occlusion: M-- are recent M$ and afib. /resents as sudden
symptoms usually in )A%numbness" coldness" delayed capillary refill" pulse deficit
in distal adrteries&. Very important toimmediate $V heparin followed by
continuous heparin infusion.
=@. -ocaine induced myocardial ischemia: $nitial R8 is nitrates" benzos" or -a
channel bloc+er. $f noimpro!ement with these %d,t possibility of coronary artery
thrombosis&" then do immediate coronaryangiography. A distinct feature of
cocaine induced !asospasm is that it might lead to coronary arterythrombosis.
==. Acute coronary syndrome: <6AM$ on ADE re.uires urgent cardiac cath. 7on1
<6AM$ can be managedwith serial cardiac enzymes" as can unstable angina
without any ADE changes.
100. 6-A o!erdose: hypotension" anticholingergic effects" -7< symptoms"
cardiac arrhythmia. -an lead toMR< prolongation and reentrey arrhythmia %!1
tach" !fib" torsades&. :est agent for 6-A inducedcardioto8icity is sodium
bicarbonate. )idocaine is the best anti1arrhythmic for 6-A inducedarrhythmias.
101. <yncope can be diagnosed by ADE I H,/ in ?0> of cases. 2<5M in a
new syncopal episode is ADE.7eurological testing %-6 hea"d AAE& are usually
not !aluable unless something in the H and / clearlyshows that it's a neurological
etiology.
*ermatology
1. Malignant melanoma: signs of malignancy include irregular borders" increasing in
size" odd colors.6hey are generally more than ; mm in diameter. A8cisional
biopsy is the 2<5M to confirm diagnosisand stage the lesion. A!entually" if it is
melanoma" you'll want to do a complete e8cision" which iscurati!e a lo the time
(. Melanoma: MaHority of melanomas are associated with e8cess sun e8posure. $t
happens more oftenin fair s+inned people" and usually de!elops in areas of the
body that are intermittently e8posed tointense sunlight. <hould wear protecti!e
clothing when e8posed to the sun. <unscreen can reduceincidence of basal and
s.uamous cell cancer" but no e!idence it helps to pre!ent melanoma
3. Chen hairs ha!e split ends" it means that there is a to8ic,chemical reaction
causing the hair loss.7umerous drugs can cause hair loss %e8 )i" thallium" chemo&
but they do not affect the hair shaft or produce split ends
9. /soriasis: inflammatory s+in disorder characterized by hyperproliferation and
abnormal differentiationof the epidermis. 6here are sharply demarcared
erythematous pla.ues in!ol!ing the scalp" +nees"e8tensor surface of elbows" nec+"
and bac+. /la.ues are raised" with a thic+ sil!ery scale co!ering thesurface.
;. /soriasis can also in!ol!e nails and Hoints" leading to psoriatic arthritis. 7ail
in!ol!ementpresents as pitting o!er the nail plates. 6he arthritis can present with
early morning stiffness which isrelie!ed by physical acti!ity. <ome drugs can
worsen psoriasis %b1bloc+er" )i" A-A$" 7<A$*s" andanti1malarials&. *8 is a
clinical one. Histology shows epidermal hyperplasia or hyperproliferation
withneutrophilic infiltration in the stratum corneum and thiined to absent layer of
the epidermis
0. Corsening of psoriasis by certain drugs: As a general rule" all drug induced s+in
rashes should bemanaged by d,c the drug
?. R8 of psoriasis: depends on se!erity of disease. Mild localized s+in disease is R8
with topical steroids%betamethasone&or emollients or coal tar products %anthralin
or calcipotriene&. 2or e8tensi!e,widespread disease" R8 include methotre8ate"
cyclosporine" JV radiation" or immunomodulators. Methotre8ate is the initial
*5- for pt with psoriasis and arthritis
@. 6inea Versicolor: fungal infection of s+in caused by Malassezia furfur. /resents
with multiple smallcircular macula which !ary in color %white" pin+" brronw&.
Rash is more prominent in summertime.Eenerally the lesionsare the only
symptom. R8 with terbinafine anti fungals. Alternati!ely" any of theazoles can
also be used.5nychomycosis: fungal infection of toenails or finger nails. M-- is
6richophyton rubrum. 7aildystrophies from other diseases can mimic this
%psoriasis" lichen planus&. Bou can confirm d8 withD5H e8am of the nail
scrapings. 6he D5H e8am will show dermatophytic hyphae and
arthrospores.6erbinafine is the 65-. An alternati!e is itraconazole.Rosacea:
chronic acneiform condition characterized by !ascular dilation in the central face.
/resentsin adults 30100. 6here are e8acerbations and remissions. <ymptoms
include facial erythema"telangiectasias" and papules,pustules. )oo+s a lot li+e
acne" but no comedoens are present. R8 withtopical metronidazole. /t with
rosacea often ha!e ocular symptoms. -halazion is a common one %it'sa cyst in the
eyelid&. 5ther eye complications include foreign body sensation" and
conHuncti!itis. Alopecia Areata: *iscrete" smooth and circular areas of hair loss
o!er the scalp with no scaling.Jsually de!elops o!er a few wee+s and has a
recurring pattern. 6here is usually regrowth of hair inthe in!ol!ed areas o!er time.
6here is no associated scalin" scarring" or inflammation. R8 is withtopical or
intralesional steroids. A!en after R8" there is still a chance of recurrence" although
it doesspeed up hair growth.6inea capitis: -an present with a patch of hair loss on
the scalp. 6he lesion is well demarcated"scaling" and somewhat erythematous. *8
is usually with D5H e8am of the hair stubs. Microsporumcanis is a cause" which
will ha!e a bright green fluorescence when lesion isobser!ed under Cood'sJV
lamp.
=.
10.
11. Deloid: benign fibrous growth that de!elops in scar tissue. 6hese lesions can be
painful andfdisfiguring. R8 with intralesional steroids. )oo+ for h8 of traum a%e8
earring piercings& Actinic Deratosis: /resents as slowly growing reddish brown
s+in lesion. $t's pre1malignant" withpotential to become s.uamous cell cancer of
the s+in.6etracycline: often used for R8 of acne. *o8ycycline is a phototo8ic
agent and ma+e ppl moresusceptible to sunburn. 5n a side note" do8y can also
cause esophageal ulceration if you don't drin+ itwith enough li.uid. R8 for
sunburn includes replacement of lost fluids and relief for pain,pruritis
with7<A$*s. *iphenhydramine can be used for the itching.$sotretinoin %systemic
retinoid&: can cause hypertriglyceridemia in up to (;> of pt. 6hus" there is a
ris+of acute pancreatitis. )oo+ for the +id who is getting isotretionoin for acne R8
who de!elopspancreatitis. $f a pt de!elops triglyceridemia # @00" should d,c the
drug.6opical Retinoid: teratogenic. 6opical retinoids aren't associated systemic
side effects %hyper6E or hepatoto8ic&.Herpes Noster: d,t reacti!ation of latent
VNV infectio earlier $n life. Any +ind of stress on the body%fracture" infection"
surgery& can reacti!ate the latent infection. /resents with grouped !esicles in
aspecific dermatome" usually unilateral. /ain is another prominent feature. R8
with acyclo!ir. )ocalizedzoster lesions are transmitted only !ia direct contact with
the open lesions. -ontact pre!autions aren'tnecessary in the community setting. $n
the hospital" howe!er" should put the pt in contact isolationuntil all the lesions
ha!e crusted. As age increases" there is a higher chance that a recurrence
willhappen./ostherpetic neuralgia %/H7&: *efined as persistence of pain or other
symptoms for # 1 month after resolution of s+in lesions of herpes zoster. $t's
described as a burning sensation in the in!ol!eddermatome. Agents pro!en to be
effecti!e for the pain include 6-A" topical capsaicin cream"gabapentin" and long
acting o8ycodone./hotoaging: arises from aging and JV light damage. $ntrinsic
aging tends to cause fine wrin+les on anotherwise smooth s+in surface. $f there is
photodamage" it can result in coarse" deep wrin+les on arough s+in surface.
/hotoaged s+in is often mar+ed with actinic +eratoses" telangiectasias" and
brownspots. -igarette smo+e can ha!e significant impact on s+in %more wrin+les"
especially at lateralcorneres of eyes&. R8 with tretinoin. $t helps reduce fine
wrin+les" mottled hyperpigmentation" androughness of the face. $t can also reduce
actinic +eratoses.Arythrasma: infection of s+in that occurs most often in
intertriginous spaces and is d,t -.minutissimum. Jse of wood lamp shows coral
red fluorescence cause by -orynebacteriumporphyries./ityriasis rosea: self
limited condition" manifests first as a single primary pla.ue %herald patch&.
Ageneralized eruption de!elops 11( wee+s later" with fine" scaling papules and
pla.ues in a christmastree distribution./oison $!y dermatitis: presents with a
pruritic dermatitis composed of papules and !escicles which aredistributed in a
linear fashion. Multiple lesions can be present in !arious areas around the
bodhy"since touching other parts of body will transfer the poison i!y resin. More
serious reactions can e!ol!einto !escicles which can e8ude a serous fluid.6inea
pedis: M- dermatophyte infection. Jsually accompanied by in!ol!ement in
another area%hands" nec+nails" or groin&. /resents as a slowly progressi!e" pruritic"
erythematous lesion" usuallybtw the toes and e8tending to the sole and side of the
foot. 6here is a sharp border btw the in!ol!edand unin!ol!ed s+in. <elf limting"
but recurrent. R8 with antifungal cream.<eborrheic *ermatitis %dandruff&: /in+1
red erythema and scaliness in the scalp" face" and sometimesupper trun+. /ruritis
is usually mild. R8 with selenium shampoo. <ometimes it's the first
presentingsign of H$V infection.
1(.
13. Amiodarone induced thyroid disease: hypothyroidism is the maHority" but
thyroto8icosis could alsohappen. 6he thyroto8icosis could be acti!ation of
Era!e's disease or by destructi!e thyroiditis. $f it'sacti!ation of Era!e's" should
gi!e methimazole or /6J. $f it's d,t destructi!e thyroiditis" R8 withsteroids.
Amiodarone can decrease the con!ersion of 69 to 63" leading to a apttern on 626
of ele!ated 69 with decreased 63./ituitary $ncidentaloma: Fust incidental pituitary
tumors are common" usually innocuous. Jsually thesetumors remains small. $f
there are no clinical or lab e!idence of pituitary dysfunction" can Hust followwith
periodic MR$ to ma+e sure doesn't get bigger. $f you disco!er these" first do lab
tests to chec+ for hormone abnormalities. 6<H" 2<H,)H" free 69" $E211"
/rolactin" de8amethasone suppression test.<ubclinical thyroto8icosis: <uppressed
6<H le!els with normal 69 and 63. M-- is usingle!othyro8ine" nodular thyroid
disease" Era!e's" and thyroiditis. $f induced by le!othyro8ine" Hustreduce dose. $f
pt is asymptomatic" Hust rechec+ 6<H after some time. $f pt was symptomatic"
consider methimazole after doing a radioacti!e iodine scan. /t with multinodular
goiter ha!e ;110>,year chance of getting symptoms" so should treat thes
guys.Hypo6H" e!en if se!ere" is not a contraindication for an emergency surgery
procedure. 7o increasedmortality for hypo6H. Fust higher postop ris+ of ileus and
hypo7a.Hyperglycemic Hyperosmolar 7on+etotic state: happens in 6(*M. -an
be precipitated by infectionsand steroid use. 6hese pt need !ery high doses of $V
insulin d,t insulin resistance. 5nce blood sugar is controlled" dose of insulin
needed drops a lot" and start pt on subcutaneous insulin. Afterwards"switch to
regular insulin before meals" and 7/H insulin as a basal le!el. 2or the periods
betweenmeals.$ncidental adrenal Masses: pretty common" Hust adrenal masses
disco!ered incidentally while wor+ingup for another problem. Asymptomatic.
<till" always get adrenal function tests when you see this. (9 hcatecholamine"
metanephrine" VMA" 1?1+etosteroid" and de8amethasone suppression test.
<urgery isindicated for: functional tumor" malignant tumor %has a
characteristicheterogenous appearance onimaging&" and all tumors # 9 cm. All
other masses can be followed w, serial abd imaging" and remo!eif
indicated.7elson's <yndrome: -lasically" presents as bitemporal hemianopsia %or
other !isual field defect&"hyperpigmentation" and pituitary enlargement after a
pre!ious bilateral adrenalectomy for -ushing'sdisease. 7eed to do MR$ and
plasma A-6H le!els to *8. $f you see !ery high A-6H and
pituitarymicroadenoma w, on MR$" it's diagnostic. 6he pituitary enlarges because
of the loss of feedbac+ bythe adrenal steroids after the surgery. <hould R8 with
surgery or pituitary radiation. /robably morerare nowadays" since the preferred
R8 for -ushing's disease is now primary pituitary surgery rather than bilateral
adrenalectomy.High anion gap met acidosis: 7ormal anion gam is 1(. M-- high
AEMA is renal failure" +etoacidosis"lactic acidosis" or into8ication w, aspirin"
ethylene glycol" or methanol. Remember metformin cancause lactic acidosis" esp
in elderly" or pt with heart" renal" or hepatic failure.6o8ic nodule: present w, <,<
of hyper6H" along w, increased focal upta+e in the thyroid.MA7 1: 3 /'s.
Hyper/6H" pituitary tumor" and pancreatic tumor %gastrinoma&. Nonger Allision
iscommonly the gastrinoma" presenting w, multiple ulcers. <hould do a
parathyroidectomy if pt ishyper-a. $n addition" the ulcers impro!e a lot after the
surgery5steoperosis: if suspected" do a bone mineral density scan %*AGA scan&.
6 and N scores reported. 6score is compared t young healthy adults. N score is
compared to same age. 6 scores: normal is #1.0. 5steopenic is between 11.0 and
1(.;. 1(.; is osteoperosis. <econdary causes of osteoperosisshould also be part
of wor+up %-:-" -M/" /6H" urinary -a&. R8 with bone specific drug treatment
isrecommended for all post menopause and score 1(" or 11.; but also ha!e R2
for fragility fractures%low bone density" h8 of fracture" 2H" smo+ing&. -a and !it
* is recommended for e!erybody. Alendronate %decreases bone resorption& us the
usual R8.
19.
1;. 5steoperosis after gastric bypass: pt who ha!e gastric bypass ha!e malabsorption"
and need higher inta+e of -a and !it * to maintain homeostasis. *ecreased
absorption of !it * leads to lowphosphorus" then a high /6H. 6here is increased
urine phosphate loss. 6he high /6H maintains anormal serum -a. 6hus" should
supplement diet with !it * and -a" adHusting accordingly if needed toget to the
right -a and !it * le!els.5steo refractory to bisphosphonates: usually" response is
!ery good. -onsider secondary causes of osteoperosis. Multiple myeloma is oen
possibility. <uspect it if there is !ery rapid progression withmultiple fractures.
5ther symptoms are wt loss" pallor" fatigue. *8 with serum protein
electrophoresis.MA7 (: (A is medullary thyroid cancer" pheo" and hyper/6H. (:
is the same medullray thyroid Ipheo" but with E$ neuroma as well as Marfanoid
fatures. $f you're gonna do surgery on the medullarythyroid" remember to gi!e a1
bloc+ers for 10119 days before" since pt li+ely also has pheo. $t'sMA7*A65RB
to screen for pheo if you see the thyroid mass. $f you try to do surgery without
+nowingthe pt has pheo" VARB :A*.$f a pt has *M" other -V ris+ factors ha!e
to be lower than for normal ppl. Remember that *M is a-A* e.ui!alent. 6hus"
Must +eep )*) 100" otherwise need a statin.$mmobilization leading to
hyper-a: Jsually see in pt with high bone turno!er rate %adolescents andolder pt
with /aget's disease&. Chen immobilized" ther is increased bone resorption and
decreasedbone formation. )eads to high -a" with low /6H. Vit * usually normal.
:isphosphonates %1dronate&are useful to pre!ent bone resorption.-a correction
rule w, albumin: 2or each 1 g of albumin below 9" must add 0.@ to the
-a.-ushing's disease: /resents w, H67" hyperglycemia" osteoperosis"mood
swings" hypoD and metacidosis. increased urinary cortisol" non1suppressible
cortisol e!en with high dose" and !ery low-A6H. $ndicati!e of an adrenal
etiology. $f the cause was central the A-6H would be normal or ele!ated. 6hus"
2<5M is to get -6 scan of adrenals.Management of thyroid nodule: 2irst" get
6<H. $f normal" go 27A. $f decreased" do a radionuclidescan to e!aluate
functional status. $f there is a hot nodule" you can Hust obser!e since
functionalglands aren't malignant.6hyroid nodule which has normal 6<H: $f 1
cm" Hust obser!e and follow w, thyroid J< annually. *o27A if # 1 cm./apillary
6hyroid -ancer: R8 is near total thyroidectomy. 6hyroglobulin is used as a tumor
mar+er after treatment" since it is only made by the thyroid. /rognosis for thyroid
cancers usually !ery good%since they are generally slow growing&. Bou can't only
od a subtotal thyroidectomy" since that wayyou're unable to get accurate
measurements of thyroglobulin./aget's disease of bone: abnormal bone
remodeling. $nitially" there is e8cess osteoclastic boneresorption" and the
replacement bone deposition starts. 6he bone becomes !ery irregular and gi!es
aOmosaicP pattern" but basically" it's poorly modeled and brittle. 6here is
increased bone turno!er %shown as increased al+ phos: mar+er to follow the
disease acti!ity and response to R8" andincreased urinary telopeptide: mar+er of
bone resorption&. 7uclear bone scan also shows increasedupta+e. -lassic present
is increased hat size %don't confuse with acromegaly&. 6here is loss hearingloss d,t
loss of bone density in cochlea. -an also present w, stiffness nad impaired
mobility in a Hoint.*isease is sometimes self1limited.R8 of /aget's: 2irst" do
serum al+ phos to get idea of acti!ity of disease. 5ptional is to do a full bodybone
scan to see which bones ha!e been affected. $ndication for R8 is bone pain"
hyper-a" neurosymptom" heart failure" in!ol!ement of weight bearing bones.
Asymptomatic don't need R8. R8 is withoral or $V bisphosphonates %1dronate&.
$t's more effecti!e than calcitonin.-eliac disease: could present w, low !it * and
iron deficiency anemia without any malabsorptionsymptoms. *8 with anti1
endomysial and anti1tissue transglutaminase antibodies. Eold standard issmall
intestine biopsy.
10.
1?. Authyroid <ic+s syndrome: commonly see in hospitalized patients. 5n labs" see
decreased 63 withnormal 69 and 6<H %low 63 syndrome&. Chen pt reco!ers from
the illness" the 6<H will transiently gohigher. 7o o!ert symptoms" maybe some
fatigue. 7o need for le!othyro8ine" Hust repeat 626 in somewee+s since should
resol!e spontaneously.Management of chronic hypo/6H: Jsually gi!e high dose
!it * and -a. 6ry to +eep -a somewherebetween @.; and =. <ometimes these pt
will ha!e increased urinary -a. $f a pt has high urinary -aand borderline low
serum -a" adding a thiazide diuretic will help to decrease urine -a and
increaseserum -a.$ndications for /6Hdectomy in secondary or tertiary hyper/6H
%e8 in -R2& pt are: -a # 10.;" se!erehyperphosphatemia" /6H # 1000" intractable
bone pain" intractable pruritis" soft tissue calcification.$odine induced
thyroto8icosis: -ould happen during coronary angiography. /resents w,
fatigue"sha+iness" wt loss" palpitations. Jsually self limiting once the iodine is
d,c" but can persist for months.Jsually refractory to antithyroid meds. :1bloc+er
can be used for mild symptoms. $f !ery se!ere" couldtry antithyroid meds.2amilial
Hypocalciuric Hypercalcemia: same /6H,-a,phosphorus profile as primary
hyper/6H. High-a" low phosphorus" and high /6H. )oo+ for hypocalciuria.
6ypically" urine -a is (00. -an R8 withconser!ati!e therapy" including
hydration" physical acti!ity" and moderate -a inta+e.A8ogenous thyroid: $n pt
who are hyper6H d,t e8ogenous source" their thyroglobulin will beundetectable.
6hyroglobulin only comes from the thyroid gland" so e8ogenous 6H would
suppress thegland. A primary 6H disease would still ha!e
thyroglobulin.Elucocorticoid affect on normal H/A regulation: using # 3 wee+s
will li+ely start suppressing H/Aa8ia." leading to tertiary adrenal insufficiency.
<hort term use % 3 wee+s& wont cause H/A distortion.6hey can be stopped
rapidly without causing any hormonal issues.$f trying to taper after long termuse"
one regimen is to switch to hydrocortisone" then gradually taper o!er a period of
11( months.Jntreated acromegaly: 38 increase in mortality" d,t cardio!ascular
disease. H67 and )V dysfunctionare common at time of diagnosis of acromegaly.
Also !arious conduction defects and myocardialfibrosis. -V disease if early can
actually be re!ersed after acromegaly is treated.*uring stress" most pt ha!e
increase in insulin resistance. 6hus" in a pt with *M" if they ha!e a stress"can
cause hyperglycemia. $nHectible steroids usually are gone from circulation within
1 wee+" so mightcause hyperglycemia in the meantime" but not after.<.uamous
cell carcinoma of lung: can produce /6H1related proteins" leading to hyper-a.
6ough todistinguish between malignancy and primary hyper/6H" but the -a in
malignancy is usually muchmuch higher .Hyper-a: di!ide into /6H dependent
and /6H independent. -an distinguish btw the two bymeasuring /6H. 6hus
2<5M in hyper-a is always /6H measurement. A-A$ has been shown to reduce
insulin resistance. Metformin has also been shown to reduce ris+ of de!elopment
of new onset 6(*M. b1bloc+er and thiazides increase ris+ for de!elopment of *M
afer prolonged use.<ulfonylurea %chlropropamide" glyburide& 5*: 6hese can
induce hypoglycemia which is se!ere andprolonged. *;0 doesn't wor+ for these
pt because the *;0 Hust increases insulin secretion" causingfurther hypoglycemia.
5ctreotide is a somatostatin analogue which inhibits insulin secretion. 5nceyou
gi!e this" the *;0 can do its Hob.<omatostatinoma: somatostatin is an inhibitory
hormone for !arious hormones. -lassic triad of gallstones" malabsorption" and
diabetes. -ause *M by inhibiting insulin secretion. *8 is somatostatin# 100.
1@.