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ER: PA easy and cardio Part A, Questions and answers, latest update, 100% pass rate.

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ER: PA easy and cardio Part A, Questions and answers, latest update, 100% pass rate. A 24-year-old intoxicated male presents to the emergency department after being in a fight. He was punched i... n the nose, and now has mild deformity of the nose and some epistaxis. An x-ray reveals a fractured nasal bone. During his physical exam, what must you look for in order to prevent permanent destruction of his nasal septum? - ✔✔A septal hematoma can cause ischemic necrosis of the nasal septal cartilage if not identified and drained. A deviated septum can be expected with a nasal bone fracture, and must be addressed by the otolaryngologist. Excessive epistaxis that does not resolve with direct pressure and anterior packing may indicate a posterior bleed. A 59-year-old woman presents to the emergency department with an acute upper gastrointestinal hemorrhage. Her medical history is pertinent for peptic ulcer disease for the past 5 years and hypertension. A nasogastric tube is inserted and bright red blood is seen. Her vital signs are BP: 110/70 mm Hg, P: 94/min, R: 14/min, oxygen saturation: 97%, T: 99°F. Which of the following diagnostic studies would be the most appropriate next step to determine the site of bleeding? - ✔✔upper GI endoscopy A 66-year-old male with a history of hypertension, diabetes mellitus, and hypercholesterolemia presents by emergency medical services (EMS) to the emergency department complaining of severe chest pain with radiation into his back. The patient states that he was feeling well in the morning, but while performing some light activity he felt a "ripping" sensation in his back, which he initially thought was a pulled muscle. The pain continued and the patient started to have chest pain, shortness of breath, and lightheadedness. On initial examination the patient is still in pain, pale, diaphoretic, and has a blood pressure of 85/40. His chest is clear to auscultation, and he has a 3/6 diastolic murmur best appreciated at the base of the heart. Given this clinical scenario, what is the best test to definitively diagnose this medical problem? - ✔✔• This patient is exhibiting a history and physical examination that is consistent with a thoracic aneurysm. The patient's history of hypertension, along with the "ripping" sensation in his back and hypotension give a clinical presentation that is suggestive of a thoracic aneurysm dissection. Given this clinical situation, the best test to evaluate for a potential dissection is by computed tomography (E What describes following s/sx: * ripping sensation in back * chest pain, SOB, light headedness, diaphoretic * 3/6 diastolic murmur at base of heart - ✔✔The patient's history of hypertension, along with the "ripping" sensation in his back and hypotension give a clinical presentation that is suggestive of a thoracic aneurysm dissection. A 22 year-old male is involved in a motor vehicle crash resulting in fracture of the left femur and left ribs 3 through 6. Approximately 24 to 36 hours after admission he becomes mildly confused and his RR increases to 40. Chest x-ray reveals diffuse pulmonary opacities. ABG shows pH 7.39, PCO2 34, PO2 55. What is the most likely diagnosis? - ✔✔ARDS ARDS criteria of dx - ✔✔• lung injury of acute onset, within 1 week of an apparent clinical insult and with progression of respiratory symptoms • bilateral opacities on chest imaging not explained by other pulmonary pathology (e.g. pleural effusion, pneumothorax, or nodules) • respiratory failure not explained by heart failure or volume overload • decreased arterial PaO 2/FiO 2 ratio: • mild ARDS: ratio is 201 - 300 mmHg (≤ 39.9 kPa) • moderate ARDS: 101 - 200 mmHg (≤ 26.6 kPa) • severe ARDS: ≤ 100 mmHg (≤ 13.3 kPa) • (a minimum PEEP of 5 cmH 2O is required; it may be delivered noninvasively with CPAP to diagnose mild ARDS). A decreased PaO 2/FiO 2 ratio indicates reduced arterial oxygen content relative to that of the inhaled gas, indicating a failure of the lung to transport oxygen into the blood. phimosis vs. paraphimosis - ✔✔Phimosis refers to the inability to retract the distal foreskin over the glans penis. Physiologic phimosis occurs naturally in newborn males. Pathologic phimosis defines an inability to retract the foreskin after it was previously retractible or after puberty, usually secondary to distal scarring of the foreskin. Paraphimosis is the entrapment of a retracted foreskin behind the coronal sulcus. Paraphimosis is a disease of uncircumcised or partially circumcised males. A 22-year-old African American male presents to the emergency department with shortness of breath, which started 2 hours prior to arrival. He does not have a history of pulmonary disease that he is aware of, and he states that in the past at random events he has had similar episodes. He does nothing to get the episodes to stop, and he also states that he feels his chest pounding at the same time of the shortness of breath. He has no medical history that he is aware of, and he takes no medications or any illicit drugs. On examination he is alert, awake, and oriented. His vital signs show T 99.0, P 142, R 18, and BP 132/82. His chest x-ray is negative for any acute cardiopulmonary disease, and his electrocardiogram has an irregularly irregular rate of 142 with visible delta waves. Given the clinical situation above, what is the best medication for managing this patient's condition with a long-term approach? - ✔✔* This patient has Wolff-Parkinson-White (WPW) syndrome along with atrial fibrillation and a rapid ventricular response. Of the choices given in managing this patient's tachycardia, oral flecainide (D) will serve to slow the process within the accessory pathway and prolong the refractory period. Amiodarone (A) has been shown to not be effective in managing the patient's tachycardia with respect to WPW. A 49-year-old female with a known history of hypertension presents to the emergency department with a generalized headache that is throbbing. She states she had run out of her normal blood pressure medication about a week ago and since then she has noticed that her headache came about and has been getting worse. She denies any nausea, vomiting, visual changes, chest pain, or other symptoms. On exam the patient has a BP 227/120, P 78, R 18. Her HEENT exam is essentially normal, lungs are clear to auscultation, and heart is a regular rhythm without murmur or gallop. Given this clinical situation, which medication would be the most appropriate to address the patients condition? - ✔✔This patient's clinical situation is one of a hypertensive emergency. In this situation the goal is to bring down the systolic pressure to prevent end organ damage. Given the possible choices, the best choice would be intravenous labetalol (D) due to its effective quick onset, and its ability to be tolerated with most patients. While oral furosemide (B) and hydralazine (E) can both be effective in managing hypertension, the IV dosing of labetalol would be the better choice. Nitroprusside (A) is no longer a treatment option. Spironolactone (C) would not have strong enough effects to appropriately lower the blood pressure in an efficient manner. Upon testing a patient for function of the hip abductors, which muscle is considered the primary muscle responsible for most abduction? - ✔✔The primary mover in the motion of hip abduction is the gluteus medius muscle. Gluteus minimus does play a supporting role in that motion. Biceps femoris is one of the three hamstring muscles and contributes to the motions of knee flexion (primary muscle) and hip extension (secondary muscle). Gluteus maximus is the primary mover for hip extension and vastus medialis is one of the four quadriceps muscles responsible for knee extension, but no hip movements. A 76-year-old man with a history of HTN and diabetes mellitus, type 2, presents to the emergency department with complaints of palpitations, tachypnea, and chest pain. He denies history of CAD, stroke, TIA, or congestive heart failure. He is afebrile, with vital signs as follows: BP 145/98, HR 138, and RR 22. His EKG is shown (Figure 1). Troponins are negative X 1. His echocardiogram demonstrates normal LV systolic function and normal valvular function. Which of the following would be considered the most appropriate long-term anti-coagulation therapy for him? - ✔✔Choice D, warfarin 5 mg dosed to INRs between 2.0 and 3.0, is correct because the patient demonstrates non-valvular atrial fibrillation, and has a CHADS2 score of 3 (1 pt each for age > 75 years old, HTN, and diabetes), placing him at a higher risk for thromboembolism. Choices A, B and E are incorrect because there is no research data to suggest that Plavix, Aspirin, or Aggrenox is of value in the prevention of thromboembolism in atrial fibrillation. 1. treatment of choice for atrial fibrillation 2. coronary artery spasm associated with ST-segment elevation, and usually occurs at rest and at the same time of the day 3. associated symptoms with above 4. chest discomfort that is worse while supine and improves with sitting up, as well as a pericardial friction rub - ✔✔1. Choice D, warfarin 5 mg dosed to INRs between 2.0 and 3.0 2. printzmetal angina 3. Patients with a history of migraine cephalgia and Raynaud's phenomenon demonstrate Prinzmetal angina more frequently than the rest of the patient population. This can occur in patients with normal coronary arteries and with coronary artery stenosis 4. pericarditis A 42-year-old woman with a history of migraine cephalgia and Raynaud's phenomenon comes to the emergency department with complaints of severe chest discomfort that occurs at rest every morning (at approximately 10 AM). An EKG performed during an episode of chest discomfort demonstrates transient ST segment elevation, which is relieved with sublingual nitroglycerin. There is no troponin elevation. Cardiac catheterization is performed, and reveals coronary artery spasm, which corresponds with ST segment elevation, and no significant coronary artery stenosis. Which of the following choices is the most likely diagnosis? - ✔✔• Prinzmetal angina, or variant angina pectoris, is defined as coronary artery spasm associated with ST-segment elevation, and usually occurs at rest and at the same time of the day. Patients with a history of migraine cephalgia and Raynaud's phenomenon demonstrate Prinzmetal angina more frequently than the rest of the patient population. This can occur in patients with normal coronary arteries and with coronary artery stenosis. Choice A, pericarditis, would present with chest discomfort that is worse while supine and improves with sitting up, as well as a pericardial friction rub • A 22-year-old African American male presents to the emergency department with shortness of breath, which started 2 hours prior to arrival. He does not have a history of pulmonary disease that he is aware of, and he states that in the past at random events he has had similar episodes. He does nothing to get the episodes to stop, and he also states that he feels his chest pounding at the same time of the shortness of breath. He has no medical history that he is aware of, and he takes no medications or any illicit drugs. On examination he is alert, awake, and oriented. His vital signs show T 99.0, P 142, R 18, and BP 132/82. His chest x-ray is negative for any acute cardiopulmonary disease, and his electrocardiogram has an irregularly irregular rhythm and a rate of 142 with visible delta waves. Based on the information provided, what is the most likely diagnosis for this patient? - ✔✔A fib with Wolf parkinson white 1. delta wave 2. pathophys of above - ✔✔1. Wolf parkinson white 2. • AV normally holds up conduction 0.1 sec for full atrial depolarization • In WPW - an alternate pathway (Bundle of Kent) bypasses the delay at the AV node and allows shorter conduction and prematurely activates the ventricles • Looks like a short PRI < 0.12 • Early ventricular depolarization reflected in delta wave • An 82-year-old male presents to the emergency department with a 2-day history of weakness, fatigue, and mild shortness of breath. His past medical history includes hypertension, arthritis, diabetes, and hypercholesterolemia. His medications include metoprolol, glyburide, simvastatin, and acetaminophen. On physical examination, the vital signs reveal T 97.7, P 40, R 15, BP 84/60. His neck exam reveals no jugular venous distention, lungs are clear to auscultation, and cardiac has a regularly irregular bradycardia rhythm. There is no evidence of edema to the extremities. The patient is placed on a telemetry monitor, which reveals the image shown. Based on the information provided, what is the most appropriate medical therapy for this patient? - ✔✔o This patient has developed complete heart block as evidenced by the telemetry rhythm strip. While the patient will require a pacemaker as the definitive treatment, the pharmacologic intervention that must be done is to halt the use of beta blockers (E), which will contribute to the patient's slower rate. The other choices (A, B, C, and D) would all exacerbate the condition the patient is already in, and make the clinical situation worse and potentially fatal. 12 lead ekg for left vs. right BBB - ✔✔1. left BBB • QRS duration ≥ 0.12 sec • Lead I: QRS notch (= Fedora hat) • Lead I, avL, V5, and V6: broad monomorphic R waves, ∅ Q wave 2. Right BBB: • QRS duration ≥ 0.12 sec • Lead I: slurred S wave • Leads V1, V2, V3 : RSR' (rabbit ears) first degree block - ✔✔• Block at the level of the AV node • Make sure to identify underlying rhythm- sinus bradycardia PRI, >20 seconds • Constant but prolonged PRI, >0.20 sec • Rhythm is regular; P:QRS = 1:1 • Seen with inferior MI, also drug effect • Usually asymptomatic; no treatment second degree block type 1 vs. type 2 - ✔✔1. second degree block, type 1, wenckebach; • Failure of some sinus impulses to be conducted to the ventricels • Sinus impulses are conducted normal, just see increased difficulty getting through the conduction system • look for a GROUPING of QRS's, decreased conduction of P waves and essentially more P waves than QRS complexes. Think of it as the AV node becoming more and more tired until it eventually does not even propagate a P wave. • PROGRESSIVELY prolonged PRI followed by nonconducted P wave • Usually transient and resolves spontaneously • Grouping of R waves= "footprints of Wenckebach" • QRS is NORMAL (<0.12) 2. type 2, mobitz II • PRI remains constant, but there is a periodic non-conducted P wave • will usually have a slower rate • P:P will be regular; ventricular response • More serious than type 1, may progress to third degree block 3rd degree heart block - ✔✔• Complete dissociation between the Atria and the ventricles • Complete block at the AV node • Atria responsive to SA node • P:P interval will be constant, but the PRI varies • More P waves than QRS complexes • Remember that ventricular rate 20-40! • there is NO GROUPING of QRS complexes and there is TWO SEPARATE RHYTHMS • Patients with suspected familial hypercholesterolemia have serum cholesterol levels > 300 mg/dL and are at increased risk of atherosclerosis. Which of the following physical exam findings are nearly pathognomonic for familial hypercholesterolemia? - ✔✔o The correct choice is A, tendon xanthomas. These are depositions of cholesterol rich substances that can present in any tendon as a mass-like lesion. They are most commonly found in the Achilles, patellar, and hand extensor tendons. •In your family practice, you perform an ankle brachial index (ABI) on your 66-year-old diabetic who smokes with the results being 0.71 on the left and 0.68 on the right. Which of the following is the most appropriate next step? - ✔✔o This patient has peripheral arterial disease (PAD). This can be treated with antiplatelet agents, including aspirin and/or clopidogrel. Warfarin is an anticoagulant and is not FDA-approved for use in PAD. Your other consideration is referral to a cardiologist and/or vascular surgeon for further evaluation, depending upon the degree of symptoms. asa/ clopidogrel vs. warfarin - ✔✔ASA/ clopidogrel is anti-platelet and warfarin is anticoagulant PAD 3 patterns; most common - ✔✔• type 1: aorta and common iliac artery; smokers • type 2: aorta, common iliac artery, and external iliac artery • type 3: most common, aorta, iliac, femoral, popliteal, and tibial • MC area of blockage is superficial femoral artery acute arterial ischemia - ✔✔6 P's of acute arterial occlusion: Pallor Pulselessness Poikilothermia Parasthesias Pain Paralysis dx of PAD - ✔✔ABI<.9; preferred dx test for PAD is arterial duplex ultrasound; * Analyzes flows: triphasic, biphasic, monophasic Degree of stenosis * triphasic is the best; monphasic the worst claudification of the buttocks area * importence * legs feel cold 3 - ✔✔lariche syndrome; illiac artery various stages; grades of venous insufficiency and dx - ✔✔C1: spider veins 2. C2: varicose veins 3. C3: edema 4. C4: skin changes; hemosiderine 5. C5:skin changes and healed ulcer 6. C6: skin changes and active ulcer o 1. dx: Lower extremity venous ultrasound to evaluate for: *Venous reflux/insufficiency *Check the 4 veins: greater saffenous vein and short saffenous vein PAD 1. definition, main cause 2. MC area of blockage 3. risk factors, which is the biggest - ✔✔PAD 1. definition, main cause: *Condition in which the arteries in your legs become blocked, your legs do not receive enough blood or oxygen *Most often caused by atherosclerosis (plaque buildup in arteries) 2. MC area of blockage: * superficial femoral artery is most common area of blockage 3. risk factors, which is the biggest: Smokers (Biggest risk factor) Age High cholesterol/trigylcerides Diabetes Obesity/Physical inactivity Heredity s/sx of PAD arterial vs. venous clots - ✔✔* common sx for both V and A: *The MOST COMMON early symptom is Intermittent Claudication —pain/cramps/weakness/numbness, especially calves after walking, relieved with rest *Leg tightness, aching *Non-healing ulcers * Infection * gangrene (black toes) Arterial: * decreased hair in lower extremes * skin discoloration: blue, purple * cold skin Venous * hair not decreased; normal * skin discoloration: hemosiderine stain * normal temperature s/sx of acute arterial ischemia - ✔✔6 P's of acute arterial occlusion: Pallor Pulselessness Poikilothermia Parasthesias Pain Paralysis Dx of PAD 1. ABI, what indicates severe dz 2. what is preferred dx test; what indicates degree of stenosis - ✔✔Dx of PAD 1. ABI, what indicates severe dz: • ABI > or = 1: normal • ABI < 0.8: mild/moderate dz • ABI < 0.4: severe dz 2. what is preferred dx test; what indicates degree of stenosis: * preferred dx test for PAD is arterial duplex ultrasound; * Analyzes flows: triphasic, biphasic, monophasic Degree of stenosis * triphasic is the best; monphasic the worst PAD: what happens if patient has abnormal US result; preferred vs. other measures - ✔✔* preferred next step: angiogram b/c can dx and treat * other: MRA and CTA (CT angiogram) Tx of PAD 1. lifestyle changes 2. medications 3. surgery - ✔✔Tx of PAD 1. lifestyle changes: Diet, exercise, smoking cessation!!!!! 2. medications: Medications—cholesterol, antiplatelet therapy (ASA, plavix), coumadin, vasodilators (CCB), Pentoxifylline (Trental) 400mg TID, Cilostazol (Pletal) (arterial vaso-dialors) 100mg BID, pain control 3. surgery: Angioplasty/stenting Surgery (bypass grafting) Amputation Local wound care/debridement surgical treatment of arterial ischemia 1. what is most common grafting surgery 2. what is lariche syndrome 3. what surgery is indicated for lariche syndrome - ✔✔surgical treatment of arterial ischemia 1. what is most common grafting surgery: * fem-pop 2. what is lariche syndrome * block in the lower part of aorta * 3 main symptoms: * claudification of the buttocks area * importence * legs feel cold 3. what surgery is indicated for lariche syndrome * fem-fem sx/s of varicose veins - ✔✔*Legs are aching and tired and heavy *Pain *Heaviness, aching in legs *Inability to walk or stand for long hours *Swelling *Brownish skin discoloration *Hemosiderin stain; *Redness, dryness, itchiness *Skin ulcerations *Bleeding from minor trauma *Infection *Superficial and deep vein thrombosis (DVT) Venous insufficiency classification 1. C1 2. C2: 3. C3: 4. C4: 5. C5: 6. C6: - ✔✔Venous insufficiency classification 1. C1: spider veins 2. C2: varicose veins 3. C3: edema 4. C4: skin changes; hemosiderine 5. C5:skin changes and healed ulcer 6. C6: skin changes and active ulcer Varicose veins 1. dx 2. tx a. pressure of compressive stalking b. gold standard for venous ulcer tx - ✔✔Varicose veins 1. dx: Lower extremity venous ultrasound to evaluate for: *Venous reflux/insufficiency *Check the 4 veins: greater saffenous vein and short saffenous vein *DVT *Superficial blood clots 2. tx a. pressure of compressive stalking: 20-30 mmHg b. gold standard for venous ulcer tx: Unna boots (wrappings with calamine lotion, zinc oxide, glycerin) Venous insufficiency [Show More]

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