sample PACKRAT-EOR Exam
Questions & Answers65
Cardiology : Clinical Intervention, Constrictive pericarditis - ANSWERS-ROSH: Treatment includes
NSAIDs, corticosteroids and colchicine. Drainage and antibiotics are usually necessary if an
infectious etiology is found.
PA EASY: Transthoracic echocardiography, would allow for monitoring of a patient with acute
pericarditis, to determine if a pericardial effusion and/or cardiac tamponade develops.
Exam Master: Most cases are due to viral infections with the treatment being rest and non-
steroidal agents, e.g. aspirin or indomethacin.
If this pericarditis progressed to tamponade, pericardiocentesis would be indicated. Symptoms
of tamponade are not seen in this patient (dyspnea, elevated jugular venous pressure,
hypotension, paradoxical pulse, and muffled heart sounds).
Treatment
● High-dose ASA or NSAIDs (naproxen, ibuprofen) for 1-3 weeks (for idiopathic, viral infection)
● Treat underlying cause (for uremia, bacterial infection)
● Colchicine: decreases duration of symptoms and frequency of recurrences
● Steroids are controversial - may increase recurrences (always AVOID on exams!)
• Cardiology : Clinical Intervention, Thrombophlebitis - ANSWERS-ROSH: Phlebitis is the
counterpart to vasculitis, in that phlebitis is inflammation of a vein. Thrombophlebitis is vein
inflammation due to thrombus (blood clot). These commonly occur in the superficial veins of
the lower extremities, whereas, deep venous thrombosus (DVT) is the term used when a clot
lodges in the deep veins. ymptoms include painful, palpable cord-like veins, distal edema and
,possibly localized erythema. Causes include a predilection to clotting, vein injury, incompetent
venous valves (varicosity), Behcet's syndrome and prolonged travel or immobility. Evaluation
usually includes Doppler ultrasonography and blood clotting studies. The key to treatment is
driven by where the disorder is located. Below-the-knee superficial thrombophlebitis is usually
treated with NSAIDs, compressive support and leg elevation. Above-the-knee superficial
thrombophlebitis is commonly associated with deep venous thrombus. As such, dislodgement
of the deeper clot can cause a life-threatening pulmonary embolus. Therefore, it is important to
ascertain whether or not an above-the-knee superficial thrombophlebitis occurs with a deep
venous clot (via Duplex ultrasound). If it does, then anticoagulation is recommended as part of
the treatment plan. If it isn't, the recommended treatment is less clear. Enoxaparin is a low
molecular weight heparin (LMWH) that is used to prevent and treat deep vein thrombosis or
pulmonary embolism.
Superficial thrombophlebitis is an inflammation of a vein and can be related to a septic
condition. One risk factor for superficial thrombophlebitis is presence of an IV catheter, which
this patient would have due to being an inpatient and post-operative.
Cardiology : Clinical Therapeutics, Hypercholesterolemia - ANSWERS-Colesevelam (WelChol) is
considered a Category B pregnancy risk. Both lovastatin and rosuvastatin (statins) are
considered Pregnancy Category X and should be avoided in pregnancy. Ezetimibea and
fenofibrate are both Pregnancy Category C.
Colesevelam, a bile acid sequestrant, decreases cholesterol absorption by forming insoluble
complexes of bile acids that can then be eliminated through feces. Bile acid sequestrants
include cholestyramine, colestipol, and colesevelam. Bile acid sequestrants interrupt
reabsorption of bile acids, resulting in lowered intrahepatic cholesterol. Maximum benefit is
typically seen within 3 weeks.
Cardiology : Clinical Therapeutics, Other hyperkalemia - ANSWERS-
Cardiology : Clinical Therapeutics, Prinzmetal angina - ANSWERS-This patient is exhibiting
Prinzmetal's angina (vasoconstriction); she does not have any stenosis. The best therapy for her
is a calcium channel blocker (e.g., nifedipine)
,Treatment is calcium channel blockers and nitrates
Thiazide and loop diuretics, have no proven benefit in patients with Prinzmetal angina. Aspirin,
may worsen episodes of prinzmetal angina, and thus is not recommended.
Cardiology : Diagnosis, Malignant hypertension - ANSWERS-A macular star results from
punctuate exudates that radiate from the fovea in a star pattern; this is seen is patients who are
experiencing malignant hypertension
Secondary cause of elevated blood pressure should be suspected in patients with severe or
resistant hypertension, in patients younger than 30 years without risk factors for hypertension,
in patients with malignant hypertension, or hypertension onset before the age of puberty.
Diagnosis, Third-degree atrioventricular block - ANSWERS-Complete, or third-degree AV block,
advanced second-degree AV block, symptomatic Mobitz I or Mobitz II second-degree AV block
are all indications for pacemaker placement
This patient has a third-degree AV block that is symptomatic, with syncope and mild shortness
of breath. The treatment for this patient is pacemaker insertion.
Third degree, or complete, heart block is characterized by absent conduction of all atrial
impulses and complete electrical AV dissociation. The hallmark findings of third-degree AV heart
block are regular PP intervals unrelated to regular R-R intervals with P waves that appear to
march through the QRS-T complexes.
Diagnostic Studies, Abdominal aortic aneurysm - ANSWERS-Ultrasonography is cost-effective
and is the most commonly utilized screening modality for AAAs. It can be utilized for initial
detection of a nonruptured AAA and for monitoring of progression. Anteroposterior and lateral
abdominal radiographs may reveal calcification of an AAA as an incidental finding but are
nonsensitive/nonspecific.
, ● Diagnosis
○ Can be diagnosed with US (bedside) if abdominal
○ Other modalities: CT, MRI
Abdominal Aortic Aneurysm (AAA)
● 'Classic' AAA presentation: severe abdominal/hip/back pain, pulsatile abdominal mass,
syncope
● **Beware that a kidney stone can present just like a AAA, including hematuria
○ Think worst first if patient has risk factors for AAA
○ Hematuria of AAA due to dissection into renal arteries
Cardiology : Diagnostic Studies, Hypertrophic cardiomyopathy - ANSWERS-Doppler
Echocardiography is test of choice: demonstrates septal hypertrophy, normal systolic
function, poor diastolic function, degree of mitral regurgitation
The murmur is a loud, harsh systolic murmur present along the left sternal border. The gradient
and the murmur may be enhanced by maneuvers that decrease ventricular volume, such as an
upright posture, standing, or Valsalva maneuver
Reducing the LV volume increases obstruction and the murmur intensity; whereas, in valvular
aortic stenosis, reducing the stroke volume across the valve decreases the murmur
Hypertrophic cardiomyopathy occurs when the myocardium is abnormally thickened, causing
impaired contractile function. It is associated with a hereditary syndrome. It typically presents
with dyspnea, chest pain, and syncope. Echocardiogram will reveal left ventricular hypertrophy.
Questions & Answers65
Cardiology : Clinical Intervention, Constrictive pericarditis - ANSWERS-ROSH: Treatment includes
NSAIDs, corticosteroids and colchicine. Drainage and antibiotics are usually necessary if an
infectious etiology is found.
PA EASY: Transthoracic echocardiography, would allow for monitoring of a patient with acute
pericarditis, to determine if a pericardial effusion and/or cardiac tamponade develops.
Exam Master: Most cases are due to viral infections with the treatment being rest and non-
steroidal agents, e.g. aspirin or indomethacin.
If this pericarditis progressed to tamponade, pericardiocentesis would be indicated. Symptoms
of tamponade are not seen in this patient (dyspnea, elevated jugular venous pressure,
hypotension, paradoxical pulse, and muffled heart sounds).
Treatment
● High-dose ASA or NSAIDs (naproxen, ibuprofen) for 1-3 weeks (for idiopathic, viral infection)
● Treat underlying cause (for uremia, bacterial infection)
● Colchicine: decreases duration of symptoms and frequency of recurrences
● Steroids are controversial - may increase recurrences (always AVOID on exams!)
• Cardiology : Clinical Intervention, Thrombophlebitis - ANSWERS-ROSH: Phlebitis is the
counterpart to vasculitis, in that phlebitis is inflammation of a vein. Thrombophlebitis is vein
inflammation due to thrombus (blood clot). These commonly occur in the superficial veins of
the lower extremities, whereas, deep venous thrombosus (DVT) is the term used when a clot
lodges in the deep veins. ymptoms include painful, palpable cord-like veins, distal edema and
,possibly localized erythema. Causes include a predilection to clotting, vein injury, incompetent
venous valves (varicosity), Behcet's syndrome and prolonged travel or immobility. Evaluation
usually includes Doppler ultrasonography and blood clotting studies. The key to treatment is
driven by where the disorder is located. Below-the-knee superficial thrombophlebitis is usually
treated with NSAIDs, compressive support and leg elevation. Above-the-knee superficial
thrombophlebitis is commonly associated with deep venous thrombus. As such, dislodgement
of the deeper clot can cause a life-threatening pulmonary embolus. Therefore, it is important to
ascertain whether or not an above-the-knee superficial thrombophlebitis occurs with a deep
venous clot (via Duplex ultrasound). If it does, then anticoagulation is recommended as part of
the treatment plan. If it isn't, the recommended treatment is less clear. Enoxaparin is a low
molecular weight heparin (LMWH) that is used to prevent and treat deep vein thrombosis or
pulmonary embolism.
Superficial thrombophlebitis is an inflammation of a vein and can be related to a septic
condition. One risk factor for superficial thrombophlebitis is presence of an IV catheter, which
this patient would have due to being an inpatient and post-operative.
Cardiology : Clinical Therapeutics, Hypercholesterolemia - ANSWERS-Colesevelam (WelChol) is
considered a Category B pregnancy risk. Both lovastatin and rosuvastatin (statins) are
considered Pregnancy Category X and should be avoided in pregnancy. Ezetimibea and
fenofibrate are both Pregnancy Category C.
Colesevelam, a bile acid sequestrant, decreases cholesterol absorption by forming insoluble
complexes of bile acids that can then be eliminated through feces. Bile acid sequestrants
include cholestyramine, colestipol, and colesevelam. Bile acid sequestrants interrupt
reabsorption of bile acids, resulting in lowered intrahepatic cholesterol. Maximum benefit is
typically seen within 3 weeks.
Cardiology : Clinical Therapeutics, Other hyperkalemia - ANSWERS-
Cardiology : Clinical Therapeutics, Prinzmetal angina - ANSWERS-This patient is exhibiting
Prinzmetal's angina (vasoconstriction); she does not have any stenosis. The best therapy for her
is a calcium channel blocker (e.g., nifedipine)
,Treatment is calcium channel blockers and nitrates
Thiazide and loop diuretics, have no proven benefit in patients with Prinzmetal angina. Aspirin,
may worsen episodes of prinzmetal angina, and thus is not recommended.
Cardiology : Diagnosis, Malignant hypertension - ANSWERS-A macular star results from
punctuate exudates that radiate from the fovea in a star pattern; this is seen is patients who are
experiencing malignant hypertension
Secondary cause of elevated blood pressure should be suspected in patients with severe or
resistant hypertension, in patients younger than 30 years without risk factors for hypertension,
in patients with malignant hypertension, or hypertension onset before the age of puberty.
Diagnosis, Third-degree atrioventricular block - ANSWERS-Complete, or third-degree AV block,
advanced second-degree AV block, symptomatic Mobitz I or Mobitz II second-degree AV block
are all indications for pacemaker placement
This patient has a third-degree AV block that is symptomatic, with syncope and mild shortness
of breath. The treatment for this patient is pacemaker insertion.
Third degree, or complete, heart block is characterized by absent conduction of all atrial
impulses and complete electrical AV dissociation. The hallmark findings of third-degree AV heart
block are regular PP intervals unrelated to regular R-R intervals with P waves that appear to
march through the QRS-T complexes.
Diagnostic Studies, Abdominal aortic aneurysm - ANSWERS-Ultrasonography is cost-effective
and is the most commonly utilized screening modality for AAAs. It can be utilized for initial
detection of a nonruptured AAA and for monitoring of progression. Anteroposterior and lateral
abdominal radiographs may reveal calcification of an AAA as an incidental finding but are
nonsensitive/nonspecific.
, ● Diagnosis
○ Can be diagnosed with US (bedside) if abdominal
○ Other modalities: CT, MRI
Abdominal Aortic Aneurysm (AAA)
● 'Classic' AAA presentation: severe abdominal/hip/back pain, pulsatile abdominal mass,
syncope
● **Beware that a kidney stone can present just like a AAA, including hematuria
○ Think worst first if patient has risk factors for AAA
○ Hematuria of AAA due to dissection into renal arteries
Cardiology : Diagnostic Studies, Hypertrophic cardiomyopathy - ANSWERS-Doppler
Echocardiography is test of choice: demonstrates septal hypertrophy, normal systolic
function, poor diastolic function, degree of mitral regurgitation
The murmur is a loud, harsh systolic murmur present along the left sternal border. The gradient
and the murmur may be enhanced by maneuvers that decrease ventricular volume, such as an
upright posture, standing, or Valsalva maneuver
Reducing the LV volume increases obstruction and the murmur intensity; whereas, in valvular
aortic stenosis, reducing the stroke volume across the valve decreases the murmur
Hypertrophic cardiomyopathy occurs when the myocardium is abnormally thickened, causing
impaired contractile function. It is associated with a hereditary syndrome. It typically presents
with dyspnea, chest pain, and syncope. Echocardiogram will reveal left ventricular hypertrophy.
