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444 Cards in this Set
- Front
- Back
- 3rd side (hint)
S1 corresponds to _____ on EKG
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QRS complex indicating ventricular depolarization (ventricular contraction- marks beginning of systole)
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S2 corresponds to _____ on EKG
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S2 follows T wave- marks beginning of diastole
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Physiologic split accentuation:
Inspiration/ expiration? |
Inspiration.
^ I = | (arrow up) accentuation |
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A2 accentuation observed in ____
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systemic hypertension
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P2 accentuation observed in ____
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pulmonary hypertension
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S3 heart sound: Associated conditions?
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Indicates increased/rapid ventricular filling in diastole.
Normal finding in children and adulthood. Abnormal in adults>40yrs: indicates regurgitation |
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1st sign of congestive heart failure?
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s3 heart sound
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S3: location best heard in?
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Best heard over apex in left lateral decubitus position.
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S4? associated conditions
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Due to increased resistance to filling.
Indicates LVH. Volume ovreload. |
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AV murmurs: radiation location?
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Neck(aortic stenosis)
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Aortic stenosis murmurs: radiation to?
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Neck
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Mitral regurg murmurs: radiation to?
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Axilla
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Change in abnormal heart sounds and murmurs with inspiration/expiration?
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Increase in intensity of murmurs/abnormal sounds with inspiration: RIGHT sided murmurs
No change in intensity of LEFT sided murmurs with inspiration/expiration |
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MCC of continuous murmur (thru systole and diastole)
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Cervical venous hum (innocent murmur)
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Continuous murmurs: associated conditions?
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PDA
Cervical venous hum |
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Innocent murmurs?
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Occur in children between age 3-7yrs.
Grade 2 systolic murmurs. |
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JVP:waves?
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+ve: acv
-ve: xy a wave: atrial contraction c wave: TV bulging during systole x wave: TV downward displacement during systole v wave: RA filling y wave: RA emptying (without contracting) **refer show-me(ipad) |
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Types of hypertrophy
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Concentric
Eccentric |
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Sequence of events leading to concentric hypertrophy
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Increased afterload/resistance-->increased wall stress-->alteration in gene expression-->duplication of sarcomeres in PARALLEL---->LVH
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LVH: causes
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1. Essential HTN
2. Aortic stenosis 3. Hypertrophic cardiomyopathy |
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Eccentric hypertrophy: sequence of events?
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Preload(increased volume)--> Increased length of sarcomere-->frank-starling law--> sarcomere duplicate in series--->eccentric hypertrophy--> dilation
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Eccentric hypertrophy- causes?
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1. Volume overload from regurgitation
2. Left to right shunting of blood |
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Ventricular hypertrophy: effects?
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Heart failure
Angina S4 heart sound |
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S4 heart sound due to?
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Blood filling non compliant ventricle
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MC hospital admission dx in elderly pts?
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Heart failure
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Heart failure types?
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1. Right sided
2. Left sided 3. Biventricular 4. High output |
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LHF: classification?
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1. Systolic dysfunction(contraction)
2. Diastolic dysfunction(compliance) |
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Causes of systolic dysfunction?
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1. Ischemia from CAD
2. Post-MI 3. Myocardial fibrosis 4. Myocarditis 5. Dilated cardiomyopathy |
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Causes of diastolic dysfunction?
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1. MCC: Concentric LVH(due to essential hypertension)
2. Glycogen storage 3. Amyloid deposition 4. AR/MR |
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Effect of systolic dysfunction on EF?
Effect of diastolic dysfunction on EF? |
Systolic dysfunction: Reduced EF
Diastolic dysfunction: Normal or Elevated EF |
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Heart failure:
Gross and Microscopic features? |
Gross:
Lungs are heavy and congested Contain pink frothy exudate Microscopic: Alveolar macrophages contain hemosiderin ("Heart failure cells) |
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Effect of heart failure on LVEDP and LVEDP
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Both elevated
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Effects of heart failure?
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1. Pulmonary edema
2. Left sided S3 3. Functional MR 4. PND 5. Increased BNP |
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Dyspnea due to heart failure: reason?
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INTERSTITIAL FLUID accumuating---> stimulating juxtacapillary I receptors innervated by VAGUS
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Sequence of events leading to Pulmonary edema?
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Increased LVEDV-->increased hydrostatic pressure in LV-->LA-->Pulm veins-->Pulm cappillaries--> over-riding of oncotic pressure-->Transudation into interstitial spaces-->(dyspnea)--->into alveolar spaces-->pulmonary edema
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Kerley's lines in CXR due to?
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SEPTAL edema
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Wheezing in CHF due to?
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PERIBRONCHIOLAR edema
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Bibasilar crackles in CHF due to?
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Air expanding alveoli filled with fluid.
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CXR findings in CHF?
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1. Kerley lines
2. Upper lobe congestion 3. Perihilar congestion- "Batwing configuration" |
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PND cause?
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Due to elimination of effect of gravity while supine--> fluid moves back into vascular compartment --> increases venous return --> back pressure in lungs --> pulmonary edema
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Brain natriuretic peptide: site of secretion?
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Ventricles
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Brain natriuretic peptide: clinical use?
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Prognostic, diagnostic, predictive value.
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RHF: causes?
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1. RVH(non compliance)
2. Right ventricular infarction(decreased contraction) 3. Increased afterload: LVH Pulmonary hypertension 4. Increased preload: TR left->right shunt |
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RHF: clinical effects?
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1. TV regurgitation
2. JVD 3. Hepatomegaly(painful) 4. Ascites 5. Peripheral edema 6. Cyanosis 7. S3 and S4 heart sounds |
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CHF: drugs used for rx?
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1. ACE inhibitors: reduce preload and afterload
2. Diuretics; Reduce preload 3. Digitalis: positive inotropic agent 4. B- blockers: Reduce oxygen consumption + Increases diastolic filling time+ Reduce sympathetic tone 5. Hydralazine: Reduce afterload + reduce pulmonary pressures 6. |
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CHF: Non pharmacologic method?
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Salt restriction<2g/day
Water restriction< 2l/day |
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CHF + HTN
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CCB
B blockers ACEI |
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High output failure: associated conditions?
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1. Anemia
2. Beriberi 3. AV malformations- 1. Paget's disease - Mosaic bone 2. 4. Hyperthyroidism |
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Coronary circulation and distribution
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LAD: (MCC for CA thrombosis)
1. Anterior portion left ventricle 2. Anterior 2/3rds of interventricular septum Right coronary artery: 1. Right ventricle 2. Posterior 1/3rd of interventricular septum 3. Postero-inferior portion of left ventricle 4. SA node 5. AV node 6. Posteroinferior papillary muscle Left circumflex artery: Lateral surface of left ventricle. |
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Types of ischemic heart disease?
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1. Angina
2. MI 3. Sudden cardiac death 4. Chronic ischemic heart disease |
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Risk factors: ischemic heart disease.
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1. Age>45yrs- m
Age>55yrs- f 2. Smoking 3. Hypertension 4. HDL<40 5. LDL> 160 6. DM 7. Family history of premature CAD/stroke |
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MCC type of ischemic heart disease?
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Chronic stable angina
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Stable angina: causes?
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1. Atherosclerotic heart disease
2. LVH (HTN and AS) 3. Hypertrophic cardiomyopathy 4. Cocaine induced vasospasm |
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Stable angina: pathogenesis?
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Subendocardial ischemia
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Stable angina: Clinical findings?
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1. Chest pain- exercise induced- 30 seconds to 30 minutes. radiation left arm/jaw
2. SOB/diaphoresis- sympathetic signs 3. Relieved by nitroglycerine 4. ST segment depression>1mm |
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Prinzmetal angina: Pathogenesis?
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Intermittent vasospasm
1. Thromboxane A2 2. Endothelin |
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Prinzmetal angina:
Stress test findings on EKG? |
ST segment elevation
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Unstable angina: Pathogenesis?
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1. Severe multivessel atherosclerotic disease
2. Disrupted plaques- with/without platelet thrombi. |
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Unstable angina: clinical findings?
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Frequent bouts of chest pain with/without exertion.
May progress to MI |
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Angina: Rx- drugs?
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Stable angina:
Nitrates B blockers Ca channel blockers Prinzmetal's angina: CCBs Unstable angina: Heparin + Aspirin Statins Folate |
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Revascularization procedures?
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1. PTCA
2. Balloon angioplasty w/wo stents 3. |
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Restenosis more common in:
1. Balloon angioplasty 2. Stents? |
Balloon angioplasty
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Prevention of complications(thrombi related) following revascularization procedures?
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Abciximab- IIb- IIIa receptor blocker
**refer show me (ipad) |
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CABG: indication?
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Symptomatic three vessel disease
Left main CAD |
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CABG: Grafts used?
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Internal mammary artery grafts
Saphenous vein grafts |
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Chronic ischemic heart disease: Pathogenesis?
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Long term ischemic damage to myocytes-->replacement of myocytes with scar tissue(non contractile)
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Chronic ischemic heart disease: clinical findings?
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1. Biventricular failure
2. Angina 3. Dilated cardiomyopathy |
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Sudden cardiac death?
Risk factors? |
Unexpected death within one hour of onset of symptoms.
1. Obesity 2. Glucose intolerance 3. HTN 4. Smoking 5. Recent non-Q wave myocardial infarction |
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Sudden cardiac death: peak time of occurance(during a typical day)
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Morning hours- hypercoagulability max
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Sudden cardiac death: pathogenesis?
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1. Ventricular fibrillation
2. Absence of detectable thrombus 3. Disrupted Fibrous plaques 4. Severe atherosclerosis |
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Sudden cardiac death: diagnosis?
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Dx of exclusion:
R/o following: 1. MVP 2. Calcified AS 3. Hypertrophic cardiomyopathy 4. Cocaine use 5. Conduction defect abnormalities (?) |
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Sudden cardiac death: diagnosis?
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Dx of exclusion:
R/o following: 1. MVP 2. Calcified AS 3. Hypertrophic cardiomyopathy 4. Cocaine use 5. Conduction defect abnormalities (?) |
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MI: Causes/associated conditions?
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1. Atherosclerotic
2. Vasculitis- (Kawasaki) (PAN) 3. Embolization (Plaques in aorta/CA) 4. Thrombosis synrdomes (Polycythemia) (A/thrombin III deficiency) 5. Cocaine use 6. Dissection: aortic |
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MI: Causes/associated conditions?
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1. Atherosclerotic
2. Vasculitis- (Kawasaki) (PAN) 3. Embolization (Plaques in aorta/CA) 4. Thrombosis synrdomes (Polycythemia) (A/thrombin III deficiency) 5. Cocaine use 6. Dissection: aortic |
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Types of MI?
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Transmural- Q wave
(Full thickness) Subendocardial- Non Q waves (Inner 1/3rd) Non Q has lesser mortality |
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Types of MI?
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Transmural- Q wave
(Full thickness) Subendocardial- Non Q waves (Inner 1/3rd) Non Q has lesser mortality |
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Reperfusion injury:
significance? |
Improves long and short term prognosis
Damaged myocytes removed by reperfusion Limits size of infarct (Injured cells consume sources denying healthy cells their needs) |
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Reperfusion injury:
significance? |
Improves long and short term prognosis
Damaged myocytes removed by reperfusion Limits size of infarct (Injured cells consume sources denying healthy cells their needs) |
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Reperfusion: Histologic findings?
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1. Contraction band necrosis
2. Hypercontraction of dying cells- influx of Ca into cytosol |
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Reperfusion: Histologic findings?
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1. Contraction band necrosis
2. Hypercontraction of dying cells- influx of Ca into cytosol |
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MI: Gross/ microscopic findings ?
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1st 24 hrs:
Gross: No changes Micro: 1. Coagulation necrosis 2. Neutrophils enter infarction area 1-3days: Gross: Pale area of infarct Micro: 1. Neutrophils(max in no) lyse dead cells 2. Myocyte striations/nuclei disappear 3-7 days: Gross: Granulation tissue appears at the edge of infarct Micro: Macrophages remove debris 7-10 days: Gross: Yellow area of necrosed infarct Micro: Granulation tissue and collagen -well formed 2 months: Infarcted tissue replaced by white patchy non contractile tissue |
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MI: Gross/ microscopic findings ?
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1st 24 hrs:
Gross: No changes Micro: 1. Coagulation necrosis 2. Neutrophils enter infarction area 1-3days: Gross: Pale area of infarct Micro: 1. Neutrophils(max in no) lyse dead cells 2. Myocyte striations/nuclei disappear 3-7 days: Gross: Granulation tissue appears at the edge of infarct Micro: Macrophages remove debris 7-10 days: Gross: Yellow area of necrosed infarct Micro: Granulation tissue and collagen -well formed 2 months: Infarcted tissue replaced by white patchy non contractile tissue |
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MI: clinical presentation
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1. Severe chest pain>30 minutes
2. No relief on nitroglycerine 3. Radiates down shoulder/jaw/neck 4. Associated with sympathetic signs Silent AMI: elderly and DM |
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MI: clinical presentation
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1. Severe chest pain>30 minutes
2. No relief on nitroglycerine 3. Radiates down shoulder/jaw/neck 4. Associated with sympathetic signs Silent AMI: elderly and DM |
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MI: complications?
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1. Cardiogenic shock
2. CHF 3. Rupture 4. Ventricular aneurysm 5. Mural thrombus 6. Arrhythmias 6. Fibrinous pericarditis |
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MI: complications?
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1. Cardiogenic shock
2. CHF 3. Rupture 4. Ventricular aneurysm 5. Mural thrombus 6. Arrhythmias 6. Fibrinous pericarditis |
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MC arrhythmias in MI?
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Ventricular premature contractions?
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MC arrhythmias in MI?
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Ventricular premature contractions?
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MCC death in MI?
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Ventricular fibrillation
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MCC death in MI?
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Ventricular fibrillation
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2MI: Rupture- time of occurence?
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3-7 days after MI
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22Effect of anterior wall rupture?
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2Causes cardiac tamponade.
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Anterior wall rupture: associated with____?
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LAD coronary artery
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Posteromedial papillary muscle rupture associated with?
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RCA thrombosis.
(inferior AMIs) |
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MI associated with mitral valve dysfunction: Commonly affected vessel?
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RCA
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Interventricular septal rupture associated with_____?
effect? |
LAD
Effect: left to right shunt causing RHF. |
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Mural thrombus associated with_____CA?
Complication? |
LAD
Complication: embolization |
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Fibrinous pericarditis: associated with Q wave/non-Q wave MI?
Day of occurence after MI? Clinical effects? |
Q wave MI
3-7 days later Clinical effects: 1. Chest pain on leaning backwards Relieved on leaning forwards Percardial friction rub |
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Ventricular aneurysm: time of occurence after MI?
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Develops within 1st 48 hrs.
Recognized after 4-8 weeks. |
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Ventricular aneurysm: Clinical presentation?
Complications? |
Anterior bulge observed during systole-->
Blood enters aneurysm causing anterior chest wall movements. Complications: 1. CHF due to lack of contractile tissue 2. Danger of embolization 3. Rupture |
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CK-MB:
Duration? |
Appears in 4-8 hrs
Peaks at 24 hrs(1 day) Disappears by 2-3 days **MB= 48yrs |
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CK-MB: significance?
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CK-MB elevation after 3rd day indicates re-infarction
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Trp I and T: duration?
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Appears in 3-12 hrs
Peaks in 24 hrs Disappears in 7-10 days **TT no 14 |
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LDH: duration and measurement in MI?
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Normally LDH2>LDH1
In AMI- "LDH flip": LDH1>LDH2 Appears in 10 hrs Reaches max in 24 hrs Disappears in 7 days |
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EKG changes and corelationships?
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Inverted T cells:
Ischemic area at infarct periphery Elevated ST segment: Injured myocardial cells New Q waves: Coagulation necrosis Elevated ST segment New Q waves |
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EKG patterns in AMI?
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Q waves in:
Anterior wall infarction (LAD): V1-V4 Anterolateral ( LAD ): V1-V4, I and aVL Anteroseptal: V1-V2 Lateral(Circumflex): I, aVL Right Inferior (RCA): II, III and aVF Posterior (Post descending): V6 + R>S in I |
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Fetal circulation?
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Chorionic villus(prim site for gas exchange)-->umbilical veins--->
1. IVC-->RA--> LA(thru foramen ovale)--> RV-->aorta OR 2. SVC-->RA-->RV--> Pulm trunk-->PDA-->Aorta (Fetal pulm arteries are constricted + hypertrophie so do not allow blood to enter) Aorta--> Umbilical arteries(2) |
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Vessels with maximum O2 concentration in fetal circulation?
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Umbilical veins
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Vessels with minimum O2 concentration in fetal circulation?
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Umbilical arteries
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Changes in fetal circulation post birth?
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1. Anatomic closure of PDA in 2weeks-2 months.
2. Gas exchange in lungs initiates due to increased pO2 3. Foramen ovale closes in 24 hrs |
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Autoimmune pericarditis: Time period of development post MI?
Cause? Clinical findings? |
1. Time period: Post 6-8wks
2. Due to Autoantibodies. 3. Fever and precordial friction rub. |
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Risk factors for Congenital heart diseases?
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1. Previous child with CHD
2. Down syndrome/other trisomies 3. Maternal- Age 4. Maternal- DM 5. Maternal- Alcohol 6. Maternal- Infections(rubella) |
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Congenital heart diseases: systemic complications?
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1. Secondary polycythemia
(reduced PaO2) 2. Infective endocarditis 3. Metastatic abscess |
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O2 saturation shunts
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Left--> right: Step UP
Right --> left Step DOWN |
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Left--> Right shunts: complications?
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1. Pulmonary HTN
2. RVH 3. LVH 4. Shunt reversal "Eisenmengerization" Cyanosis and clubbing |
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MC congenital HD?
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Ventricular septal defect
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VSD: associated conditions?
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1. Corrected transposition
2. Fallot's quad 3. Cri du chat 4. Fetal alcohol syndrome |
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VSD: associated complication?
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Infectious endocarditis
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VSD: fate?
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Spontaneous closure in 1/2 cases
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MC adult Congenital HD?
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ASD
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VSD: clinical finding?(murmur)
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Pansystolic murmur
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ASD: clinical associations?
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Down's syndrome
Fetal alcohol syndrome Paradoxical embolus |
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ASD: types
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Septum primum type
Septum secondum |
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MC type of ASD?
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Septum primum type
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Murmur in ASD?
Abnormal heart sound? SaO2: increased/decreased? |
Midsystolic in upper left sternal border
Fixed S2 split SaO2: increased in right atrium/ventricles |
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PDA: associations?
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1. Congenital rubella syndrome
2. Down's syndrome 3. RDS (decreased PaO2) 4. Transposition- complete |
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PDA: effects?
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1. Continuous machinery murmur
2. Right to left shunt due to Pulm HTN--> Deox blood shunts into aorta (below subclavian)--> differential cyanosis 3. Increased SaO2 in pulmonary artery |
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Left--> Right shunts?
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1. ASD
2. VSD 3. PDA |
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Right--> left shunts?
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1. Fallot's
2. Transposition |
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Fallot's Quad?
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1. VSD
2. PS 3. Aortic dextrorotation 4. RVH |
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ToF: onset of cyanosis: time frame?
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After 3 months
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ToF: associated murmur?
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Systolic murmur along left sternal border.
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ToF: decisive factor for cyanosis?
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PS severity.
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Tet spells?
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Hypoxic spells in ToF: due to increase in hypoxemia and cyanosis
Squatting increases resistance--> increases left sided pressure--> reverses shunt temporarily |
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Coarctation of aorta: site?
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Constriction site: Between subclavian artery and ductus arteriosus
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Coarctation associated with?
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Turner's syndrome
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Coarctation of aorta: Clinical findings?
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1. Hypertension in UL
2. Hypotension in LL 3. Dilation of aorta and aortic rings--> dissection 4. Increased cerebral blood flow--> berry aneurysm 5. Claudication in LL 6. RAA activation--> hypertension 7. Collateral circulation- anterior IC(internal mammary) and posterior IC vessels ( Aorta) : NOTCHING OF RIBS Superior- inferior epigastric artery 8. Bicuspid aortic valve. 9. Systolic murmurs |
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Rheumatic fever: Site of primary infection?
|
Pharynx(pharyngitis)
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RF: Type of autoimmune reaction?
Pathogenesis? |
Type II
Type IV "Molecular mimicry" Group A strept infection--> immune reaction--> AB cross react against human tissue |
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Difference between RF starins of grp B strept and Nephrogenic strains?
|
Nephrogenic strains lack M proteins
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Earliest clinical presentation of RF?
|
Migratory polyarthritis
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Migratory polyarthritis:
Sites? Damage mediated: Permanent/ temporary? |
Knees
Ankles Wrists Damage- temp |
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MCC of death in RF?
|
Myocarditis
(pancarditis) |
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RF Myocarditis: microscopic finding?
|
Aschoff bodies:
Central area of fibrinoid necrosis surrounded by Anitschkow cells: reactive histiocytes |
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RF endocarditis: MC valves involved?
Gross? |
#1 MV: MR
#2 AV: AR Gross: Sterile Verucoid vegetation along lines of closure of valves. Recurrent MV/AV infection--> MV/AV stenosis |
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RF endocarditis: embolism common / uncommon?
|
uncommon
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Subcut nodules: site of development?
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Extensor surfaces of arms/legs
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Erythema marginatum?
|
Evanescent redness that develops around normal skin
|
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Latest manifestation of RF?
|
Sydhenam's chorea
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Sydhenam's chores?
|
Reversible, rapid involuntary movement
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RF: Dx?
|
One major+ 2 minor+ antecedent proof of streptococcal infection
Major: 1. Migratory polyarthritis 2. Carditis 3. Erythema marginatum 4. Sydhenam's chorea 5. Subcutaneous nodules Minor: 1. Fever 2. Arthralgia 3. Previous RF 4. Increased APR: ESR/CRP/Neutrophilic leukocytosis 5. Prolonged PR |
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RF: Lab tests?
|
1. ASO titres >400 Todd units
2. A/DNAse B titres 3. Throat cultures |
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RF: rx?
|
Penicillin
Aspirin Corticosteroids if murmur present |
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Mitral stenosis: Etiology? Pathogenesis?
|
Etiology: RF
Pathophys: Narrowing of mitral orifice--> Left atrial dilation and hypertrophy |
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Mitral stenosis: Complications/Clinical effects?
|
1. Atrial fibrillation
2. Pulmonary hypertension 3. Dysphagia for solid foods 4. Opening snap with mid-diastolic rumble 5. Dyspnea/hemoptysis 6. Systemic embolization from A-fib |
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Mitral regurgitation: Causes/ Associated conditions?
|
1. Mitral Valve prolapse:(Marfan's, ED syndrome)
2. Infective endocarditis 3. Rupture of papillary muscles 4. Libman sack endocarditis |
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Most frequent valvular lesion?
|
Mitral valve prolapse
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Mitral valve regurg: Pathophysiology?
Clinical findings? |
Dilated and hypertrophied left atrium from
Volume overload. Clinically: Dyspnea Inspiratory crackles Cough(LVH) PANSYSTOLIC MURMURS |
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Mitral valve prolapse: Associated conditions
|
Marfan's syndrome
Ehlers Danlos sydrome |
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MVP: Pathophysiology?
|
Bulging of leaflets into left atrium during systole.
Mainly due to redundancy of valve tissue from myxomatous degeneration from excess production of dermatan sulfate. |
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Mitral valve prolapse: associated murmur?
|
Mid-systolic click.
(sudden restrain of chordae tendinae) followed by mid systolic murmur. |
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Effect of preload alteration on mitral valve prolapse murmurs?
|
Effect:
Increased preload causes sound to move closer to S2 (squatting/sustained hand grip, reclining) squatting increases peripheral resistance and impedes emptying. Decreased preload causes sound to mover closer to S1. (anxiety, standing, valsalva maneuver) Clinical findings? 1. Palpitations 2. Chest pain 3. Chordae rupute |
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Mitral valve prolapse: rx?
|
B-blockers- less force of contraction therefore less traction and damage to MV
|
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Mitral stenosis: Etiology? Pathogenesis?
|
Etiology: RF
Pathophys: Narrowing of mitral orifice--> Left atrial dilation and hypertrophy |
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Mitral stenosis: Complications/Clinical effects?
|
1. Atrial fibrillation
2. Pulmonary hypertension 3. Dysphagia for solid foods 4. Opening snap with mid-diastolic rumble 5. Dyspnea/hemoptysis 6. Systemic embolization from A-fib |
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Mitral regurgitation: Causes/ Associated conditions?
|
1. Mitral Valve prolapse:(Marfan's, ED syndrome)
2. Infective endocarditis 3. Rupture of papillary muscles 4. Libman sack endocarditis |
|
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Most frequent valvular lesion?
|
Mitral valve prolapse
|
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Mitral valve regurg: Pathophysiology?
Clinical findings? |
Dilated and hypertrophied left atrium from
Volume overload. Clinically: Dyspnea Inspiratory crackles Cough(LVH) PANSYSTOLIC MURMURS |
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Mitral valve prolapse: Associated conditions
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Marfan's syndrome
Ehlers Danlos sydrome |
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MVP: Pathophysiology?
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Bulging of leaflets into left atrium during systole.
Mainly due to redundancy of valve tissue from myxomatous degeneration from excess production of dermatan sulfate. |
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Mitral valve prolapse: associated murmur?
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Mid-systolic click.
(sudden restrain of chordae tendinae) followed by mid systolic murmur. |
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Effect of preload alteration on mitral valve prolapse murmurs?
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Effect:
Increased preload causes sound to move closer to S2 (squatting/sustained hand grip, reclining) squatting increases peripheral resistance and impedes emptying. Decreased preload causes sound to mover closer to S1. (anxiety, standing, valsalva maneuver) Clinical findings? 1. Palpitations 2. Chest pain 3. Chordae rupute |
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Mitral valve prolapse: rx?
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B-blockers- less force of contraction therefore less traction and damage to MV
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Aortic valve: area of the valve?
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3 cm^2
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Aortic valve stenosis: definition?
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Area of AV< 1cm^2
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Aortic valve stenosis: area below which pt presents clinically?
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0.5 cm^2
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Aortic stenosis: causes?
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1. Bicuspid aortic valve--> calcification
2. Age related degeneration >60 yrs 3. Rheumatic fever 4. Congenital aortic stenosis < 30 yrs |
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Aortic stenosis: Pathophysiology/clinical effects?
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Concentric LVH d/t increased afterload
Angina Syncope on exertion Palpitations S4 heart sound Systolic murmur Hemolytic anemia- schistocytes Stenotic valve reduces blood flow --> decreased coronary and central perfusion--> angina/syncope LVH also contributes to angina |
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Aortic stenosis: effects of preload/afterload on murmurs?
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Murmur intensity
Increases with increased preload |
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Aortic regurgitation: Causes?
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1. Aortic root dilation(marfan's)
2. Syphilitic aortitis 3. Ankylosing spondylitis aortitis 4. Aortic dissection 5. Aortic coarctation 6. Infectious endocarditis 7. RF 8. Takayasu's arteritis 9. Long standing HTN |
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Aortic regurgitation: Clinical findings?
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1. Early diastolic murmur
2. S3 and S4 3. Increased systolic pressure 4. Decreased diastolic pressure 5. Widened pulse pressure (signs of widened pulse pressure) 6. Austin Flint murmur |
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Austin Flint murmur?
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Observed in AI.
Regur jet hit MV and produces noise |
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Widened pulse pressure signs?
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1. Watson's water hammer pulse
2. Corrigan's pulse (rapid upstroke and collapse of the carotid artery pulse) low diastolic and increased pulse pressure 3. De Musset's sign (head nodding in time with the heart beat) 3. Quincke's sign (pulsation of the capillary bed in the nail; named for Heinrich Quincke) 4. Traube's sign (a 'pistol shot' systolic sound heard over the femoral artery; named for Ludwig Traube) 5. Duroziez's sign (systolic and diastolic murmurs heard over the femoral artery when it is gradually compressed with the stethescope) |
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Tricuspid regurgitation: causes?
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1. Functional:
1. RVH (Pulm HTN RV infarction Dilated cardiomyopathy) 2. Congenital malformation 3. Infective endocarditis 4. Carcinoid heart diseases |
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Tricuspid regurgitation: causes?
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1. Functional:
1. RVH (Pulm HTN RV infarction Dilated cardiomyopathy) 2. Congenital malformation 3. Infective endocarditis 4. Carcinoid heart diseases |
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Tricuspid regurgitation: causes?
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1. Functional:
1. RVH (Pulm HTN RV infarction Dilated cardiomyopathy) 2. Congenital malformation 3. Infective endocarditis 4. Carcinoid heart diseases |
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Tricuspid regurgitation: clinical findings?
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1. Pansystolic murmur. S3 and S4
2. Right atrial hypertrophy and dilation 3. RHF 4. Pulsating liver 5. Giant c and v wave on JVP |
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Tricuspid regurgitation: clinical findings?
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1. Pansystolic murmur. S3 and S4
2. Right atrial hypertrophy and dilation 3. RHF 4. Pulsating liver 5. Giant c and v wave on JVP |
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Tricuspid regurgitation: causes?
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1. Functional:
1. RVH (Pulm HTN RV infarction Dilated cardiomyopathy) 2. Congenital malformation 3. Infective endocarditis 4. Carcinoid heart diseases |
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Pulmonic stenosis: disease association?
Murmur? |
Dz assoc: Carcinoid heart disease.
Murmur: Ejection systolic murmur (RVH) |
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Pulmonic stenosis: disease association?
Murmur? |
Dz assoc: Carcinoid heart disease.
Murmur: Ejection systolic murmur (RVH) |
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Tricuspid regurgitation: causes?
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1. Functional:
1. RVH (Pulm HTN RV infarction Dilated cardiomyopathy) 2. Congenital malformation 3. Infective endocarditis 4. Carcinoid heart diseases |
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Pulmonic valve regurg: disease cause/assoc?
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Pulm HTN
Diastolic murmur |
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Tricuspid regurgitation: clinical findings?
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1. Pansystolic murmur. S3 and S4
2. Right atrial hypertrophy and dilation 3. RHF 4. Pulsating liver 5. Giant c and v wave on JVP |
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Tricuspid regurgitation: clinical findings?
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1. Pansystolic murmur. S3 and S4
2. Right atrial hypertrophy and dilation 3. RHF 4. Pulsating liver 5. Giant c and v wave on JVP |
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Tricuspid regurgitation: clinical findings?
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1. Pansystolic murmur. S3 and S4
2. Right atrial hypertrophy and dilation 3. RHF 4. Pulsating liver 5. Giant c and v wave on JVP |
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Pulmonic valve regurg: disease cause/assoc?
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Pulm HTN
Diastolic murmur |
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Carcinoid heart disease: Associated valvular heart lesions
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TI
PS "TIPS" |
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Pulmonic stenosis: disease association?
Murmur? |
Dz assoc: Carcinoid heart disease.
Murmur: Ejection systolic murmur (RVH) |
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Pulmonic stenosis: disease association?
Murmur? |
Dz assoc: Carcinoid heart disease.
Murmur: Ejection systolic murmur (RVH) |
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Carcinoid heart disease: Associated valvular heart lesions
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TI
PS "TIPS" |
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Pulmonic stenosis: disease association?
Murmur? |
Dz assoc: Carcinoid heart disease.
Murmur: Ejection systolic murmur (RVH) |
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Austin flint murmur: significance?
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Indicates Aortic valve replacement necessary.
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Pulmonic valve regurg: disease cause/assoc?
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Pulm HTN
Diastolic murmur |
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Infectious endocarditis: risk factors?
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IVDA
IV caths Poor dental hygiene Aortic stenosis Mitral valve prolapse Prosthetic valves Hemodialysis DM HIV Congenital heart diseases |
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Pulmonic valve regurg: disease cause/assoc?
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Pulm HTN
Diastolic murmur |
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Austin flint murmur: significance?
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Indicates Aortic valve replacement necessary.
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Infectious endocarditis: risk factors?
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IVDA
IV caths Poor dental hygiene Aortic stenosis Mitral valve prolapse Prosthetic valves Hemodialysis DM HIV Congenital heart diseases |
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Infectious endocarditis: associated pathogens?
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Strept viridans
Strept bovis Staph aureus Staph epidermidis |
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Pulmonic valve regurg: disease cause/assoc?
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Pulm HTN
Diastolic murmur |
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Carcinoid heart disease: Associated valvular heart lesions
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TI
PS "TIPS" |
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Carcinoid heart disease: Associated valvular heart lesions
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TI
PS "TIPS" |
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Infectious endocarditis: associated pathogens?
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Strept viridans
Strept bovis Staph aureus Staph epidermidis |
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Austin flint murmur: significance?
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Indicates Aortic valve replacement necessary.
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Infectious endocarditis: risk factors?
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IVDA
IV caths Poor dental hygiene Aortic stenosis Mitral valve prolapse Prosthetic valves Hemodialysis DM HIV Congenital heart diseases |
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Carcinoid heart disease: Associated valvular heart lesions
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TI
PS "TIPS" |
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MCC of infectious endocarditis?
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Strept viridans
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Infectious endocarditis: associated pathogens?
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Strept viridans
Strept bovis Staph aureus Staph epidermidis |
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MCC of Infectious endocarditis in IVDS?
Prognosis? |
Staph aureus
High mortality |
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MCC of infectious endocarditis?
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Strept viridans
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Austin flint murmur: significance?
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Indicates Aortic valve replacement necessary.
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Austin flint murmur: significance?
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Indicates Aortic valve replacement necessary.
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Infectious endocarditis: risk factors?
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IVDA
IV caths Poor dental hygiene Aortic stenosis Mitral valve prolapse Prosthetic valves Hemodialysis DM HIV Congenital heart diseases |
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MCC of Infectious endocarditis in IVDS?
Prognosis? |
Staph aureus
High mortality |
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Infectious endocarditis: associated pathogens?
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Strept viridans
Strept bovis Staph aureus Staph epidermidis |
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MCC of infectious endocarditis?
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Strept viridans
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Infectious endocarditis: risk factors?
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IVDA
IV caths Poor dental hygiene Aortic stenosis Mitral valve prolapse Prosthetic valves Hemodialysis DM HIV Congenital heart diseases |
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MCC of infectious endocarditis?
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Strept viridans
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MCC of Infectious endocarditis in IVDA?
Prognosis? |
Staph aureus
High mortality |
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MCC of Infectious endocarditis in IVDS?
Prognosis? |
Staph aureus
High mortality |
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Infectious endocarditis: associated pathogens?
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Strept viridans
Strept bovis Staph aureus Staph epidermidis |
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MCC of infectious endocarditis?
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Strept viridans
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MCC of Infectious endocarditis in IVDA?
Prognosis? |
Staph aureus
High mortality |
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infective endocarditis: valves involved : left side/ right side?
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left sided valves generally involved
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Right sided valve involvement associated with?
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Infective endocarditis
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MC valve involved in infective endocarditis?
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Mitral valve
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MC valves involved in Infective endocarditis due to IVDA?
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Tricuspid and aortic valves.
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Infective endocarditis: Pathogenesis?
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Turbulent blood flow--> damage of valve--> adherence of fibrin platelet--> trapping of bacteria and fungi--> proliferation--> fibrin deposited to encase vegetation
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Previously damaged valves are infected by
? |
Strept viridans
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MCC of infective endocarditis in colorectal ca/ ulcerative colitis?
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Strept bovis
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MCC of infective endocarditis after prosthetic valve insertion?
Time frame of occurence? |
Staph epidermidis
After 2 months |
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Previously normal valve involvement in infectious endocarditis: associated organism?
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Staph aureus
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Infective endocarditis: pathology?
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Vegetations damage valve leaflets and chordae tendinae--> regurgitation
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Infective endocarditis: Clinical finding?
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1. Fever
2. Immune complex vasculitis: a. Osler's nodes: Painful nodules reddish, on palms and soles- immune complex deposits b. Glomerulonephritis c. Roth spots-(retinal white spot surrounded by irregular red hemorrhagic area) 3. Microembolization findings: i. Splinter hemorrhages in nail bed ii. Janeway's lesion: painless lesions on palms and feet. Microabscess of DERMIS does NOT involve epidermis iii. Mucosal petechiae iv. Infarctions(micro?)- digits and brain 4. Splenomegaly 5. Hematuria + RBC cast |
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Osler's nodes vs Janeway lesions?
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Similarities:
Erythematous Occur on palms and feet Macules or papules Differences: Osler's nodes- painful Janeway lesions- painless Osler's nodes- immune complex Janeway nodes: septic emboli |
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Osler's nodes: associated diseases?
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1. SLE
2. Marantic endocarditis 3. Disseminated Gonococcal infection 4. Infected arterial catheter |
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Osler's nodes are indicative of :
Subacute/ acute bacterial endocarditis? |
Subacute bacterial endocarditis
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Infective endocarditis: lab findings?
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1. Positive blood cultures: serial +ve cultures required for Dx.
2. Neutrophilic leukocytosis 3. Monocytic leukocytosis 4. Anemia of chronic disease 5. Transesophageal echocardiography: for detecting vegetations |
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Infective endocarditis:
Neutrophilic leukocytosis indicates: Acute/ Subacute IE? Monocytic leukocytosis indicates: Acute/subacute IE? |
Neutrophilic: Acute IE
Monocytic: Subacute IE |
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Libman sack endocarditis: associated dz?
Pathology? |
SLE
Sterile vegetations over Mitral valve and chordae--> regurg |
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Marantic endocarditis
Associated condition? Pathogenesis? Complication? |
Associated condition: Paraneoplastic syndrome
Pathogenesis: Mucin secreting tumor--> procoagulant effect Complication: 1. Embolization 2. Secondary infection |
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Major cause of sudden death in adults?
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Myocarditis
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Myocarditis: Etiology?
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1. Coxsackie virus
2. Chagas' disease: Trypanosoma cruzi 3. Lyme disease 4. ARF 5. Drugs- dauxorubicin, daunorubicin, cocaine 6. SLE 7. Systemic sclerosis 8. Sarcoidosis 9. Diphtheria 10. CO |
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Myocarditis: pathology?
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1. Enlargement and dilation of heart
2. Lymphocytic inflitration(coxsackie v) 3. Focal areas of necrosis (coxsackie v) |
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Myocarditis: clinical picture?
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Fever
Chest pain Pericardial friction rub MV regurgitation |
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Myocarditis: lab findings?
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CK-MB
Trop I and T Detection of antibodies |
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Pericarditis: MCC?
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Coxsackie
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Pericarditis: Pathology?
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1. Fibrinous type of exudate
(with effusion) 2. Scar tissue with dystrophic calcification |
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Pericarditis: Clinical findings?
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1. Tachycardia
2. Fever 3. Precordial chest pain- relived on leaning forwards 4. Pericardial friction rub 5. Sr CK-MB- normal 6. Trop I and T increased 7. Pericardial effusion 8.Muffled heart sounds(effusion) 9. Drop in systolic blood pressure by 10mm on inspiration 10. Neck vein distention on inspiration |
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Hypotension/pulsus paradoxus associated with pericardial effusion? reason?
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10mm drop in systolic BP: due to
increased pressure of blood in rt ventricle--> displaces septum to left --> Decrease in left ventricle volume--> Decreased BP |
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Pericardial effusion: Neck vein distension on inspiration?
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Due to decreased blood entering right side of heart-->
blood refluxes back into jugular vein aka "Kussmaul sign" |
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Pericardial effusion: CXR?
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CXR:
"Water-bottle" configuration Pericardial calcification (constrictive pericarditis) |
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Constrictive pericarditis: Etiology?
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1. Tb
2. Scarring from prior open heart sx 3. Pericardial calcification |
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Constrictive pericarditis: pathophysiology?
|
Incomplete filling of cardiac chamber
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Pericardial knock:
Associated condition? Reason? |
Condition: Constrictive pericarditis
Ventricles hitting the thickened pericardium |
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Cardiomyopathy: primarily involves:
Endocardium Pericardium Myocardium? |
Myocardium
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Cardiomyopathy: types?
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Dilated
Hypertrophic Restrictive |
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MC cardiomyopathy?
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Dilated cardiomyopathy
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Dilated cardiomyopathy: Etiology?
|
1. Idiopathic
2. Genetic 3. Myocarditis 4. Drugs Daunorubicin Dauxorubicin Cocaine Alcohol- thiamine deficiency 5. Post partum 6. Organic solvents "glue sniffers' heart 7. Acromegaly 8. Myxedema |
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Dilated cardiomyopathy:
Clinical findings? |
1. Dilated chambers
2. MR, TR 3. Reduced pulse pressure 4. Reduced EF<40% 5. S3 and S4 6. Echocardiography- poor contractility 7. Arrhythmias |
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Dilated cardiomyopathy: Rx?
|
Cardiac transplantation
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MCC of dilated cardiomyopathy?
|
Myocarditis
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MCC of sudden cardiac death?
|
Hypertrophic cardiomyopathy
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Hypertrophic cardiomyopathy: types/forms?
|
Familial
Sporadic |
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Hypertrophic cardiomypathy: familial form: inheritance pattern?
|
AD
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Hypertrophic cardiomypathy: Genetic defect?
|
Chromosome 14 affected:
Mis-sense mutation in atleast 1/10 genes : code for cardiac sarcomeres Mutation in myosin heavy chain |
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Hypertrophic cardiomypathy: Pathophysiology?
|
1. Hypertrophy of myocardium
2. Disproportionate hypertrophy of Interventricular septum 3. IVS hypertrophy obstructs outflow tracts (Obstruction BELOW aortic valve level) 4. Abberant myofibrils present--> Conduction defects 5. Non compliant left ventricle |
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Hypertrophic cardiomypathy:
Clinical findings? |
1. Systolic ejection murmur
2. Palpable double apical impulse 3. Murmur intensity increases with decreased preload(worsens obstruction) vice versa Increased preload-->opens obstruction--> opens outflow tract 4. Angina/syncope with excercise. |
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Hypertrophic cardiomypathy: Rx?
|
Avoid exercise
Avoid drugs that decreased preload (diurectics)/ increase force of contraction(digitalis) b-blockers- Decrease contractility Improves diastole--> increase preload Implantable cardio-defibrillator Screen relatives with Echo |
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Restrictive cardiomyopathy: Causes?
|
1. Amyloidosis
2. Myocardial fibrosis(post sx) 3. Radiation 4. Pompe's dz 5. Hemochromatosis 6. Endocardial fibroelastosis 7. Systemic sclerosis |
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Restrictive cardiomyopathy: pathophysiology? clinical findings?
|
Decreased ventricular compliance
Diastolic dysfunction progressive LHF and RHF EKG- ST-wave changes |
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MC tumor of heart?
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Metastasis
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MC site for metastsis?
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Pericardium
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Primary cardiac tumors?
|
Cardiac myxoma
Rhabdomyoma |
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MC prim adult heart tumor?
|
Cardiac myxoma
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Cardiac myxoma: benign/malignant?
|
benign
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Cardiac myxoma: type of tumor? mc site?
|
Mesenchymal tumor
site: left atrium |
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Cardiac myxoma: presentation similar to____ valvular defect?
why? |
Ball valve effect blocks mitral valve orifice-->prevents diastolic filling of heart
simulates MS |
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Cardiac myxoma: Clinical findings?
|
Fever fatigue malaise
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Cardiac myxoma: complication?
dx? |
Embolization
Syncope dx: transesophageal ultrasound (viewing left atrium) |
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MC primary tumor in infants and children?
|
Rhabdomyoma
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Rhabdomyoma: dz association?
|
Tuberous sclerosis
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Rhabdomyoma: type of tumor?
|
Hamartoma: Non neoplastic
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TG transporters in blood?
|
Chylomicrons
VLDL (major component= TGs) Diet: Chylomicrons Liver: VLDL |
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Lipoprotein composition?
|
1. Proteins
2. TG 3. Cholesterol 4. Phospholipids |
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Chylomicron synthesis requires_____apolipoprotein
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apoB48
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Source of apoCII and apo E?
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HDL
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Chylomicrons: function?
|
Source of FAs and glycerollo
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Chylomicrons: hydrolysis/metab?
|
Hydrolysed by capillary LPLase--> chylomicron remnant--> taken up by liver (receptors for apoE)
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VLDLs require ____apoprotein for assembly.
|
apoB100
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VLDL: function?
|
Source of FAs and glycerol for synthesis of triglycerides.
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VLDL: hydrolysis/metab?
|
VLDL(Capillary LPL)--> IDL -->LDL
IDL--> removed by liver(receptors to apo E) |
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Cholesterol ester transport protein: fn?
|
Transfers CH from HDL to VLDL
Transfers TG from VLDL to HDL Increase in VLDL causes decrease in HDL |
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VLDL and chylomicrons location in plasma?
|
VLDL: infranate
Chylomicrons: supranate |
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TG levels: optimal levels?
|
<150mg/dl
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LDL: function?
|
Transport if CHOLESTEROL in blood
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LDL: source?
|
VLDL--> IDL--> LDL
(by capillary LPL) |
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LDL: calculation?
|
LDL= Sr cholesterol- HDL- TG/5
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Cholesterol fn?
|
A= Adrenal cortex hormones
B= Bile C= Cell membrane D= Vit D |
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LDL: optimal levels?
|
<100 mg/dl
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LDL measured during fasting: reason?
|
Chylomicrons post food consumption falsely lowers calculated LDL.
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LDL: risk for coronary heart disease when LDL level are ____.
|
> 190mg/dl
|
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Cholesterol lowering therapy?
|
Subdivide-
1. Patients with known coronary artery disease Hmg CoA reductase inhibitors: target < 100mg/dl 2. Patients without known coronary artery disease. a. With risk factor: 0-1 <160mg/dl b. with risk factors:2+ <130mg/dl Risk factors: 1. Male>45 Females>55 2. Hypertension 3. Family history of CAD 4. HDL<40 5. LDL>160mg/dl 6. Cigarette smoking |
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HDL increased with?
|
Exercise
Wine Estrogen |
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HDL: synthesis site?
|
1. Iiver
2. Small intestines |
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HDL: function?
|
Source for apolipoprotein.
Removes CH from periphery |
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HDL: optimal levels?
suboptimal? |
Optimal: HDL>60
Suboptimal: HDL<40 |
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Lipoprotein disorders
|
Types I-V
Abetalipoprotinemia ****refer show-me(ipad) |
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Type I hypercholesterolemia: Inheritance pattern?
Pathogenesis? |
Autosomal recessive
LPL deficiency ApoCII deficiency |
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Type I hypercholesterolemia: Clinical findings?
|
1. Chylomicrons increased
2. VLDL increased 3. Acute pancreatitis (Rupture of pancreatic vessels filled with chylomicrons) |
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Type I hypercholesterolemia:
lab findings? |
1. TG>1000mg/dl
2. Turbid supranate 3. Clear infranate 4. Cholesterol levels NOT increased |
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Type II hypercholesterolemia:
Inheritance pattern(familial)? Other causes? |
Inheritance: AD
Causes: Hypothyroidism (Nephrotuc syndrome, extrahepatic cholestasis) |
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Type II hypercholesterolemia: Pathogenesis?
|
LDL receptor deficiency
|
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Type II hypercholesterolemia:
Clinical findings? |
1. Premature coronary artery disease
2. Tendon xanthoma 3. Xanthelasma |
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Polygenic hypecholesterolemia?
|
Type IIa
Multifactorial inheritance Normal sr. TG Increased sr CH |
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Familial combined hypercholesterolemia?
|
Type IIb
AD Increased sr. TG Increased sr. CH |
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Familial combined hypercholesterolemia: associated condition?(IIB)
|
Metabolic syndrome
|
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Type III hyperlipoprotenemia: Inheritance pattern?
Pathogenesis? |
AD
Pathogenesis: Deficiency of apoE--> decreased uptake of IDL and chylomicron remnants |
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Type III hypercholesterolemia: Inheritance pattern?
pathogenesis? |
Inheritance pattern: AD
Pathogenesis: Deficiency of apoE--> decreased liver uptake of chylomicron remnants |
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Type III hypercholesterolemia:
Clinical findings? |
Palmar crease xanthoma
Increased risk for: CAD Peripheral vascular disease |
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Type III hypercholesterolemia:
lab findings/Dx? |
CH and TGs increased
LDL--normal Lipoprotein electrophoresis and apoE gene identification |
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Type IV hyperlipoproteinemia:
Inheritance pattern? Pathogenesis? |
AR
Increased synthesis and reduced catabolism of VLDL |
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Type IV hypercholesterolemia:
Acquired causes? |
1. Excess alcohol
2. OC pills 3. DM 4. Thiazides, B blockers 5. CRF Thiazides, b blockers- inhibit LPL |
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Disorders(hypercholesterlemias) associated with PVDs?
|
Type III, IV
|
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Type V hypercholesterolemia?
(Hyperchylomicronemia syndrome) Clinical findings? |
Increased VLDLs + chylomicrons pptd by exacerbation (MC= DKA, alcohol)
Clinical findings: 1. Xanthomas 2. Acute pancreatitis 3. Lipemia retinalis 4. Dyspnea (hypoxemia) 5. Hepatosplenomegaly 6. Increased serum TG>1000mg/dl 7. Normal sr CH and LDL |
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Abetalipoproteinemia?
|
Deficient apoB48 and apoB100
Decrease in CH and TG |
|
|
Abetalipoproteinemia?
Clinical findings? |
Malabsorption: Chylomicrons accumulate in villi--> prevent absorption of micelles
Ataxia Hemolytic anemia Acanthocytes--from vit E deficiency |
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Abetalipoproteinemia: Rx?
|
Vit E
|
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Arteriosclerosis: Types?
|
1. Medial calicification
2. Atherosclerosis 3. Arteriolosclerosis |
|
|
Medial calcification: pathogenesis?
Effect? |
Dystrophic calcification in muscular arteries
Effect: none |
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Endothelial cell injury: causes?
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HTN
LDL Homocysteine Tobacco |
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Atherosclerosis: pathogenesis?
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Damage to endothelium--> platelet and macrophage activation-->release of cytokines--> smooth muscle proliferation--> migration to tunica intima--> CH enters sm cells-->foam cells--> SM release cytokines--> form extracellular matrix(proteoglycans, elastina and collagen)
-->fibrous plaque |
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Fibrous plaque composition?
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Components:
Fibrous cap: made of i. Smooth muscles ii. Foam cells iii. Inflammatory cells iv. Extracellular matrix Necrotic center: Cellular debris CH crystals Foam cells |
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Increased CRP indicates?
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Disrupted plaques
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Plaque sequaleae?
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1. Disrupted
2. Calcified 3. Ulcerated |
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Atherosclerosis: Sites?
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#1. Abdominal aorta
#2. Coronary artery #3. Popliteal artery #4. Carotid artery |
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Atherosclerosis: Complications
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1. Vessel weakness-> (aneurysm)
2. Thrombosis (MI) 3. HTN (Renal artery atherosclerosed) 4. Cerebral atrophy (Circle of Willis) 5. PVDs- claudications/ gangrene |
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Arteriolosclerosis:
Types? Pathogenesis? |
Types:
Hyaline arteriolosclerosis Hyperplastic arteriolosclerosis Pathogenesis: Hyaline: Due to protein deposition in the vessel wall HTN--> forces protein into the vessel wall DM--> enzymatic glycozylation of BM--> increased permeability--> protein deposition in the vessel wall Hyperplastic: Severe/malignant hypertension Smooth muscle hyperplasia and BM duplication **** "ONION SKIN APPEARANCE" **** |
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Vessel aneurysm: types?
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1. Abdominal aneurysm
2. Mycotic aneurysm 3. Syphilitic aneurysm 4. Berry aneurysm 5. Aortic dissection |
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Abdominal aorta aneuryms: location?
Predisposing factor? |
Location: Located below renal artery orificae.
Predisposing factor: Atherosclerosis (no vasa vasorum, increased stress, connective tissue structure defect) |
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Aortic aneurysm rupture: Clinical findings?
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TRIAD:
1. Left flank pain 2. Hypotension 3. Pulsatile mass |
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Mycotic aneurym:
Causes? Clinical findings? |
Causes:
Aspergillus Candida Mucor ("ACM") Bacterial: Pseudomonas aeruginosa Salmonella Bacteroides fragilis Clinical findings: Rupture-->hemorrhage Thrombosis-->infarction |
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Berry aneurysm:
Site? Cause? Effect? clinical findings? |
Site: Junction of
ACA-ACA: 40% PCA-MCA: 20% PCA-PCA:4% Cause: Lack internal elastic lamina and smooth muscle Clinical findings: 1. nuchal rigidity 2. Occipital headache 3. "Worst headache of life" |
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Syphilitic aneurysm:
Affecting Stage of syphilis ? |
Complication of tertiary syphilis
Causative organism: T.Pallidum |
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Syphilitic aneurysm: Pathogenesis?
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"End arteritis obliterans"
"Plasma cell infiltrate in vessel wall" Vessel ischemia of medial tissue-->dilation of aorta and aortic valve ring |
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Syphilitic aneurysm: clinical findings?
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1. Aortic valve regurgitation
2. Brassy cough(recurrent laryngeal nerve compression) |
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Aortic dissection: MC group affected?
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Men
40-60yrs with HTN |
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Aortic dissection: associated connective tissue disorder?
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Marfan's syndrome
Ehlers Danlos syndrome |
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Aortic dissection: Pathogenesis?
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**Tunica Media**
"Cystic medial degeneration" 1. Elastic tissue fragmentation 2. Matrix material collection |
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Risk factors for cystic medial degeneration?
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Wall stress:
1. HTN 2. Pregnancy 3. Coarctation Connective tissue disorders: Marfan's EDS |
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Intimal tear: site?
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1. Within 10cm of aortic valve
2. Blood dissects areas of weakness |
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Aortic dissection: clinical findings?
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Severe retrosternal pain
AR Loss of UL pulse (compression of subclavian) Rupture-->pericardial/pleural/peritoneal cavity |
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Varicose veins: sites?
Causes? |
1. Saphenous vein (MC site)
2. Distal esophagus (portal htn) 3. Anorectal region 4 Left scrotal sac Pregnancy Obesity Prolonged standing OC PILLS Secondary TO DVT INCOMPETENCE OF PERFORATOR VESSELS |
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Superficial varicosities: causes?
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1. Pregnancy
2. Prolonged standing 3. Obesity 4. OC pills 5. Age 5. Familial tendency 6. DVT |
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Superficial varicosities: rx?
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Compression stockings
Sclerotherapy Ligation and stripping Laser/diathermy obliteration |
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Phlebothrombosis?
Causes? |
1. Thrombosis without inflammation
2. Causes: 1. Stasis of blood 2. Hypercoaugulability |
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Phlebothrombosis: MC site?
Other sites? |
#1. Deep vein of calf
Others: Portal vein Hepatic vein Dural venous sinuses |
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DVT: clinical findings?
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1. Swelling
2. Pain on dorsiflexing foot(Homan's sign) 3. Pitting edema 4. Stasis dermatitis: Orange discoloration + Ischemic ulcers |
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Stasis dermatits?
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Orange discoloration: from hemosiderin
Ischemic ulcers: reduced O2 perfusion |
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DVT: dx? rx?
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Ultrasound + d-dimer assay
Rx: 1. Low molecular weight heparin 2. Compression stockings |
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Thrombophlebitis?
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Pain and tenderness along superficial vein.
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Thrombophlebitis: disease associations/causes?
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1. IV venous cannulation
2. Staph aureus infection 3. Ca-head of pancreas- "Superficial migratory thrombophlebitis" (Trosseau sign) |
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Trosseau sign?
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Trosseau's sign of latent tetany:
Blood pressure cuff around arm compresses the brachial artery--> tetany of hand (Main de accoucher) Trosseau's sign of malignancy: Microvesicals released from malignant cells contain procoagulant factors---> spontaneous formation and resolution of clots (migratory) |
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Thrombophlebitis: Clinical findings?
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1. Tender palpable cord
2. Erythema and edema of overlying skin |
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Thrombophlebitis:
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1. Warm moist compresses
2. NSAIDs |
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SVC syndrome: Causes?
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Extrinsic SVC compression (primary lung ca): Small cell ca of lungs
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SVC syndrome: findings?
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1. Retinal cell hemorrhage
2. Stroke |
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SVC syndrome: rx?
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Stent - bypass(?)
Radiation |
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Thoracic outlet syndrome
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Cervical rib
Spastic ant scalene |
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Thoracic outlet syndrome: clinical findings?
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Brachial plexus
Subclavian artery and vein Vascular and nerve root signs. (Tingling etc) Adson's test: loss of radial pulse when the person looks to the side and inspires |
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Acute lymphangitis: Causative agent?
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Strept Pneumoniae
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Turner's syndrome: webbed neck due to?
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Dilatation of lymphatic vessels
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Vascular Tumors:
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Angiomyolipoma
Angiosarcoma Bacillary angiomatosis Capillary hemangioma Cavernous hemangioma |
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Angiomyolipoma: disease association?
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Tuberous sclerosis
Kidney hamartoma: Muscle, fat and blood vessel (components) |
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Angiosarcoma: site/risk factors?
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site: Liver
Risk factors: 1. Polyvinyl chloride 2. Arsenic 3. Thorium dioxide |
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Bacillary angiomatosis: causative agent?
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Bartonella henselae involves skin and visceral organs
(in HIV infection- simulates kaposi's sarcoma) |
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Capillary hemangioma?
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Facial lesion- regresses with age
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Cavernous hemangioma?
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Benign liver and spleen tumor.
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Hereditary telengectasia?
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Dilated vessel on skin and mucos membranes---> GIT and mouth---
> epistaxis/other bleeds--> fe deficiency anemia |
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Spider telengectasia?
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AV fistula
associated with pregnancy/ cirrhosis (hyperestrenism) |
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Sturge weber syndrome?
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Nevus flamues. Birth mark along the distribution of opthalmic division of trigeminal nerve.
Ipsilateral malformation of meningeal vessels (over |
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Von Hippel Lindau syndrome
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1. Cavernus hemangiomas in cerebellum/retina
2. Renal angioma 3. RCC 4. Pheochromocytoma |
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ANCA: effect?
types? |
Release of enzymes from neutrophils.---> free radicals--->vessel damage
c-ANCA: ABs against proteinase 3 in cytoplasmic granules(Wegner's granulomatosis) p-ANCA: AB against myeloperoxidase (Microscopic polyangiitis Churg-Strauss syndrome) |
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Small vessel vasculitis? clinical findings?
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Henoch-schonlein purpura,
Microscopic polyangiitis "Palpable purpura" Hemorrhagic, raised, PAINFUL skin lesion. ****Refer show me (ipad) for all vasculitides |
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Medium vessel vasculitis?
Clinical findings? |
Muscular artery involvement
(PAN, Kawasaki) Clinical finding: 1. Thrombosis/Infarction 2. Aneurysm |
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Large vessel vasculitis?
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Elastic artery vasculitis
Takayasu arteritis, Giant cell arteritis(temporal) |
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Takayasu arteritis: Vasculitis type?
Clinical features? Populations affected? Rx? |
"PULSELESS DISEASE"
1. Granulomatous large vessel arteritis. 2. Absent upper extremity pulses 3. Discrepancy in BP between arms > 10mm 4. Visual defects 5. Stroke. (Imagine Takayasu: Japanese zen grand master- blind, handicap, with weak pulse(apparently absent) from transcendental meditation) Population : Young ASIAN women and children Rx: Corticosteroids |
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Giant cell(temporal) arteritis
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1. Involves superficial temporal and ophthalmic arteries.
Temporal headache Jaw claudication(pain while chewing) Blindness on ipsilateral side "Polymyalgia rheumatica" (muscle and joint pain: normal sr. creatine kinase) Increased ESR Rx: corticosteroids |
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Hereditary telengectasia?
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Dilated vessel on skin and mucos membranes---> GIT and mouth---
> epistaxis/other bleeds--> fe deficiency anemia |
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Spider telengectasia?
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AV fistula
associated with pregnancy/ cirrhosis (hyperestrenism) |
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Sturge weber syndrome?
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Nevus flamues. Birth mark along the distribution of opthalmic division of trigeminal nerve.
Ipsilateral malformation of meningeal vessels (over |
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Von Hippel Lindau syndrome
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1. Cavernus hemangiomas in cerebellum/retina
2. Renal angioma 3. RCC 4. Pheochromocytoma |
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ANCA: effect?
types? |
Release of enzymes from neutrophils.---> free radicals--->vessel damage
c-ANCA: ABs against proteinase 3 in cytoplasmic granules(Wegner's granulomatosis) p-ANCA: AB against myeloperoxidase (PAN Microscopic polyangiitis Churg-Strauss syndrome) |
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Small vessel vasculitis? clinical findings?
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Henoch-schonlein purpura,
Microscopic polyangiitis "Palpable purpura" Hemorrhagic, raised, PAINFUL skin lesion. ****Refer show me (ipad) for all vasculitides |
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Medium vessel vasculitis?
Clinical findings? |
Muscular artery involvement
(PAN, Kawasaki) Clinical finding: 1. Thrombosis/Infarction 2. Aneurysm |
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Large vessel vasculitis?
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Elastic artery vasculitis
Takayasu arteritis, Giant cell arteritis(temporal) |
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Takayasu arteritis: Vasculitis type?
Clinical features? Populations affected? Rx? |
"PULSELESS DISEASE"
1. Granulomatous large vessel arteritis. 2. Absent upper extremity pulses 3. Discrepancy in BP between arms > 10mm 4. Visual defects 5. Stroke. (Imagine Takayasu: Japanese zen grand master- blind, handicap, with weak pulse(apparently absent) from transcendental meditation) Population : Young ASIAN women and children Rx: Corticosteroids |
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Giant cell(temporal) arteritis
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1. Involves superficial temporal and ophthalmic arteries.
Temporal headache Jaw claudication(pain while chewing) Blindness on ipsilateral side "Polymyalgia rheumatica" (muscle and joint pain: normal sr. creatine kinase) Increased ESR Rx: corticosteroids |
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Polyarteritis nodosa?
Common arteries involved? Disease association? Clinical effects? |
Medium(muscular) vessel vasculitis
Renal Coronary Mesenteric Disease association: 1. HbsAg 2. pANCA Clinical effects: 1. Kidney infarction: increased BUN: Creat 2. Heart: Acute MI 3. Bowels: Diarrhea 4. Skin: Livedoreticularis 5. Testicular pain 6. Diastolic HTN **Renal>heart>liver>GI** |
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Polyarteritis nodosa: Ix?
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Ix:
1. Biopsy 2. Angiography |
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Kawasaki disease?
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Necrotizing medium(muscular) vessels
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MCC of MI in children?
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Kawasaki disease
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Kawasaki disease: clinical features?
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1. Fever
2. Erythema + Edema of hands and feet 3. Cervical adenopathy 4. Desquamating rash 5. Oral erythema/cracking of lips 6. ABNORMAL EKG 7. Strawberry tongue 8. Conjunctivitis In Children: Skin rash + Abnormal EKG (EKG shows acute MI) Risk for CORONARY ANEURYSM |
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Kawasaki disease: rx?
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Rx:
IVIG Aspirin (NO Corticosteroids- danger of vessel rupture) |
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Thromboangiitis obliterans?
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"Digital vessels thrombosis"
"Neutrophilic vasculitis" Raynaud's phenomenon Extremities involved Intermittent claudication Microabscess formation/ Segmental thrombosis--> Gangrene Ulceration SMOKERS Ulceration Gangrene |
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Thromboangiitis obliterans:
Pathology |
"Digital vessels thrombosis"
"Neutrophilic vasculitis" Raynaud's phenomenon Intermittent claudication (extremities) Microabscess formation/ Segmental thrombosis--> Gangrene Ulceration |
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Thromboangiitis obliterans:
rx? |
Smoking cessation
IV iloprost(vasodilator) |
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Raynaud's disease?
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Small vessel vasculitis
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Raynaud's disease:
Vessels affected? sites affected? |
Small sized vessels
Sites: Fingers Toes Tip of nose Ears |
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Raynaud's disease:
clinical finding? |
White-->Blue-->Red
Chronic conditions: ulceration and gangrene atrophy of skin |
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Raynaud's phenomenon
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Observed secondary to:
*SLE *Systemic sclerosis *CREST syndrome Buerger's disease Atherosclerosis *Important associations with secondary raynaud's |
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Raynaud's phenomenon: pathology?
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Digital ulceration
Gangrene 1. VESSEL FIBROSIS 2. DYSTROPHIC CALCIFICATION |
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Raynaud's phenomenon: rx?
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1. Avoid cold temperatures
2. Calcium channel blockers |
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Wegner's granulomatosis
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"Necrotizing granulomas":
Respiratory tracts- Upper: Saddle nose deformity Chronic sinusitis Tracheal collapse Lower respiratory tract: Cavitating nodular lesion Necrotizing vasculitis in lungs Kidneys: Crescentic glomerulonephritis c-ANCA |
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Wegener's granulomatosis: Associated AB?
Rx? |
c-ANCA
Rx: corticosteroids+cyclophosphamide 3Cs: c-ANCA Corticosteroids Cyclophosphamide c-ANCA: Wegner's p-ANCA: PAN, Churge strauss |
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Microscopic polyangiitis?
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pANCA+ glomerulonephritis+ Palpable purpura
ppt by drug(penicillin), infections, immune disorders |
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Churg-Strauss: type of vasculitis?
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Small vessel vasculitis
Skin+lungs+heart (Allergic granulomatosis + angiitis) Allergic rhinitis+ asthma+ pANCA+ eosinohilia |
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Henoch schonlein purpura?
Type of autoimmune disorder? |
Type III disorder
Follows URTI---> AB against Strept pharyngeal infection --> immune COMPLEX formation--> Immune COMPLEX reaction Palpable purpura- Buttocks Lower extremities Polyathritis Nephropathy GI bleed Immune complexes in Henoch Schonlein purpura? |
IgA-anti-IgA immune complexes
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pANCA +ve vasculitides
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1. PAN
2. Microangiopathic polyangiitis 3. Churge Strauss syndrome |
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Henoch Schonlein purpura: Rx?
|
Self resolves after 4 months
When are corticosteroids indicated? |
Severe GI or renal disease
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Cryoglobulinemia: disease associations?
|
HCV
Type I MPGN Multiple myeloma |
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pANCA +ve vasculitides
|
1. PAN
2. Microangiopathic polyangiitis 3. Churge Strauss syndrome |
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Cryoglobulinemia:
Vessel affected? pathology? |
Vessel affected- small vessels
Due to cryoglobins- precipitate when exposed to cold temperature. Raynaud's phenomenon Palpable purpura Glomerulonephritis Arthritis Abdominal pain |
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Infectious vasculitis?
Causative agents? |
Small vessel vasculitis
Causative agents: Rickettsia rickettsiae Neisseria meningitis |
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Henoch Schonlein purpura: Rx?
|
Self resolves after 4 months
When are corticosteroids indicated? |
Severe GI or renal disease
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Essential hypertension: primary proposed mechanism?
|
Reduced sodium excretion
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Cryoglobulinemia: disease associations?
|
HCV
Type I MPGN Multiple myeloma |
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Renovascular hypertension?
|
Renal artery affected by:
1. Atherosclerotic plaque 2. Fibromuscular hyperplasia --> Decreased renal blood flow --> Activates renin-angiotensin system --> Plasma renin |
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Cryoglobulinemia:
Vessel affected? pathology? |
Vessel affected- small vessels
Due to cryoglobins- precipitate when exposed to cold temperature. Raynaud's phenomenon Palpable purpura Glomerulonephritis Arthritis Abdominal pain |
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Renovascular hypertension: clinical findings?
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1. Severe uncontrolled hypertension
2. Increased plasma renin in involved kidney 3. Decreased plasma renin in uninvolved kidney 4. Epigastric bruit 5. Angiography: i. Atrophy of involved kidney ii. Beaded appearance in fibromuscular hyperplasia |
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Infectious vasculitis?
Causative agents? |
Small vessel vasculitis
Causative agents: Rickettsia rickettsiae Neisseria meningitis |
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Essential hypertension: primary proposed mechanism?
|
Reduced sodium excretion
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Renovascular hypertension?
|
Renal artery affected by:
1. Atherosclerotic plaque 2. Fibromuscular hyperplasia --> Decreased renal blood flow --> Activates renin-angiotensin system --> Plasma renin |
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Renovascular hypertension: clinical findings?
|
1. Severe uncontrolled hypertension
2. Increased plasma renin in involved kidney 3. Decreased plasma renin in uninvolved kidney 4. Epigastric bruit 5. Angiography: i. Atrophy of involved kidney ii. Beaded appearance in fibromuscular hyperplasia |
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