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105 Cards in this Set

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CARDIOVASCULAR ADULT MED
CARDIOVASCULAR ADULT MED
What is the most important diagnostic factor in the approach to a pt with CP
history! Ask OPQRST questions
Specify several symptoms that would help exclude angina from consideration in a person with chest pain.
Duration lasting days.
Pain that occurs with recombancy or bending over.
Pain relief with antacids, H2 antagonists, PPIs
Distinguish typical angina pectoris from other causes of chest pain by characteristics related to:
onset and precipitating factors




Quality.
Quick onset, associated with stress or exertion, occurs more commonly after meals and with exposure to the cold
Distinguish typical angina pectoris from other causes of chest pain by characteristics related to:
Duration
Short, lasting less than 3 minutes. Lasts longer if patient is angry or develops angina after meal
Distinguish typical angina pectoris from other causes of chest pain by characteristics related to:
Characteristics
Tightness, squeazing, aching, bursting, gas, indigestion Location
Distinguish typical angina pectoris from other causes of chest pain by characteristics related to:
Relief
rest with Nitroglycerin
Distinguish typical angina pectoris from other causes of chest pain by characteristics related to:
Quality
Stabbing, tightness, squeazing, aching, bursting, gassy, indigestion
Distinguish typical angina pectoris from other causes of chest pain by characteristics related to:
Location
Felt directly behind or slightly left of the sternum
Compare and contrast teh typical presentation of: Variant or Prinzmental's Angina
Affects women under 50, Occurs early in the AM, Involves the RCA, Pain at rest for no apparent reason, Associated with arrythmias and conduction defects
Compare and contrast teh typical presentation of: Unstable angina
Increasing duration, Progressively getting worse, Coronary thrombosis may be to blame
Differentiate by symptoms other diseases/conditions besides coronary artery disease that may cause chest pain.
•Costrochondritis
•Pneumonia
•Esophageal spasm
•Reflux esophagitis
•Cervical or thoracic pathology
•Intercostal neuritis
Differentiate by symptoms other diseases/conditions besides coronary artery disease that may cause radiation of chest pain.
•Splenic rupture
•Gallbladder
Be able to differentiate several common chest-wall syndromes.
Tietze's, Intercostal neuronitis, Costrovertebral syndrome (Posterior chest wall pain), Thoracic disk herniation (Unusual cause of posterior chest pain), Psychogenic (Anxiety, stress)
Summarize the following common test ordered for patients with chest pain, their possible indications, and their limitations: EKG
•Conduction, ischemia, injury, infarcts, rhythm disturbances
•Pace makers, bundle branch block, no baseline for comparison
Summarize the following common test ordered for patients with chest pain, their possible indications, and their limitations: Cardiac panel: Troponin
Cardiac damage,
Specific to cardiac muscle
patients with chest pain, their possible indications, and their limitations: Cardiac panel: Myoglobin
Unspecific,
Can be elevated in cardiac damage
patients with chest pain, their possible indications, and their limitations: Cardiac panel: CK-MB
Specific for cardiac damage
patients with chest pain, their possible indications, and their limitations: Cardiac panel: CBC
r/o anemia, infection, hypovolemia
patients with chest pain, their possible indications, and their limitations: Cardiac panal: Lipid Panel
Hypercholesterolemia
patients with chest pain, their possible indications, and their limitations: Cardiac panal: Chemistry panel
Scintigraphy
Radionuclitide angiography
Explain the general role of each of the following in the management of angina pectoris: coronary angiography
To visualize the coronary arteries, looking for narrowing of the vessels
Explain the general role of each of the following in the management of angina pectoris: coronary artery surgery
Uses a graft to bypass the blockage
Explain the general role of each of the following in the management of angina pectoris: long-acting nitrates
Same effect as nitro but lasts longer
Explain the general role of each of the following in the management of angina pectoris: beta blockers
Decrease myocardial oxygen consumption, Slows HR
Explain the general role of each of the following in the management of angina pectoris: sublingual nitroglycerin
Vasodilitation, Decreases preload
Explain the general role of each of the following in the management of angina pectoris: calcium channel blockers
Slow HR, Peripheral vasodilation (mild)
Explain the general role of each of the following in the management of angina pectoris: aspirin
Decreased platelet, aggregation
Explain the general role of each of the following in the management of angina pectoris: risk factor modification
Lowers LDL cholesterol, Decreases sodium intake, Quit smoking, Lose weight, fatty!
Explain the general role of each of the following in the management of angina pectoris: Exercise
Lowers BP
Increase HDL, decrease LDL
Assists in weight loss
Describe the patient presentation and common important causes of acute pleuritic chest pain
Presentation: stabbing CP, worse on inspiration, pleural rub. Causes: autoimmune (SLE) pleuritis
Describe the differential that would be appropriate for a patient presenting with the following complaint: Dyspnea
•Asthma
•COPD
•Pneumonia
•Pleural effusion
•Hypovolemia
•MI
Describe the differential that would be appropriate for a patient presenting with the following complaint:
•Palpitations
•Caffiene
•Arrythmias
•Valvular defect
•hyperthyroidism
Describe the differential that would be appropriate for a patient presenting with the following complaint: Drugs or ETOH
•Psycho
•Hypotension
Describe the differential that would be appropriate for a patient presenting with the following complaint: Edema
•CHF
•Hypoalbuminemia
•Kidney failure
•Allergic reaction
•Liver failure
•Nephrotic syndrome
•Venous stasis
Describe the differential that would be appropriate for a patient presenting with the following complaint: Syncope
•Arrhythmia
•Seizure
•Vertebrobrasilar TIA
Explain the role and limitations of the following enzyme in making the diagnosis of acute myocardial infarction, including recognition of their initial and peak elevation times: CK and CK-MB
•Become positive in 4 hours
•Peak from 12-24 hours, normal by 48-72h
•CK-MB is specific for cardiac damage
•Must be greater than 10% of total CK
Explain the role and limitations of the following enzyme in making the diagnosis of acute myocardial infarction, including recognition of their initial and peak elevation times: Troponin I & T
•More sensitive and specific
•Stays elevated for days, making acute diagnosis hard
•Peaks at 12 hours, normal after 7-12 days
•Shows up in 6 hours
Briefly explain the general use and limitations of the following: ECG
•Ischemia, injury, ST segment elevation, inverted Ts
•No baseline makes analysis difficult
Briefly explain the general use and limitations of the following: Echocardiography
•Heart wall motion
•Shows heart valves
•Estimates ejection fraction
•Does not show coronary anatomy
•Thickened chest wall or if you are tubby make visualization difficulty
Briefly explain the general use and limitations of the following: Radionuclide heart scan
•Demonstrates akinesis or dyskinesis in areas of infart
•Calculates EF
Define "congestive heart failure."
The inability of the heart to pump blood out of it as quickly as it comes in
Describe the basic pathologic mechanisms that may result in heart failure and list one or two common examples of each for the following: alteration in the contractile state of the myocardium
MI, Tamponade
Describe the basic pathologic mechanisms that may result in heart failure and list one or two common examples of each for the following: Preload of the ventricle
Valvular regurg
Describe the basic pathologic mechanisms that may result in heart failure and list one or two common examples of each of the following: Afterload applied to the ventricles
Aortic stenosis, hypertension
Describe the basic pathologic mechanisms that may result in heart failure and list one or two common examples of each of the following: Heartrate
Atrial fibrillation w/ rvr or lvr, WPW
Define Preload
Amount of blood left in the heart directly after diastole
Define Afterload
SVR
Define ejection fraction
Percentage of blood ejected from the ventricle during a single heart beat
Define cardiac output
Cardiac output = amount of blood ejected from the left side of the heart over one minute.
Define stroke volume
Stroke volume = amount of blood ejected from the heart in a single beat
Determine the role of the following as compensatory mechanisms in CHF:
Frank-Starling relationship
More afterload, the harder the heart will beat. All related to stretch.
Determine the role of the following as compensatory mechanisms in CHF: ventricular dilatation
Result of chronic end-diastolic filling.
Determine the role of the following as compensatory mechanisms in CHF: ventricular hypertrophy
Enlargement of the heart r/t increased workload causing muscle to enlarge
Determine the role of the following as compensatory mechanisms in CHF: increased sympathetic nervous system activity
•Stimulate myocardial contractility
•Increase heart rate
•Increase venous tone
•Increased PVR or SVR
Determine the role of the following as compensatory mechanisms in CHF: excess salt and water retention
•Due to decreased cardiac output
•Aldosterone released to retain sodium and water
•The body thinks it is dehydrated
Distinguish the following form of heart failure, causes and PE: acute heart failure
Causes: AMI, ischemia, volume overload of LV, mitral stenosis. PE: dyspnea, pink frothy sputum, rales, diaphoresis, cyanosis, hypoxemia
Distinguish the following form of heart failure, causes and PE: chronic heart failure
causes: damage from MI, HTN, leaky valves, viral infection, congenital. PE: SOB, weight gain, edema, fatigue, nocturia, PND
Distinguish the following form of heart failure, causes and PE: Left sided heart failure
low cardiac ouput and elevated pulmonary venous pressure, dyspnea predominant feature
Distinguish the following form of heart failure, causes and PE: Right sided heart failure
Signs of fluid retention predominate in right heart failure, with the patient exhibiting edema, hepatic congestion, and, on occasion, ascites
Distinguish the following form of heart failure, causes and PE: low output
Inadequate ability to pump blood effectively form the ventricles
Distinguish the following form of heart failure, causes and PE: high output
cardiac pump function may be supranormal but inadequate when metabolic demands or requirements for blood flow are excessive. though uncommon, tends to be specifically treatable
Compare and contrast the following common precipitating or aggravating factors in heart failure:
Patient related factors
i.Exertion
ii.Emotional stress
iii.Excess fluid or sodium intake
iv. Medication Non-compliance
Compare and contrast the following common precipitating or aggravating factors in heart failure: Physician related factors
i.Use of salt and water retaining drugs
ii.Use of negative inotropic agents (CCB's)
Compare and contrast the following common precipitating or aggravating factors in heart failure: Heart failure related disease states
i.Uncontrolled hypertension
ii.Angina or MI
iii.Arrhythmias
iv.PE
Compare and contrast the following common precipitating or aggravating factors in heart failure: Other disease states
i.Systemic infection
ii.Renal or hepatic failure
iii.High-output states (anemia, pregnancy, hyperthyroidism)
Review, discuss and explain the role of each of the following laboratory studies and diagnostic procedures in CHF: CBC
Anemia r/t high output failure
Review, discuss and explain the role of each of the following laboratory studies and diagnostic procedures in CHF: BUN and creatinine levels
elevated
Review, discuss and explain the role of each of the following laboratory studies and diagnostic procedures in CHF: electrolyte levels
Hypokalemia, hyperkalemia, hyponatremia
Review, discuss and explain the role of each of the following laboratory studies and diagnostic procedures in CHF: EKG
May provide info to the nature of the heart failure. Can see LVH or left atrial enlargement on an EKG.
Review, discuss and explain the role of each of the following laboratory studies and diagnostic procedures in CHF: chest X-ray
Size and shape of cardiac silhouette, Eveidence of, Pulmonary venous hypertension, Interstitial edema, Pleural effusions
Review, discuss and explain the role of each of the following laboratory studies and diagnostic procedures in CHF: echocardiography
Gold standard and the most useful. Reveals the size and function of both atria and ventricles, Detects: pericardial effusion, Valvular abnormalities
Intracardiac shunts,
Segmental wall motion
Review, discuss and explain the role of each of the following laboratory studies and diagnostic procedures in CHF: radionuclide angiography
Measures LVEF and regional wall motion. Used if echo is suboptimal
Review, discuss and explain the role of each of the following laboratory studies and diagnostic procedures in CHF: cardiac catheterization
Necessary to r/o significant valvular disease, Presence of CAD must be determined
Review, discuss and explain the role of the following laboratory study and diagnositic procedure: ANP and BNP
Released by the ventricles when overstretched. Hormone released that stimulated diuresis
Compare and contrast in general terms the role of each of the following in the treatment of CHF: rest
Decreases the metabolic demand of the heart
Compare and contrast in general terms the role of each of the following in the treatment of CHF: diet
Reduction of dietary sodium
Compare and contrast in general terms the role of each of the following in the treatment of CHF: diuretics
By reducing the water and sodium retention, edema improves and symptoms improve
Compare and contrast in general terms the role of each of the following in the treatment of CHF: digitalis
Improves cardiac contractility
Compare and contrast in general terms the role of each of the following in the treatment of CHF: vasodilators (especially ACE inhibitors)
Blocks ACE, allows the heart to beat against less systemic vascular resistance
Define and distinguish the following:
pre-hypertension
120-139/80-89
Define and distinguish the following: stage I hypertension,
140-159/90-99
Define and distinguish the following: Stage II hypertension
>160/100
Define and distinguish the following: isolated systolic hypertension,
Elevated systolic pressure >140 and diastolic <90
Define and distinguish the following: hypertensive emergencies
Contigent on presence of relative blood pressure increases combined with evidence of injury to the "target" organs
Define and distinguish the following: hypertensive urgencies
Risk for imminent target organ damage although acute injury hasn't occured
Identify and explain the effects of prolonged uncontrolled hypertension on the following "target organ"
Heart
LV hypertrophy causing MI, sudden death, CHF, arrhythmias, LV diastolic dysfunction
Identify and explain the effects of prolonged uncontrolled hypertension on the following "target organ" Brain
Hemorrhagic CVA, ischemic cerebral infarct, dementia
Identify and explain the effects of prolonged uncontrolled hypertension on the following "target organ" Kidney
Nephrosclerosis
Identify and explain the effects of prolonged uncontrolled hypertension on the following "target organ"
Retina/eyes
Hypertensive retinopathy
Name the 4 "target" organs that prolonged uncontrolled HTN can effect
Heart, brain, kidney and retina/eye
List diseases that can result from hypertension.
o Organ failure
o Stroke
o CAD
o Retinopathy
Compare and contrast the most common causes of secondary hypertension by their characteristic signs and symptoms, or lab values uncovered on routine tests for the following: Estrogen use
Discontinue meds
Compare and contrast the most common causes of secondary hypertension by their characteristic signs and symptoms, or lab values uncovered on routine tests for the following: Primary hyperaldosteronism
Screen with aldosterone levels
Compare and contrast the most common causes of secondary hypertension by their characteristic signs and symptoms, or lab values uncovered on routine tests for the following: Pheochromocytoma
Orthostatic decreases in BP
Compare and contrast the most common causes of secondary hypertension by their characteristic signs and symptoms, or lab values uncovered on routine tests for the following: Cushing's
Angiotensinogen levels 2X normal
Compare and contrast the most common causes of secondary hypertension by their characteristic signs and symptoms, or lab values uncovered on routine tests for the following: Pregnancy
Preeclampsia, eclampsia
Compare and contrast the most common causes of secondary hypertension by their characteristic signs and symptoms, or lab values uncovered on routine tests for the following: Renal vascular hypertension
Below age 20 or after 50, Epigastric or renal bruit, Athersclerotic dx of aorta, Abrupt decline in renal function due to ACEI use
Establish which laboratory tests should be obtained on a patient with newly discovered hypertension, and explain the reason why each one is necessary.
1.Hemoglobin, UA, & renal function studies for proteinuria, hematuria, casts
2.Serum potassium 3. Aldosterone 4.Renin to detect mineralcorticoid excess 5.FBS to r/o DM, pheochromocytoma 5. Lipids, Indicator for athersclorosis
6.Uric acid: Contraindication diuretic therapy
Outline general principles of non-pharmacologic treatment of hypertension.
Loose weight, Reduce salt, Diet Rich in fruits, vegis, and low fat dairy and low in saturated fats, excercise, Reduce ETOH, No smoking, Calcium and Potassium supplements
List Differential diagnosis of valvular heart disease.
Mitral Stenosis
Mitral Regurgitation
Aortic Stenosis
Aortic Regurgitation
Tricuspid Stenosis
Tricuspid Regurgitation
Describe the typical presentation, and complications for infective endocarditis
Fever, New, changing murmer, Evidence of systemic emboli, Positive blood cultures, Evidence of vegetation on Echo, Destruction of infected valves with subsequent regurg, Infection extends into the myocardium leading to conduction disturbances, Invades aortic wall causing sinus of Valsalva aneurysms, Preexisting heart lesions
Describe the most common causative organisms for infective endocarditis.
•Staphylococcus aureus
•Enterococcus
•Viridan's Strep
•Usually tricuspid valve
Describe the diagnostic studies for infective endocarditis
•Echocardiogram
•Blood cultures
•CXR
Determine who is at increased risk for developing infective endocarditis and explain the importance of antibiotic prophylaxis before certain medical or dental procedures in this population.
IV drug users, Prosthetic heart valves, People with murmurs, Immunocompromised, Rheumatic heart disease, Prior hx of endocarditis, Any structural abnormalities of the heart, These people should use antibiotics before invasive procedures