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143 Cards in this Set
- Front
- Back
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Whats deemed hypertension in someone younger than 18?
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BP at or above 95th percentile for age, height, gender
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Whats deemed hypertension in a pt. above the age of 18?
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140/90
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What is essential hypertension?
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No Cause
90% of hypertension has no cause |
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Whats the prevalence of essential hypertension?
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50 million Americans
1:4 are age 18 and above Normotensive at 55 = 90% risk of developing hypertension |
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Essential Hypertension is detected via BP. Increasing the BP does what to your risk of CVD?
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Increases it.
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What are the steps to obtaining a BP?
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Pt. seated for 5 min. w/ feet on floor + arm supported at heart level.
Cuff bladder encircle 80% of arm Cuff width 2/3rds of arm width 2 readings two min. apart then averaged No Smoking or caffeine |
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What two substances are contraindicated when taking BP?
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smoking and caffeine
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What are the BP readings of Pre-Hypertension?
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120-139/80-89
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Do you put a pt. who is pre-hypertensive on drugs?
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NO
But you DO do lifestyle modification |
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What are the BP readings of Stage 1 Hypertension?
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140-159/90-99
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Do you do lifestyle modification with a pt. who has Stage 1 Hypertension?
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YES
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What are the BP measurements for a pt. with Stage 2 Hypertension?
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160/100
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Do you do lifestyle modification with a pt. w/ stage 2 hypertension?
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YES
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How many drugs are given to a pt. with stage 2 hypertension?
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2
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BP = 164/94. What stage of hypertension is it?
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Stage 2
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What do you want to make sure to cover in the history portion of your workup for Hypertension?
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Duration and Severity
Family Hx Concurrent Vascular disease Meds Social Rev. of Systems |
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What labs should you order in your hypertension workup?
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UA
FBS HCT (Anemia, Renal Insufficiency) K+ Cr (GFR) Lipid Profile EKG Glucose (diabetes) SG (=kidney's ability to concentrate - impaired in chronic renal failure, hypokalemia, hypercalcemia) |
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Whats included in the Physical Diagnosis of a hypertensive pts. workup?
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BOB C PLANAR
BP Both Arms Optic Fundi BMI CV Palpate Thyroid Lower Extremity (edema? pulses?) Abdomen (enlarged kidneys?) Neurological Auscultation for Bruits (carotid, femoral, abdominal) Respiratory |
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Early Indication of LVH?
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Localized forceful impulse with pt. in left lateral decubitus
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Late indication of LVH?
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Laterally displaced impulse
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Describe the Grading in the diagnosis of Retinopathy
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Grade 1-5
Grade 1 = Narrowing of Arterioles Grade 2 = AV Nicking Grade 3 = Flame Hemorrhage Grade 4 = Soft Exudates Grade 5 = Papilledema |
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What are the goals of treatment of essential hypertension?
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1. Achieve Systolic BP LESS THAN 140/90
OR if pt is diabetic/has renal disease 130/80 |
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HOW does one attempt to achieve the BP goal of less than 140/90 in treatment of essential hypertension?
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Lifestyle Modification:
1. BMI 18.5-24.9 2. DASH Diet (Dietary Approach to Stop Hypertension) 3. Physical Activity 4. Moderate Alc. Consumption OR DRUGS |
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Why is BP taken in the ambulance usually lower than that taken in clinic?
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B/c of "white coat" hypertension
Why is this important? so we get the most acurate BP to make accurate correlations between it and end organ damage |
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Home monitoring can help determine what?
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The extent of "white coat" hypertension because home readings are usually lower
Response to Anti-hypertensive drugs Improve compliance Reduce cost |
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Describe the Grading in the diagnosis of Retinopathy
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Grade 1-5
Grade 1 = Narrowing of Arterioles Grade 2 = AV Nicking Grade 3 = Flame Hemorrhage Grade 4 = Soft Exudates Grade 5 = Papilledema |
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What are the goals of treatment of essential hypertension?
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1. Achieve Systolic BP LESS THAN 140/90
OR if pt is diabetic/has renal disease 130/80 |
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HOW does one attempt to achieve the BP goal of less than 140/90 in treatment of essential hypertension?
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Lifestyle Modification:
1. BMI 18.5-24.9 2. DASH Diet (Dietary Approach to Stop Hypertension) 3. Physical Activity 4. Moderate Alc. Consumption OR DRUGS |
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Why is BP taken in the ambulance usually lower than that taken in clinic?
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B/c of "white coat" hypertension
Why is this important? so we get the most acurate BP to make accurate correlations between it and end organ damage |
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Home monitoring can help determine what?
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The extent of "white coat" hypertension because home readings are usually lower
Response to Anti-hypertensive drugs Improve compliance Reduce cost |
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What are the BP Determinants of Hypertensive Emergency/Urgency?
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BP > 180/120
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Whats the difference between Hypertensive emergency and Urgency?
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Emergency = evidence of end or damage
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What are some examples of NEURO end organ damage?
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Encephalopathy
Stroke Hemorrhage |
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What are some examples of HEART end organ damage?
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MI
Unstable Angina Acute CHF Aortic Dissection |
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What are some examples of KIDNEY end organ damage?
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Acute renal failure
ex. = oliguria, Inc. Creatinine levels |
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What are some examples of HEME end organ damage?
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Microangiopathic Hemolytic Anemia
(MAHA) |
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When do you start looking for for end organ damage?
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if BP 180 or over
(urgency/emergency = 180/120) |
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With treatment, what does the chance of death decrease to?
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after 1 yr. with treatment, death incidence decreases to 10%
After 5 yrs. with treatment, incidence of death decreases to 0% |
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What are the normal BP regulatory mechanisms?
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Baroreceptor of carotid bodies and aorta
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If the baroreceptor is stimulated, what happens to symp. parasymp tone?:
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Symp decreases
parasymp increases |
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Whats the mechanism of action of dec. symp. tone in decreasing BP as far as the alpha receptors are concerned?
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Inc. BP
=Dec. Symp. output =Less NE released =Dec. alpha receptor activity =Vasodilation of arteriolar sm m. \=dec. PVR =Dec. BP |
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Whats the mechanism of action of dec. symp. tone in decreasing BP as far as the beta receptors are concerned?
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Dec. Symp. output
=Less NE released =Dec. B receptor activity =myocardium = dec. force of contraction = dec. CO =Dec. BP ALSO: the SA node is worked on, decreasing the rate at which it fires, dec. HR = Dec. CO = Dec. BP |
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What classes of drugs do you NOT want to give to a hypertensive pregnant woman?
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ACE inhibs
ARBs THEY'RE TERATOGENIC |
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What do you use to treat a pt. with Acute MI and Hypertension?
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B Blocker
ACE inhib/ARB Nitrates |
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What do you NOT want to give to a pt. with Acute Congestive Heart Failure and Hypertension?
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B Blocker
CCB |
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What do you NOT want to give to a pt. who has acute Renal failure and Hypertension?
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ACE inhib
ARBs |
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Whats a good drug to give a pt. with an Arotic Dissection?
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B Blocker
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What do you NOT want to give a pt. who is a drug user (like coccaine) with Hypertension?
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B Blocker (b/c it leaves the alpha receptors unopposed)
(Same for a pt. with pheochromocytoma) |
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Whats the treatment for a pt. in emergency room with Hypertensive urgency?
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Oral short acting anti-hypertensive w/ observation
Send home Apt w/ primary care Dr. 1-2 days later PRIOR to pt leaving ER (discharge) |
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Whats the treatment for a pt. in emergency room with Hypertensive Emergency?
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ICU
IV agents 1st Hr = 25% reduction in MAP Subsequent 6 hrs: 160/100-110 Next 48 Hrs: Normotension Note: we don't want to lower pts BP too fast so the tissues aren't under-perfused |
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Define acute rheumatic fever
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Cardiac damage most often associated with mitral valve stenosis
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Whats the mechanism of action of Rheumatic Fever?
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Streptococci Infection
Upper Respiratory Infection -18 days- Group A Strep infects heart (proliferative inflammatory lesions in CT of joints, heart, skin, CNS) Rxn against self - Autoimmune Immunoglobulin + Complement deposits Heart-reactive Abs in blood Heart valves have T cell infiltrates |
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Streptococci are rich in what?
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M Protein
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How many days from time of initial infection until we see proliferative inflammatory lesions of CT in body with Rheumatic Fever?
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18 days
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The M protein of strep reacts with what human tissue component in rheumatic fever?
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Tropomyosin
Myosin Sarcolemma/Subsarcolemma |
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The Cell Membrane of strep reacts with what human tissue component in rheumatic fever?
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Sarcolemma/Subsarcolemma
Neurons of Caudate and Subthalmic nuclei |
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The Group A carb. of strep reacts with what human tissue component in rheumatic fever?
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Heart Valve Glycoprotein
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The Hyaluronic acid of strep reacts with what human tissue component in rheumatic fever?
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CT protein polysaccharide complex
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How do you Diagnose Rheumatic Fever?
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Recent Strep infection PLUS
2 Major Criteria OR 1 Major and 3 minor criteria |
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What are the Major criteria in strep Diagnosis?
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Polyarthritis (most common)
Carditis Erythema Marginatum(pink rings on trunk/limbs) Subcu nodules Sydenham's Chorea (rapid, uncorrdinated jerky movements) |
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What are the minor criteria for Rheumatic fever diagnosis?
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Arthralgia
Fever Previous Rheumatic Fever Prolonged PR on EKG Elevated Erythrocyte Sedimentation rate (ESR) C-Reactive protein or Leukocytosis |
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How do you diagnose whether a pt has had a previosu group A strep infection?
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Streptozyme test
(if positive, do ASO) |
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If you screen a pt. for previous group A strep infection, and it comes back positive, what do you order?
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ASO (anti-streptolysin O)
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What are some of the features of Strep that make it virulent?
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M protein
T Antigen Peptidoglycan Layer Immunoglobulin A Receptor Protein Receptor Fc (Fc portion of immunoglobulin) Fibrils with M protein and Lipoteichoic Acid Group A Carbohydrate |
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Rheumatic Fever infections occur most often WHEN?
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highest infection period for strep throat (5-15 yrs)
Cooler months (of temperate climates) March-April in climates like WV's Over-crowded populations Dampness Dec. socioeconomic area |
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If a population is at increased risk of strep infections because they are 1. young (5-15), 2. overcrowded, 3. live in damp area 4. are low socioeconimically, 5. and its a cooler month
What are they at risk for? |
Inc. Strep infection = Inc Chance of Rheumatic Fever
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What are the soluble virulence factors of Strep?
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Streptolysins O and S
O = Oxygen Labile (=can change), Antigenic S = Oxygen Stable, Nonantigenic (there are others but these seem most important) |
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What is the treatment for rheumatic fever?
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Salicylates (4-8 weeks)
OR for pts. with severe carditis Prednisone |
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A pt. comes to your office. You do a stretozyme test and determine they previously had a strep infection. They show signs of sever carditis and jerky movements. What do you use to treat them with?
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Predisone
(b/c they have severe carditis) Use Salicylates if theres no severe carditis |
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How do you prevent rheumatic fever?
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recognize and treat strep throat with penicillin
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A pt. comes in to your office with Rheumatic fever that has progressed to heart failure. How do you treat them?
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Bed rest + Corticosteroids
THEN surgery if that doesn't work |
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Define Infective Endocarditis
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Infection of:
Valve (natural God-given valve) Prosthetic valve Endocardium |
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What two organisms cause Infective endocarditis?
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Staph (42%)
Strep (40%) |
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What are the different types of Infective Endocarditis?
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Acute
Subacute IV Drug Use Prosthetic Valve Endocarditis |
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What causes Acute Infective Endocarditis?
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Staph. aureus
(also causes IV Drug and EARLY onset Prosthetic valve infective endocarditis) |
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What causes Subacute Infective Endocarditis?
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Strep. Viridans
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What causes LATE onset prosthetic valve infective endocarditis?
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Staph epidermis
(vs. early onset prosthetic valve endocarditis which is caused by staph aureus) |
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What are some of the common sources of bacteria (staph or strep) in infective endocarditis?
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Dentists!
IV Pulmonary |
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Infective Endocarditis occurs most often in patients with what condition?
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Heart Disease
(these hearts undergo cellular distortion resulting in non-bacterial thrombolytic endocarditis lesions) |
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Whats the Pathogenesis of infective endocarditis?
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Endothelial damage
Tissue loses collagen Platelets adhere/agragate Fibrin deposits Bacteria Colonize Vegetations form Stimulate thrombi/platelets Vegetations enlarge (OR you can have the Venturi effect - high pressure) |
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Whats the Venturi effect in producing infective endocarditis?
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High Pressure and Low Pressure areas
Platelet-Fibrin agragate Injury to wall of leaflets or ventricle wall Platelet fibrin thrombi Infection |
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What are the symptoms Unique to Rheumatic Fever (vs. Acute and Subacute Infective Endocarditis)?
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Polyarthritis (arthritis in 5 or more joints)
Carditis Erythema Marginatum |
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What are the Symptoms Unique to Acute infective endocarditis?
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Prostration = body in a certan position
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What are the Symptoms Unique to Subacute Infective Endocarditis?
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Ill-defined wasting:
Anorexia, weight loss Petechiae Splinter Hemmorrhages (blood clots under nails) Urinalysis = Hematuria (protein in blood) |
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How do you Diagnose Infective Endocarditis in the lab?
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Blood cultures
ACUTE - 3 blood cultures over 1-2 hrs. SUBACUTE - 3 blood cultures per day for 2 days THEN Echocardiogram for both |
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What do you use when taking a blood culture to diagnose infective endocarditis to prevent contamination of the sample?
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Skin prep
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When you do the Lab diagnosis of infective endocarditis, do you take the blood culture samples before or after treatment is begun?
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BEFORE
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Whats the treatment for Infective Endocarditis?
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Bacterial Abx
Monitor Blood Cultures Surgery (valve replacement) |
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A blood culture comes back containing Gram positive cocci in chains and is catalase Negative. What two diagnoses could it be?
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Organism is Streptococci
Which can cause Rheumatic fever (strep.) or Infective Endocarditis (Staph viridans causes Subacute IE) |
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What is the Streptolysin component of Group A Strep that reacts with antigens?
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Streptolysin O (oxygen Labile)
(vs. streptolysin S, which is Nonantigenic and oxygen stable) |
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What is another piece of evidence you can use to determine if a pt. was previously infected with Group A Strep besides Stretozyme followed by ASO?
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Acute Phase Reactants will be elevated ie ESR, CRP, PMNs etc.
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Whats the difference between Infective endocarditis and rheumatic fever?
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Infective endocarditis = infection, colonizes valves, edocardium etc., vegetations grow
Rheumatic Fever = Infection, delayed reaction (18 days), then reaction against self occurs as Abs are produced = damages heart |
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Which forms of Infective endocardits are caused by Staph aureus?
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The "acute" or early forms:
Acute infective endocarditis IV drug use Early prosthetic valve endocarditis (vs. Subacute = STREP viridans and late valve endocarditis = staph epidermis) |
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What do the Grades of Heart Murmurs stand for?
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1 = Barely Aduble
2 = Soft, but easily audible 3 = moderately loud, NO thrills 4 = Louder with THRILL 5 = Audible with Steth. barely on chest 6 = audible withOUT steth. of chest |
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What are the Signs of a pathologic murmur?
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Murmurs in Diastole
Systole great than 3/6 Thrill Long Duration Transmit to other part of body Abnormal Heart Sounds Assoc. with strong or weak pulses |
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What are the sings of a non-pathological murmur?
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Low pitch - hear with bell
Grade 1-3/6 Vibratory, Twanging, Musical Midstystolic (Ejection) Murmur Heard On Axilla, Back, Left and Right Chest Grade 1-3/6 = pulmonary flow murmur Venous Hum Carotid Bruit |
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You hear a Murmur on the axilla, back, left and right chest of an infant graded 2/6. Is it pathological?
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NO
Its a normal Pulmonary Flow Murmur |
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You hear a continuous Venous hum murmur grade 3/6 on L or R Supra-infraclavicular areas. Is it pathologic?
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NO
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You hear a carotid Bruit in the R. Supraclavicular area under and over carotids. Is it pathologic?
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NO
Normal carotid bruit |
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Pt. age 20-30 with L--> R Shunt. VSD (or ASD, Atrioventricular septal defect --> medial hypertrophy and or intimal hyperplasia in pulmonary vasculature.) Whats you Dx?
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Eisenmenger Syndrome
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Clinical Findings in TOF?
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TET Spells (Rapid, Deep breathing, dissappearance of murmur, restlessness)
R--L ventricular Shunt Dec. pulmonary blood flow Put child in Knee-to-chest positions, which should dec. restlessness |
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Cause of TOF?
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alcoholic mother.
hey yo mom |
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PaO2 rises above 150 apon taking ABG. What does this leasd you to believe may be the cause of the problem?
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Pulmonary Disease or PPHN
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PaO2 Less than 150 mmHG apon taking ABG. What may be the cause of the problem?
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Intracardiac shunt or Cyanotic Congenital Heart Abnormality
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What are the Anatomical findings of TOF?
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POVR
Pulmonic stenosis Over-riding aorta VSD Right Ventricular Hypertrophy |
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PaO2 saturation increases 15% or greater after taking ABG. What may be the cause of the problem?
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pulmonary disease
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X-ray shows egg shaped or egg on a string appearance of the heart. Dx?
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Transposition of Great Arteries
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X-ray shows Boat shaped heart. Dx?
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TOF
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X-ray shows that the heart looks like a snowman. Dx?
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TAPVR
Total Anomalous Pulmonary Venous Return ie a mouthful. |
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Cardiogenic shock vs. Hypoxemia during the neonatal period. What do they mean?
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Cardiogenic shock = systemic blood flow lesion
Hypoxemia = Pulmonary blood flow lesion |
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Cardiogenic shock during neonatal period. Dx?
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systemic blood flow lesion
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Hypoxemia during neonatal period. Dx?
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Pulmonary blood flow lesion
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HypOperfusion or Cyanosis during late neonatal period. Dx?
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Ductal Dependent Lesion
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Clinical Findings of PDA?
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Continuous, machine-like murmur @ ULSB
Bounding Peripheral Pulses Hyperactive Precordium HypOtension Respiratory Deterioration (Tachypnea, Crackles, Apneic episodes) |
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Treatment of PDA?
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Indomethacin or Ibuprofen
THEN Surgery or Transcatheter Approach |
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Signs of Heart Failure in infant?
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Poor feeding
Poor weight gain Fatigue, Diaphoresis, Cyanosis during feeding Unable to stay awake for full feeding |
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Signs of TOF?
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Squatting during distress (TET spell)
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Signs of L-->R shunt?
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Edema, Puffy eyelids, Sacral Edema
Freq. of Lower respiratory infections (due to inc. pulmonary blood flow b/c of the L--> R shunt) |
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Signs of Fetal Alcohol Syndrome?
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Dysmorphic appearance
Midface Hypoplasia (Under-development) Micrognathia (small jaw) Flat Philtrum Developmental Abnormalities (low % for height/weight) |
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Treatment for TOF?
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Oxygen + Morphine
Then Surgery? |
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Pt. has strong upper extremity pulses with weak lower extremity pulses. Dx?
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Coarctation of Aorta
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What are some of the clinical findings of HF in children?
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Tachycardia
Low Height/Weight % weak pulses Diaphoresis (cold sweats) |
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Clubbing of fingers means what?
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chronic low arterial blood O2 saturation
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Mom was an alcoholic. What might baby have?
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VSD, ASD, TOF, PDA
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Lithium poisoning in 2nd trimester. Baby has?
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severe right heart abnormalities
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Phenytoin poisoning in 2nd trimester. Baby has?
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PS, AS, Coarctation of Aorta, PDA
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Retinoic Acid (Vit. A). Baby has?
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Conotruncal Abnormalities
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Warfarin taken by mother during pregnancy. Baby has?
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PDA, VSD
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Diabetic mother. Baby has?
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Congenital heart disease (cardiomyopathy, VSD, TGA, PDA)
Could be a lot of dif. shit. |
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Maternal SLE (Lupus). Baby has?
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congenital heart block
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Maternal CHD increases risk of what in baby>?
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CHD
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Rubella infection during pregnancy. baby has?
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CHD
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Mom is HIV positive. baby has?
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Cardiomyopathy
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Conditions that lead to basically general heart disease or cardiomyopathy?
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Diabetes, Maternal CHD, Rubella infection, CMV/HSV/Coxsackie/Parvovirus, HIV
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Clinical findings suggestive of CNS problem in babies?
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Weak suck
Convulsions shallow, irregular respirations poor muscle tone alleviated by ventilation help |
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Clinical findings suggestive of lung disease?
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diminished breath sounds
crackles/wheezes abnormal pulmonary findings on Xray Alleviated by O2 administration (PaO2/ABG test) |
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Fixed, widely split S2. Dx?
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ASD
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Harsh or blowig halosystolic murmur @ LLSB. Dx?
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VSD
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Diastolic Rumble Holosystolic murmur @LLSB. Dx?
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AV Canal
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Continuous, machine-like murmur @ ULSB. Dx?
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PDA
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SEM @ ULSB (and ejection click, soft P2). Dx?
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PS (pulmonary stenosis
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SEM @ URSB (and ejection click, soft A2, Mid LSB). Dx?
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AS (aortic stenosis)
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T/F: chest pain in children is rarely related to cardiac pathology
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TRUE
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