Internal Medicine, Paragh, Nephreology

Front 1

Arrives to you a patient complains about tierdness, shortness of breath after physical activity,
edema in legs, patient is 50 year old man.

Back 1

Heart failure
● Anamnesic data we should ask:
○ Riskfactors for Atherosclerosis (smoking, DM, hyperlipidemia, HTN)
○ Cardiomyopathy can be dilativ, restrictive or hypertropied.
○ BUT more important questions for required or heritance cardiomyopathy
(heritance begin earlyer) so required!! RHEUMATIC FEVER as a child!!! –
following a streptococcus pyogenes (strep throat/scarlet fever)
● Rheumatic fever is cross reactivity of ABs
● Symptoms the Jons criteria: MAJOR and MINOR
● MAJOR:
○ Rheumatic Carditis
○ Polyarthritis (starting in legs and migrates up)
○ Rheumatic subcutant nodules
○ Erythema marginatum
○ Sydenham´s/Huntington‘s chorea
● MINOR:
○ ↑ESR and CRP
○ Leukocytosis
○ Blood smear shifts to the left
○ Subfebrility or fever
● RF: causes cardiac decompensation in 4050
years old patients.
○ Vale abnormalities are Mitral valve (stenosis)
○ After Mitral comes Aortic valve
○ Post streptococcal = Ag+Immune complexes cause local inflammation in valves
and later the scarification of them.

Front 2

1. Patient complains about: Headache , dizzyness, palpitation

Back 2

Face – Red (essential)/ White (renal)
● Hypertension! above 140/90 on 3 measurement occasions
● 110/80 optimal
● 120/80 ideal
● Causes
○ Primary: Na+ uptake, obesity, genetic, lipids, smoking
○ Secondary:
■ Renal (renovascular/renoparenchyme)
■ Hormonal (pheochromocytoma, hyperthyroidism, hyperparathyroid, cons
→hyperaldosteron, cushing)
■ Toxins (mercury ↑TPR, sympatomimetics)
● Depends on: TPR, CO, hyperviscosity (polycytemia vera, leukemia, myeloma), TPR
(coarction of the aorta, Ach)
● Lab: electrolytes in blood, catecholamines (urine + blood), urinanalysis, ECG
● Treatment: lifesteyle changes → Diuretics → βBlocker
→ ACE inhibitors/ARB → Ca++
Blockers → Nitrates
● NB!! In Diabetic patients : βBlockers
+ Diuretics NOT given because they can induce
hypoglycemia!!
2. Patient complains about:

Front 3

2. Patient complains about: after surgery about pain in legs.

Back 3

2. Patient complains about: after surgery about pain in legs.
● Thrombus → Thromboembolism = Thrombus from endocarditis!
● Endocarditis : Aents : S. Aureus – S. Epidermidis – S. Mutans – S.Viridans
● Dukes criteria
○ Major: Endocardium involvement, + Blood culture
○ Minor: fever, predisposition, vascular/immune signs, (+blood dont answer. It is
written like this on the paper don‘t know what it means)
● 2 major OR 1 major + 3 minor
● Other signs: Arthralgia, malaise, stroke, murmurs, weight loss
● Treatment: Penicillin + Gentamycin NB!! If MRSA: Vancomycin + Gentamycin
○ Treament for 46
weeks.
Between DVT and Thromboembolism
● DVT: warm, edema, cyanosis
● TE: cold, pale, no pulse

Front 4

Arrives to you a patient complains about palpitation sensation, shortness of breath that began
with standing up from a chair.

Back 4

Myocarditis
● Symptoms:
○ low physical activity provokes tachycardia and shortness of breath
○ heart palpitation after low physical activity
○ subfebrility or fever
○ chest pain that mimics Angina BUT the difference is that the pain intensity
changes with changed position!!!
● Anamnestic data: have to ask about if they had any respiratory tract infections? Because
causes can be viral (Coxaciae)!!! Also could be AI, Chagase (developed),Toxins
● Examination: ECG (ST depression, PQ interval longer), + cardiac enzymes, CRP &
ESR↑
● Treament: . Symptomatic therapy!
○ 1. Rest (immobilization)
○ 2. βBlockers
○ 3. NAIDS
○ In extreme Viral cases = antiviral therapy or in bacterial = steroids.
Anticoagulant therapy
● Heparin (LMWH, UH)
● After 2 days Warfarin
● After 5 days check for heparin induced Trhombocytopenia

Front 5

Arrives to you a patient: complains about abdominal pain, he is old and has history of positive
thromboembolic complications.

Back 5

thromboembolic complications.
Abdominal Aneurism
● Abdominal aneurysm: ATH, Marfan, Collagen abnormality
● Signs: epigastric pulsation, abdominal mass, weak pulse in low extremities, murmur or
bruits upon auscultation
● Etiology: HTN!!!!! Marfan, collagen abnormality
● Treatment:
○ 24cm
○ 46
cm = Anticoagulants, Anti HTN drugs prepare for elective operation.
○ >6cm = Urgent operation, very high rupture incidence
● NB! Examination before we do an elective operation
○ 1. Carotid and coronary examination bec. Drop in Bp in surgery can lead to MI or
Ischemic stroke. So first we need to solve the atherosclerosis problem (in
coronaries or carotids) with anti HTN drugs and get the Bp to normal.
Syncope patient
● Cardiac! →Arrythmia (Bradycardia + Tachycardia)
● Bradycardia: AVBlock,
Sinus block (SSS) Long QT
● Tachycardia: SVT, VT
● Obstructive: Aortic stenosis, constrictive pericarditis, some word could‘t make it out
(cardonyopgics)
● Neurological: postural hypotension, TIA, Vasovagal
SSS (S

Front 6

Arrives to you a patient and complains about oppression chest pain after physical activity:

Back 6

Stabile Angina Pectoris
● First we need to check for anamnesic data to confirm our suspicion it is a Angina
○ Ask for Smoking, DM, Hyperlipidemia, HTN! Positive answer supports the finding.
● Causes: AMI, Angina, Pericarditis, Myocarditis, Mitral valve prolapse, Aortic aneurysm,
Mediastinosis, Pleuritis, Pulmonary embolism, Esophageal reflux, muscle origin.
● Angina!: Stabile – Unstabile – Prinzmetal
● Stabile: lasts 1015mins,
after exercise (effort), relief in rest, ST depression in all
● Unstabile: spontaneous, more than 15 mins
● Non Stemi: + cardiac markers (not like in unstabile angina)
● Angina to MI differents: AMI→ ↑15 mins, no relief from nitrates
○ Hyperacute (mins): ST elevation (Dome shaped) →Lesion
○ Acute (24hr):
Pathological Q waves →Necrosis
○ Late: invert T wave
● Complication:
○ Acute: arrythmias, SCD, Acute HF
○ Chronic: Rupture (septal/papillary), Arrythmias, CHF, Afib, Thromboembolism,
DVT, Dresslers syndrome
● Dresslers syndrome: postmyocardial infarction syndrome

Front 7

DVT

Back 7

● Virchow triad:
○ Hypercoagulability
○ Endothelial dysfunction
○ Flow disturbances
● Symtomes: unilateral swollen leg, cyanosis, warm, pain during walking
● Tests: Homan‘s test, US, Ddimer,
Perthes test( clinical test for assessing the patency of the
deep femoral vein prior to varicose vein surgery.The limb is elevated and an elastic bandage is
applied firmly from the toes to the upper 1/3 of the thigh to obliterate the superficial veins only. With
the bandage applied the patient is asked to walk for 5 minutes. If deep system is competent, the
blood will go through and back to the heart. If the deep system is incompetent, the patient will feel
pain in the leg.)
● Treatment: Anticoagulant therapy (heparin 2 days and Warfarin simultaneusly)

Front 8

Pain in chest and starts rapidly – Pulmonary embolism

Back 8

● Signs: Dyspnea, chest pain, hemoptysis, RVF, ↑JVP
● Exams: pulmonary wedge pressure, Ddimer,
Xray
(wedge shape)
● Treatment: LMWH → Warfarin , Streptokinase
Claudication
● Claudication = muscular cramping with excercise
● Thrombolingitis obliterans = young, Israel, smoking
● Arterial obstruction with ulceration of the digits also (mostly effect low (dont understand
1srib)
● Ankle – Brachial Index: should be more than 1 – 0.90.7:
moderate – lower than 0.4:
severe claudication
● Treatment: Pentoxytyllin, cylostazole, prostacyclin, Angiogenic growth factors

Front 9

Pericarditis

Back 9

● Causes: Coxacie and Echo /Fungal/TB/Post MI/AI/SLE/Radiation
● Signs: usually no palpitation + dyspnea, friction rub sound, pain relief lying forward,
aggrevated in respiration, all leads ST eleveation, T inversion, (something leter Q waves,
didn‘t understand the writing)
● Treatment: NSAIDS

Front 10

classification of claudication

Back 10

Fontana classification of claudication
● Stage 1: symptoms in severe exertion (only extreme)
● Stage 2: usuall exertion causes pain
● Stage 3: pain at rest + secere claudication
● Stage 4: Trophic changes, ulcers, gangrene.

Front 11

Heart sounds

Back 11

Heart sounds
● 1st heart sound: closing of mitral and tricuspid valves
● 2nd heart sound: closing of aortic and pulmonary valves
● 3rd heart sound: beginning of diastole, mitral and tricuspid are open, blood flows into the
chamber = Filling sound
● 4th heart sound: End of diastole, atrium contract, end diastole filling = presystolic sound.
● In mitral stenosis: valves are stiff and when open = opening snap! After that we hear
diastolic murmur and the intensity of the sound decreases but increases again in
presystolic because there is increase in pressure because the atria are contracting. The
1st heart sound intensity is also lower than normal, Punctum maximum is over mitral
valve.
Arrives to you a patient old, complains

Front 12

Arrives to you a patient old, complains about leg pain after walking in both legs that stops when
he stops walking

Back 12

Atherosclerosis obliterans
● Anamnesic data:
○ HTN
○ DM
○ Smoking
○ Hyperlipidemia
● Examinations:
○ Peripheral arteries (popliteal, posterior tibial, dorsalis pedis)
○ Ankle brachial index / doppler index – upper limb/lower limb = normal > or at 1
severe if <0,5
○ Color doppler exam →visualizes abnormalities
○ Angiographic examination
○ Decide conservative vs. Surgery
● Fontana stages:
○ Symptoms only at severe exertion
○ 2A: pain >200 meters
○ 2B: pain < 200 meters
○ 3: pain at resting (severe claudication)
○ 4: trophic changes, ulcers/gangrene
● Sacroiliac joint abnormalities (pain when stand up)

Front 13

Arrives to you a woman, young with shortness of breath after physical activity (can walk around
15meters), with stabbing pain over chest.

Back 13

Pulmonary embolism
● Anamnesic data:
○ Is on the pill? – did change recently?? How long taking??
○ Familial history of DVT
○ Previous operation/immobilization
● Examination:
○ Check for leg swelling
○ Lung exam (auscultation for bronchial, crepitus sounds)
○ Look for symptoms of DVT – Löwenberg, Homans
○ If suspect pheochromocytoma and not PE= hit kidneys at back – Bp ↑ or put hand
in cold water Bp↑
in
pheochromocytome the first symptom is usually
headhache (+ palpitation) and HTN but in 10% we cant detect HTN
○ Lab test:
■ Blood for Ddimers
= if high – Thrombosis
■ ECG
■ Chest x ray
■ CT = can reveal multiple microemboli in lung if PE
■ Antiphospholipid positivity usually lead to DVT in young ppl

Front 14

Arrives to you a patient that had fainted at home, old woman.

Back 14

Syncope
● Anamnestic data: HTN, Headache
● 3 characteristic reasons for syncope
○ 1. 3rd degree AV block (ECG can recognize)
○ 2. SSS: has 4 symptoms
■ 1. Bradicardia sinus
■ 2. Tachybradycardia
syndrome
■ 3. Syncope
■ 4. Atrial Fibrilation with low pulse frequency
○ 3. Carotid sinus hypersensitivity (males shaving – push the carotid synus and
collapse) 3 symptoms:
■ 1. Cardio inhibitory HR↓
when press sinus
■ 2. Vaso depressive Bp↓
when massage the sinus
■ Mixed
● Examination:
○ ECG to exclude 3rd degree AV block but we cant differentiate btw. SSS and
Carotid in ECG.
○ Holter ECG to detect the Tachybrady
syndrome.
○ SSS: the sinus node is abnormal so also the reaction is abnormal
■ Atropin blocks the parasymp. So we get sympathetic overactivity =
Tachycardia in normal NOT in SSS
■ Physical activity = HR ↑ in normal NOT in SSS
■ Efferent test sympatomymetic = Ephedrin BUT it is dangerous in
TachyBrady
syndrome
■ Electrophysiological exam= suppress sinus node own activity – withdraw
ext