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185 Cards in this Set

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20 yo female, Early diastolic murmur. Next step?
20 yo female, Early diastolic murmur. Next step? Echo. Diastolic and continuous murmurs as well as Loud systolic murmurs reveals on cardiac auscultation should always be investigated using transthoracic doppler ech. Midsystolic soft murmurs (grade 1-2 out of 6) in asymptomatic young pt are usually benign and need no further workup.
64 yo caucasian male in ER with sharp, left-sided chest pain. Pain worse when he takes deep breaths, but he gets relief with Leaning forward. Acute NSTEMI six months ago and Angioplasty of Right coronary artery. Diabetes, hypertension, hyperlipidemia, peripheral neuropathy, diabetic retinopathy, paroxysmal atrial fibrillation, hypothyroidism, chronic renal insufficiency. bp 142 by 86. Pericardial rub. EKG shows diffuse ST elevation. Hb 9, WBC 8000, Platelet 210,000, Blood glucose 248, Serum Na 135, Serum K 5.8, Bicarbonate 17, BUN 86, Serum Creatinine 4.4. Next Step?
64 yo caucasian male in ER with sharp, left-sided chest pain. Pain worse when he takes deep breaths, but he gets relief with Leaning forward. Acute NSTEMI six months ago and Angioplasty of Right coronary artery. Diabetes, hypertension, hyperlipidemia, peripheral neuropathy, diabetic retinopathy, paroxysmal atrial fibrillation, hypothyroidism, chronic renal insufficiency. bp 142 by 86. Pericardial rub. EKG shows diffuse ST elevation. Hb 9, WBC 8000, Platelet 210,000, Blood glucose 248, Serum Na 135, Serum K 5.8, Bicarbonate 17, BUN 86, Serum Creatinine 4.4. Next Step? Hemodialysis. Uremic Pericarditis absolute indication of initiation of dialysis, or for intensification of dialysis for those already on dialysis. Pericardial fluid in uremic pericarditis is most often hemorrhagic. Uremic pericarditis associated with BUN more than 60 and Anemia.
33 yo Russian male recurrent episodes of Pounding and Racing heart over last several months. Symptom worse while lying supine and while lying on left side. Bp 150 over 55. Dx?
33 yo Russian male recurrent episodes of Pounding and Racing heart over last several months. Symptom worse while lying supine and while lying on left side. Bp 150 over 55. Dx? Aortic Regurgitation. MCC of AR is Aortic Root dilation and Bicuspid aortic value. Widening of Pulse Pressure - felt as Water Hammer pulse. Lying down and Turning to Left brings heart closer to chest wall and more aware of forceful heartbeat.
65 yo man follow up for inadequately controlled hypertension. Difficulty walking uphill or climbing stairs because pain in right thigh, which requires him to stop and rest in order for pain to go away. Hx - stable angina, requiring coronary angioplasty and stenting 2 years ago. Hypercholesterolemia. 20 year history of hypertension. 10 year history of diabetes mellitus 2. Med - aspiring, metoprolol, hydrochlorothiazide, amlodipine, pravastatin and glyburide. Smoke 1 pack per day. Bp 160 over 100 in right arm 180 over 110 in left arm. Potential cause of resistant hypertension?
65 yo man follow up for inadequately controlled hypertension. Difficulty walking uphill or climbing stairs because pain in right thigh, which requires him to stop and rest in order for pain to go away. Hx - stable angina, requiring coronary angioplasty and stenting 2 years ago. Hypercholesterolemia. 20 year history of hypertension. 10 year history of diabetes mellitus 2. Med - aspiring, metoprolol, hydrochlorothiazide, amlodipine, pravastatin and glyburide. Smoke 1 pack per day. Bp 160 over 100 in right arm 180 over 110 in left arm. Potential cause of resistant hypertension? Renal artery stenosis (continuous murmur in paraumbilical area to the right). Pt has Atheroscloerosis in multiple sites - coronary arteries (stable angina with prior coronary intervention), lower extremity arteries (intermittent claudication which improves with rest), and left subclavian artery (asymmetrically increased bp in left arm). Subclavian artery atherosclerosis has preference for left artery - present with Vertebrobasilar insufficiency secondary to Subclavian Steal Phenomenon. Multiple risk factors for Atherosclerosis - Hypercholesterolemia, diabetes, smoking, and hypertension.
35 yo caucasian male evaluated for poor exercise tolerance and muscle weakness. Bp ranges from 175-185 systolic and 105-115 diastolic on repeat measurements. serum K of 2.4. CT of abdomen reveals 3 cm mass in left adrenal gland. Additional finding expected in Plasma renin activity, Serum aldosterone, and Serum bicarbonate?
35 yo caucasian male evaluated for poor exercise tolerance and muscle weakness. Bp ranges from 175-185 systolic and 105-115 diastolic on repeat measurements. serum K of 2.4. CT of abdomen reveals 3 cm mass in left adrenal gland. Additional finding expected in Plasma renin activity, Serum aldosterone, and Serum bicarbonate? Plasma renin activity Low, Serum Aldosterone High, Serum bicarbonate High. Primary Hyperaldosteronism (Conn Syndrome) causes Hypertension, Mild Hypernatremia, Hypokalemia, and Metabolic Alkalosis. Confirm by Low renin level and elevated aldosterone level. Conn syndrome - Hypertension, Mild Hypernatremia, Hypokalemia, and Metabolic Alkalosis.
Absolute indication for Initiation of Dialysis?
Absolute indication for Initiation of Dialysis? Uremic Pericarditis in pt with Chronic Renal Failure.
43 yo male frequent epigastric burning not relieved by antacids. Sensation typically brought on by Heavy lifting at work and takes 10-15 minutes to go away. SLE diagnosed five years ago, for which he takes low-dose prednisone daily. bp 140 by 90. EKG normal. Next step?
43 yo male frequent epigastric burning not relieved by antacids. Sensation typically brought on by Heavy lifting at work and takes 10-15 minutes to go away. SLE diagnosed five years ago, for which he takes low-dose prednisone daily. bp 140 by 90. EKG normal. Next step? Exercise EKG, as exertional nature of his discomfort is concerning for ischemic heart disease. Both SLE and Chronic Steroid use are Risk factors for Accelerated coronary atherosclerosis. Exercise may induce ischemic changes on EKG that might not be present at rest.
Acute limb ischemia Px?
Acute limb ischemia Px? 5 P - Pain, Pulselessness, Paresthesias, Poikilothermia (Coldness), and Pallor. Angiography - shows abrupt cutoff of arterial blood flow. IV heparin start right away. Definitive tx - surgical embolectomy or Intra-arterial fibrinolysis/mechanical embolectomy.
Adenosine function? Tx?
Adenosine function? Tx? Adenosine Decreases conduction through AV node. First line for Paroxysmal Supraventricular tachycardia.
Aortic Dissection Px? Cause?
Aortic Dissection Px? Cause? Chest pain - Sudden, Tearing, and Radiating to Back. Hypertension is Most Common Predisposing factor.
Aortic Dissection. Tx?
Aortic Dissection. Tx? Type A dissections - Ascending aorta - Tx medical and surgery. Type B dissections - Decending aorta - Tx - Medical therapy alone. BB is most appropriate initial Tx for acute aortic dissection. Nifedipine (CCB) - vasodilates to decrease blood pressure - can induce reflex tachycardia, which would increase aortic shear stress.
Atrial fibrillation on EKG?
Atrial fibrillation on EKG? Irregularly irregular R-R interval with absent P waves and Narrow QRS complexes. Unstable pts, Immediate cardioversion. Stable pt Less than 48 Hours, Cardioversion. Stable with More than 48 Hours, 3-4 weeks of Rate control and Anticoagulation should be precede cardioversion. Unstable - Low BP, Altered Mental Status. Rate control - BB, or CCB (Diltiazem).
Causes of Peripheral edema?
Causes of Peripheral edema? 1 CHF, 2 Liver Disease, 3 Renal Disease, 4 Venous Insufficiency, 5 Drug (Amlodipine - Dihydropyridine CCB)
Chest pain in young women common cause?
Chest pain in young women common cause? Anxiety and other Psychological factors. High Risk pt, more likely to be Positive and False Negative. Low Risk pt, more likely to be Negative and False Positive.
CHF px? Cause in Young healthy?
CHF px? Cause in Young healthy? Paroxysmal Nocturnal dyspnea, Dyspnea on Exertion, Peripheral edema, Hepatomegaly, Cardiomegaly, Bilateral Pleural effusions, and Third Heart sound. CHF Cause in Young healthy pt - Myocarditis - Viral Infection - Coxsackie B virus is Most common cause.
Cirrhosis triad?
Cirrhosis triad? Hepatomegaly, Splenomegaly, and Ascites.
Cocaine Related Cardiac Ischemia Tx?
Cocaine Related Cardiac Ischemia Tx? First line Tx - 1 Benzodiazepines (Reduce anxiety, hypertension, and tachycardia), 2 Nitrates (Vasodilators), and 3 Aspirin (retards thrombus formation).
Contraindication for Renal replacement therapy in end stage renal disease?
Contraindication for Renal replacement therapy in end stage renal disease? 1 Debilitating Chronic disease, 2 Severe irreversible dementia.
Contrast Vasovagal, Cardiac Arrhythmia, and Autonomic dysfunction Syncope?
Contrast Vasovagal, Cardiac Arrhythmia, and Autonomic dysfunction Syncope? Vasovagal (aka Fainting spell. Trigger - Emotional reaction, Preceded by Presyncopal Dizziness, Weakness, and nausea). Cardiac Arrhythmia (Sudden onset of syncope without warning signs, Structural heart disease [Post-infarction scar and probable mitral regurgitation because of characteristic murmur], and frequent Ectopic beats. HCTZ can cause electrolyte disturbances predisposing to Ventricular arrhythmia). Autonomic dysfunction or Drug-induced postural hypotension (orthostatic. Occurs while standing up. Body position change)
Dangerous complication of Marfan syndrome?
Dangerous complication of Marfan syndrome? Aortic dissection. Px - tearing chest pain that radiates to back and neck, and it must be identified immediately to decrease risk of death. Common exam finding - Early diastoic murmur - dissection causes aortic regurgitation.
Decending Aorta on MRI chest position?
Decending Aorta on MRI chest position? Decending is close to Spine.
Digoxin class? function?
Digoxin class? function? Digoxin is cardiac glycoside - slows AV node condution.
Distinguish between Seizure, Syncopal event, and Orthostatic Hypotension?
Distinguish between Seizure, Syncopal event, and Orthostatic Hypotension? Seizure (Loss of Consciousness, Post-Ictal state of Clouded Sensorium). Syncopal Event (Rapidly return to their baseline mental status after syncopal event). Orthostatic Hypotension symtoms - Drop in blood pressure after standing. Lightheaded or Presyncopal sensation prior to losing consciousness.Stress and Poor Sleeping are common Seizure triggers. Seizure - Tongue biting, Sore muscles. New Onset Seizure evaluated with CBC, Comprehensive Metabolic Panel, Drug Screen, EEG, and Brain MRI.
Ehlers-Danlos syndrome problem?
Ehlers-Danlos syndrome problem? Connective tissue disease involving Collagen - Predispose to Aortic Dissection. Aortic Dissection in Young patient.
Epigastric pain. What to suspect?
Epigastric pain. What to suspect? Ischemic cardiac pain can sometimes be mistaken for epigastric pain, but should remain high on differential, especially in setting of symptoms worsened with exertion. An exercise stress test without imaging is most reasonable first step if baseline resting EKG is normal.
Hepatomegaly, Splenomegaly, Ascites. Dx?
Hepatomegaly, Splenomegaly, Ascites. Dx? Cirrhosis
High-output heart failure caues?
High-output heart failure caues? Supranormal ventricular function that cannot meet body metabolic demand. Causes - Anemia, Hyperthyroidism, Beriberi, Paget's disease, and Arteriovenous fistulas.
Hydralazine function?
Hydralazine function? Vasodilates
In a pt with an MI who develops a Cold leg. Next Step?
In a pt with an MI who develops a Cold leg. Next Step? Cold leg due to embolus and block artery (No Distal pulses and leg appears mottled). Get Echo to Rule out a thrombus in the Left Ventricle. In DVT Leg is Swollen and Pulses will be present.
Indication for Renal replacement therapy in end stage renal disease?
Indication for Renal replacement therapy in end stage renal disease? Renal replacement therapy (dialysis) in end stage renal disease Absolute indication - 1 Fluid overload not responsive to medical tx, 2 Hyperkalemia not responsive to medical management, 3 Uremic pericarditis, 4 Refractory metabolic acidosis.
Indictions for surgery in AAA?
Indictions for surgery in AAA? Diameter Greater than 5 cm, Presence of Symptoms, or Rapid Rate of Growth. Medical Management - Smoking cessation is intervention with greatest likelihood of slowing progression.
Lidocaine? Tx for?
Lidocaine? Tx for? class 1B anti-arrhythmic - effective against a variety of ventricular arrhythmias and wide therapeutic-to-toxic ratio. Control complex forms of ventricular arrhythmia (V tachy) in pt with ACS. Prophylactic use to prevent V fibrillation with MI is discouraged. Lidocaine can increase risk of Asystole. Lidocaine not use prophylactically in ACS. Use Decreases risk of V Fibrillation, it may Increase risk of Asystole.
Marfan syndrome genetic mutation?
Marfan syndrome genetic mutation? Fibrillin Gene mutation Weakened connective tissue. Increased risk of Aortic Dissection. Aortic Dissection in Young patient.
Marfanoid habitus?
Marfanoid habitus? Fibrillin defects. Px - Ligamentous laxity of joints, long thin digits and limbs, blood vessel fragility, spontaneous pneumothorax, pectus excavatum, mitral valve prolapse, and regurgitation, and retinal detachment.
Nephrotic syndrome triad?
Nephrotic syndrome triad? Proteinuria, Edema, Hyperlipidemia. Can cause Ascites. Typically causes Anasarca as well due to severe hypoalbuminemia
Nifedipine med class?
Nifedipine med class? CCB - vasodilate.
Orthostatic Hypotension symtoms?
Orthostatic Hypotension symtoms? Drop in blood pressure after standing. Lightheaded or Presyncopal sensation prior to losing consciousness.
Pericardial Effusions vs Pericardial Tamponade?
Pericardial Effusions vs Pericardial Tamponade? Pericardial effusion (earlier stage, while cardiac sac can expand. Large pericardial effusions appear on CXR as enlarged and globular-appearing cardiac shadow - Water Bottle heart shape. Low Voltage amplitude on EKG. Distant heart sounds, Diffuse point of maximal impulse - hard to palpate apex.) Cariac tamponade (pericardial space can no longer stretch. Decreased Venous return to Right Atrial, and Decreased Cardiac Output from Left ventricle. Hypotension, Right heart failure - JVD, Pulmonary edema, Tachycardia, Pulsus paradoxus)
Pericarditis Tx?
Pericarditis Tx? NSAID (sometimes Corticosteroids) for most cases of Pericarditis, but Not Uremic Pericarditis.
Peripheral Edema- contrast CHF, Liver Disease, Renal Disease, Venous Insufficiency, Drug?
Peripheral Edema- contrast CHF, Liver Disease, Renal Disease, Venous Insufficiency, Drug? CHF (Dyspnea, Orthopnea, JVD, Liver enlargement). Liver Disease (Ascites, Abnormal LFT, Hypoalbuminemia, Hyperbilirubinemia). Renal Diseases (Massive Proteinuria - nephrotic syndrome, Fluid retention - acute nephritic syndrome, hypoalbuminemia, high creatinine level). Venous insufficiency (skin changes, varicosities), Drugs (Amlodipiine - Dihydropyridine CCB).
Procainamide class?
Procainamide class? Class 1A anti-arrhythmic
Prolonged QRS complex. Dx?
Prolonged QRS complex. Dx? Bundle Branch block - below AV node and impedes ventricular depolarization. Prolonged QRS complex.
Prolonged tachysystolic atrial fibrillation tx?
Prolonged tachysystolic atrial fibrillation tx? LV dilation and depressed ejection fraction. LV dysfunction results from Tachycardia, Neurohumoral activation, absense of an atrial Kick (25 perc of LVEDV) and AV desynchronization. Rate and Rhythm Control improves LV function significantly.
Pt with WPW syndrome who develops atrial fibrillation with rapid ventricular rate. Tx?
Pt with WPW syndrome who develops atrial fibrillation with rapid ventricular rate. Tx? Cardioversion or antiarrhythmics like Procainamide. AV nodal blockers (BB, CCB, Digoxin, and Adenosine - used in general a fib and rapid ventricular rate tx) should be avoided because they can cause increased conductance through accessory pathway.
Pulsus bisferiens. Px?
Pulsus bisferiens. Px? Biphasic pulse - two strong systolic peaks of aortic pulse from left ventricular ejection separated by midsystolic dip. May be seen in Aortic Regurgitation with or without Aortic Stenosis, and HOCM.
Rhematic fever in childhood. Chronic genitourinary infection. What can cystoscopy cause?
Rhematic fever in childhood. Chronic genitourinary infection. What can cystoscopy cause? Cystoscopy can cause Enterococcal Bacteremia (Endocarditis) in patients with Chronic Genitourinary infections and have underlying valvular lesions.
Strep Viridans endocarditis Tx?
Strep Viridans endocarditis Tx? IV penicillin G or IV ceftriaxone.
Supraventricular tachycardia Tx?
Supraventricular tachycardia Tx? Hemodynamically stable SVT (Narrow complex) Tx - Vagal Maneuvers, followed by Adenosine, and AV nodal blockers. Unstable - DC cardioversion.
Syncope in a young patient with Crescendo-Decrescendo murmur at Lower Left Sternal border. Dx?
Syncope in a young patient with Crescendo-Decrescendo murmur at Lower Left Sternal border. Dx? Hypertrophic Cardiomyopathy. Syncope in HOCM is multifactorial - Outflow obstruction, Arrhythmia, Ischemia, and Ventricular Baroreceptor Response that Inappropriately causes vasodilation
Tamponade triad?
Tamponade triad? Hypotentioin, Distended neck Veins (JVD), Muffled heart sounds. Also, Pulsus paradoxus.
Vasovagal syncope Lx?
Vasovagal syncope Lx? Aka Common Faint. Most common cause of syncope. Neurally mediated or neurocardiogenic syncope. Prodrome (Lightheadness, Weakness, Blurred vision), Provocation by an emotional situation, and Rapid recovery of consciousness. Frequently recurrent. Upright Tilt table testing confirm diagnosis. Pharmacologic provocation - Isoproterenol.
Ventricular preexcitation leads to?
Ventricular preexcitation leads to? Premature ventricular complexes (PVC)
Verapamil class?
Verapamil class? Verapamil is CCB. Slows AV node conduction.
What are different types of leg edema?
What are different types of leg edema? Peripheral edema is either 1 Pitting (Vascular Pressure differences), or 2 Non-Pitting (Obstruction or Decreased Flow in Lymphatic system). Bilateral lower extremity pitting edema may be a sign of Hypoalbuminemia due to Decreased Oncotic pressure secondary to malnutrition.
What are Right Ventricular failure physical finding?
What are Right Ventricular failure physical finding? Elevated Jugular Venous Pressure, Hepatosplenomegaly, Ascites, and Peripheral Edema.
What does Asymmetrically elevated blood pressure in Left arm suggest?
What does Asymmetrically elevated blood pressure in Left arm suggest? Subclavian artery stenosis.
What does Asymmetrically elevated blood pressure in Right arm suggest?
What does Asymmetrically elevated blood pressure in Right arm suggest? Or elevated blood pressure in arms greater than legs - suggest Coarctation
What does Continuous murmur in the paraumbilical area to the right shows?
What does Continuous murmur in the paraumbilical area to the right shows? Renal Artery Stenosis.
What does Pulmonary Artery systolic pressure reflects?
What does Pulmonary Artery systolic pressure reflects? Right Ventricular pressure. Elevation in Pulmonary hypertension (pulmonary diseases), leading to RV hypertrophy, and RV failure.
What does Pulmonary Capillary Wedge Pressure reflects?
What does Pulmonary Capillary Wedge Pressure reflects? Left Atrial Pressure. It is elevated in Left Ventricular Failure.
What electrolyte abnormality is a bad prognostic factor in heart failure?
What electrolyte abnormality is a bad prognostic factor in heart failure? Hyponatremia is a bad prognostic factor in heart failure. It show Severe Heart Failure and a High level of Neurohumoral activation. Other abnormality is Hypo- and Hyperkalemia - activity of Renin-Angiotensin-Aldosterone system, or due to Different Drugs and Drug combinations.
What is Amlodipine med class?
What is Amlodipine med class? Dihydropyridine CCB - can cause Peripheral Edema by dilating peripheral blood vessels.
What is anasarca? What disease cause it?
What is anasarca? What disease cause it? Anasarca is extreme generalized edema - widespread swelling of skin due to effusion of fluid into extracellular space. Usually cause by Liver Failure (Cirrhosis), or Renal Failure (Nephrotic syndrome), Severe Malnutrition or Protein deficiency.
What is another name for Prinzmetal Angina?
What is another name for Prinzmetal Angina? Variant Angina.
What is another name for reentrant ventricular arrhythmia?
What is another name for reentrant ventricular arrhythmia? Ventricular fibrillation.
What is another name for Variant Angina? Tx?
What is another name for Variant Angina? Tx? Prinzmetal Angina. Tx - CCB (Diltiazem), Nitrates to prevent Coronary Vasoconstriction. Nonselective BB and Aspirin should be Avoided because they can promote Vasoconstriciton.
What is another name for ventricular fibrillation?
What is another name for ventricular fibrillation? reentrant ventricular arrhythmia.
What is effect of arterial vasodilation on heart?
What is effect of arterial vasodilation on heart? Arterial vasodilation resulting in modest decrease in afterload and myocardial oxygen consumption.
What is importance of flat neck vein?
What is importance of flat neck vein? Flat neck veins and hypotension shows Hypovolumia.
What is in metabolic syndrome?
What is in metabolic syndrome? Hypertension, Dyslipidemia, Abdominal Obesity.
What is inheritance of HOCM?
What is inheritance of HOCM? Autosomnal Dominant.
What is Kussmaul sign?
What is Kussmaul sign? Increase in Jugular venous pressure in response to Deep inspiration. Seen in 1 Right Ventricular Failure, Constrictive pericaritis, 3 Restrictive cardiomyopath, 4 Right Ventricular infarction
What is most common cause of ascites?
What is most common cause of ascites? Portal hypertension is most common cause of ascites. Portal hypertension usually due to Cirrhosis from Chronic liver disease (alcoholic or viral). IV drug user predisposes to cirrhosis by putting individuals at increase risk for chronic infection with Hepatitis B or C.
What is most common cause of death in pt with acute myocardial infarction?
What is most common cause of death in pt with acute myocardial infarction? reentrant ventricular arrhythmia (ventricular fibrillation).
What is Nitrates function? How does it help chest pain?
What is Nitrates function? How does it help chest pain? Nitrates cause Venodilation - Improves cardiac chest pain by reducing cardiac preload (decrease left ventricular volume) and thus decreasing myocardial oxygen demand.
What is Pulsus parvus et tardus? Dx?
What is Pulsus parvus et tardus? Dx? Carotid pulse that is Slow (parvus) and late (tardus). In Aortic Stenosis.
What is Second degree heart block?
What is Second degree heart block? Mobitz 1 - PR interval gradually lengthens until a drop beat (QRS). Mobitz 1 is AV node dysfunction (Impaired AV node conduction). Mobitz 2 - PR intervals constant length before dropped beat.
What is sick sinus syndrome?
What is sick sinus syndrome? Impaired SA node automaticity (aka Sick sinus syndrome) - fibrosis of sinus node or disease of SA nodal artery. Bradycardia, Lightheadedness, Syncope. EKG - Tachycardia-bradycardia syndrome (bursts of atrial tachyarrhythmia followed by bradycardia).
What is the most common cause of secondary hypertension? Lx?
What is the most common cause of secondary hypertension? Lx? Renal artery stenosis is most cmmon cause of secondary hypertension, particularly in pt with evidence of Atherosclerotic disease elsewhere in the body. Lx - A continuous periumbilical murmur is a helpful physical finding in the presence of renal artery stenosis.
What is the normal liver on physical exam?
What is the normal liver on physical exam? What is normal spleen on physical exam? Normal Liver is not palpable below costal margin. Normal Spleen is not palpable on physical exam.
What is the Strongest Influence on Long term prognosis following an STEMI?
What is the Strongest Influence on Long term prognosis following an STEMI? The duration of Time that passes before Coronary blood flow is restored (via PTCA or Fibrinolysis)
When to get esophageal motility studies?
When to get esophageal motility studies? Pt with Dysphagia or Suspected Diffuse Esophageal Spasm or Nutcracker Esophagus.
What is the cause of myopathy with statin?
What is the cause of myopathy with statin? Decrease in synthesis of non-cholesterol products may be responsible for some adverse effects of statin. Reduced CoQ10 production is implicated in pathogenesis of statin-induced myopathy.
55 yo caucasian male - muscle pain of recent onset. Px hypertension and acute myocardial infarction experienced 2 months ago. Med metoprolol, captopril, aspirin and simvastatin. LFT slightly abnormal. Serum creatine kinase level is elevated. You suspect Drug-induced reaction. Which of the following is the most possible mechanism of drug-induced reaction in this patient?
55 yo caucasian male - muscle pain of recent onset. Px hypertension and acute myocardial infarction experienced 2 months ago. Med metoprolol, captopril, aspirin and simvastatin. LFT slightly abnormal. Serum creatine kinase level is elevated. You suspect Drug-induced reaction. Which of the following is the most possible mechanism of drug-induced reaction in this patient? Synthetic reaction inhibition
What medication has cell surface receptor blockage and extracellular enzyme blockage?
What medication has cell surface receptor blockage and extracellular enzyme blockage? effects produced by BB and ACEI respectively.
What is anasarca? General reasons anasarca? Causes of each reason?
What is anasarca? General reasons anasarca? Causes of each reason? Anasarca is generalized edema (Pulmonary edema, Ascities, Swollen extremities). General reasons for anasarca - 1 Increased capillary hydrostatic pressure, 2 Hypoaluminemia, 3 Increased capillary permeability, 4 Lymphatic obstruction or Increased oncotic pressure. Cause of each reason - 1 Increased capillary hydrostatic pressure (aaa Heart Failure - Left ventricle and Cor pulmonale, bbb Primary renal sodium retention - renal disease, drugs, and pregnancy, ccc Venous obstruction - Cirrhosis, Acute pulmonary edema, and Venous Insufficiency), 2 Hypoaluminemia (aaa Protein loss - Nephrotic syndrome and GI tract losses, bbb Decreased albumin synthesis - Cirrhosis and Malnutrition), 3 Increased capillary permeability (aaa Burns, Trauma, and Sepsis, bbb Allergic reactions, ccc Adult Respiratory distress syndrome, ddd Malignant ascities), 4 Lymphatic obstruction or Increased oncotic pressure (aaa Malignant Ascites, bbb Hypothyroidism).
Increased capillary hydrostatic pressure . Cause?
Increased capillary hydrostatic pressure . Cause? aaa Heart Failure - Left ventricle and Cor pulmonale, bbb Primary renal sodium retention - renal disease, drugs, and pregnancy, ccc Venous obstruction - Cirrhosis, Acute pulmonary edema, and Venous Insufficiency
Hypoaluminemia . Cause?
Hypoaluminemia . Cause? aaa Protein loss - Nephrotic syndrome and GI tract losses, bbb Decreased albumin synthesis - Cirrhosis and Malnutrition
Increased capillary permeability . Cause?
Increased capillary permeability . Cause? aaa Burns, Trauma, and Sepsis, bbb Allergic reactions, ccc Adult Respiratory distress syndrome, ddd Malignant ascities
Lymphatic obstruction or Increased oncotic pressure . Cause?
Lymphatic obstruction or Increased oncotic pressure . Cause? aaa Malignant Ascites, bbb Hypothyroidism
45 yo man in ER due to dyspnea, fatigue, poor appetite, and weight gain over past several weeks. Began to develop worsening shortness of breath with exertion about 4 weeks ago and has been waking at night with breathlessness more recently. Difficult to open eyes in the morning due to facial edema. Bp 200 over 120 and Pulse 100. Generalized bodily edema and distention of his jugular veins while he is sitting upright. Lung auscultation reveals bibasilar crackles. Urinalysis shows trace protein, no nitrites, trace leukocyte esterase, 50 plus RBCs, and occasional neutrophils. Most likely mechanism of this patients's edema?
45 yo man in ER due to dyspnea, fatigue, poor appetite, and weight gain over past several weeks. Began to develop worsening shortness of breath with exertion about 4 weeks ago and has been waking at night with breathlessness more recently. Difficult to open eyes in the morning due to facial edema. Bp 200 over 120 and Pulse 100. Generalized bodily edema and distention of his jugular veins while he is sitting upright. Lung auscultation reveals bibasilar crackles. Urinalysis shows trace protein, no nitrites, trace leukocyte esterase, 50 plus RBCs, and occasional neutrophils. Most likely mechanism of this patients's edema? Primary Glomerular damage. Generalized edema (anasarca) - pulmonary edema, ascites, swollen extremities. Hypoalbuminemia can be cause, but pt has Increased capillary hydrostatic pressure. Microscopic hematuria favors a diagnosis of acute glomerulonephritis, and edema usually results from glomerular damage and a decreased glomerular filtration rate (GFR). Glomerular disease can clinically present with signs of significant volume overload, including pulmonary edema, distended neck veins, and anasarca. Urine sediment in glomerulonephritis can show RBCs, RBC casts, and possibly WBCs. As the volume increases from third spacing, the GFR drops, leading to further renal sodium retention. This inicreased volume can also cause a significant rise in bp. Pt can also have significant proteinuria, which further contributes to their edema. Pt has only trace protein on urinalysis, meaning that the majority of his edema is secondary to a decreased GFR. Decreased GFR is also the cause of edema in pt with end-stage renal disease.
What is Anasarca typically results from?
What is Anasarca typically results from? 1 Organ Failure or 2 Hypoalbuminemia.
Glomerulonephritis reasons for edema?
Glomerulonephritis reasons for edema? Decreased glomerular filtration rate as well as Proteiinuria and Hypoalbuminemia in some cases.
What murmur is pansystolic murmur loudest at apex and radiates to axilla? What is most common cause? What can it lead to?
What murmur is pansystolic murmur loudest at apex and radiates to axilla? What is most common cause? What can it lead to? Mitral Regurgitation and MVP. MVP is MCC of Mitral Regurgitation. Mitral regurgitation can lead to Left Atrial Dilation and Atrial Fibrillation.
What is most common site of thoracic aortic aneurysms? What is second most common? Which one show as well circumscribed lesion? Cause? Risk of surgery?
What is most common site of thoracic aortic aneurysms? What is second most common? Which one show as well circumscribed lesion? Cause? Risk of surgery? MCC Ascending aorta. Second MCC is Descending aorta. Decending Aortic Aneurysm show Well circumscribed lesion (Arch down right middle, parallel to lateral chest wall.) Descending Aortic Aneurysm are usually fusiform and due to Atherosclerosis. Pt with Decending aortic aneurysm also have abdominal aortic aneurysms. Risk of surgery is in large part related to associated coronary artery or lung disease.
What are PVC? Tx?
What are PVC? Tx? PVC are common in pt Post-MI and can be recognized by their Widened QRS (More than 120 msec), Bizarre morphology, and compensatory pause. Even though they may indicate a worse prognosis, treatment is not indicated unless symptomatic. Tx - Asymptomatic - None. Tx - Symptomatic - BB.
What is nifedipine class? Can be used in ACS?
What is nifedipine class? Can be used in ACS? Nifedipine is Dihydropyridine CCB. Nifedipine can worsen cardiac ischemia since they cause peripheral vasodilation and reflex tachycardia. Nifedipine is contraindicated in pt with acute coronary syndrome. Non-dihydropyridine CCB (Diltiazem and Verapamil) can be used in STEMI after BB, but they do not improve mortality.
47 yo white female occasional episodes of nocturnal substernal chest pain that wakes her up during sleep. Pain episodes last 15-20 minutes and resolve spontaneously. Sedentary lifestyle, but climb two flights of stairs without any discomfort. No history of hypertension or diabetes. ECG shows transient ST segment elevation in leads 1, aVL, and V4-V6 during the episodes. Best Tx?
47 yo white female occasional episodes of nocturnal substernal chest pain that wakes her up during sleep. Pain episodes last 15-20 minutes and resolve spontaneously. Sedentary lifestyle, but climb two flights of stairs without any discomfort. No history of hypertension or diabetes. ECG shows transient ST segment elevation in leads 1, aVL, and V4-V6 during the episodes. Best Tx? Variant angina Tx - CCB and_or nitrates to prevent coronary vasoconstriction. Nonselective BB and aspirin should be avoided because they can promote vasoconstriction. Variant angina greatest risk factor is Smoking. Lacks cardiovascular risk factors. Episodes occur at Night (from midnight to 8 am) and can be associated with transient ST elevation on ECG.
What is characterisitc of hyperdynamic type of septic shock?
What is characterisitc of hyperdynamic type of septic shock? 1 An Elevated Cardiac Output, 2 Low systemic vascular resistance, Right atrial pressure and pulmonary capillary wedge pressure, and 3 Frequently normal mixed venous oxygen concentration.
53 yo white female in ER with hypotension. Very serious condition, and invasive hemodynamic monitoring is established. Bp by intra-arterial method is 72 by 46. HR 120, regular. PCWP using Swan-Ganz catheter is 6. Mixed venous oxygen concentration is 16 vol perc (normal = 15.5 vol perc). Most likely cause of pt condition?
53 yo white female in ER with hypotension. Very serious condition, and invasive hemodynamic monitoring is established. Bp by intra-arterial method is 72 by 46. HR 120, regular. PCWP using Swan-Ganz catheter is 6. Mixed venous oxygen concentration is 16 vol perc (normal = 15.5 vol perc). Most likely cause of pt condition? Septic shock - a form of distributive shock results from Decreased systemic vascular resistance due to significant vasodilatation. Hyperdynamic circulation can be observed during septic shock, leading to an elevated cardiac output. Normal MVo2 can be observed in pts with Septic shock, and results from hyperdynamic circulation and improper distribution of cardiac output. It is not indicative of normal tissue perfusion in this case.
What does low mixed venous oxygen concentration means?
What does low mixed venous oxygen concentration means? Increased oxygen extraction by hypoperfused tissues. It is seem in 1 Hypovolemic shock, and 2 Neurogenic shock.
Enhance natriuresis, Decreases serum angiotensin 2 concentration, Decrease aldosterone production. Antihypertensive Medication?
Enhance natriuresis, Decreases serum angiotensin 2 concentration, Decrease aldosterone production. Antihypertensive Medication? Direct Renin Inhibitor. Renin-Angiotensin-Aldosterone system is important for hypertension. Renin is produced in Juxtaglomerular cells of kidney in response to hypoperfusion. Renin cleaves angiotensinogen into angiotensin 1. Angiotensin 1 is converted into angiotensin 2 by angiotensin converting enzyme in lung. Angiotensin 2 is a potent vasoconstrictor. It promotes vasopressin (ADH) release from pituitary and aldosterone production in adrenal cortex. Aldosterone acts on distal convoluted tubules and collecting ducts to promote sodium and water resorption from kidneys. Net result of activation of this system is an increase in blood pressure, total body sodium, total body water, and blood volume.
Describe Renin-Angiotensin-Alodosterone system.
Describe Renin-Angiotensin-Alodosterone system. Renin is produced in Juxtaglomerular cells of kidney in response to hypoperfusion. Renin cleaves angiotensinogen into angiotensin 1. Angiotensin 1 is converted into angiotensin 2 by angiotensin converting enzyme in lung. Angiotensin 2 is a potent vasoconstrictor. It promotes vasopressin (ADH) release from pituitary and aldosterone production in adrenal cortex. Aldosterone acts on distal convoluted tubules and collecting ducts to promote sodium and water resorption from kidneys. Net result of activation of this system is an increase in blood pressure, total body sodium, total body water, and blood volume.
What does ARB cause in term of natriuresis, serum angiotensin 2 concentration, and aldosterone production?
What does ARB cause in term of natriuresis, serum angiotensin 2 concentration, and aldosterone production? ARB prevent angiotensin 2 from acting on angiotensin receptors. ARB Increase natriuresis, No Change in serum angiotensin 2 concentration, and Decrease aldosterone production
What does Aldosterone receptor antagonist cause in term of natriuresis, serum angiotensin 2 concentration, and aldosterone production?
What does Aldosterone receptor antagonist cause in term of natriuresis, serum angiotensin 2 concentration, and aldosterone production? Aldosterone receptor antagonist Increase natriuresis, No Change in serum angiotensin 2 concentration, and No Change in serum aldosterone production
What are 3 most common causes of aortic stenosis?
What are 3 most common causes of aortic stenosis? 1 Senile calcific aortic stenosis (Above 70 yo), 2 Bicuspid aortic valve, and 3 Rheumatic heart disease. Bicuspid aortic valve is cause of aortic stenosis in majjority of pt under 70 yo.
48 yo white male with progressive exertional dyspnea. getting bothersome over past 2 months. short of breath after climbing one flight of stairs. Harsh systolic murmur best heard at right second intercostal space with radiation along carotid arteries. S4 heard at apex. Most likely cause of pt smptoms?
48 yo white male with progressive exertional dyspnea. getting bothersome over past 2 months. short of breath after climbing one flight of stairs. Harsh systolic murmur best heard at right second intercostal space with radiation along carotid arteries. S4 heard at apex. Most likely cause of pt smptoms? Bicuspid aortic valve (under 70 yo) cause aortic stenosis.
ST Elevation in leads 2, 3, and aVF. Dx? What vessel? Symptom?
ST Elevation in leads 2, 3, and aVF. Dx? What vessel? Symptom? ST Elevation in Inferior leads 2, 3, and aVF suggest Acute Inferior Wall Myocardial Infarction. IWMI - Occlusion of either 1 Right Coronary Artery (Majority), or 2 Left Circumflex Artery. Inferior MI with Right Ventricular Infarction is always Right Coronary Artery. Bradycardia and Hypotension suggest involvement of SA node and Right Ventricle.
Anterior Wall MI. Artery occlusion?
Anterior Wall MI. Artery occlusion? Left Anterior Descending Artery occlusion causes Anterior Wall MI.
Inferior Wall MI. Artery occlusion - general?
Inferior Wall MI. Artery occlusion - general? Right Coronary Artery occlusion in Inferior Wall MI.
46 yo man collapsed while getting out of bed. Feeling weak over last several days and complained of vague chest discomfort. Respiratory infection symptoms without doctor visit. Blood cholesterol was 200. ECG show electrical alternans. Best initial management?
46 yo man collapsed while getting out of bed. Feeling weak over last several days and complained of vague chest discomfort. Respiratory infection symptoms without doctor visit. Blood cholesterol was 200. ECG show electrical alternans. Best initial management? Pericardiocentesis. Pericarditis from an URI causing a pericardial effusion. Cardiac tamponade is a grave condition - Hypotension, Tachycardia, and Distended Jugular Veins. Electrical alternana - amplitude of QRS alternates as heart moves in fluid-filled pericardial sac. Tx - Massive volume resuscitation and emergent Pericardiocentesis.
Electrical alternans. Dx?
Electrical alternans. Dx? One QRS amplitude is Tall, and next is short. Cardiac Tamponade.
53 yo man with weakness and exertional dyspnea over last week. Father died of MI at age 55. Heart rate is 100 and bp is 90 over 60. Internal jugular venous pulsation is observed 7 cm above sternal angle. Heart sounds are muffled. Most likely cause of this pt complaints?
53 yo man with weakness and exertional dyspnea over last week. Father died of MI at age 55. Heart rate is 100 and bp is 90 over 60. Internal jugular venous pulsation is observed 7 cm above sternal angle. Heart sounds are muffled. Most likely cause of this pt complaints? Decreased Left Ventricular Preload. Cardiac Tamponade - Pulsus paradoxus, Beck Triad (Hypotension, Jugular Venous Distension, and Muffled Heart Sound). Pericardial space fills with fluid, Ventricles are less able to oexpand to accept venous return to heart. Overall preload to heart decreases.
Decreased cardiac contractility. Dx?
Decreased cardiac contractility. Dx? Systolic heart failure. Sign of both LV failure (Crackles on pulmonary exam and S3), and RV failure (JVD and peripheral edema).
Left Ventricular outflow obstruction. Dx?
Left Ventricular outflow obstruction. Dx? Critical Aortic Stenosis, or from HOCM.
Heart sound like ken-tuc-KY. Dx?
Heart sound like ken-tuc-KY. Dx? S3. LV failure. Intravenous diuretics provide symptomatic benefits with decompensated heart failure.
Describe S3?
Describe S3? ken-tuc-KY
32 yo man in ER with three day history of fever, cough, and weakness. Bp 120 over 80, and HR 110. Multiple needle tracks on his arms. CXR shows scattered round lesions in peripheral lung fields bilaterally. Urinalysis is positive for 2+ protein. Most likely accompanying findings?
32 yo man in ER with three day history of fever, cough, and weakness. Bp 120 over 80, and HR 110. Multiple needle tracks on his arms. CXR shows scattered round lesions in peripheral lung fields bilaterally. Urinalysis is positive for 2+ protein. Most likely accompanying findings? Systolic murmur that Increases on Inspiration. IV drug abuse has increased risk for subacute bacterial endocarditis (SBE) of both the right and left heart. If tricuspid or pulmonic valve is affected, SBE can present with embolic phenomena to lung. SBE must be in differential for all IV drug abusers presenting with fever and malaise.
Septic emboli to lung symptom?
Septic emboli to lung symptom? cough, chest pain, and hemoptysis, and produce numerous round alveolar infiltrates on CXR.
Septic emboli to kidney symptom?
Septic emboli to kidney symptom? proteinuria.
Heart sound - paradoxical splitting of second heart sound (S2). Dx?
Heart sound - paradoxical splitting of second heart sound (S2). Dx? Left bundle branch block (LBBB) due to delayed closure of aortic valve.
EKG with regular, narrow QRS complex tachycardia without definite P wave. Dx? Tx?
EKG with regular, narrow QRS complex tachycardia without definite P wave. Dx? Tx? SVT. SVT cause by either Atrioventricular nodal reentrant tachycardia (AVNRT), or Atrioventricular reentrant tachycardia (AVRT). Tx - Adenosine is TOC and often terminates arrhythmia, serving both diagnostic and therapeutic utility
60 yo female with progressive exertional dyspnea and new-onset ankle swelling. Recently worked up for proteinuria and easy bruisability. Ten pack-year history of smoking and drinks two to three glasses of wine every day. Mild jugular venous distention. Scattered bibasilar crackles. Echo shows symmetrical thickening of ventricular walls, normal ventricular dimensions and slightly reduced systolic function. Most like diagnosis?
60 yo female with progressive exertional dyspnea and new-onset ankle swelling. Recently worked up for proteinuria and easy bruisability. Ten pack-year history of smoking and drinks two to three glasses of wine every day. Mild jugular venous distention. Scattered bibasilar crackles. Echo shows symmetrical thickening of ventricular walls, normal ventricular dimensions and slightly reduced systolic function. Most like diagnosis? Amyloidosis is a restrictive cardiomyopathy with thickened ventricular walls and preserved ventricular dimensions, as well as involvement of liver (bruisability) and kidneys (proteinuria).
Amyloidosis common causes? effect on organs?
Amyloidosis common causes? effect on organs? Multiple myeloma (AL amyloidosis), and chronic inflammatory diseases (Rheumatoid arthritis - AA amyloidosis). Amyloidosis effect on organs - Kidney (proteinuria), Liver (inhibit synthesis of coagulation factors - bruisability), Heart (restrictive cardiomyopathy with thickened ventricular walls and diastolic dysfunction.)
Hemochromatosis symptoms?
Hemochromatosis symptoms? Restrictive cardiomyopathy. Classic findings - Pancreatic dysfunction, Bronzed skin, and Hepatomegaly.
Sarcoidosis symptoms?
Sarcoidosis symptoms? Restrictive cardiomyopathy. More common in African-Americans and usually presents in pt in their 20s-30s. Bilateral hilar adenopathy and erythema nodosum are classic findings.
Contrast constrictive pericarditis and restrictive cardiomyopathy.
Contrast constrictive pericarditis and restrictive cardiomyopathy. Restrictive cardiomyopathy has Increased wall thickness and extracardiac manifestations.
Inotropic effect?
Inotropic effect? Contractility
Dromotropic effect?
Dromotropic effect? Nerve - AV condution
Alcoholism Lx?
Alcoholism Lx? Alcoholism - 1 Thrombocytopenia, 2 Macrocytosis, and 3 Elevated Transminases
64 yo male in ER with chest pain. ST elevations in leads 2, 3, and aVF. Thrombolytic therapy and heparin are administered, and pain resolves. Eight hours after admission, pt develops hypotension. Bp 84 by 55. Medications include - nitroglycerin drip, beta locker, aspirin, heparin, and simvastatin. Elevated jugular venous pressure of 14 cm, cold clammy extremities, and clear lung fields. Next best step in management?
64 yo male in ER with chest pain. ST elevations in leads 2, 3, and aVF. Thrombolytic therapy and heparin are administered, and pain resolves. Eight hours after admission, pt develops hypotension. Bp 84 by 55. Medications include - nitroglycerin drip, beta locker, aspirin, heparin, and simvastatin. Elevated jugular venous pressure of 14 cm, cold clammy extremities, and clear lung fields. Next best step in management? Administer normal saline bolus and stop nitroglycerin. Clear lung fields, Hypotension, and JVD in setting of IWMI are suggestive of RV infarct. Fluid resuscitation is appropriate management, and nitrates should be avoided.
When should Nitrates avoided in ACS management?
When should Nitrates avoided in ACS management? Nitrates not indicated in Aortic stenosis, Recent Phosphodiesteraes inhibitor use, or Right ventricular infarction (IWMI).
54 yo overweight man wakes up in middle of night with substernal discomfort that describes as a burning sensation. Left sided neck pain and feels sweaty and short of breath. Never had similar pain before. Prior to going to bed he had eaten a big meal. Diabetes and hypertension. Most consistent with clinical presentation?
54 yo overweight man wakes up in middle of night with substernal discomfort that describes as a burning sensation. Left sided neck pain and feels sweaty and short of breath. Never had similar pain before. Prior to going to bed he had eaten a big meal. Diabetes and hypertension. Most consistent with clinical presentation? Fourth heart sound. Ischemic damage in setting of MI may lead to diastolic dysfunction and a stiffened left ventricle, resulting in atrial gallop (S4). New S4 is classic finding of MI.
Types of AV fistula?
Types of AV fistula? Congenital - Patent Ductus Arteriosus, Angiomas, Pulmonary AVF, CNS AVF. Acquired - Trauma, Iatrogenic (Femoral catheterization), Atherosclerosis (Aortocaval fistula), Cancer.
AVF symptoms?
AVF symptoms? effect on Systemic vascular resistance, Cardiac preload, and Cardiac output. Widened Pulse pressure, Strong Peripheral arterial pulsation (Brisk carotid upstroke), Systolic flow murmur, Tachycardia, and Usually flushed extremitites. Shunting of a large amount of blood through fistula decreases systemic vascular resistance, increases cardiac preload, and increases cardiac output.
Aortic Regurgitation symptoms and findings?
Aortic Regurgitation symptoms and findings? Early diastolic murmur. Physical signs - cause by Hyperdynamic pulse, Bounding or Water Hammer Peripheral Pulses.
ST elevation in leads 1, aVL, and V1 - V3. Dx?
ST elevation in leads 1, aVL, and V1 - V3. Dx? Anterolateral MI with Acute Mitral Regurgitation due to Papillary muscle dysfunction in pt with acute MI. Acute Mitral Regurgitation characteristically causes a rise in left atrial pressure without significant changes in left atrial size, left ventricular size or left ventricular ejection fraction. Increase in Left atrial pressure.
Ventricular aneurysm Px?
Ventricular aneurysm Px? Ventricular aneurysm is late complication of MI characterized by persistent ST elevation on ECG. Pt may have CHF, Ventricular arrhythmias, and_or thrombus formation along with mitral regurgitation.
42 yo male started on a medication for recurrent palpitation. Two weeks later, he undergoes a stress test. During the test his HR increases from 75 to 165 and QRS complex during increases from 0.09 sec to 0.13 sec. Which of the following medications has been used to treat this pt palpitations?
42 yo male started on a medication for recurrent palpitation. Two weeks later, he undergoes a stress test. During the test his HR increases from 75 to 165 and QRS complex during increases from 0.09 sec to 0.13 sec. Which of the following medications has been used to treat this pt palpitations? Flecainide. Antiarrhythmic medications with property of use-dependence are more effective at higher HR because there is not as much time between heartbeats for medication to dissociate from its receptor. This phenomenon is seen with class 1 (particularly 1C) medications such as Flecainide and class 4 medications. Class 1 medications prolong the QRS complex whereas class 4 medications do not.
Causes of Pulsus paradoxus?
Causes of Pulsus paradoxus? 1 Cardiac Tamponade, 2 Tension Pneumothorax, and 3 Severe Asthma
Cardiac cause of syncope?
Cardiac cause of syncope? Sudden onset of syncope without warning signs, Presence of structural heart disease (Post-infarction scar and probable mitral regurgitation), and Frequent ectopic beats.
Vasovagal syncope cause?
Vasovagal syncope cause? Vasovagal syncope, aka common fainting spell, usually precipitated by emotional reaction and is preceded by presyncopal dizziness, weakness and nausea.
Autonomic dysfunction syncope cause?
Autonomic dysfunction syncope cause? Autonomic dysfunction, or Drug-induced postural hypotension may cause syncope, but Orthostatic in nature. It occurs on standing up when blood is redistributed to dependent parts of body.
What is most common primary intracardiac tumor?
What is most common primary intracardiac tumor? Atrial myxoma is most common primary intracardiac tumor, and usually located in left atrium. It can cause systemic symptoms (Fever, and weight loss, neurologic symptoms due to tumor embolization, and presents as a mass on echo.
What is a sensitive indicator of pt hydration status?
What is a sensitive indicator of pt hydration status? BUN over Creatinine ratio is a useful indicator of dehydration.
Causes of Pulseless Electrical Activity?
Causes of Pulseless Electrical Activity? PEA causes 6Hs and 6Ts. H - 1 Hypovolemia, 2 Hypoxia, 3 Hydrogen ions (Acidosis), 4 Hypothermia, 5 Hypoglycemia, 6 Hyper_HypoKalemia. T - 1 Tamponade (cardiac), 2 Tension Pneumothorax, 3 Thrombosis (MI, PE), 4 Trauma (Hypovolemia), 5 Tablets (Drugs), and 6 Toxins.
What are shockable rhythm in Cardiac Arrest pt?
What are shockable rhythm in Cardiac Arrest pt? V Fib and V Tachy. Defibrillation is utilized as early as possible.
Cardiac arrest with PEA. Next step?
Cardiac arrest with PEA. Next step? Requires immediate initiation of CPR, including manual chest compression.
56 yo man in ER with dyspnea. Waking up during night with difficulty breathing and chest pain that kept him from falling back to sleep. Long-standing hypertension and non-compliance with his antihypertensive therapy. Smoked a pack of cigarettes per day for the past 30 years. Bp 170 over 100 and his HR is 120 and regular. Lung auscultation reveals bibasilar rales and scattered wheezes. Most like to relieve dyspnea?
56 yo man in ER with dyspnea. Waking up during night with difficulty breathing and chest pain that kept him from falling back to sleep. Long-standing hypertension and non-compliance with his antihypertensive therapy. Smoked a pack of cigarettes per day for the past 30 years. Bp 170 over 100 and his HR is 120 and regular. Lung auscultation reveals bibasilar rales and scattered wheezes. Most like to relieve dyspnea? Nitroglycerin. Cardiogenic pulmonary edema results from left heart failure and is characterized by crackles on pulmonary exam. Nitroglycerin is most rapidly acting medication to relieve symptoms of pulmonary edema. Nitroglycerin rapidly reduces preload.
What is situational syncope?
What is situational syncope? Middle age or older male, who loses his consciousness immediately after urination, or a man who loses his consciousness during coughing fits.
How does vagal maneuver helps PSVT?
How does vagal maneuver helps PSVT? PSVT is most commonly from accessory conduction pathways through AV node. Vagal maneuvers (Valsalva, Carotid sinus massage, Immersioon in cold water) and medications that decrease conduction through AV node often resolve PSVT. Adenosine is used as well.
Sharp x and y descents on Central Venous Tracing. Dx?
Sharp x and y descents on Central Venous Tracing. Dx? Constrictive Pericarditis. Signs of decreased cardiac output and venous overload.
Pericardial Knock. Dx?
Pericardial Knock. Dx? Constrictive pericarditis
Symptoms of decreased cardiac output?
Symptoms of decreased cardiac output? Fatigue, Dyspnea on Exertion, Muscle wasting.
Signs of Venous Overload?
Signs of Venous Overload? Elevated JVP, Ascites, Positive Kussmaul sign, Pedal Edema.
Common cause of Constrictive pericarditis?
Common cause of Constrictive pericarditis? In developing countries, Tuberculosis is common cause of Constrictive pericarditis. In US, Idiopathic or Viral (40 perc), Radiation (30 perc), Cardiac surgery (10 perc)
What does Trypanosoma Cruzi cause?
What does Trypanosoma Cruzi cause? Chagas disease. Endemic to South America and cause Megacolon, Megaesophagus, and cardiac disease.
Venous insufficiency risk factor? Complications? Tx?
Venous insufficiency risk factor? Complications? Tx? Chronic venous insufficiency risk factor - age, female, obesity, history of lower extremity surgery, and lower extremity DVT. Complications - Chronic edema, Stasis dermatitis, and Ulceration. Tx Leg elevation, Compression stockings, and Wound care.
Asthma. Hypertension initial Tx?
Asthma. Hypertension initial Tx? HCTZ is initial drug of choice in general population, and BB are relatively contraindicated with Asthma.
Diabetes. Hypertension initial Tx? ACEI are first line antihypertensive agent for pt with Diabetes, CHF, MI, and Chronic Kidney disease.
Diabetes. Hypertension initial Tx? ACEI are first line antihypertensive agent for pt with Diabetes, CHF, MI, and Chronic Kidney disease.
ACEI are first line antihypertensive agent for who?
ACEI are first line antihypertensive agent for who? 1 Diabetes, 2 CHF, 3 MI, and 4 Chronic Kidney disease.
Diabetes, CHF, MI, and Chronic Kidney disease. Hypertension Tx?
Diabetes, CHF, MI, and Chronic Kidney disease. Hypertension Tx? ACEI are first line antihypertensive agent
55 yo male in ICU after being involved in MVA. Requires exploratory laparotomy for suspected bowel perforation. Two days after surgery he remains hypotensive and requires both aggressive intravenous fluids and vasopressors to maintain his blood pressure. Fingertips are blue. All four extremities feel cold to touch. Most likely responsible?
55 yo male in ICU after being involved in MVA. Requires exploratory laparotomy for suspected bowel perforation. Two days after surgery he remains hypotensive and requires both aggressive intravenous fluids and vasopressors to maintain his blood pressure. Fingertips are blue. All four extremities feel cold to touch. Most likely responsible? Norepinephrine-induced vasospasm. Pressors (Norepinephrine) can cause ischemia of the distal fingers and toes secondary to vasospasm. Diagnosis suggested by symmetric duskiness and coolness of all fingertips. Norepinephrine has alpha-1 agonist (vasoconstriction) - increases blood pressure. Pt with decreased blood flow, vasoconstriction can result in ischemia and necrosis of distal fingers and toes. Similar phenomenon can occur in intestines (mesenteric ischemia) or kidney (renal failure).
Amiodarone med class? AE?
Amiodarone med class? AE? Amiodarone Antiarrhythmic class 3. AE - Pulmonary fibrosis, Hepatotoxicity, and Thyroid dysfunction. Pulmonary function tests, LFT, and Thyroid function tests should be monitored in pt on chronic amiodarone.
Interventricular wall rupture signs?
Interventricular wall rupture signs? Interventricular wall rupture occurs around 5 days after infarction and causes an acute Left-to-Right shunt with Right sided heart failure and New-onset systolic murmur heard best at Left lower sternal border.
Ventricular free wall rupture signs?
Ventricular free wall rupture signs? Ventricular free wall rupture occurs around 5 days after MI and causes Acute pericardial tamponade and Rapid decompensation with Pulseless electrical activity
Papillary muscle rupture signs?
Papillary muscle rupture signs? Papillary muscle rupture occurs 3-7 days after an infarct, and can cause severe Acute mitral regurgitation and Pulmonary edema.
Acute Pericarditis signs?
Acute Pericarditis signs? Acute pericarditis occurs first several days after infarction, while Dressler syndrome is Immune-mediated pericarditis that can occur Weeks to months after infarction. Diffuse ST elevations are typically present on ECG, and positional chest pain is usually primary complaint.
36 yo female in ER with chest pain that started suddenly while she was shopping at the mall. Short of breath, palpitations, and diaphoresis. Retrosternal pain and radiates to left arm. Had a runny nose, sore throat and dry cough for past 3 days. Past medical history of panic attacks, for which she takes paroxetine, and dysfunctional uterine bleeding, for which she takes estrogen. Family history of significant for suddent death of her father at age 44 from heart attack. Smoked one pack of cigarettes per day for past 15 years. Most appropriate initial therapy?
36 yo female in ER with chest pain that started suddenly while she was shopping at the mall. Short of breath, palpitations, and diaphoresis. Retrosternal pain and radiates to left arm. Had a runny nose, sore throat and dry cough for past 3 days. Past medical history of panic attacks, for which she takes paroxetine, and dysfunctional uterine bleeding, for which she takes estrogen. Family history of significant for suddent death of her father at age 44 from heart attack. Smoked one pack of cigarettes per day for past 15 years. Most appropriate initial therapy? Aspirin. Chest pain in a young person with cardiovascular risk factors (family history oac ACS at young age, Longerstanding personal history of Smoking and taking estrogen therapy, risk increased further due to Age more than 35) warrants a thorough cardiac work-up. Aspirin should be first drug administered when suspicion of coronary artery event is high due to its ability to prevent platelet aggregation.
25 yo G2, P1 at 28 weeks gestation in ER, who was found lying on her bed in a pool of blood. Very drowsy. Temp 100.4 F. Transverse lie. Perineum reveals gross blood and active bleeding per vagina. What parameters in Cardiac Output, PCWP, SVR, BP, HR?
25 yo G2, P1 at 28 weeks gestation in ER, who was found lying on her bed in a pool of blood. Very drowsy. Temp 100.4 F. Transverse lie. Perineum reveals gross blood and active bleeding per vagina. What parameters in Cardiac Output, PCWP, SVR, BP, HR? Hypovolemic shock - Decrease Cardiac Output, Decrease PCWP, Increase SVR, Decrease BP, Increase HR. Hypovolemic or Hemorrhagic shock - 1 Hypotension, 2 Tachycardia, 3 Decreased Central Venous Pressure (or PCWP), Decreased CO, and Increased Peripheral Vascular resistance.
Depressed PCWP and Normal Mixed Venous Oxygen Concentration. Dx?
Depressed PCWP and Normal Mixed Venous Oxygen Concentration. Dx? Septic shock. Septic shock has warm skin because SVR Decreased.
Shock with Increased PCWP. Dx?
Shock with Increased PCWP. Dx? Cardiogenic shock. CO - Decreased, Systemic Vascular Resistance - Increased, PCWP - Increased, Right Atrial Pressure - Increased.
Shock with Low Mixed Venous Oxygen concentration. Dx?
Shock with Low Mixed Venous Oxygen concentration. Dx? Neurogenic and Hypovolemic Shock (Increased Oxygen extraction by hypoperfused tissue). CO - Decreased, Systemic Vascular Resistance - Increased, PCWP - Decreased, Right Atrial Pressure - Decreased.
CO - Decreased, Systemic Vascular Resistance - Increased, PCWP - Increased, Right Atrial Pressure - Increased. Dx? Skin?
CO - Decreased, Systemic Vascular Resistance - Increased, PCWP - Increased, Right Atrial Pressure - Increased. Dx? Cardiogenic shock (Same for Pulmonary Edema). Cold Skin.
CO - Decreased, Systemic Vascular Resistance - Increased, PCWP - Decreased, Right Atrial Pressure - Decreased. Dx? Skin?
CO - Decreased, Systemic Vascular Resistance - Increased, PCWP - Decreased, Right Atrial Pressure - Decreased. Dx? Hypovolemic shock. Cold Skin.
CO - Increased, Systemic Vascular Resistance - Decreased, PCWP - Decreased, Right Atrial Pressure - Decreased. Dx? Skin?
CO - Increased, Systemic Vascular Resistance - Decreased, PCWP - Decreased, Right Atrial Pressure - Decreased. Dx? Septic shock. Warm Skin.
CO - Decreased, Systemic Vascular Resistance - Increased, PCWP - Decreased, Right Atrial Pressure - Increased. Dx? Skin?
CO - Decreased, Systemic Vascular Resistance - Increased, PCWP - Decreased, Right Atrial Pressure - Increased. Dx? Pulmonary HTN or Pulmonary Fibrosis. Cold Skin.
What shock has cold skin? warm skin?
What shock has cold skin? Cardiogenic, Hypovolemic, Pulmonary HTN has Cold skin. Warm skin? Septic shock has warm skin
Cardiogenic shock. CO, Systemic Vascular Resistance, PCWP, Right Atrial Pressure?
CO - Decreased, Systemic Vascular Resistance - Increased, PCWP - Increased, Right Atrial Pressure - Increased. Dx? Cardiogenic shock (Same for Pulmonary Edema). Cold Skin.
Pulmonary Edema. CO, Systemic Vascular Resistance, PCWP, Right Atrial Pressure?
CO - Decreased, Systemic Vascular Resistance - Increased, PCWP - Increased, Right Atrial Pressure - Increased. Dx? Cardiogenic shock (Same for Pulmonary Edema). Cold Skin.
Hypovolemic shock. CO, Systemic Vascular Resistance, PCWP, Right Atrial Pressure?
CO - Decreased, Systemic Vascular Resistance - Increased, PCWP - Decreased, Right Atrial Pressure - Decreased. Dx? Hypovolemic shock. Cold Skin.
Septic shock. CO, Systemic Vascular Resistance, PCWP, Right Atrial Pressure?
CO - Increased, Systemic Vascular Resistance - Decreased, PCWP - Decreased, Right Atrial Pressure - Decreased. Dx? Septic shock. Warm Skin.
Pulmonary HTN. CO, Systemic Vascular Resistance, PCWP, Right Atrial Pressure?
CO - Decreased, Systemic Vascular Resistance - Increased, PCWP - Decreased, Right Atrial Pressure - Increased. Dx? Pulmonary HTN or Pulmonary Fibrosis. Cold Skin.
Pulmonary Fibrosis. CO, Systemic Vascular Resistance, PCWP, Right Atrial Pressure?
CO - Decreased, Systemic Vascular Resistance - Increased, PCWP - Decreased, Right Atrial Pressure - Increased. Dx? Pulmonary HTN or Pulmonary Fibrosis. Cold Skin.
What is the same as Increased PCWP?
What is the same as Increased PCWP? Increased PCWP is same as JVD, and Increased CVP.