acute cards pt 2

Question 1

s/s chronic PH

Answer 1

prominent S2
S2 splitting
RV heave
loud pulmonary valve
JVD
tricuspid regurgitation murmur
peripheral edema
ascites
hepatomegaly

Question 2

cardiac tamponade exam findings

Answer 2

becks triad - elevated JVP, hypotension, muffled heart sounds

pulsus paradoxus
JVD
narrow pulse pressure
tachycardia

hemodynamic impact depends on rate of fluid accumulation

Question 3

cardiac tamponade diagnosis

Answer 3

TTE

maybe clinical diagnosis

Question 4

cardiac tamponade management

Answer 4

preload support - IVF, avoid sedation, inotropes

pericardiocentesis / pericardial window

Question 5

endocarditis etiology

Answer 5

infection with gram positive cocci (most common), IVDU, prosthetic valves, dental procedures

infection of endothelial layer of heart causes valvular dysfunction

Question 6

endocarditis exam findings

Answer 6

fever
murmur

petechiae
osler’s nodes
splinter hemorrhages
laneway’s lesions
Roth’s spots

splenomegaly
embolic disease

Question 7

osler’s nodes

Answer 7

painful, red, sub cuticular nodules on finger tips

Question 8

splinter hemorrhages

Answer 8

linear, subungual hemorrhages

Question 9

Janeway’s lesions

Answer 9

painless macules on palms

Question 10

endocarditis diagnostics

Answer 10

persistent bacteremia in BC x3
leukocytosis
TTE/TEE - TEE more sensitive

pathologic & clinical criteria needed for definite diagnosis

Question 11

endocarditis mgmt

Answer 11

consult ID
prolonged IV abx w empiric therapy, then narrow
4-6 weeks abx

may need surgery if causes HF

Question 12

endocarditis prophylaxis

Answer 12

for pt w prosthetic valves, previous endocarditis, unrepaired CHD, transplant recipients

for dental, oral, respiratory tract procedures

with amoxicillin 2g PO 1h before procedure

Question 13

myocarditis

Answer 13

inflammatory disease of the myocardium

often in otherwise healthy person

progresses to rapidly progressive heart failure

Question 14

myocarditis s/s

Answer 14

may be asymptomatic
chest pain
flu like symptoms
recent URI
HF symptoms - severe
tachycardia, gallop, MR, edema, pericardial friction rubm

Question 15

myocarditis diagnositics

Answer 15

leukocytosis (eosinophilia)
elevated ESR/CRP
trop elevation (50%)
TTE - r/o other causes
EKG - mimic ischemia

endomyocardial biopsy - gold standard
cardiac MRI - standard

Question 16

myocarditis mgmt

Answer 16

supportive
treat like HF (devices, diuretics, inotropes)
avoid NSAIDs
vaccination (MMR, varicella, flu)

Question 17

aortic aneurysm s/s

Answer 17

asymptomatic until expanding, dissecting, or rupture

back/flank/chest pain
pulsating sensation in abdomen

palpable mass in abdomen

hypotension, tachycardia, overt shock, bleeding

Question 18

aortic aneurysms diagnostics

Answer 18

labs helpful for supportive care

US - screening (refer if 4cm +)

CTA - more sensitive and detailed, determine if candidate for surgery

Question 19

aortic aneurysm mgmt

Answer 19

rupture - surgical emergency

consult vascular (descending thoracic, AAA)/cardiac surgery (ascending/arch) if >4cm

supportive care (SBP 100-120, IVBB)

surgical repair - significant preop testing (open or endovascular options)

Question 20

DVT/PE RF

Answer 20

virchow’s triad - venous stasis, hyper coagulability, endothelial injury

acute infectious disease or injury/ obesity, prior DVT, cancer, immobility, surgery

Question 21

DVT diagnostics

Answer 21

wells score - pretest probability

duplex US

Question 22

acute DVT mgmt

Answer 22

distal DVT w/o severe symptoms or RF - serial imaging for 2 weeks (preferable to AC)

severe sx or RF - AC

superficial w RF: AC for 45 d (fondaparinux/rivaroxaban)

CI to AC - consider IVC

AC: DOACs

major provoked - 3 mos
minor provoked - consider extended
unprovoked - extended phase

stopping AC is shared decision making, consider ASA if d/c

Question 23

post-thrombotic syndrome

Answer 23

chronic venous insufficiency following DVT

venous stasis ulcers, pain, can lead to permanent disability

Question 24

PE s/s

Answer 24

gradual progressive dyspnea vs. sudden catastrophic hemodynamic collapse

tachypnea, shocky, hypoxia, CP, hemoptysis, crackles, febrile, diaphoresis, RHF s/s, murmur

Question 25

fat embolization s/s

Answer 25

sudden, marked dyspnea in susceptible patient

AMS

febrile >102

petechiae over thorax, shoulder, axillae

Question 26

PE diagnostics

Answer 26

labs nonspecific
CTA (PE protocol) - initial
CXR - abnormal but nonspecific
duplex US

ABG - hypoxemia, hypocapnea, resp alkalosis

EKG

wells criteria/geneva score

Question 27

PE mgmt

Answer 27

resp support
caution w IVF
hemodynamic support - NE, dobutamine, ECMO

subsugmental w/o proximal DVT: surveillance

symptomatic/high risk : AC

hypotension w/o bleeding risk: thrombolytic therapy

bleeding, deteriorating, shock: catheter-assisted thrombus removal (Ekos)

heparin gtt, therapeutic lovenox, therapeutic fondaparinux

transition to PO - DOACs (duration same as DVT)

Question 28

PH diagnosis

Answer 28

vasoreactivity testing at time of RHC

nitric oxide admin

Question 29

ABI interpretation

Answer 29

normal 1-1.4
noncompressible >1.4 (calcified vessel)
borderline 0.91-0.99
abnormal <0.9 duplex US