Cardio/Endo Flashcards
6 predictors of surgical cardiac complications
Ischemic heart disease, congestive heart failure, cerebrovascular disease, a high-risk operation, preoperative treatment with insulin, and preoperative serum creatinine greater than 2.0 mg/dL
What cardiac conditions would you want to avoid elective surgeries
Unstable angina
Noninvasive stress testing before noncardiac operations is indicated in patients with:
Active cardiac conditions (eg, unstable angina, recent MI, significant arrhythmias, or severe valvular disease)
Patients who require vascular operations and have clinical risk factors and poor functional capacity
Coronary revascularization before noncardiac operations in patients with:
Significant left main coronary artery stenosis
Stable angina with three-vessel coronary disease
Stable angina with two-vessel disease
Significant proximal left anterior descending coronary artery stenosis with either an ejection fraction <50% or ischemia on noninvasive testing
High-risk unstable angina or non–ST-segment elevation MI, or acute ST-elevation MI
The P’s of arterial emboli
P ain, P allor, P ulselessness, P aresthesia, P aralysis, P oikilothermia
common causes of thrombus formation
Atrial fibrillation and mitral stenosis
Gold standard dx for Arterial embolism/thrombosis
Angiography is considered the gold standard for diagnosis
Tx of Acute arterial occlusion
Acute arterial occlusion: Treat with IV heparin if not limb threatening then call the vascular surgeon for angioplasty, graft or endarterectomy
PAD is defined as
PAD is defined as an ABI < 0.9. The ABI Confirms the Diagnosis of PAD:
Dx of PAD vs PVD
Angiography is considered the gold standard for diagnosing PAD/PVD
Tx of PVD/PAD
Platelet inhibitors: Cilostazol, Aspirin, Clopidogrel
- Treat lipids - Statins
-
Revascularization with PTA, bypass grafts, stenting
- Exercise - walking to the point of claudication
Which drug is contraindicated in isolated PAD – it will worsen claudication!
βblockers
Which cardiac conditions are associated with dyspnea on exertion
Arrhythmia: Atrial fibrillation, inappropriate sinus tachycardia,sick sinus syndrome/bradycardia
- Hx: Palpitations, syncope
- PE: Irregular rhythm, pauses
- DX: ECG, event recorder, Holter monitor, stress testing
Myocardial: Cardiomyopathies, coronary ischemia
- Hx: Dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, chest pain or tightness, prior coronary artery disease or atrial fibrillation
- PE: Edema, JVD, S3, displaced cardiac apical impulse, hepatojugular reflex, murmur, crackles, wheezing, tachycardia, S4
- Dx: ECG, brain natriuretic peptide, echocardiography, stress testing, coronary angiography
Restrictive: Constrictive pericarditis, pericardial effusion/tamponade
- Hx: chest pain, dyspnea
- PE: Paradoxical pulse (exaggerated variation in blood pressure with respiration).
- Dx: EKG showing low voltage QRS along with electric alternans (see media section). Echocardiogram with increased pericardial fluid. Radiograph: Water bottle heart
Valvular: Aortic insufficiency/stenosis, congenital heart disease, mitral valve insufficiency/stenosis
- Hx: Dyspnea on exertion
- PE: Murmur, JVD
- Dx: Echocardiography
Structural cardio pulmonary causes for syncope
- Aortic Stenosis - angina, syncope, and CHF - 3 -years life expectancy if left untreated (if experiencing syncope)
- Cardiomyopathy: HOCM - (young athlete with a positive family history has sudden death or syncopal episode)
- Pulmonary hypertension
- Acute MI
sudden “ripping” or “tearing” CP radiating to back
Aotic dissection
rare disease that can also be functional but should be considered on the differential of any adrenal mass, especially tumors larger than 4 cm
Adrenal cortical cancer
Functional adrenal tumors
- Functional tumors include pheochromocytomas, aldosteronoma, and cortisol-producing adenomas. In patients with a previous or present history of malignancy, adrenal metastasis should be considered in the differential
Workup for adrenal carcinoma includes:
- Plasma fractionated metanephrines or 24-hour urine metanephrines—must rule out pheochromocytoma for any adrenal mass
- Serum potassium and aldosterone and plasma renin activity
- 24-hour urinary-free cortisol or dexamethasone suppression test
- DHEA-S—high levels can be associated with ACC; virilization is the clinical manifestation of androgen overproduction
- CT scan - size > 4 cm
- MRI
Why is laproscopic adrenalectomy not recommended?
- Laparoscopic adrenalectomy is NOT recommended for ACC given higher local recurrence rates due to positive or close margins
Lab workup for fatigue
- Complete blood count - anemia
- Erythrocyte sedimentation rate - inflammatory state
- Chemistry panel - liver disease, renal failure, protein malnutrition
- Thyroid function tests - hypothyroidism
- Human immunodeficiency virus antibodies - if not previously tested
- Pregnancy test, if indicated
Labs for hypothyroid
- Labs: TSH- elevated in primary disease. Low T4 (↑ TSH and ↓ Free T4)
Labs for hashimotos
- Hashimoto’s: Antithyroid peroxidase, antithyroglobulin antibodies
PALPABLE neck tumor and hypercalcemia
Parathyroid cancer → Hyperparathyroidism
Female with heat intolerance, palpitations, sweating, weight loss, tremor, anxiety, tachycardia
Hyperthyroid
Best test for hyperthyroid workup
- TSH (best test): Decreased in primary disease (↓ TSH and ↑ Free T4), elevated in secondary disease (↑ TSH and ↑ Free T4)
- Thyroid radioactive iodine uptake:
- Graves: Diffusely high uptake
- Toxic multinodular: Discrete areas of high uptake
Tx of hypethyroid
- Beta-blockers (symptomatic), methimazole/propylthiouracil, radioactive iodine, thyroidectomy
- Thyroid storm- prompt beta blockers, hydrocortisone, methimazole/propylthiouracil, iodine
- Thyroidectomy- most likely complication is recurrent laryngeal nerve (hoarseness)
What 2 adrenal conditions are palpations seen in?
Hyperthyroidism (see above) -heat intolerance, palpitations, sweating, weight loss, tremor, anxiety, tachycardia
Pheochromocytoma - recurrent headaches, HTN, sweating, palpitations
Hypertension, diaphoresis (episodic), and palpitations
Pheochromocytoma
Dx of pheochromocytoma
-
24-hour catecholamines including metabolites (metanephrine and vanillylmandelic acid)
- MRI or CT of the abdomen to visualize tumor
MC type of thyroid cancer
Most often papillary carcinoma (80%) - think papillary is “popular”
Dx of thyroid cancer
- Ultrasound is the best initial screen followed by a thyroid uptake scan. Usually normal thyroid function.
- Microcalcifications, hypoechogenicity, a solid cold nodule, irregular nodule margins, chaotic intranodular vasculature, and a nodule that is more tall than wide.
- Fine needle biopsy for definitive diagnosis (all lesions >1 cm should be biopsied)
- TSH, calcium level, CXR
Tx of thyroid cancer
Treatment: Surgical resection
- Surgical resection with chemotherapy and external beam radiation reserved for anaplastic thyroid cancer.
Diagnostic test of choice for thyroid nodule
The diagnostic test of choice for thyroid nodule is Fine Needle Aspiration (FNA)
Thyroid nodule that is hot indicates?
- U/S—solid or cystic nodule
-
Fine Needle Aspirate (FNA) -> cytology 123 I scintiscan (hot or cold nodule)
- Hot—Increased 123 I uptake = functioning/ hyperfunctioning nodule (non-cancerous)
- Cold—Decreased 123 I uptake = nonfunctioning nodule (cancerous)
Hot = Not cancer
Cold = Cancer
3 cardinal features of Parkinson’s disease
Rest tremor, cogwheel rigidity, and bradykinesia
What is the classic tremor associated with PD?
A pill-rolling 4- to 6-Hz tremor seen at rest; usually begins asymmetrically. This is the most specific clinical sign of PD.
TRAP symptoms of Parkinson’s disease
-
Tremor
- Resting tremor that is often asymmetric (disappears with voluntary movement)
- Disappears with voluntary movement
- Frequently emerges in a hand while walking and may present as pill-rolling
- May also present in jaw, chin, lips, tongue
- Rigidity: cogwheel (catching and releasing) or lead pipe (continuously rigid) - rigidity is also responsible for the stooped posture and an almost expressionless face (masked facies) that some individuals with Parkinson’s might have
- Akinesia (absence of movement)/bradykinesia (slowness of movement)/hypokinesia (lessened movement) - examples of this are having the legs freeze up when trying to walk and also walking with a shuffling gait, or small steps
- Postural instability - a late feature of the disease which causes problems with balance and can lead to falls
Tx of Parkinsons disease
- < 65 Dopamine agonists: bromocriptine, pramipexole, ropinirole. Directly stimulates dopamine receptors. Less side effects than Levodopa. Used in younger patients to delay the use of Levodopa.
- > 65 Sinemet (levodopa/carbidopa)
