cardio / pulm cases

Question 1

cough sob hx

Answer 1

acute v chronic, frequency of cough, timing, sputum (color, amounts, blood), hemoptysis, posttusive emesis, alleviate/exacerbate (positional, morn/night, exercise), smoking, Hx lung dz, heart failure, allergies, meds (esp ACE is as inhibits bradykinin)

b Sx, uri, postnasal drip, dysp, wheeze, chest pain, heartburn

Question 2

cough sob ex

Answer 2

vitals, pulse ox, nasal mucosa/oropharynx, heart, lungs, lymph, extremeties (clubbing, cyanosis, edema)

Question 3

cough sob wu

Answer 3

cbc, cxr, chest ct, ecg, echo, abgs, bnp for chf or pe, asthma(peak flow, pfts, methacholine), bronchoscopy for lung ca diagnosis

sputum gram stain/culture/cytology, ppd, igM detection for mycloplasma, urine legionnella Ag, anca (wegener’s), HIV Ab

Question 4

cough sob ddx

Answer 4

pneumonia (or atypical - presents like uri, uri associated/ postinfectious cough and postnasal drip), copd exacerbation (bronchitis: cough for 3 mo/yr over past 2 yrs), gerd, chf or cardiac valvular diz if orthopnea/exertional, pulm edema, mitral valve stenosis, arrythmia

pneumonitis, foreign body, TB, lung ca (or mets from breast/prostate etc), bronchiectesis (CF, primary ciliary dyskinesia), lung abcess, pericarditis, interstitial/restrictive lung dz, pulmonary fibrosis, vasculitis, sarcoid, acute HIV infection (pneumocystis jiroveci or MAC)

Question 5

chest pain hx

Answer 5

socrates (radiation to left arm/jaw/neck or back, character can be pressure or acute/stabbing), context (exertional, positional, postrandial, cocaine etc, trauma), diaphoresis, n&v, sense of doom, fever, exacerbating/alleviating (due to meds), Hx episode or dz,

cardiac risk factors: htn, hyperlipdemia, smoking, Fhx early MI. PE rf’s: hypercoagulopathies, ca/hypercalcemia, immobile

Question 6

chest pain ex

Answer 6

vitals, bp (both arms, rad rad or rad fem, orthostatic differences for syncopal causes, aortic regurg-head bob or collapsing pulse, weak pulses - arms in takayasus or legs in preductal coaractation)

cardio(jvd, pmi/apex, palpate for heaves/thrills, sacral or leg edema, chest wall tenderness, heart sound, pulses RRR). lung (clubbing, cyanosis, pulm edema), abdo (aaa-palpate, auscultate bruits), lower extremity (DVT, peripheral vasc dz)

Question 7

chest pain wu

Answer 7

ecg, cxr, echo, cbc (+/- retics, smear for heme origins ie sickle cell), euc, ck-mb, serial troponins (3x), ldh, d dimer, abg, exercise stress test.
esr for pericarditis (inflammatory marker). bun/cr, glucose, amylase, lipase for pancreatitis as a ddx for aortic dissection

more imaging: ardiac cath, helical ct, cta / angio with iv contrast, doppler u/s legs, tee (can be done bedside), mri/mra aorta, aortic angio

for gerd: barium swallow, upper endoscopy, esophageal pH monitoring

Question 8

chest pain ddx

Answer 8

MI, gerd (ddx esohagitis, peptic ulcer dz, esophag spasm or rupture/boorhaves, latter is dd for pericarditis since stabbing pain), angina….pneumonia, costochondritis, aortic dissection, pericarditis, pleurisy, PE, penumothorax, chf

acute chest syndrome (sickle cell). for dissection: pancreatitis (radiates to back), fat embolism

Question 9

pericarditis

Answer 9

retrosternal stabbing chest pain, imroves with forward leaning, worsens with deep inspiration. uri recently

Question 10

costochondritis

Answer 10

stabbing chest pain, worsens with deep inspiration, relieved by aspirin, chest wall tenderness. pleurisy, PE, muscle strain, pericarditis are ddx since pain sharp pain changes in these conditions

Question 11

PE

Answer 11

sob, tachycardia and tachypnea, hypotensiion, recent surgery, pleurtic chest pain

Question 12

palpitations hx

Answer 12

gradual v acute onset, factors (exertion, caffeine, anxiety), lightheaded, LOC, chest pain, dyspnea, fever, diaphoresis, pallor skin/oral/conjunctival, flushing, diarrhea, thyroid sx (fatigue and see Ex below), anemia/easy bleeding or bruising. hx: heard dz, htn, diabetes

Question 13

palpitations ex

Answer 13

vitals, cardio, endo ie thyroid: exophthalmos, lid retraction/lag, hyper or hyporeflexia-hung up reflexes, tremors, enlarged gland or bruit, lymph nodes, prox myopathy, peau de orange

Question 14

palpitations wu

Answer 14

cbc, glucose, euc, tsh/t4, ecg, holter, echo, utox, MSE

24 hr urinary catecholamines for pheo, 5-hiaa for cardinoid

Question 15

palpitations ddx

Answer 15

hypoglycemia, arrythmia, angina, hyperthyroid,

hyperventilation, panic disorder/attack, anxiety, acute stress, specific phobia (ie agora, social), substance abuse

pheo, carcinoid, mitral valve prolapse

Question 16

mitral valve prolapse

Answer 16

episodic palpitations, lightheadedness, sharp/atypical chest pain