Cardiology (PANCE PEARLS) Flashcards
Heart failure (Systolic/Left) - how do you identify it best?
Echo
Heart failure (Systolic/Left) - how do you identify it best?
Echo
Heart failure (Systolic/Left) - what will you see? Hear?
Decreased ejection fraction (
Heart failure (Systolic/Left) - Buzz
Pink frothy sputum
Main goals for HF
Every HF patient (unless contraindicated) should be on what?
An ACE and a diuretic
MOA of ACE
Decreased aldosterone production degreasing angiotensin II leading to decrease water retention. Bradykinin is also affected and can cause dry coughing and angioedema
Does ACE affect mortality?
Yes
SE of ACE
Hypotension with first dose. Renal insufficiency (with Cr > 3 or CrCl
Heart failure (Systolic/Left) - what will you see? Hear?
Decreased ejection fraction (
Heart failure (Systolic/Left) - Buzz
Pink frothy sputum
Main goals for HF
Every HF patient (unless contraindicated) should be on what?
An ACE and a diuretic
MOA of ACE
Decreased aldosterone production degreasing angiotensin II leading to decrease water retention. Bradykinin is also affected and can cause dry coughing and angioedema
Does ACE affect mortality?
Yes
SE of ACE
Hypotension with first dose. Renal insufficiency (with Cr > 3 or CrCl
Why give an ARB instead?
This only blocks the effects of angiotensin II not the creation of it and doesn’t affect bradykinin which won’t lead to cough.
How do you remember ACE drugs?
PRIL (aces (pilots) are PRIcks)
How do you remember ARBS?
Sartans (spartans don’t eat cARBS)
What do you want to be careful of when adding a beta blocker with HF?
It can decrease EF transiently so DON’T give with decompensated HF
When do you add a beta blocker?
Usually after an ACE or ARB.
What is the MOA of hydralazine?
Vasodilator (decreases afterload)
Name 3 loops
Furosemide, Bumetanide, Torsemide.
MOA of loops.
They inhibit water transfer across the loop of henle. They get rid of water, chloride, Na, K+
What are the two main SE of potassium sparing diuretics?
Hyperkalemia and gynecomastia
What are the P’s of pericarditis?
Persistent, pleuritic, postural, pain, pericardial friction rub
Dresslers syndrome
Post MI pericarditis
Becks triad
Associated with tamponade. Becky’s tampon. Distant heart sounds, JVP, hypotension.
Treatment for pericarditis?
NSAIDS, ASA, Colchicine, corticosteroids if persistent.
What two complications of pericarditis?
Effusion (common), tamponade (less common)
Kerley B lines
CHF
Batwing/Butterfly pattern
CHF
What might you see on ECG in pericardial effusion?
Low voltage QRS complexes! You may also electric alternans implying the heart is “swinging in fluid”
How will the heart look on CXR with pericardial effusion?
Cardiomegaly.
Distant heart sounds with auscultation of suspected pericardial effusion?
Yes. Its in water. Low sound conduction
Becks triad
Distant heart sounds, JVP, hypotension.
What is Kussmaul’s sign
Increased JVD during inspiration due to impaired filling of RV.
When do you see Kussmaul’s sign?
During constrictive pericarditis as well as restrictive cardiomyopathy.
Treatment for constrictive pericarditis?
Pericardiectomy. Gotta remove that crappy pericardium
PR elevation and ST depression in AVR
Acute pericarditis. “knuckle sign”
What will you see in the V leads with acute pericarditis?
PR depression in V3-V5 and ST elevation in V1-V6
Pulsus paradoxis is commonly seen in what?
Tamponade and constrictive pericarditis
Most common cause of myocarditis?
Viral
Whats the difference between children and adults with myocarditis?
Children often present in florid HF
Most common viral cause of myocarditis?
Coxsackie B. Other causes are adenovirus, parvovirus, herpes simplex 6, EBV, HIV, VZV. think “my oh my you have a pretty coxsackie”
What are the bacterial causes of myocarditis?
Lyme disease, Rocky mountain spotted fever, Q fever (Rickettsial). Think “my oh my you have a pretty mouth.
What south/central american bacterial cause of myocarditis is common?
Chagas of course. He’s “breaking hearts” all over south america.
What will you see on CXR with myocarditis?
Cardiomegally.
How will a patient with viral myocarditis look?
Fever, myalgias, malaise with on onset of HF symptoms.
CKMB and troponin will do what with myocarditis?
Elevate but not due to blockage.
What is the GOLD STANDARD for diagnosis myocarditis?
Endomyocardial biopsy
How do you want to treat myocarditis?
Same as HF. Diuretics, afterload reducing agents (ACE), increase contractility (dopamine, dobutamine, milrinone)
What 3 things will you see on echo of dilated cardiomyopathy?
Left ventricular dilation (thin walls and large chamber), decreased EF, regional or global hypokinesis (shit doesn’t work)
Treatment for dilated cardiomyopathy?
Same as HF.
What the hell is broken heart syndrome?
Tako-Tsubo were two japanese lovers. Tako flew away in a “balloon” when Tsubo started menopause and the surge of catacholamines broke her heart.
Most common type of cardiomyopathy?
Dilated (95%), Hypertrophic (4%), Restrictive (1%).
What is the most common cause of restrictive cardiomyopathy?
Amyloidosis (Amy restricts the heart). Sarcoidosis too
What is the trademark of restrictive cardiomyopathy?
Impaired diastolic function with preserved contractility
What if you saw bright speckled myocardium on echo?
Amyloidosis present and likely causing cardiomyopathy
Difference on echo between dilated and restrictive?
Dilated ventricle on the first but dilated atria on the other.
What part of the heart is most commonly affected with hypertrophic cardiomyopathy.
Septal.
What kind of murmur with hypertrophic cardiomyopathy?
Harsh systolic crescendo-decrescendo murmur best heard at left upper sternal border
Why does the murmur on hypertrophic cardiomyopathy go quite with squatting or lying down?
Increased blood return which pushes septum out of the way and decreases SAM (systolic anterior motion). Helps the blood go the right direction.
How do you measure the ankle brachial index?
Highest ankle pressure over highest arm pressure (both arms). You calculate the index. 1 to 1.4 is normal. 0.5 to 0.8 to 1 the pt has PAD.
What two arteries do you use with ankle brachial index?
Dorsalis pedis, posterior tibial (just behind medial maliolus)
First line treatment for hypertrophic cardiomyopathy?
Beta blockers.
What causes rheumatic fever?
GABHS
What valve is most affected?
Mitral then aortic
Jones MAJOR criteria for RF. Must have 2 major or 1 major and 2 minor.
Polyarthralgia, carditis, chorea, subcutaneous nodules, erythema marginatam.
Jones Minor criteria for RF.
Fever (101 to 104), arthralgias, elevated labs (ESR, CRP, leukocytosis), prolonged PR. Supporting evidence of recent GABHS infection.
Where are the nodules seen?
Nodules seen over extensor surfaces.
Whats the difference between arthralgias and polyarthragias (minor/major criteria?)
Heat, redness, swelling, severe tenderness MUST be present for polyarthralgias (multiple joints more conclusive)
How do you treat the chorea of RF?
Haldol
What does the rash look like with RF?
Macular, erythematous, NON pruritic ANNULAR lesions with well defined borders and some possible central clearing. Appears on TRUNK and EXTREMITIES (not the face).
How do you treat RF?
PCN G (erythromycin if PCN allergic).
What other drug should RF patients possibly get for 2-6 weeks?
ASA with a taper.
What can cause a split of S2?
Normal would be inspiration. This would be transient only during inspiration. Abnormal would be fixed. Commonly seen with ASD or VSD or pulmonary HTN or MS. Delayed closure of pulmonary valve. Paradoxical split (during exhalation) you will see it with delayed emptying of ventricle where aortic portion is later than pulmonic. Seen with LBBB or severe aortic stenosis.
When would you hear an ejection click?
Mitral valve prolapse where the chordae tendonae pull the valve shut rapidly.
S3.
Lub de bub. Rapid filling of ventricle. You hear S1 then S2 then S3
S4.
Belup dub. Atria contracting into stiff ventricle. S4 then S1 then S2.
Stenosis leads to what?
Pressure overload
Regurgitation leads to what?
Volume overload
Harsh murmurs are usually ____
Stenotic (forward flow)
Blowing murmurs are usually ____
Regurgitation (back flow)
Systolic murmurs
Mitral and tricuspid regurgitation AND Aortic and pulmonic stenosis
Diastolic murmurs
Mitral and tricuspid stenosis AND Aortic and pulmonic regurgitation
Where does aortic stenosis radiate to?
Carotid
Where does mitral regurgitation radiate to?
Axilla
Where does aortic regurgitation radiate to?
L upper sternal border
In was pt position can you best hear a mitral murmur?
Decubitus (lying left side)
In was pt position can you best hear an aortic murmur?
Pt seated up leaning forward
With the exception of hypertrophic cardiomyopathy, increasing venous return does what to murmurs?
Makes them louder
What is the classic triad of transposition of the great vessels?
It’s a right to left shunt (which causes what in newborns? CYANOSIS!!!) CXR will show 1) Egg on a string sign. 2) Pulmonary vascular congestion. 3) Mild cardiomegaly
Most common type of cardiac defect?
VSD - V=Very common
When would you see cyanosis? What kind of shunting?
Right to left (no oxygenation of blood)
Murmur. Harsh holosystolic murmur at left sternal border. Management?
VSD. 35% close. Surgery possible. Give diuretic and digoxin early if necessary.
Pulmonary stenosis. What disease of the young causes it?
Congenital RUBELLA syndrome
Murmur. Harsh midsystolic crescendo-decrescendo murmur at upper left sternal border radiating into the neck.
Pulmonary stenosis. May have WIDE split of S2 as blood can’t get out for the pulmonary valve to close.
Mid systolic click is virtually diagnostic for what?
Mitral valve prolapse
Early diastolic murmur with decrescendo shape?
Aortic regurgitation
Opening diastolic snap with mid mid diastolic rumble with presystolic accentuation.
Mitral stenosis
Volume overload can cause what sound?
S3. During rapid filling phase of diastole
Pressure overload can cause what sound?
S4. It’s the atrial kick against a bad ventricular wall.
A pt has a lower BP in his legs than in his arms and delayed weak femoral pulses
Coarctation of the Aorta
What sign might you see with coarctation of the aorta?
3 sign or backward E sign.
Infantile coarctation is ____ ductal
Pre
Adult coarctation is ____ ductal
Post
What is rib notching? Another name for it?
Roesler sign. Dilated, tortuous vessels erode the rib walls as collateral vasculature forms to feed the aorta downstream from stenosis
How do you test for coarctation of the aorta?
Angiogram
How do you treat coarctation of the aorta?
Balloon angioplasty
Cyanotic or not? PDA
Not. Left to right shunt
Cyanotic or not? Tetrology of fallot
Cyanotic. Right to left shunt
The production of what continues to keep a PDA patent?
PG E2
What will you hear with PDA
Continual “machine murmur” over pulmonic area. You will also see WIDE PULSE PRESSURE and bounding peripheral pulses. This is because blood is running off from the aorta into the pulmonic valve
What syndrome can occur with PDA
Eisenmenger syndrome. Pulm HTN causes shunt from L to R to R to L. Bad.
What is the treatment for PDA in a preterm infant?
Indomethacin (it closes the duct). Surgery if not preterm.
Amiloride, epleronone
Potassium sparing diuretics with spironolactone (inhibit aldosterone mediated water/Na absorption). These cause gynecomastia in addition to hyperkalemia.
If pt has HTN and it is refractory to antihypertesives…
Think 2ndary cause.
Abdominal bruit?
Renal artery stenosis
What finding on PE signifies advanced stage of malignant HTN?
Papilledema
What are 3 diuretics commonly used as first line in HTN?
HCTZ, chlorthalidone, metolazone
Where do thiazides work?
Distal tubule. Prevents sodium and thus water reabsorption there.
Loop diuretics get rid of water, Na, Cl, and K
True
What diuretics are contraindicated in sulfa allergy?
Loops. Furosemide and bumetanide
HTN emergency is what? How would you treat it?
220/120 + with signs of organ damage. Eyes, brain, kidneys, heart damage. You want 10% reduction in MAP within first hour and an additional 15% reduction over next 2-3 hours. using IV agents.
ARBS are contraindicated in what?
Pregnancy
When do you use dyhydroperidine CCB’s and non-dyhydroperidine CCB’s? And what are the?
Dyhydroperidines (dipine) are good for HTN alone. Non-dyhydroperidines (verapamil, diltiazem) good for HTN and A-fib. (they work on contractility and conduction AND vasodilation (the dipines only work on vasodilation).
Should beta blockers be used as first line mono therapy in HTN?
NO
What does a beta blocker do?
Blocks adrenergic renin release.
When would you use an alpha blocker? What is the first SE?
On a dude who wants to be the alpha male but has HTN and BPH. He will probably faint the first time he takes it.
Zosin drugs
Alpha 1 blockers. A=Zosin
HTN emergency is what? How would you treat it?
220/120 + with signs of organ damage. Eyes, brain, kidneys, heart damage. You want 10% reduction in BP within first hour and an additional 15% reduction over next 2-3 hours. using IV agents.
HTN urgency is what? How would you treat it?
Elevated BP without signs of organ damage. You want to decrease MAP by 25% in first 24-48 hours using PO agents
What are the 4 main oral drugs used for HTN urgency and their side effects?
Clonidine (Alpha 2 agonist - dry mouth, headache, tachycardia, N/V, sedation, fatigue). Captopril (ACE - andioedema, renal failure). Labetalol (Alpha 1/Beta 1/2 blocker - COPD, heart block, heart failure exacerbation). Nicardipine (CCB - reflex tachycardia, HA, N/V, flushing)
What class of medication do you NOT want to give to an asthmatic?
Beta blocker. Lebetalol for example.
What is the DRUG OF CHOICE for HTN emergency?
Sodium nitroprusside
Is sodium nitroprusside ok for pregnancy?
NO
What should you give a pregnant patient in a HTN emergency? What class drug is it?
Methyldopa. Alpha 2 agonist.
What would you give a pt who is in HTN emergency and is having an aortic dissection due to it?
Labetalol, NTP + esmolol
Patients over 60 BP goals?
150/90
Pt with CKD and HTN goals?
140/90
A non-african american with uncomplicated HTN can have which drugs?
Thiazide type diuretic, ACE, ARB, BB, or CCB
Main causes of hypercholesterolemia?
Hypothyroid, pregnancy, kidney failure
Main causes of hypertriglyceridemia
DM, obesity, steroids, ETOH, estrogen
What is one finding that is common with hypercholesterolemia
Xanthomas (around eyelids, achilles tendon)
What abdominal issue does hypertriglyceridemia sometimes cause?
Pancreatitis
Common bacteria with IV drug abuse endocarditis?
MRSA, pseudomonas, candida (fungal)
Common cause of acute bacterial endocarditis?
Staph. A
Common cause of prosthetic valve endocarditis?
Staph epidermis
What is the infection of normal valves?
Acute bacterial endocarditis.
Common cause of subacute bacterial endocarditis (abnormal valves)
Strep viridans
What are the 5 organisms responsible for large endocarditis vegetations?
HACEK. Haemophilus, actinobacillus, cardiobacterium, eikenella, klingella
How might a person with infective endocarditis present?
Fever, weight loss, fatigue, EKG abnormalities.
What might you find on skin exam?
Janeway lesions (painless palms), Osler nodes (painful pads), Roth spots (retinal hemorrhage with pale center), petechiae (palate, conjunctiva), Splinter hemorrhages, clubbing, hepatosplenomegally, septic emboli.
What do you want to do if you suspect it?
Blood culture (before ABX), EKG, echo (TTE before TEE), CBC,
What criteria is used for infective endocarditis?
DUKE
What are the major Duke criteria?
Bactermia (2 cultures positive), Endocardial involvement (either positive echo or new MR or AR murmur)
Empiric treatment for NATIVE VALVE ACUTE infective endocarditis?
Nafcillin + gentamicin 4-6 weeks. If PCN allergy or if you suspect MRSA use Vancomycin and gentamicin
Empiric treatment for NATIVE VALVE SUBACUTE infective endocarditis?
PCN/Ampicillin + gentamicin. If IVDA use Vancomycin with gentamicin
Empiric treatment for PROSTHETIC VALVE infective endocarditis?
Vancomycin + gentamicin + rifampin (for staph A)
Empiric treatment for fungal infective endocarditis?
Amphotericin B or Capsofungin if severe
Prophy treatment is what before procedures for pts with what?
Amoxicillin 2g 30-60minute before surgery OR clindamycin 600mg (if PCN allergy). Dental work, respiratory surgery, or procedures involving skin (includes I&D)
Whats the most common presentation of PAD?
Intermittent claudication. Pain with activity relieved by rest.
Most common arteries involved with PAD claudication
Femoral and branches and popliteal
What if there is resting leg pain with PAD?
Advanced disease
What are the s/s of acute arteriole emboli?
6 P’s. Parathesias, pain, pallor, pulselessness, paralysis, poikilothermia
If there is arterial occlusion, what can happen?
Gangrene (wet and dry) Wet is gross and dry is mummy
What skin findings will you have with PAD?
Atrophic changes. muscle atrophy, thin/shiny skin, hair loss, nail thickening, cool limbs, possible necrotic areas.
What color will the skin be?
Dependent rub or with paleness on elevation.
Where are some common ulcers of PAD?
Lateral maleolar ulcers.
How do you screen/dx PAD?
Ankle brachial index (ABI).
Normal value for ABI?
1-1.2
PAD dx with an ABI of what?
Severe PAD with ABI of what?
What ABI would you need to heal diabetic ulcers?
At least 0.85
What is the GOLD standard for PAD testing?
Arteriography
How would you treat PAD?
Cilostazol is the mainstay as it’s a vasodilator and ADP inhibitor.
What other drugs would you use for PAD?
ASA and clopidogrel (plavix).
An aneurysm greater than what is considered aneurysmal?
3.0cm
Where do AAA usually occur?
Infrarenally.
Give me the picture of an AAA candidate?
Atherosclerosis (#1 cause) >60 MALE SMOKER who is WHITE
What law says that wall tension = pressure x radiates and as the wall dilates the force on the wall increases causing more dilation making larger aneurysms expand more rapidly than small ones.
Laplace’s law
Ripping chest pain is indicative of what?
Thoracic dissection
Dx of AAA
Abdominal US
DX of thoracic aneurysms
CT scan
What is the gold standard for AAA dx
Angiography
When do you operate on an AAA?
> or equal to 5cm or 0.5cm expansion in 6 months (remember Laplace’s law!!!)
When do you refer?
> 4.5cm
AAA 4.0 to 4.5cm
US monitoring every 6 months
AAA 3.0 to 4.0cm
US monitoring every year
What drug helps reduce sheering forces?
Beta blockers!!! Non selective (labetalol) and add nitroprusside if needed.
Where does an aortic dissector most commonly occur and in what layer of the aorta?
Ascending aorta (60%) and in the INTIMA layer
What is the most common predisposing factor to aortic dissection?
HTN
What syndrome predisposes people to AAA and aortic dissection while young?
Marfan syndrome
What is the aortic dissection pain like?
Severe, tearing, knife like ripping chest/upper back pain
Where do the ascending aorta, aortic arch, descending aorta dissections pain radiate to?
Anterior chest, neck/jaw, intrascapular
What pulse changes might you see with aortic dissection?
Variation of pulses between arms of more than 20mm/hg
If pt is hemodynamically stable, how might you diagnose this?
Angiography (gold standard) or TEE
How is this dx urgently?
CXR showing widening mediastinum and CT scan with contrast (CT 3-D is happening now too)
A pt presents with new onset localized headache and scalp tenderness and fevers. He has noticed some pain after chewing and some jaw muscle spasms (truisms) as well. While in clinic he suddenly has feels as though a shade came down and covered one of his eyes causing monocular blindness or amaurosis fugax. What is it? How will you know? What will you do?
Temporal arteritis. Clinical diagnosis though ESR and CRP will likely be elevated. Treat with high dose corticosteroids 40-60mg/day for 6 weeks with tapering. You can try methotrexate or azathioprine if refractory to steroids.
Temporal arteritis is generally a ____ disease?
Autoimmune sparked by a virus
Another name for temporal arteritis
Giant cell arteritis
A pt presents with very tender nodules following venous distribution. There is claudication and even some ulcers forming on the distal extremities. What are you thinking? What else might you see?
Thromboantiitis obliterans (buerger disease). I think the fingers, toes, ears, nose, and tongue could worsen with cold, SMOKING, or emotional stress (Raynaud’s phenomenon).
How would you know it’s Buerger disease and how would you treat it?
You would not see atherosclerosis
Young smoker with numb digits going from pale, to blue, to red in the vasospasm tricolor classic presentation of what?
Buerger disease
What test may be abnormal with Buerger disease?
Allen test
What is the only definitive management of buerger disease?
Smoking cessation
What is the medication treatment for buerger disease?
Dyhydroperidine CCB. “DIPINE” Nifedipine, nicardipine, amlodipine
What is the triad for clot development?
Virchow’s triad. 1) Damage (trauma, infection, inflammation 2) Stasis (sitting, surgery) 3) Hypercoagulability (factor V leiden, oral contraception)
What is migratory thrombophlebitis?
Trousseau’s sign. Associated mostly with malignancy or vasculitis.
A pt presents with tenderness, pain, induration, edema, and erythema along a palpable cord of superficial vein. How will you confirm what you suspect and how will you treat it?
Confirm by venous duplex US. You will see a non compressible vein with a clot. Do a hypercoag workup (factor 5, protein C, S, lupus, factor 7, homocysteine). Treatment is supportive. Elevation, warm compresses, NSAIDS, compression stockings.
When would you consider heparin and warfarin with superficial thrombophlebitis?
If in saphenofemoral junction (may throw clot)
What if the superficial thrombophlebitis is septic?
If they have fever or it’s purulent. Treat with PCN + aminoglycoside.
Pt presents with unilateral leg swelling, calf pain, and noticeable phlebitis. What are you thinking? How will you know? How will you treat?
DVT. Venous duplex US. Also a D-dimer may be helpful. But the GOLD STANDARD is venography. The main goal is to prevent PE. Heparin/LMWH then Warfarin for 3-6 months is the mainstay of treatment.
Where do most DVT clots that throw to a PE originate?
Calf
When would you consider lifelong warfarin treatment?
Pts with protein C, S or antithrombin III deficiency or factor 5 leiden.
How does heparin work?
Potentiates antithrombin III and coagulation factors of the INTRINSIC pathway.
How would you treat heparin toxicity?
Protamine sulfate.
What should the PTT goal be for a pt on heparin?
1.5-2 x the normal value
What is the trade name for LMWH and what is the advantage of it? How is it given and when should it be avoided.
Enoxaparin. No need to monitor PTT. Given SQ and lasts 12 hours so patients can go home. Don’t give in renal disease (Cr > 2.0) or in thrombocytopenia.
How does warfarin (coumadin work)?
Inhibits vitamin K dependent coagulation in EXTRINSIC pathway.
What coagulation factors are affected by coumadin?
2, 7, 9, 10, and protein C and S.
Should coumadin be overlapped with heparin?
YES. For at least 5 days.
What is the goal INR for warfarin patients?
2.0-3.0
What is the antidote for warfarin overload?
Vitamin K
Talk through unlikely DVT workup
Low clinical probability? D-dimer. If negative then DVT is excluded. If positive then do venous US. If negative, then DVT is excluded. . If positive then DVT is dx.
Talk through likely DVT workup
Intermediate or high probability? Venous US. If positive then DVT is dx. If negative then do D-dimer. If negative then DVT is excluded. If positive then do serial US. If positive then DVT is dx. If negative then DVT is excluded.
What are the features of the DVT ____ Criteria?
Wells criteria. 1) Cancer 2) Paralysis, paresis, or immobilization of lower extremity 3) Bedridden for more than 3 days 4) Localized tenderness along deep vein distribution 5) Entire leg swollen 6) Unilateral calf swelling > 3cm 7) Unilateral pitting edema 8) Collateral superficial veins 8) Alternative diagnosis as likely or more likely than DVT (-2)
What has the higher risk of heparin induced thrombocytopenia?
Unfractionated heparin
Redness with dependency (PVD/PAD)
PAD
Pain worse with dependency (PVD/PAD)
PVD
Pain better with walking (PVD/PAD)
PVD
Pain better with dependency (PVD/PAD)
PAD
Pain worse with walking (PVD/PAD)
PAD
Lateral Malleolus ulcers (PVD/PAD)
PAD
Medial Malleolus ulcers (PVD/PAD)
PVD
Unclear margins of ulcers (PVD/PAD)
PVD
Clear margins of ulcers (PVD/PAD)
PAD
Cyanosis with dependency
PVD
Stasis dermatitis with thickening of skin and brown pigmentation (PVD/PAD)
PVD
Limited edema (PVD/PAD)
PAD
Lots of edema (PVD/PAD)
PVD
Thin shiny skin with loss of hair and muscle, pallor, thickened nails (PVD/PAD)
PAD
Livedo reticularis (PVD/PAD)
PAD. This is that mottled appearance
Pulses and temp in lower extremities normal (PVD/PAD)
PVD
Pulses and temp in lower extremities cool and diminshed (PVD/PAD)
PAD
Who gets varicose veins?
People with increased estrogen, OCP’s pregnancy, obesity, prolonged standing. Treat with stockings and elevation.
What kind of shock is this? Pt is in severe respiratory distress and appears cool and clammy. Pt has decreased CO and increased PCWP and increased systemic vascular resistance
This could be cardiogenic or obstructive
What are the common causes of cardiogenic shock?
MI, myocarditis, valvular disease, cardiomyopathy, arrhythmias
What are the common causes of obstructive shock?
Tamponade, PE, tension pneumo, aortic dissection
What kind of shot is this? Increased cardiac output
Septic shock (distributive)
In what shock might you see hypotension without tachycardia?
Neurogenic (distributive)
What are the causes of distributive shock?
Sepsis, neurogenic, anaphylactic, hypoadrenal
Treatment for adrenal insufficiency shock
Hydrocortisone 100mg.
Sepsis treatment initial?
Zosyn + rocephin or imipenem
What if you suspect pseudomonas for your sepsis?
Gentamicin
What if you suspect MRSA for your sepsis?
Vancomycin
What if it’s an intrabdominal source for your sepsis?
Clindamycin or metronidazole.
What if the patient has not spleen and they are septic?
Rocephin to cover N meningitides and H. Flu.
