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Internal Medicine > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q 
Angina 
Path and Risk factors:
Pt:
Dx:
Tx:
A

Path: ischemia w/ myocardial oxygen demand > oxygen supply
Risks-> CAD, family hx, old age, HTN, HLD, DM, CKD, smoking

Pt:
Stable angina: Chest discomfort precipitate by activity but sx abate after activity
Unstable angina: sx at rest or a change in usual sx pattern
+/- SOB, NA, diaphoresis, dizziness, fatigue

Dx:
EKG: J point or ST segment depression, normal
Stress Test-> exercise, nuclear, ECHO

Tx:
Lifestyle modifications
Beta Blockers
CCB
Nitrates
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2
Q 
Aortic Stenosis 
Path:
Pt:
Dx:
Tx:
A

Path: Congenital (>70 y/o)-> MC degenerative calcification, Bicuspid aortic valve
LV outflow obstruction-> fixed CO; Inc afterload-> LVH

Pt: Angina, syncope, CHF, dyspnea
Older patient hx of DM, HTN

Dx: Systolic ejection crescendo-decrescendo murmur @ RUSB; radiates to carotid arteries
Pulsus parvus et tardus-> weak; delayed pulse
S4 if LVH
Narrow pulse pressure
LV heave due to LVH
Paradoxically split S2 (if severe)

Tx: Aortic valve replacement
Severe AS is dependent on preload: Avoid exertion, ventilators & negative inotropes (CCB, BB)

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3
Q 
Mitral Stenosis 
Path:
Pt:
Dx:
Tx:
A

Path: Obstruction of flow from LA to LV -> LA enlargement and inc LA pressure-> pulm HTN, Rheumatic heart disease

Pt: 
R sided heart failure
Pulmonary HTN-> hemoptysis 
A-fib
Mitral facies-> flushed cheeks 
Dx: 
Diastolic rumble @ apex in L lateral decubitus +/- opening snap; no radiation
Pulse usually dec intensity 
LA enlargement 
Prominent S1 (closing snap)

Tx:
Valvotomy in young pts -> rheumatic dz is cause, static & valve orifice <1cm
Repair preferred over replacement

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4
Q 
Aortic Regurgitation 
Path:
Pt:
Dx:
Tx:
A

Path: Back flow from aorta to LV-> LV volume overload
Rheumatic disease, HTN, endocarditis, Marfan, Syphilis, Ankylosing spondylitis

Pt:
L sided heart failure

Dx:
Diastolic decrescendo blowing @ LUSB radiates along L-sternal border
-Inc w/ handgrip
-Dec w/ nitrate
Austin flint murmur: mid-late diastolic rumble @ apex
Bounding pulses-> inc. SV
Wide pulse pressure
Pulsus bisferiens-> if combined with AS + AR
Water hammer pulse

Tx:
Vasodilators-> dec afterload increases forward flow
Surgery-> acute or static AR or dec LV <55% (need hyperdynamic ventricle to maintain CO)

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5
Q 
Mitral Valve Prolapse
Path:
Pt:
Dx:
Tx:
A

Path: Myxomatous degeneration of mitral valve-> floppy, redundant valve
Abnormal movement of 1 or both leaflets across valve during systole
MC young women, benign condition
Connective tissue disease-> Marfan, Ehlers-Danlos

Pt: Most asx
Autonomic dysfunction: Chest pain, panic attacks, Arrhythmias causing palpitations, Syncope, dizziness, fatigue
Sx associated w/ MR progression: Fatigue, dyspnea, CHF, Stroke, endocarditis, PVCs

Dx:
Mid to late systolic ejection click @ apex; dec venous return (valsalva, standing, inspiration) -> earlier click (inc. prolapse) and longer murmurs duration
+/- mid-late systolic murmur
Narrow AP diameter
Low body weight, Hypotension, scoliosis, pectus excavatum

Tx:
Reassurance-> good prognosis in asx pts or mild sx
BB for autonomic dysfunction

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6
Q 
Mitral Regurgitation 
Path:
Pt:
Dx:
Tx:
A

Path: Backflow from LV to LA-> LV volume overload-> dec. CO
Mitral Valve prolapse MC
Rheumatic, endocarditis, ischemia (ruptured papillary muscle/chordae tendinae post MI)

Pt:
Acute: Pulmonary edema, Dyspnea
Chronic: A-fib, CHF, May have pulmonary HTN (less often than mitral stenosis)

Dx:
Blowing holosystolic murmurs @ apex radiates to axilla
-Inc with handgrip, left lateral decubitus
-dec. w/ nitrate
Pulse may have brisk upstroke-> due to hyperdynamic ventricle from inc. preload and dec. afterload
Widely split S2

Tx:
Vasodilators: dec. afterload inc forward flow (ACEi)
Surgery: vale repair preferred vs valve replacement

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7
Q

Tricuspid Regurgitation
Dx:
Tx:

A

Dx: Holosystolic blowing high-pitched murmur @ subxiphoid area (L mid sternal border)
-Little-no murmur radiation
-Inc murmur intensity w/ inc venous return (squatting, inspiration)
Carvallo’s sign: increased murmur intensity w/ inspiration (due to inc right sided blood flow during inspiration
- Helps distinguish TR from MR
- +/- pulsatile liver

Tx:
Medical: diuretics (for volume overload and congestion)
If LV dysfunction-> standard HF therapy
Surgical: suggested for pts w/ severe TR despite medical therapy
Repair > replacement

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8
Q

Tricuspid Stenosis
Path:
Dx:
Tx:

A

Path: Blood backs up into RA -> inc RA enlargement -> right-sided heart failure

Dx: Mid-diastolic murmurs @ left lower sternal border (4th ICS). Low frequency
Inc intensity of murmur: inc venous return (squatting, laying down, leg raising, inspiration)
Opening snap: usually occurs later than the opening snap of mitral stenosis

Tx:
Medical: decrease RA volume overload w/ diuretics and Na+ restriction
Surgical: commisurotomy or replacement if right heart failure or dec CO

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9
Q 
Pulmonic Regurgitation 
Path:
Pt:
Dx:
Tx:
A

Path: Pulmonary HTN, tetralogy of fallot, endocarditis, rheumatic heart disease
Retrograde blood flow from pulmonary artery into RV-> right sided volume overload

Pt:
Most clinically insignificant
If sx-> right sided heart failure

Dx:
Graham Steell murmur: brief decrescendo early diastolic murmur @ LUSB (2nd L ICS) w/ full inspiration
-Inc murmur w/ inc venous return (squatting, supine, inspiration)
-Dec murmur w/ dec venous return (Valsalva, standing, expiration)

Tx:
No tx needed in most
Almost always congenital

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10
Q 
Pulmonic Stenosis
Path:
Pt:
Dx:
Tx:
A

Path: RV outflow obstruction of blood

Pt:
Almost alway congenital and disease of the young (congenital rubella syndrome)

Dx:
Harsh mid systolic ejection crescendo-decrescendo murmur (maximal @ LUSB) radiate to neck
-Murmur inc w/ inspiration; the longer the murmur duration = inc stenosis
-Signs of r-sided heart failure
-Systolic ejection click (often buried in S1) may precede the murmur (click increases w/ expiration) wide, split S2 (delayed P2) +/-S4

Tx:
Balloon valvuloplasty

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11
Q

What is pulsus alternans?

A

S1: mitral and tricuspid valve closure

S2: aortic and pulmonary valve closure

S3: in early diastole

  • during rapid ventricular filling phase
  • large amount of blood striking a very compliant LV
  • normal in children, pregnant women

S4: “atrial kick”

  • late diastole
  • blood flowing against noncompliant LV
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12
Q 
Angina 
Path:
Pt:
Dx:
Tx:
A

Path: ischemia w/ myocardial oxygen demand > oxygen supply
Risks-> CAD, family hx, old age, HTN, HLD, DM, CKD, smoking

Pt:
Stable angina: Chest discomfort precipitate by activity but sx abate after activity
Unstable angina: sx at rest or a change in usual sx pattern
+/- SOB, NA, diaphoresis, dizziness, fatigue

Dx: EKG: J point or ST segment depression, normal, Stress Test

Tx:
Lifestyle modifications
Beta Blockers
CCB
Nitrates
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13
Q

Sinus bradycardia

tx:

A

Tx:
Atropin if pt sx
Epi or transcutaneous pacing if unresponsive to atropine

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14
Q

2nd degree heart block- Mobitz I/ Wenckebach
EKG:
Tx:

A

EKG:
Progressive PRI lengthening -> dropped QRS

Tx:
Symptomatic: atropine; Epi +/- pacemaker
Asx: observation

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15
Q

2nd degree heart block- Mobitz II
EKG:
Tx:

A

EKG:
Constant/prolonged PRI-> dropped QRS

Tx:
Atropine or temporary pacing
Progression to 3rd degree AV block common so permanent pacemaker is definitive tx

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16
Q

3rd degree AV block
EKG:
Tx:

A

EKG:
P wave not related to QRS
All p waves not followed by QRS-> dec CO

Tx:
Acute/symptomatic: temporary pacing-> permanent pacemaker
Definitive tx: permanent pacemaker

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17
Q

A-flutter

Tx:

A 
Tx:
Stable: vagal, BB or CCB
Unstable: synchronized cardioversion
Definitive: radiofrequency ablation 
Anticoagulation use similar to a-fib (CHADSVAS-2 score)
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18
Q

Determine need for anticoagulation

A 
CHA2DS2-VAS-2 score
CHF... 1
HTN... 1
Age >/=75... 2
DM... 1
S: stroke, TIA, thrombus... 2
Vascular disease (prior MI, aortic plaque, PAD)... 1
Age 65-75 yr... 1
Sex (female)... 1

> /=2: moderate to high risk-> chronic oral anticoagulation recommended

1 = low risk: based on clinical judgement, consideration of risk to benefit assessment and discussion with patient. anticoagulation may be recommended in some cases

0=very low risk

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19
Q

A-fib

Tx:

A

Stable:
Rate Control
-Non-dihydropyridines CCB: diltiazem/verapamil
-BB: metoprolol (caution in reactive airway disease)
-Digoxin: hypotension + CHF
Rhythm Control
-Synchronized cardioversion
-AF present <48hrs
-3-4w after anticoagulation or TEE shows no atrial thrombi
-Start IV heparin, cardiovert within 24hrs and anticoagulate for 4w
-Pharm: ibutilidie, flecainide, sotalol, amiodarone
-Radiofrequency ablation-> permanent pacemaker

Unstable: cardioversion

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20
Q

SVT

Tx:T

A

Tx:
Vagal maneuvers
Adenosine
Cardioversion

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21
Q

RBBB EKG

A

wide S wave in lead I and V6

RSR’ pattern in lead VI

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22
Q

LBBB EKG

A

large R wave in lead I

Large QS or rS in lead V1

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23
Q

Vtach

Tx:

A

Tx: Determine hemodynamic stability

Stable: procainamide; sotalol (2nd line)

Unstable: Synchronized cardioversion

Pulseless: defibrillation

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24
Q

Wolff-Parkinson-White Syndrome
Path:
EKG:
Tx:

A

Path:
Accessory bundle pathway -> bundle of Kent
Premature depolarization of ventricles by bypassing the AV node

EKG:
Delta waves-> wide QRS
Shortened PR interval

Tx: Radiofrequency ablation

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25
Q

Wellens Syndrome
Path:
EKG:
Tx:

A

Path:
Critical stenosis of proximal left anterior descending coronary artery (LAD)

EKG:
large, inverted T wave in leads V2 and V3

Tx: Cath Lab!

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26
Q

Brugada Syndrome
Path:
EKG:

A

Path: Hereditary

EKG
Right BBB-like pattern w/ ST elevation in leads V1-V3

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27
Q 
Non-ST segment elevation acute MI
Path:
Pt:
Dx:
Tx:
A

Path: Acute reduction in blood flow, incomplete occlusion w/ cardiac enzymes

Pt: Angina at rest >20 mins

Dx:
Troponin elevation
EKG: ST depression

Tx:
ASA, O2, heparin, BB, nitrates, stress tests, cardiac cath

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28
Q 
ST segment elevation acute MI
Path:
Pt:
Dx:
Tx:
A

Path: Thrombus formation causing blockage of coronary vessel

Pt: Chest tightness/pressure radiates to arms or neck

Dx: 
Labs
Elevated troponin I or troponin T and CK
EKG
ST segment elevations >1mm in >2 contiguous leads

Tx:
PCI (gold standard)
Thrombolytic therapy
ASA

29
Q

Anterior wall MI
EKG:
Coronary vessel:

A

EKG: V1-V4

Coronary vessel: left anterior descending (LAD)

30
Q

Inferior wall MI
EKG:
Coronary vessel:

A

EKG: II, III, aVF
Coronary vessel:
right coronary artery (RCA) (70%+)
left circumflex (LCx)

31
Q

Lateral wall MI
EKG:
Coronary vessel:

A

EKG: I, aVL, V5, V6
Coronary vessel:
left circumflex (LCx)
diagonal of left anterior descending

32
Q

Posterior wall MI
EKG:
Coronary vessel:

A

EKG: ST depression V1-V4, elevation in V8-V9

Coronary vessel: posterior descending artery (PAD)

33
Q 
Hyperlipidemia 
Tx
Lowering LDL
Lowering triglycerides
Increasing HDL
Type II DM
A

Lowering LDL:

  • Statins
  • Bile acid sequestrants
  • Ezetimibe (zetia)
  • PCSK9 inhibitor-> repatha (evolocumab), praluent (alirocumab)

Lowering triglycerides:

  • Fibrates
  • Omega-3 fatty acids-> lovaza, vascepa, epanova
  • PCSK9 inhibitor-> repatha (evolocumab), praluent (alirocumab)

Increasing HDL:

  • Niacin, niaspan, slo niacin
  • exercise

Type II DM:
-Fibrates
-Statins
(niacin may cause hyperglycemia)

34
Q 
Dilated cardiomyopathy 
Path:
Pt:
Dx:
Tx:
A

Path: dec contractility
virus, EtOH, ischemia, chemo

Pt: systolic CHF-> orthopnea, DOE, crackles, dyspnea, JVD

Dx: Echo-> Dilated

Tx: CHF
Ace-i, BB, Diuretics
avoid EtOH/chemo
transplant

35
Q 
Restrictive cardiomyopathy 
Path:
Pt:
Dx:
Tx:
A

Path: amyloid, sarcoid, hemachromatosis, cancer, fibrosis

Pt: diastolic CHF
amyloid-> neuropathy
Sarcoid-> pulmonary dz
Hemachromatosis-> cirrhosis, DM, CHF

Dx: echo-> restrictive, marked dilation of both atria
amyloid-> fat pad bx
sarcoid -> cardiac MRI -> bx
hemachromatosis-> ferritin -> genetics

Tx: Diastolic HF
BB=CCB
gentle diuresis 
transplant
underlying dz
36
Q 
Hypertrophic obstructive cardiomyopathy 
Path:
Pt:
Dx:
Tx:
A

Path: genetics, sarcomeres

Pt: murmur = aortic stenosis
young athletes-> sudden cardiac death, syncope, DOE

Dx: Echo = Asymmetric

Tx: avoid dehydration, exercise
BB = CCB
EtOH ablation, myectomy 
AICD for inc risk of death 
transplant
37
Q 
Concentric hypertrophic cardiomyopathy 
Path:
Pt:
Dx:
Tx:
A

Path: HTN

Pt: Diastolic CHF

Dx: ECHO = concentric

Tx: Diastolic CHF
avoid dehydration
CCB = BB
control BP
transplant
38
Q 
Coronary Artery disease
Path: 
Pt: 
Dx: 
Tx:
A 
Path:
Atherosclerosis
Coronary artery vasospam
Aortic stenosis/aortic regurgitation
Pulm HTN
Severe systemic HTN
Hypertrophic cardiomyopathy 
Pt: pectoris angina 
Risk factors:
DM
Cigarette smoking
HLD
HTN
Males
Age >45 men, >55 women
Family hx
Dx: 
EKG:
-ST depression
-LVH
-Resting EKG normal in 50%
Wave inversion, non specific ST changes, poor r wave progression, t wave pseudo normalization 
Stress test:
Stress EKG + with:
-ST depressions
-hypotension/hypertension
-Arrhythmias 
-Symptoms 
Myocardial perfusion imaging stress (exercise or pharmacologic)
-Indicated for patients with abnormal baseline EKGs to localize regions of ischemia 
Stress ECHO (exercise of pharmacologic)
Cardiac MRI
Coronary angiography: GOLD STANDARD

Tx:
Revascularization:
-PTCA (percutaneous transluminal coronary angioplasty)
-CABG (coronary artery bypass graft)

Medical:

  • Nitroglycerin
  • Beta blockers
  • CCB
  • ASA
39
Q 
Endocarditis
Path:
Pt:
Dx:
Tx:
A

Path:
Acute: S. Aureus, MRSA-> IV drug users
Subacute: S. Viridians-> oral flora infection

Pt: Fever, anorexia, weight loss, fatigue, EKG conduction abnormalities

Dx: Modified Duke Criteria
2 major
1 major + 3 minor
5 minor

Tx:

  • Acute/IVDU: vanc + cefepime
  • Subacute: Vanc + amp/ceftriaxone/cipro
  • Surgery if refractory CHF, persistent/refractory infection, invasive infection, prosthetic valve, recurrent systemic emboli, fungal infections
40
Q

Modified Duke Criteria

A

Major
*Sustained bacteria: 2+ blood cultures by organic known to cause endocarditis
*Endocardio involvement
…+ echo: vegetation, abscess, valve perforation, prosthetic dehiscence
…New valvular regurgitation: aortic or mitral

Minor 
*predisposing condition: abnormal valves, IVDU, indwelling catheters
*Fever >38 (100.4)
*Vascular and embolic phenomena
...Janeway lesions
...septic arterial/pulmonary embolic
...intracranial hemorrhage
*Immunologic phenomena
...Osler's nodes, roth spots
...+RF
...acute glomerulonephritis
*+blood culture not meeting major criteria
* +echo not meeting major criteria-> worsening of existing murmur
41
Q

Abx prophylaxis for endocarditis
Cardiac conditions
Procedures
Regimens

A

Cardiac conditions:

  • Prosthetic heart valves
  • Heart repairs using prosthetic material (not stents)
  • Prior hx of endocarditis
  • Congenital heart disease
  • Cardiac valvulopathy in a transplanted heart

Procedures:

  • Dental: manipulation of gums, roots of teeth, oral mucosa perforation
  • Respiratory: surgery on respiratory mucosa, rigid bronchoscopy
  • Procedures involving infected skin/musculoskeletal tissues (including I&D)

Regimens

  • Amox 2g 30-60mins before procedure
  • Clinda if PCN allergy

No longer recommended for GI/GU procedures or most types of valvular heart disease (MV prolapse, bicuspid aortic valve, acquired MV, AV disease, hypertrophic cardiomyopathy

42
Q

Systolic ejection crescendo-decrescendo murmur @ RUSB; radiates to carotid arteries

A

Aortic stenosis

43
Q

Diastolic rumble @ apex in L lateral decubitus +/- opening snap; no radiation

A

Mitral stenosis

44
Q

Diastolic decrescendo blowing @ LUSB radiates along L-sternal border

A

Aortic regurgitation

45
Q

Mid to late systolic ejection click @ apex

A

Mitral valve prolapse

46
Q

Blowing holosystolic murmurs @ apex radiates to axilla

A

Mitral regurgitation

47
Q

Holosystolic blowing high-pitched murmur @ subxiphoid area

A

Tricuspid regurgitation

48
Q

Mid-diastolic murmurs @ left lower sternal border (4th ICS)

A

Tricuspid stenosis

49
Q

Early diastolic murmur @ LUSB (2nd L ICS) w/ full inspiration

A

Pulmonary regurgitation

50
Q

Harsh mid systolic ejection crescendo-decrescendo murmur (maximal @ LUSB) radiate to neck, murmur increases w/ inspiration

A

Pulmonary stenosis

51
Q

HTN
dx:
tx:

A

Dx:
Elevated BP >/= 2 readings on >/= 2 different visits
If initial average of 2+ readings is >160/100
Normal: <120 / <80
Elevated: 120-129 / <80
Stage 1: 130-130 / 80-89
Stage 2: >/=140 / >/=90

Tx:
Lifestyle modifications
Thiazide/thiazide type diuretic
ACEi
ARB
CCB

DM, CKD: ACEi, ARB
African American: CCB, thiazide type diuretic

52
Q 
Non-ST segment elevation acute MI
Path:
Pt:
Dx:
Tx:
A

Path: Acute reduction in blood flow, incomplete occlusion w/ cardiac enzymes

Pt: Angina at rest >20 mins

Dx:
Troponin elevation
EKG: ST depression

Tx:
ASA, O2, heparin, BB, nitrates, stress tests, cardiac cath

53
Q 
ST segment elevation acute MI
Path:
Pt:
Dx:
Tx:
A

Path: Thrombus formation causing blockage of coronary vessel

Pt: Chest tightness/pressure radiates to arms or neck

Dx: 
Labs
Elevated troponin I or troponin T and CK
EKG
ST segment elevations >1mm in >2 contiguous leads

Tx:
PCI (gold standard)
Thrombolytic therapy
ASA

54
Q

Anterior wall MI
EKG:
Coronary vessel:

A

EKG: V1-V4

Coronary vessel: left anterior descending (LAD)

55
Q

Inferior wall MI
EKG:
Coronary vessel:

A

EKG: II, III, aVF
Coronary vessel:
right coronary artery (RCA) (70%+)
left circumflex (LCx)

56
Q

Lateral wall MI
EKG:
Coronary vessel:

A

EKG: I, aVL, V5, V6
Coronary vessel:
left circumflex (LCx)
diagonal of left anterior descending

57
Q

Posterior wall MI
EKG:
Coronary vessel:

A

EKG: ST depression V1-V4, elevation in V8-V9

Coronary vessel: posterior descending artery (PAD)

58
Q

Cardiac biomarkers

A

Troponin: Highest sensitivity and specificity

  • Time detectable from onset: 3-12 hrs
  • Peak: 24-48 hrs
  • Return to baseline: 5-14 days

CK-MB

  • Time detectable from onset: 3-12 hrs
  • Peak: 24 hrs
  • Return to baseline: 48-72 hrs
  • Useful for dx of re-infarction

Myoglobin

  • First to appear, first to peak, first to decline
  • Lacks specificity
59
Q

Right ventricular infarct
Pt:
EKG:
Tx:

A

Pt: hypotension, JVD, clear lungs
EKG: elevation in II, III, aVF

Tx:
Aggressive fluid resuscitation with NS bolus
-preload dependent

Dopamine/dobutamine if hypotension persists after fluid resuscitation

Avoid meds that lower

  • Preload-> nitroglycerin, morphine
  • HR-> beta blockers
60
Q 
Myocarditis
Path:
Pt:
Dx:
Tx:
A

Path: inflammation of heart muscle
Myocellular damage-> myocardial necrosis and dysfunction -> +/- HF
-Infectious: viral-> enteroviruses (coxsackie), bacterial-> rickettsial
-Toxic: Scorpion envenomation, Diphtheria toxins
-Autoimmune: SLE. Rheumatic fever
-Systemic : Uremia , Hypothyroidism
-Medications: Clozapine

Pt:
Viral prodrome: fever, myalgia, malaise-> for several days-> HF sx
Dyspnea @ rest, exercise intolerance, syncope, tachypnea, tachycardia, hepatomegaly
S3 +/- S4

Dx:
-CXR: cardiomegaly (dilated cardiomyopathy)
-EKG: Non-specific: sinus tach (MC), Pericarditis: precordial ST elevations + PR depression , Pericardial effusion: alternans
-Cardiac Enzymes: +CK-MB and troponin (distinguish myocarditis from chronic dilated cardiomyopathy)
-ECHO: ventricular dysfunction
-Other: Inc ESR
-Endomyocardial biopsy: GOLD STANDARD
Infiltration of lymphocytes w/ myocardial tissue necrosis

Tx: Supportive, standard systolic HF tx:
diuretics
ACEi
inotropic drugs if severe: dopamine, dobutamine, milrinone

61
Q 
Pericarditis
Path:
Pt:
Dx:
Tx:
A

Path:
Fibrinous inflammation of pericardium
Idiopathic
Viral-> enteroviruses, coxsackie and echovirus
Dressler syndrome-> post-MI pericarditis

Pt: 
Chest pain 
Pleuritic-> sharp; worse w inspiration 
Persistent
Postural-> worse when supine and relieved by sitting/leaning forward
Pericardial friction rub
Best heard at end expiration while upright and leaning forward
Fever usually present

Dx:
EKG: diffuse ST elevations in precordial leads and associated PR depressions
ECHO assess for complications

Tx:
ASA or NSAIDs x7-14 days
Colchicine 2nd line
+/- corticosteroids if sx >48hrs and refractory to 1st line meds

Complications:
Effusion
Tamponade

62
Q 
Peripheral artery disease
Path:
Pt:
Dx:
Tx:
A

Path: atherosclerotic disease of the lower extremities

Pt: intermittent claudication, resting leg pain
PE: decreased/absent pulses, bruits, dec cap refill, cool limbs, shiny skin, hair loss, pale w/ dependent rubor

Dx:
(GS) contrast angiography
ABI <0.9
duplex U/S
hand held doppler

Tx:
Plt inhibitor: cilostazol, ASA, clopidogrel
revascularization surgery

63
Q

Peripheral artery disease which vessel is affected?

intermittent claudication in buttock, hip, groin

A

aortic bifurcation

common iliac

64
Q

Peripheral artery disease which vessel is affected?

intermittent claudication in thigh/upper calf

A

femoral artery or branches

65
Q

Peripheral artery disease which vessel is affected?

intermittent claudication in lower calf, ankle, foot

A

popliteal artery

66
Q

Peripheral artery disease which vessel is affected?

intermittent claudication in foot

A

tibial and peroneal arteries

67
Q 
Rheumatic Fever
Path:
Dx:
Tx:
Complications:
A

Path: Acute autoimmune inflammatory multi-systemic illness; MC affect 5-15yr
Infection with GABHS (Strep pyogenes) stimulated antibody production to host tissues and damages organs directly; Infection usually precedes rheumatic fever by 2-6w

Dx: Jones Criteria 2 major OR 1 major + 2 minor AND evidence of recent GAS infection

Major:
-Joint-> migratory polyarthritis
2+ joints affected or migratory (lower to upper), Heat, redness, swelling, severe joint tenderness must be present
-Oh my heart-> active carditis, Valves-> mitral/aortic, Myocardium, Pericardium
-Nodules-> subcutaneous, Rare finding, Seen over joint (extensor surface), scalp and spinal column
-Erythema marginatum : macular, erythematous, non-pruritic annular rash w/ rounded, sharply demarcated borders (may have central clearing), MC seen on trunk and extremities
-Sydenham’s chorea: Sudden involuntary jerky, non-rhythmic, purposeless movements especially involving head/arms

Minor:
Clinical
-Fever >101.3/38.5
-Arthralgia 
Laboratory 
Inc. acute phase reactant 
-ESR
-CRP
-Leukocytosis
ECG: prolonged PR interval

Evidence of recent group A streptococcal infection
+ throat cultures
Rapid antigen detection tests
elevated/increasing streptococcal antibody titers (ASO)

Tx:
Anti-inflammatory: ASA 2-6w taper
+/- corticosteroids in severe cases and carditis
Penicillin G (Erythromycin is PCN allergy)

Complications: Rheumatic valvular disease

  • Mitral 75-80%
  • Aortic 30%
  • Tricuspid and pulmonic 5%
68
Q 
Aortic dissection 
Path:
Pt:
Dx:
Tx:
A

Path: Risk factor-> HTN, advanced age, connective tissue dz (marfan, Ehlers-Danlos)

Pt:  Older, usually male
CC: sudden “ripping/tearing” CP radiating to back 
PE asymmetric pulses/BP
CXR-> widened mediastinum 
Bimodal peak
<40 yrs w/ connective tissue disorder
>50 yrs w/ chronic HTN

Dx:
CT angio (goldstandard)
TEE-> used in unstable pt

Tx: Reduce BP w/ negative inotropes
Short-acting beta-blockers first line 
-Labetalol
-Esmolol
-Propranolol 
CCB (if BB contraindicated)

Persistent HTN
Vasodilators
-Nitroprusside
-Nicardipine

Hypotensive-> Fluid resuscitation: Crystalloids

Surgery
Typically Standard type A and complicated type B
Uncomplicated type B manage medically

Stanford type A: involves Ascending aorta
Stanford type B: involves only descending aorta

69
Q 
Aortic aneurysm
Path:
Pt:
Dx:
Tx:
Screening:
A

Path: Focal dilation of aortic diameter at least 1-1.5x measured at renal arteries
>3cm
MC infrarenally
Risk factors-> atherosclerosis, age>60, smoking, males, HLD, connective tissue disorder (marfan’s), syphilis, HTN

Pt: Most Asx
>60yr old male, severe back/abdominal pain, syncope, hypotension
Tender, pulsatile abdominal mass
+/- flank ecchymosis

Dx: 
Abdominal U/S
CT scan-> test of choice
Angiography-> gold standard
MRI/MRA
Abdominal radiograph 
Tx:
BB
Surgical repair-> endovascular stent graft or open repair 
Asx repair:
-AAA grows >/= 5.5cm
-Grows > 0.6-0.8 cm in 6m

Screening: Abd U/S in males aged 65-75 who have ever smoked

Internal Medicine (10 decks)

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