Clinical Appraoch (Lecture 3)

Question 1

“knifelike” pain may describe aortic dissection or pericarditis? How do you differentiate?

Answer 1

AD = sudden, unrelenting

Pericarditis = Lasts hours to days, may wax/wane

Question 2

In cardiovascular conditions, chronic dyspnea usually is caused by increases in pulmonary venous pressure as a result of left ventricular failure or valvular heart disease . Orthopnea, which is an exacerbation of dyspnea when the patient is recumbent, is caused by increased
work of breathing because of either increased venous return to the pulmonary vasculature or loss of gravitational assistance in diaphragmatic effort. ____ is severe dyspnea that awakens a patient at night and forces the assumption of a sitting or standing position to achieve gravitational redistribution of fluid.

Answer 2

Paroxysmal nocturnal dyspnea

Question 3

Old lady with fatigue?

Answer 3

Be concerned with MI

Question 4

Hemoptysis is a classic presenting finding in patients with pulmonary embolism, but it is also common in patients with _____, pulmonary edema, pulmonary infections, and malignant neoplasms

Answer 4

mitral stenosis

Question 5

If a patient has an MI, 5 days later they’ve developed a holosystolic murmur. What’s it most likely?

Answer 5

Mitral valve regurgitation (heard at apex)

other holosystolic murmurs include Tricuspid regurge and VSD…

Question 6

Pulmonary HTN… EKG characteristic?

Answer 6

Large p-waves in lead 2

Question 7

Most COMMON symptom in heart disease?

Answer 7

Dyspnea

Question 8

What will you NOT see in AFIB?

Answer 8

S4 heart sound

Question 9

ORder of prevalence of cardiomyopathies…?

Answer 9

1. Dilated
2. Hypertrophic
3. Restrictive

Question 10

Hyperthyroidism presents w/ what type of HTN?

Answer 10

isolated systolic

Question 11

What type of edema is more attributable to CVD?

Answer 11

dependent “pitting” edema

“non-pitting” = lymphedema

Question 12

What are the 5 modifiable TRADITIONAL risk factors for atherosclerosis

Answer 12

Tobacco smoking
HTN
Dyslipidemia
Diabetes/metabolic syndrome
Lack of physical activity/obesity

Question 13

What are the 3 non-modifiable TRADITIONAL risk factors for atherosclerosis?

Answer 13

Advanced age
Male sex
Family Hx

Question 14

Diabetes has how much a fold increase in risk of coronary events?

Answer 14

3-5 fold increase

Question 15

What are the 4 risk factors that comprise metabolic syndrome?

Answer 15

HTN, hypertriglyceridemia, reduced HDL, insulin resistance, visceral obesity

(notice that LDL is NOT a part of this cluster)

Question 16

Traditional risk factors include an age of > 45 for men and >55 for women.

However, the FamHx component of the risk factors have different numbers for their relatives… which are?

Answer 16

Male first degree relative with diagnosis of CAD before age 55

• Female first degree relative with diagnosis of CAD before age 65

Question 17

What are the 8(9) non-traditional risk factors for CAD?

Answer 17

Homocysteine
Lipoprotein A 
Small LDL size (smaller = worser)
Pro-inflammatory markers (CRP)
Coronary-artery calcification (assessed w/ EBCT)
Pro-thrombotic factors
ESRD, chronic inflammatory diseases, HIV

Question 18

Homocysteine requires B12/Folate…

Answer 18

Patients w/ enzyme deficiences related to homocysteine metabolism have higher risk of premature atherosclerosis

Question 19

Circulating lipoprotein similar to LDL with a unique glycoprotein (apo(a)) bound to apo B100

Lipoprotein (a) levels are genetic. Levels > ___ mg/dL appear to be associated w/ an independent increased risk of CVD

Answer 19

20

Question 20

When is it appropriate to screen with CRP?

Answer 20

INTERMEDIATE ONLY!

High risk you already know…

Low risk not necessary becuase it’s expensive

Question 21

How do you screen for coronary artery calcification?

Answer 21

EBCT (electron beam CT)

Gives you a Calcium score (>100, you’re posotive for calcium)

Once calcium is deposited… it’s there fo lyfe

Question 22

What type of heart sound would you see with ASD?

Answer 22

fixed/wise S2

Question 23

____ have increased mortality with ischemic coronary disease, which is why these agents are not considered first-line agents. At best, ___ are second-line agents.

Answer 23

calcium channel blockers

Question 24

Which of the following EKG abnormalities is most likely to be seen in the setting of atrial septal defect?

Answer 24

RBBB

Question 25

Diaphoresis and substernal chest pain longer than __ minutes are the physical examination signs that are most
consistent with MI.

Answer 25

30

Question 26

____ occur from abnormal ballooning of mitral valve into the left atrium as the mitral valve prolapses. Decrease in venous return bring the click closer to S1 and increase in venous return move the click closer to S2.

Answer 26

Mid-systolic clicks

a non-ejection click

Question 27

____ occurs in mitral and tricuspid stenosis (MS and TS). The earlier the ___, the worse the disease, because it indicates that the atrial pressure must have been very high to open the valve fast. Later, in diastole the OS, better the prognosis.

Answer 27

Opening snap (OS)

Question 28

Ejection click occurs shortly after S1 (i.e., early) and typically accompanies the murmur of _____

Answer 28

aortic stenosis

can also occur in pulmonic stenosis… but obviously the location will be different