CVB Clinical Medicine (except MDM) Flashcards
A 61 year old woman with a history of smoking and diabetes presents with crushing chest pain that started with walking to the kitchen in her apartment.
What diagnostic testing would you order?
A. None
B. Electrocardiogram (ECG)
C. Non-invasive Stress Testing
D. Coronary Angiogram
E. Coronary CT Scan
D. Coronary Angiogram
If you did a non-invasive stress test or a coronary CT, there is high pre-test probability that you would need to do a coronary angiogram anyway
(But you would need to do an ECG first, basically on the way to the cath lab)
What pathologies are possible if a patient has high jugular venous pressure?
Hypevolumemia
Heart failure (right side)
Pulmonary edema
A 73 yo man w/ a history of CAD s/p stent placement 4 months ago, hypertension, and hyperlipidemia presents with chest pain while walking on the treadmill for the past 2 weeks. The symptoms are alleviated by rest and similar to right before he needed a stent previously.
What testing would you order?
A. None
B. Nuclear Stress Testing
C. Stress Echo
D. Regular Treadmill Stress Test
E. Coronary Angiogram
E. Coronary Angiogram
(Can make an argument for stress testing with imaging)
What is the grade of a pulse that is absent, or that you are unable to palpate?
0+
Where should you find the point of maximum impulse of the heart?
The apex of the left ventricle
(5th intercostal space, left of the sternum but medial to the mid-clavicular line)
What symptoms would make aortic dissection a more likely diagnosis?
- Tearing pain
- Sudden onset (Acute)
- Very severe
- History of hypertension
- Radiates to the back
What are the 5 characteristics that we use to describe murmurs?
- Timing
- Shape (crescendo? decrescendo?)
- Location of maximum intensity
- Radiation
- Quality
How would you find a Right Ventricle Heave on physical exam?
If you found one, what pathology might be present?
Palpate with the heel of your hand along the left parasternal area
Normal = you don’t feel anything
RV heave = you can feel the RV contracting. This indicates pulmonary hypertension or RV hypertorphy
What strategy would you use to hear S3, if it is present?
With the patient in LLD, use light pressure to listen with the bell at the apex of the heart (5th intercostal space, between the left sternal boarder and mid-clavicular line)
If present, you would hear S3 early in every diastole (right after S2)
“WHAT THE hell” pattern
What is the grade of an “increased” pulse?
3+
What is the pre-test probability threshold above which a coronary angiogram is the most cost-effective diagnostic test?
>75%
If a patient is not fasted, what should you calculate instead of LDL-C?
Non-HDL-C
You cannot determine the LDL-C in a non-fasted patient because the Friedwald equation is not accurate when TG > 400 mg/dL
Use this instead:
Non-HDL-C = [Total cholesterol] - [HDL cholesterol]
What are the indications for stress cardiac imaging or advance dnon-invasive imaging in the initial evaluation of a patient?
These tests are indicated in an initial evaluation if any of the following are present
- Diabetes in patietns older than 40
- Peripheral arterial disease
- Greater than 2% yearly risk for coronary disease events
According to the U.S. Preventive Services Task Force, all men age ____ and older should be screened for lipid disorders
According to the U.S. Preventive Services Task Force, all men age 35 and older should be screened for lipid disorders
Which symptoms would make coronary ischemia a less likely diagnosis?
- Pain is sharp
- Exercise does not make the pain worse
Are Point of Care Tests (POCTs) more or less accurate than central lab instrumentation?
Usually, POCTs are considered less acurate; the central lab result is considered the reference
However, POCTs have become more accurate in recent years, and some are considered diagnostic (rather than just screening tools)
What strategy would you use to hear S4, if it is present?
With the patient in LLD, use light pressure to listen with the bell at the apex of the heart (5th intercostal space, between the left sternal boarder and mid-clavicular line)
If present, you would hear S4 late in every diastole (right before the next S1)
It will sound like a “gallop”
Why is it important to test for dyslipidemia in the clinic?
Dyslipidemia is a risk factor for CVD, and correcting it leads to treatment, and subsequently reduced CVD risk
List 4 possible disadvantages of POCTs
- Quality is operator dependent
- More expensive than laboratory testing
-
Assay performance
- Bias
- Lower Specificity/Sensitivity (Laboratory testing is the reference for most diagnoses)
- Reduced regulatory oversight
-
Orders and results may not be interfaced
- Requires manual entry
- Opportunity for errors, omission
Which cardiac pathology causes a murmer that is characterized as a…
Holosystolic murmur that does not change in intensity throughout systole
Mitral regurgitation
What is pulsus paradoxus?
How is it diagnosed?
If SBP on expiration is >10 mmHg higher than SBP on inspiration
- Basically, you are taking blood pressure but letting the air out slower (2 mmHg/second)
- Inflate the cuff
- Gradually deflate until Korotkoff sounds are heard, but only on expiration (this is SPB on expiration)
- Keep deflating until Korotkoff sounds are heard continuously (this is SBP on inspiration)
- If there is >10 mmHg difference between these two numbers, pulsus paradoxus is present
What pathologies are indicated by S4?
S4 is always pathologic
It indicates forceful atrial contraction, ejecting blood in to a stiff left ventricle
This indicates hypertension or aortic stenosis with LV hypertrophy
How can you calculate LDL cholesterol from total cholesterol?
Friedewald Equation
LDL-C = [Total cholesterol] - [HDL-C] - [TG]/5
TG/5 is an estimate fo the VLDL
Note: This equation is not accurate if TG >400 (indicates that the patient was not fasted)
Which symptoms would make aortic dissection a less likely diagnosis?
- Gradual onset
- Dull pain
Which cardiac pathology causes a murmer that is characterized by…
Crescendo-decrescendo during systole that can be heard diffusely
Aortic stenosis
What are the major organs that, when diseased, could cause a patient to present with chest pain?
In the chest: HALPP
- Heart
- Aorta
- Lungs
- Pericardium
- Pleura
Related to digestion: SPEG (sounds like spaghetti)
- Stomach
- Pancreas
- Esophagus
- Gallbladder
Other
- Muscle
- Bone
- Skin
- Psycogenic
What symptoms would make a diagnosis of GERD more likely?
- Pain is episodic
- After meals
- When lying down
- Radiation to throat
- Leaves sour taste in the mouth
Which tests are included in an un-fasted lipid profile?
Total cholesterol, HDL-C, Non-HDL-C
Where would you palpate the popliteal artery?
Behind the knee
List some examples of point of care tests
(Objective from the LG was to be able to name 3)
- Glucose
- HbA1c
- Lipids
- Urinalysis
- Blood gases
- Electrolytes
- Creatinine
- Infectious disease
- Fertility
- Drugs of abuse
- Prothrombin time
- Cardiac markers
A 49 yo man w/ a history of asthma presents with chest discomfort radiating down his left arm and into his jaw which occurred while walking to the bus. His ECG is shown below
What further testing would you order?
A. None
B. Nuclear Stress Testing
C. Stress Echo
D. Regular Treadmill Stress Test
E. Coronary Angiogram
E. Coronary Angiogram
(ECG shows ST elevation inferiorly and laterally)
Where would you palpate the dorsalis pedis artery?
The top of the foot
(UCSD Practical Guide to Clinical Medicine)
List the systolic murmurs
Aortic stenosis
Mitral regurgitation
Which symptoms would make pulmonary embolism a more likely diagnosis?
- Sharp pain
- Pain is worse with inspiration
- May have hemoptysis (coughing up blood)
What are the 6 life-threatening “can’t miss” diagnosis that present with chest pain?
- Coronoary ishemia
- Aortic dissection
- Pulmonary embolism
- Pneumothorax
- Esophageal rupture
- Pericarditis
Which heart sound is louder at the apex of the heart?
A. S1
B. S2
A. S1