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
Why is the Allen Test performed?
To test for ulnar artery patency; do this before puncturing the radial artery for an IV or blood draw
If the patient’s heart rate is <120, which is longer?
A. Diastole
B. Systole
A. Diastole
(S1 will occur “first” after the longer pause)
Which cardiac pathology causes a murmer that is characterized by…
An opening snap that is followed by a low-pitched decrescendo-crescendo rumble
Mitral stenosis
A 55 year old man with a history of hyperlipidemia, diabetes, and hypertension presents with chest pain when he reaches the top of a flight of stairs, which is alleviated by rest.
Which diagnostic test would you order?
A. None
B. Electrocardiogram (ECG)
C. Non-invasive Stress Testing
D. Coronary Angiogram
E. Coronary CT Scan
C. Non-invasive Stress Testing
He has risk factors, so more than just an ECG is necessary
What symptoms would make coronary ischemia a more likely diagnosis?
- Dull pain
- Increased pain with exercise
- Radiation to…
- Jaw
- Shoulder/back
- Angina
- Episodic, lasting minutes to hours
According to the U.S. Preventive Services Task Force, women aged 45 and older and older should be screened for lipid disorders if _______________
According to the U.S. Preventive Services Task Force, women aged 45 and older and older should be screened for lipid disorders if they are at an increased risk for coronary heart disease
What strategy would you use to hear aortic regurgitation, if it is present?
What are you listening for?
Listen in the aortic area (2nd intercostal space, right of the sternum) with the patient sitting upright
- Occurs early in diastole (after S2)
- Woosh that decrescendos
- Associated with wide pulse pressure
- Heard diffusely; heart throughout the heart area
What is the grade of a normal pulse?
2+
Where would you palpate the posterior tibeal artery?
Under/cupping the medial malleolus
(http://lsu32.nodusstudios.com/pulses.html)
On physical exam, you notice that the abdominal aorta is enlarged.
What is your next step?
Why?
Order prompt imaging (ultrasound or CT) to exclude an abdominal aortic aneurysm;
If present, risk of rupture should be assessed
What are the markers of a positive treadmill stress test?
- Significant ST depression or elevation
AND/OR
- Patient develops angina symptoms during the test
What is the normal range for jugular venous pulse height?
5-9 centimeters total
(so 0-4 cm above the Angle of Louis)
What signs of cardiac pathology can be seen on inspection of general appearance?
Cyanosis
Clubbing (vasodilation of capillaries in nail beds)
Peripheral edema
What strategy would you use to hear mitral stenosis, if it is present?
What are you listening for?
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)
- Occurs in mid-diastole
- Crescendo right before S1
- Opening snap followed by a low-pitched rumble
- The valve begins to open, but stops
Which test is not included in a fasted lipid profile?
A) Triglycerides
B) HDL cholesterol
C) Chylomicrons
D) LDL cholesterol
E) Total cholesterol
C) Chylomicrons
If you are fasted, you presumably do not have any chylomicrons floating around in your body
What pathology is implicated if the point of maximal impulse of the heart is lateral to its normal position?
Normal position: apex of left ventricle
(5th intercostal space, left of the sternum but medial to the mid-clavicular line)
If the PMI is lateral to this, it indicates cardiomegaly
According to the U.S. Preventive Services Task Force, men aged 20-35 should be screened for lipid disorders if _________________
According to the U.S. Preventive Services Task Force, men aged 20-35 should be screened for lipid disorders if they are at an increased risk for coronary heart disease
Is POCT more or less expensive than laboratory testing?
Why?
POCT is more expensive per test
Packaging is designed for single use
However, the argument can be made that POCT testing reduces costs in the long term if they are more convenient, therefore leading to earlier diagnosis
What is the grade of a “bounding” pulse?
4+
When you are listening to the heart, what are you most likely to hear (if it is present) when the patient is seated upright, leaning forward slightly?
Aortic regurgitation
(Listen at the left sternal border
What strategy would you use to hear mitral regurgitation, if it is present?
What are you listening for?
Listen at the apex of the heart, in the mitral area (5th intercostal space, left of the sternum, medial to the mid clavicular line)
- Occurs at the beginning of systole, continues through end of systole (holosystolic)
- May obscure both S1 and S2
- No change in intensity throughout duration
- Radiates to the axilla
List 4 advantages of POCTs
- Convenient and available
- Reduces turnaround time
- Requires small sample volumes
- Test using non-invasive samples
If you hear bruits in the carotid arteries, how should you modify the rest of the physical exam?
If you hear bruits in the carotid arteries, you should not palpate
(If a plaque is present, palpation could cause it to rupture)
Should annual stress cardiac imaging or advanced non-invasive imaging be included as part of routine follow-up in asymptomatic patients?
No!
May lead to unnecessary invasive procedures, excess radiation exposure if these screening tests are falsely positive
[Exception: Bypass patients >5 years after operation]
With the patient in LLD, you use light pressure to listen with the bell at the apex of the heart
What sounds (if present) would you hear in this position?
S3, S4 and/or mitral regurgitation
Results from Point of Care Testing are available in _____ minutes or less
Results from Point of Care Testing are available in 5-10 minutes or less
Does the carotid pulse occur during systole or diastole?
Systole
What strategy would you use to hear aortic stenosis, if it is present?
What are you listening for?
Listen in the aortic area (2nd intercostal space, right of the sternum)
- Occurs during systole
- Crescendo-Decrescendo
- Radiates to the carotid arteries (heard diffusely)
- Severe
- S2 may be absent
According to the U.S. Preventive Services Task Force, women aged 20-45 should be screened for lipid disorders if ________________
According to the U.S. Preventive Services Task Force, women aged 20-45 should be screened for lipid disorders if they are at an increased risk of coronary heart disease
How is the Allen test performed?
- Ask pt to make a fist
- Compress the radial and ulnar artery (2-3 seconds)
- Ask pt to open their hand
- Palm will be pale
- Release ulnar artery only
- If the ulnar artery is patent, the palm will return to normal color in 3-5 seconds
If present, what pathology does pulsus paradoxus suggest?
Cardiac tamponade (most likely)
Pulsus paradoxus is also present in…
- Constrictive pericarditis
- Severe asthma
- COPD
Which lipid components are measured in blood tests?
Which are calculated?
(Assume the patient is fasted)
- Measured
- Total cholesterol
- HDL-C
- Triglycerides
- Calculated
- LDL-C (difficult to isolate)
- Non-HDL-C
Which symptoms would make pneumothorax a more likely diagnosis?
- Sharp pain
- Severe dyspnea
- Acute onset
- No breath sounds on one side
- May be caused by recent trauma or spontaneous rupture
What is the grade of a diminished, or weaker than expected pulse?
1+
List some of the common components of Point of Care Tests
- Minimal sample required
- Consumable reagent cartridte
- Easy to use operating protocol
- Few steps, does not require laboratory expertise
- Internal calibration, QC
- Results available in 5-10 min or less
- Data is printed on a screen or on paper
- Results are documented in the patient chart
Which heart sound is louder at the base of the heart?
A. S1
B. S2
B. S2
What are the markers of a positive stress echocardiogram?
ECG evidence of ischemia
Wall motion abnormality (difference between rest and stress)
How can you distinguish S1 and S2?
Palpate the carotid artery: The pulse occurs during systole, between S1 and S2
Should stress cardiac imaging or advanced non-invasive imaging be included as a pre-operative assessment in patients scheduled to undergo low-risk non cardiac surgery?
No
No change in clinical management or outcomes
Why isn’t calculated LDL cholesterol reported when TG >400 mg/dL?
The calculation is not accurate since TG > 400/dL indicates the presence of chylomicrons (the patient was not fasted)
What pathologies are implicated by auscultation of S3?
Distended or incompliant ventricle (the sound is the rapid deceleration of blood as it hits the ventricle)
Note: S3 may be physiologic in healthy patients
What are some of the symptoms of esophageal rupture?
- Severe chest and upper abdominal pain
- Acute onset
- Severe vomiting and/or retching
What is the “first line” test that can reasonably be given to anyone witt worrisome chest pain?
ECG
How can you distinguish the carotid artery from the jugular vein?
- Palpable?
- Carotid is palpable
- Jugular is not
- Pulsations?
- Carotid has 1 puslation
- Jugular has 2 peaks and 2 troughs per cycle (it flickers)
- Changes?
- Carotid pulse does not change with respiratory cycle
- Height of jugular flicker will change with the patient’s position and decrease with inspiration
What does a split S2 indicate?
No pathology!
Splitting of S2 occurs physiologically upon inspiration.
Inspiration -> More right sided filling -> takes longer to empy -> Pulmonary valve takes longer to close than aortic valve
List the diastolic murmurs
Mitral stenosis
Aortic regurgitation
What is true about a disease that we would NOT want to screen for?
We would not screen for a disease that…
- Does not have a high burden of suffering
- Is extremely rare
- Does not have a latent/asymptomatic period
What 3 positions should the patient be in when you asuscultate heart sounds?
- Supine
- Majority of auscultation
- Left lateral Decubitus (LLD)
- 3rd and 4th heart sounds
- Mitral stenosis murmur
- Seated upright, leaning forward
- Aortic regurgitation murmur: listen at left sternal border
When you are listening to the heart, what are you most likely to hear (if it is present) when the patient is in the left lateral decubitus position (LLD)?
3rd and 4th heart sounds
Mitral stenosis murmur
(listen with bell)
Which cardiac pathology causes a murmer that is characterized by…
Blowing decrescendo along the sternal boarder that begins right after S2
Aortic regurgitation
What symptoms would make pericarditis a more likely diagnosis
- Changing position = changing pain
- Relief with leaning forward
- More severe when leaning back/lying down
- Radiation to the back
- ECG changes are often present
- History of virus/fever
When you palpate with the heel of your hand along the left parasternal area, what are you looking for?
RV heave
Normal = you don’t feel anything
RV heave = you can feel the RV contracting. This indicates pulmonary hypertension or RV hypertorphy
What is a point of care test?
Any test that can be conducted at or near the site of patient care
(If the patient has to go down the hall or across the street to the lab, it is not a point of care test)
Which murmurs (systolic vs. diastolic) are always pathologic?
Diastolic murmurs; any sound heard during diastole is pathogenic
- Aortic regurgitation
- Mitral stenosis
