EM 1 Flashcards
a 48-year-old male with type I diabetes mellitus and end-stage renal disease currently on hemodialysis with dyspnea, cough, and chest pain. He describes the pain as worse during inspiration and when he is lying on his back. The patient reports significant relief of his chest pain by sitting up or leaning forward.
pericarditis
PE findings for pericarditis
-often leads to??
- pleuritici CP—–worse with inspiration and laying down— better when pt sits up or leans forward
- pericardial friction rub–heard when upright/leaning forward
- diffuse ST seg elevations in precordial leads
often will lead to pericardial effusion *****
MCC of percarditis
MC=idiopathic
-SLE
-Uremia
-viral infection—– coxsackie MC
-TB
-RA
-neoplasms
-drugs
POST MI PERICARDITIS 2-5 days post op= DRESSLER
how to diagnose percarditis
need two of the following
- typical CP—- sharp and pleuritic, improved when sit up/leaning forward
- pericardial friction rub—best heard over left sternal boarder
- suggestive EKG changes–widespread ST elev in precaridoals and T wave inversion
- new or worsening pericardial effusion
type of breathing pattern seen with pt in restrictive percarditis
kussmauls sign ——-obstruction to R ventric outflow—— elevating jugular venous and right atrial pressures with inspiration
tx pericarditis
ID cause— tx it
- NSAIDs, ASA— 7-14 days
- corticos for >48 hrs of s/s
- ABs for bacerial
- pericardiocetesis if effusion
- Head at 45 degrees
- Pericardial window——– pt can develop tamponade or effusion—- window is cut on the pericardium to allow drainage of fluid
bacterial invovled in endocarditis
- acute
- IVDU
- subacute
- prosthetic valve
acute=staph A
IVDU=staph A
subacute=S. viridans
prosthetic= staph epidermidis
dukes criteria vs jones criteria
DUKE is for endocarditis
JONES for rheumatic fever
tx for Candida endocarditis
Amphotericin B
MCC overall of endocarditis
Strep viridans
**late complication of valve replacement
PE findings for endocarditis
- splinter hemorrhages in fingernail beds
- osler nodes—paiful lesions on fleshy portions of extremities
- roth spots– retinal hems
- janeway lesions– cutaneous evidence of septic emboli
- palatal or conjunctival petechiae
- splenomegaly
- hematuria
neuro findings— CVA—visual loss, motor weakness, aphasia
diagnosis for endocarditis
-GS?
blood cultres— 3 sets 1 hour apart
EKG
LABS— CBC, ESR, RF
transesophageal echocardiogram is GOLD STANDARD
MODIFIED DUKES CRITERIA
- *definite= 2 major criteria or 1 major + 3 minor OR 5 minor
- *Possible= 1 major and 1 minor or 3 minor
MAJOR CRITERIA
- blood cultures
- single positive blood culture for C. burnetii or antiphase iGG antibody titer >1:800
- positive echo showing vegetation, abscess or new partial dehiscence of a prosthetic valve
- new valvular regurgitation– simple change in pre-exist murmur not sufficient
MINOR
- predisposing heart condition or IVDU
- Fever > 38C or 100.4F
- Vascular phenom: arterial emobli, septic pulmonary infarcts, janeway, conjunct hem,
- immunologic pheomena: glomerulonephritis, Osler nodes, Roth spots, rheumatoid factor (RF) Microbiologic evidence: positive blood culture, but not a major criterion (excluding single positive cultures for coagulase-negative staphylococci and organisms that do not cause endocarditis) or serologic evidence of infection likely to cause IE
who should get AP before dental work
- prosthetic valves
- hx of IE
- unrepaired cyanotic congenitial HD or repaired with shunts
- cardiac transplant with valvue regurg
tx for IE
- with a native valve and is IVDU
- with prosthetic valve
- IVD abusers
IVDU= ampicillin 500 mg/h + nafcillin 2 g IV q 4 hr + gentamicin 1 mg/kf
PROSTHETIC= vanco 15 mg/kg + gentamicin 1 mg/kg + rifampin 300 PO
valve affected in IVDU and non IVDU
IVDU= tricuspid non= mitral
def diag for stable angina
most sensitive clinical signs to diagnose
tx for stable angina
angiography =GS—- useed only for severe cases bc costly
-stress test= most useful and cost effective
horizontal or downslopping ST-segment depression on ECG during attack
stable angina
-BB + nitro
SEVERE= angioplasty and bypass
what is considered a + stress test
st seg depression of 1 mm
unstable angina vs NSTEMI vs STEMI
unstable= ischemic changes, NO ELEV in troponins, with or without EKG changes for ischemia
NSTEMI= same manifestations as unstable angina, but with elevated troponins—— subendocardial —–ekg changes include ST seg depressions, T wave inversion or BOTH. NO ST ELEVATIONS
SSTEMI= same manifestations as those in unstable angina but with elevations in troponins and EKG Changes—– TRANSMURUAL (full thickness of myocardium)— ST ELEVS
diagnosis of unstable angina
-GS??
- ekg normal— then do a stress test
ANGIO to diagnose CAD— done if PCI or CABG being considered
tx for unstable angina
- mod of RF– smoking, BP, lipids
- antiplatelet drugs— ASA and/or clopidogrel or ticagrelor
- BB
- nitro and CCB for symptoms
- revasc if s/s persist despite medical tx
- ACE and statins
number 1 RF for printzmetal angina
smoking
second is cocacine
how to diagnose printzmetal angina
- ***HX of smoking (or no hx of CAD, DM, HTN, HCOL)
- *** preservation of exercise capacity
- **EKG: can show inverted U waves, ST seg or T wave abnormals
- *pain can sligtly be relieved with nitro
- Positive troponins
- **CP provoked by IV ergonovine
GS to diagnose vasospastic angina
angio with IV provoactive agents like ergonovine into coronary artery
prophylaxtic tx for prinztmetal angina
-what is contraindicated
CCB– tx the vasopsasms like amlodipine + long acting nitrates
CONTRA= use of BB like propranlol