Exam 3, CIS Pales, Heart Failure

Question 1

63 female with SOB mid sternal chest pain, sudden onset, constant 10/10 to L arm
dyspnea is moderately severe with cough
+HTN, PAD, HLD
+hysterectomy and aorto-femoral bypass
20 pack year Hx smoking
PMI 7th ICS, tachy, b/l crackles, trace edema
Ddx?

Answer 1

AMI
Unstable angina
CHF
PE
aortic dissection
pleuritis, pneumonia
myocarditis
pyscho somatic
takotsubo
pneumothorax
GERD

Question 2

Why is PMI displaced

Answer 2

L ventricular hypertrophy

Question 3

63 female with SOB mid sternal chest pain, sudden onset, constant 10/10 to L arm
dyspnea is moderately severe with cough
+HTN, PAD, HLD
+hysterectomy and aorto-femoral bypass
20 pack year Hx smoking
PMI 7th ICS, tachy, b/l crackles, trace edema
What tests to order

Answer 3

echo
EKG
troponins
CXR
CBC and CMP

Question 4

63 female with SOB mid sternal chest pain, sudden onset, constant 10/10 to L arm
dyspnea is moderately severe with cough
+HTN, PAD, HLD
+hysterectomy and aorto-femoral bypass
20 pack year Hx smoking
PMI 7th ICS, tachy, b/l crackles, trace edema
echo shows left sided dilated cardiomypathy

Answer 4

AMI causing Acute CHF

Question 5

63 female with SOB mid sternal chest pain, sudden onset, constant 10/10 to L arm
dyspnea is moderately severe with cough
+HTN, PAD, HLD
+hysterectomy and aorto-femoral bypass
20 pack year Hx smoking
PMI 7th ICS, tachy, b/l crackles, trace edema
what medications are appropriate for use at this time

Answer 5

aspirin, morphine, oxygen, NTG(monitor because BP is low)

betablocker ACEI etc..

Question 6

COPD patient getting worse
paroxsymal dyspnea, LE edema, abdominal distention, +COPD, DM, HTN, HLD, CAD
+appendectomy, cholescystectomy, heart cath
85% O2 on O2, JVD, S4, tachy, dec breath sounds b/l with bibasilar crackels
shifting dullness positive, extremities 2+ edema b/l
Ddx dyspnea?

Answer 6

CHF
COPD excacerbation
R sided HF
PE

Question 7

COPD patient getting worse
paroxsymal dyspnea, LE edema, abdominal distention, +COPD, DM, HTN, HLD, CAD
+appendectomy, cholescystectomy, heart cath
85% O2 on O2, JVD, S4, tachy, dec breath sounds b/l with bibasilar crackels
shifting dullness positive, extremities 2+ edema b/l
Ddx LE swelling?

Answer 7

Venous insufficiency**
lymph obstruction
nephrotic syndrome
CHF

Question 8

most common cause lower extremity edema

Answer 8

venous insufficiency

Question 9

COPD patient getting worse
paroxsymal dyspnea, LE edema, abdominal distention, +COPD, DM, HTN, HLD, CAD
+appendectomy, cholescystectomy, heart cath
85% O2 on O2, JVD, S4, tachy, dec breath sounds b/l with bibasilar crackels
shifting dullness positive, extremities 2+ edema b/l
Ddx for cough?

Answer 9

pneumonia
pulm edema
CHF

Question 10

3 most common causes of cough

Answer 10

post nasal drip
GERD
asthma

Question 11

most common cause abdominal distention

Answer 11

obesity

Question 12

what is significance of precordial heave

Answer 12

Large R ventricle

Question 13

COPD patient getting worse
paroxsymal dyspnea, LE edema, abdominal distention, +COPD, DM, HTN, HLD, CAD
+appendectomy, cholescystectomy, heart cath
85% O2 on O2, JVD, S4, tachy, dec breath sounds b/l with bibasilar crackels
shifting dullness positive, extremities 2+ edema b/l
What tests do you order

Answer 13

EKG
CXR
ECHO

Question 14

positive deflection in V1 could mean what on EKG

Answer 14

RAD, posterior MI, R ventricular hypertrophy

Question 15

COPD patient getting worse
paroxsymal dyspnea, LE edema, abdominal distention, +COPD, DM, HTN, HLD, CAD
+appendectomy, cholescystectomy, heart cath
85% O2 on O2, JVD, S4, tachy, dec breath sounds b/l with bibasilar crackels
shifting dullness positive, extremities 2+ edema b/l
what medications should be used or not used in patient

Answer 15

DIURETIC

probably not beta blocker. but has preivous MI so do want.

Question 16

Patient with swollen legs

Answer 16

Lymphedema - Filariasis

Question 17

22 y.o male cold Sx malaise and extreme fatigue. b/l leg swelling and SOB, gain 25 Lb, rash on back. no PMH, mom has lupus
BP100/50 HR 135 pulse 89
O2 RA 90%
JVD, PMI displaced, 2/6 systolic murmur tachy
dec lung sounds and b/l basilar crackles
3+ pitting edema b/l, erythematoud macular papular rash
Why is there a difference between HR and pulse (pulse deficit)?

Answer 17

HR too fast for ventricle to fill so cannot propel wave to extremities

Question 18

what could cause 2/6 systolic murmur

Answer 18

infectious myocarditis dilating the heart
stretches annulus around valve
mitral regurg

Question 19

22 y.o male cold Sx malaise and extreme fatigue. b/l leg swelling and SOB, gain 25 Lb, rash on back. no PMH, mom has lupus
BP100/50 HR 135 pulse 89
O2 RA 90%
JVD, PMI displaced, 2/6 systolic murmur tachy
dec lung sounds and b/l basilar crackles
3+ pitting edema b/l, erythematoud macular papular rash
how could rash connect to CHF syndrome

Answer 19

systemic viral infection
could be rheumatic fever
lupus

Question 20

22 y.o male cold Sx malaise and extreme fatigue. b/l leg swelling and SOB, gain 25 Lb, rash on back. no PMH, mom has lupus
BP100/50 HR 135 pulse 89
O2 RA 90%
JVD, PMI displaced, 2/6 systolic murmur tachy
dec lung sounds and b/l basilar crackles
3+ pitting edema b/l, erythematoud macular papular rash
What test would you order

Answer 20

TSH, CBC, CMP
ECHO
EKG
CXR

Question 21

22 y.o male cold Sx malaise and extreme fatigue. b/l leg swelling and SOB, gain 25 Lb, rash on back. no PMH, mom has lupus
BP100/50 HR 135 pulse 89
O2 RA 90%
JVD, PMI displaced, 2/6 systolic murmur tachy
dec lung sounds and b/l basilar crackles
3+ pitting edema b/l, erythematoud macular papular rash
Echo results: EF 37%, dilation atria and ventricle, moderate mitral regurg
most likely Dx

Answer 21

infectious myocarditis

coul dbe lupus myocarditis– need to biopsy rash

Question 22

infectious myocarditis
could be lupus myocarditis– need to biopsy rash
What medications should we use?

Answer 22

ACEI
Beta blocker
Aldosterone antagonist

Question 23

45 female with passing out, SOB, chest pain, LE edema
few weeks ago normal exercise stress test
NTG caused syncope
BP 110/80 4/6 holosystolic crescendo decrescendo murmur dec with valsalva
Ddx?

Answer 23

aortic stenosis

Question 24

what does normal exercise stress test indicate

Answer 24

no CAD

Question 25

what does a 4/6 holosystolic crescendo decrescendo murmur dec with valsalva suggest

Answer 25

aortic stenosis

Question 26

what is pulses parvus et tardus and what is it a sign of?

Answer 26

weak begining of pulse
later in pulse is normal
aortic stenosis

Question 27

45 female with passing out, SOB, chest pain, LE edema
few weeks ago normal exercise stress test
NTG caused syncope
BP 110/80 4/6 holosystolic crescendo decrescendo murmur dec with valsalva
does she have CHF?

Answer 27

no because it is a syndrome, does not have Sx of it

Question 28

45 female with passing out, SOB, chest pain, LE edema
few weeks ago normal exercise stress test
NTG caused syncope
BP 110/80 4/6 holosystolic crescendo decrescendo murmur dec with valsalva
What Tx?

Answer 28

heart surgery

NOT NTG

Question 29

give NTG have syncope, what is it

Answer 29

aortic stenosis

Question 30

32 y.o female to ER with SOB
over last 1-2 weeks had increasing dyspnea, extreme anxiety, swelling of legs, HA, b/l eye pain
heart palpuations, lost 30 LB gained 15
sweating, hot, shaky hands, hair loss, lump in neck, servere Resp distress, intubation
P 160, HR 160 RR 46 75% O2 on RA
+shifting dullness(ascites), extremity 4+ edema, jaundice
Ddx?

Answer 30

hyperthyroidism
thyrotoxicosis- high output failure
HTN causing HF

Question 31

32 y.o female to ER with SOB
over last 1-2 weeks had increasing dyspnea, extreme anxiety, swelling of legs, HA, b/l eye pain
heart palpuations, lost 30 LB gained 15
sweating, hot, shaky hands, hair loss, lump in neck, servere Resp distress, intubation
P 160, HR 160 RR 46 75% O2 on RA
+shifting dullness(ascites), extremity 4+ edema, jaundice
why is their hepatomegaly and elevated liver enzymes?

Answer 31

congestive hepatopathy

back up from heart