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Adult/Ped Medicine Cumulative Final > Exam 4 > Flashcards

Exam 4 Flashcards

1
Q

Functional Classification of Heart Disease

New York Heart Association Classification of Heart Disease: CLASS 1

A
  • no limitations of physical activity
  • ordinary physical activity does not cause undue fatigue, dyspnea or anginal pain
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2
Q

Describe the specific testing modalities used to further evaluate cardiac patients

ECHOCARDIOGRAM

A

provides more accurate information on:

  • chamber size
  • global systolic function
  • chamber wall thickness
  • valve motion & function
  • pericardial fluid
  • blood flow and pressure gradients

types:

  • transesophageal echo (TEE)
  • stress echo
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3
Q

Describe the specific testing modalities used to further evaluate cardiac patients:

ELECTROCARDIOGRAM

A

used to evaluate for:

  • cardiac rhythms
  • conduction abnormalities
  • evidence of LVH, MI, ischemia

** compare changes to old EKGs

** not used for routine screening for cardiac disease

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4
Q

Describe the specific testing modalities used to further evaluate cardiac patients

CHEST X-RAY

A

provides information about:

  • heart size
  • pulmonary circulation
  • primary pulmonary disease
  • aortic abnormalities

** compare with old films **

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5
Q

Functional Classification of Heart Disease

New York Heart Association Classification of Heart Disease: CLASS 3

A
  • marked limitation of physical activity
  • comfortable at rest, but less than ordinary activity causes symptoms
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6
Q

Functional Classification of Heart Disease

New York Heart Association Classification of Heart Disease: CLASS 4

A
  • unable to engage in any physical activity without discomfort
  • symptoms may be present at rest
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7
Q

Describe the specific testing modalities used to further evaluate cardiac patients:

CORONARY ARTERY CALCIUM SCORE

A

measures amount of calcium in coronary arteries

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8
Q

Describe the specific testing modalities used to further evaluate cardiac patients:

STRESS TESTING

A

useful to elicit ischemia due to fixed coronary lesions

limited usefulness in asymptomatic patients

follow protocols

useful in diagnosis and follow-up with CAD

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9
Q

Describe the specific testing modalities used to further evaluate cardiac patients:

ANKLE BRACHIAL INDEX

A
  • measure pt’s brachial BP
  • measure ankle BP
  • divide ankle by brachial
  • 0.9-1.0 = normal
  • 0.7-0.9 = mild
  • 0.5-0.7 = moderate
  • < 0.5 = severe
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10
Q

Describe the specific testing modalities used to further evaluate cardiac patients:

ELECTROPHYSIOLOGIC TESTING (EP)

A

catheter-delivered electrodes induce rhythm disorders, identify structural basis for problem

more accurate than an EKG

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11
Q

Describe the specific testing modalities used to further evaluate cardiac patients:

PERCUTANEOUS INTERVENTION (PCI)

A
  • treatment modality for coronary artery stenosis
  • typically a stent is placed in the affected vessels
  • performed in cath lab, results are good
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12
Q

Describe the specific testing modalities used to further evaluate cardiac patients:

CT

A
  • original use to quantify amount of calcium in coronary vessels
  • allows for non-invasive coronary angiography
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13
Q

Common Symptoms of Possible Cardiac Origin

A
  • chest pain
  • chest pressure
  • dyspnea (+/- exertion)
  • orthopnea
  • paroxysmal nocturnal dyspnea
  • syncope or near syncope
  • transient neurologic deficits
  • edema
  • palpitations
  • cough
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14
Q

Describe the specific testing modalities used to further evaluate cardiac patients:

CARDIAC CATH & ANGIOGRAPHY

A
  • invasive procedure - performed in Cath Lab by interventional cardiologist
  • visualizes coronary vasculature
  • measures wedge pressures of valves and pulmonary capillaries
  • significant complications can develop
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15
Q

general approach to the evaluation and diagnosis of cardiac disorders

A
  • from the hx - develop a ddx which will direct your exam and need for further testing
  • EXAM
    • vital signs:
      • BP in 2 positions
      • pulse rate
      • weight
    • lungs
    • heart
    • peripheral vascular findings
    • jugular venous pulse
  • DIAGNOSTIC TESTS
    • Chest X-ray
    • Echocardiogram
    • ECG or EKG
    • Stress Testing
    • MRI & Fast CT
    • Cardiac Catheterization
    • Percutaneous Coronary Intervention
    • Blood Chemistry Tests
  • rule out life-threatening disorders first
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16
Q

define: Prevalence

A

estimate of how many people have a disease at a given point of time

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17
Q

Functional Classification of Heart Disease

New York Heart Association Classification of Heart Disease: CLASS 2

A
  • slight limitation of physical activity
  • ordinary physical activity results in symptoms
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18
Q

define: Incidence

A

estimate of the number of new cases of disease that develop in a population in a 1 year period

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19
Q

cardiovascular disease differences between men and women

A

Risk

  • risk is similar between men and women
  • MEN devlop disease earlier
  • risk equals out approximately 10 years after menopause, then WOMEN increase risk

Presenting Symptoms

  • MEN chest pain is most common
  • WOMEN shortness of breath, nausea/vomiting, back or jaw pain, lower chest or abdominal pain, dizziness, lightheadedness, fainting, fatigue
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20
Q

cardiovascular disease presentation in women

A
  • shortness of breath
  • nausea/vomiting
  • back or jaw pain
  • lower chest or abdominal pain
  • dizziness, lightheadedness, fainting, fatigue
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21
Q

Describe the specific testing modalities used to further evaluate cardiac patients:

BLOOD TESTS

A
  • Serum Lipid Profile
  • C-Reactive Protein
  • Blood Glucose
  • Troponin I or T
  • CK-MB
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22
Q

Describe the specific testing modalities used to further evaluate cardiac patients:

CARDIAC MRI

A

useful in imaging cardiac structures and function

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23
Q

define: risk factor

A

characterisitc or feature of an individual or population that is present in early life and is associated with an increased risk of developing future disease

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24
Q

non-modifiable cardiac risk factors

A
  • age
    • male > 45
    • female > 55
  • male gender
  • family history
    • male < 55
    • female < 65
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25
Q

modifiable cardiac risk factors

A
  • hyperlipidemia
  • smoking
  • hypertension
  • insulin resistance and diabetes
  • sedentary lifestyle
  • obesity
  • unhealthy diet
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26
Q

describe the modification of risk factors and thier role in prevention of heart disease

HYPERLIPIDEMIA

A
  • increased TC is a modifiable risk factor
  • early trials - decrease TC = decreased CHD events

ATP III Classification LDL

  • < 100 optimal
  • 100-129 near optimal
  • 130-159 borderline high
  • 160-189 high
  • > 190 very high

level of treatment is based on overall CV risk assessment

  • Clinical ASCVD: moderate to high-intensity statin
  • LDL > 190 - high intensity statin
  • Diabetic pts - moderate intensity statin
  • without ASCVD or DM; LDL 70-189 mg/dL estimated 10 year risk > 7.5% - moderate to high intensity statin
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27
Q

High-Intensity Statin Therapy

A

lowers LDL by > 50%

  • Atrovastatin
  • Rosuvastatin
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28
Q

Moderate-Intensity Statin Therapy

A

lowers LDL by 30-49%

  • Atrovastatin
  • Rosuvastatin
  • Simvastatin
  • Pravastatin
  • Lovastatin
  • Fluvastatin
  • Pitavastatin
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29
Q

describe the modification of risk factors and thier role in prevention of heart disease

DIABETES, INSULIN RESISTANCE AND HYPERTRIGLYCERIDEMIA

A
  • patients with diabetes tend to cluster other risk factors
  • insulin resistance increases risk
  • patients with type 1 and type 2 diabetes are at high risk
  • added sugars
    • should be less than
    • > 21% of daily calories - double risk of CV
    • > 7 sugar-sweetened beverages increase risk of CV death by 29%
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30
Q

Metabolic Syndrome

A

waist circumfrence: > 40 men, > 35 women

insulin resistance: fasting glucose > 100

high blood pressure: BP > 130/85

dylipoproteinemia

  • elevated plasma triglycerides: TG > 150
  • reduced HDL levels: < 40 men, 50 women
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31
Q

describe the modification of risk factors and thier role in prevention of heart disease

HYPERTENSION

A

lowering diastolic BP (5-6 mmHg) reduces

  • risk of stroke
  • risk of vascular mortality
  • risk of coronary heart disease

slows the progression of

  • congestive heart failure
  • renal failure
  • ophthalmologic complications
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32
Q

describe the modification of risk factors and thier role in prevention of heart disease:

SMOKING

A

single most important modifiable risk factor for coronary artery disease

benefits of cessation

  • reduce cardiovascular risk of 50% in the first 1-2 years
  • risk approaches baseline in 5-15 years
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33
Q

Smoking: Mechanisms of Atherosclerosis

A
  • enhances oxidation of HDL
  • reduces levels of LDL
  • increases inflammatory markers (hs-CRP, fibrinogen)
  • spontaneous platelet aggregation
  • increases monocyte adhesion
  • increased prevalence of coronary spasm
  • reduces threshold for ventricular arrhythmias
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34
Q

describe the modification of risk factors and thier role in prevention of heart disease:

Sedentary Lifestyle

A

250,000 deaths annually can be attributed to physical activity

recommendation: 40 minutes of moderate intensity daily

activity can help reduce - non-fatal cardiovascular events and cardiovascular deaths

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35
Q

Physiologic Benefits of Regular Exercise

A
  • reduced myocardial oxygen demand
  • increased exercise performance
  • reduced blood pressure
  • weight control
  • reduced cholesterol, increased HDL
  • improved glucose tolerance
  • improved endothelial function
  • enhances fibrinolysis
  • reduces platelet reactivity
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36
Q

Inflammation Markers

A

present in every stage of atherothrombosis

  • hs-CRP
  • ICAM-1
  • IL-6
  • TNF-a
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37
Q

describe the modification of risk factors and thier role in prevention of heart disease

hs-CRP

A

inflammatory marker

strong predictive value in men, women, elderly, smokers, stable and unstable angina, prior MI

higher hsCRP - lower survival after MI; can predict recurrent events with CVA and PAD

modifiable risk factor?

  • Aspirin
  • Statins
  • Angiotensin converting enzyme inhibitors
  • thiazolidine derivatives
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38
Q

identify the signs, symptoms, and approach to the diagnosis of:

Abdominal Aortic Aneurysm

A

Signs & Symptoms

  • most are Asymptomatic and discovered on routine exam or chest x-ray or ultrasound
  • expanding AAA: sudden, severe and constant low back, flank, abdominal or groin pain
  • syncope may be chief complaint

Diagnosis

  • pulsatile abdominal mass
  • plain x-ray
  • CT
  • MRI
  • Ultrasound is gold standard

Treatment

  • surgery
    • any symtomatic aneurysm
    • asymptomatic aneurysm > 5 cm
    • any aneurysm that has shown an increase in size over last 6 months
  • stents
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39
Q

*identify the signs, symptoms, and approach to the diagnosis of the following: *

Acute arterial occlusion

A

SIGNS - recognition is vital

  • Pain hearlds onset of ischemia
  • Paralysis and Parasthesia are most important
  • Pallor - indicates decreased circulation
  • Absence of Pulses confirms the diagnosis and localizes the point of occlusion

Causes

  • embolism
  • trauma
  • thrombosis

TX

  • emergent referral
  • immediate anticoagulation
  • embolectomy
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40
Q

Identify this condition and describe the management:

pt presents with pain in his leg and that it feels like it is “asleep”

exam reveals absence of dorsal pedis pulse

A

Acute Arterial Occlusion

treatment:

  • emergent referral
  • immediate anticoagulation
  • embolectomy
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41
Q

ANKLE BRACHIAL INDEX

A
  • measure pt’s brachial BP
  • measure ankle BP
  • divide ankle by brachial
  • 0.9-1.0 = normal
  • 0.7-0.9 = mild
  • 0.5-0.7 = moderate
  • < 0.5 = severe
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42
Q

identify the signs, symptoms, and approach to the diagnosis of:

Aortic Dissection

A

event of sudden onset in which blood leaves the normal aortic channel through a usually discrete point of exit (intimal tear) - dissects into layers of the aorta

causes

  • medial degneration
  • Marfan Syndrome
  • bicuspid aortic valve
  • dilated ascending aorta
  • aortic coarctation
  • systemic arterial hypertension

clinical features

  • sudden death
  • hypovolemic shock
  • sudden severe arterial hypertensive event
  • radiating pain through to back, neck or arms, occlusion of a major vessel

diagnosis and treatment

  • CXR
  • Echo
  • CT or MRI
  • Aortography
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43
Q

Identify this condition and describe the management:

pt is a 60 year old female reporting radiating pain to her back, neck and arms

pt has decreased blood pressure, weak thready pulse, pale skin, and is sweating

A

Aortic Dissection

diagnosis: CXR, echo, CT or MRI, aortography
tx: immediate surgical referral

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44
Q

Aortoiliac PVD

A
  • claudication involving calf, thigh and buttock
  • impotence
  • rest pain, ulceration and gangrene not common
  • forth, fifth to sixth decade of life
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45
Q

identify the signs, symptoms, and approach to the diagnosis of:

Carotid Artery Stenosis

A

Signs & Symptoms

  • transient ischemic attacks
    • transient focal neurological deficits
    • all symptoms resolve within 24 hours
  • ataxia
  • vertigo
  • drop attacks
  • diplopia
  • visual blurring
  • amaurosis fugox
  • bruits over carotids

Diagnosis and Treatment

  • doppler ultrasound
  • angiography
  • medical vs. surgical
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46
Q

Identify this condition and describe the management:

pt presents with complaints of vertigo and visual blurring

exam reveals pt burits on ascultation of carotid arteries

A

Carotid Artery Stenosis

  • medical and surgical treatment
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47
Q

Chronic Venous Insufficiency

A
  • dysfunction of valves in the superficial and/or communicating veins
  • dysfunction of valves
  • deep venous outflow obstruction
  • muscle dysfunction
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48
Q

identify the signs, symptoms, and approach to the diagnosis of:

Deep Vein Thrombosis

A

Signs and Symptoms

  • painful swollen leg
  • temperature
  • positive Homan’s sign
  • positive risk factor

Diagnosis

  • duplex scanning
  • venography

Treatment

  • elevation and rest
  • thrombolytic agents
    • heparin
    • lovenox
    • coumadin
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49
Q

Diagnostic Testing of Venous Ulcers

A
  • LAB - CBC, blood sugar, ESR, albumin
  • culture
  • biopsy
  • plain film radiographs
  • test for peripheral arterial disease
  • duplex ultrasonography
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50
Q

Femoropopliteal PVD

A
  • common in smokers
  • tissue necrosis more common
  • rest pain more common
  • more common in older individuals
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51
Q

History - Peripheral Artery Disease

A
  • pain
    • rest-pain poor prognosis sign
  • intermittent claudication
    • most common complaint
    • due to limb ischemia
    • highly specific symptom, virtually diagnostic
  • smoking history
  • diabetes
  • cardiac disorders
  • trauma
  • familial disease
  • occupational history
  • impotence
  • drugs
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52
Q

Indications for Surgical Revascularization - Peripheral Artery Disease

A
  • pain at rest
  • ischemic ulcers or gangrene
  • atheroembolic (trash foot)
  • low ABI
  • claudications at short distance, worsening symptoms
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53
Q

Ischemic Leg Ulcers

A
  • little or no bleeding
  • irregular edge, poor granulation tissue
  • distal location on dorsum of foot & toes
  • severe pain
  • trophic changes of chronic ischemia
  • distal pulses are weak or gone
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54
Q

Laboratory/Diagnostic Tests Peripheral Artery Disease

A
  • blood sugar
  • lipid profile
  • ankle/brachial index
  • duplex ultrasound
  • arteriography
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55
Q

Neurotrophic Ulcers

A
  • brisk bleeding with manipulation
  • punched out, with deep sinus
  • demonstrable neuropathy
  • located under calluses or pressure points
  • no pain
  • common in diabetic patients
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56
Q

Pathogenesis of Deep Vein Thrombosis

A
  • Venous Stasis
  • Endothelial Damage
  • Hypercoagulability
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57
Q

Physical Exam Peripheral Artery Disease

A
  • color
  • temperature
  • loss of hair
  • atrophy and rubor in skin
  • atrophy of the muscles
  • ulcers and gangrene
  • capillary refill
  • PALPATION OF PERIPHERAL PULSES
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58
Q

Risk Factors for Peripheral Artery Disease

A
  • smoking
  • increasing age
  • sex M > F
  • diabetes
  • hyperlipidemia
  • hypertriglyceridemia
  • hyperhomocystinemia
  • hypertension
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59
Q

Risk Factors of Deep Vein Thrombosis

A
  • CHF
  • MI
  • Stroke
  • Malignancy
  • Major Surgery
  • Trauma
  • Immobilization
  • Obesity
  • Age
  • Pregnancy
  • Oral Contraceptives
  • Smoking
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60
Q

Stasis Ulcers

A
  • venous ooze with manipulation
  • shallow, irregular shape, granulating base, rounded edges
  • stasis dermatitis
  • located lower third of leg
  • mild pain, relieved by elevation
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61
Q

Tibioperoneal PVD

A
  • common in diabetics
  • tissue necrosis
  • older individuals
  • most difficult to treat
  • amputation common
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62
Q

Treatment of Peripheral Artery Disease

A
  • abstinence from tobacco in any form
  • exercise
    • walk 35-30 min, 3-5 x/week
    • achieve moderate claudication pain the first 5 min
  • antiplatelet therapy
    • aspirin
    • plavix
    • pletal
    • trental
  • antihypertensives: ACE inhibitors
  • diabetes control
  • lipid-lowering agents
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63
Q

Treatment of Venous Ulceration

A
  • elevation of leg
  • compression therapy (stasis)
  • treat infection
  • dressings and topical agents - wet to dry
  • treatment of arterial insufficiency
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64
Q

Identify this condition based on symptoms and the rhythm strip presented:

pt complains of palpitations, shortness of breath with exertion, fatigue, and edema

exam reveals irregular pulse, variable BP, crackles on ascultation

A

Atrial Fibrillation

Rate: Variable, usually fast > 100 bpm
Rhy: Irregularly irregular (chaotic)
P-wave: Not consistently present or reproducible
PR: Not measurable
QRS: Normal (narrow,

Differentiate between atrial fibrillation, atrial tachycardia, and atrial flutter.

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65
Q

Identify this condition based on symptoms and the rhythm strip presented:

pt reports feeling light-headed and having fainted

signs: rapid HR

A

Paroxysmal Supraventricular Tachycardia

Rate: 140 - 250 bpm*
Rhy: Very Regular
P-wave: Lost in the T-wave, not typically observed on rhythm strip
PR: Not measurable
QRS: Normal (narrow,

Differentiate between atrial fibrillation, atrial tachycardia, and atrial flutter.

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66
Q

What pathology is present?

Rate: Variable, usually fast > 100 bpm

Rhy: Irregularly irregular (chaotic)

P-wave: Not consistently present or reproducible

PR: Not measurable

QRS: Normal (narrow,

A

Atrial Fibrillation

Differentiate between atrial fibrillation, atrial tachycardia, and atrial flutter.

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67
Q

Differential Diagnosis for a Wide-QRS Complex

A

in order of descending mortality

  • hyperkalemia
  • ventricular tachycardia
  • idioventricular rhythm, including heart block
  • drug effects and overdose (tricyclics)
  • Wolff-Parkinson-White
  • Bundle Branch Blocks & IVCD
  • PVCs
  • Aberrantly conducted complexes
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68
Q

What pathology is present?

Rate: Atrial rate 250 – 400 Ventricular rate Varies

Rhythm: Regular or Irregular

P-waves: Saw tooth deflection (F waves)

PR: Not measurable

QRS: Typically normal

A

Atrial Flutter

Differentiate between atrial fibrillation, atrial tachycardia, and atrial flutter.

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69
Q

Analyze the basic ECG components required to assess pathology to include, heart rate, rhythm, axis, and intervals

Rhythm Determination on an ECG

A

Is the distance between one QRS complex the same as the others?

If yes - the rhythm is regular

If no - the rhythm is irregular

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70
Q

Insignificant Q Waves

A
  • do not meet the criteria for significance
  • typically found in leads: I, aVL, V4-V6
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71
Q

Criteria for Diagnosis of MI: Injury Pattern

A
  • ST segment elevation (1 mm or greater)
  • T wave peaks initially then inverts later
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72
Q

Criteria for Diagnosis of MI: Infarction Pattern

A

Presence of SIGNIFICANT Q WAVES

  • Q wave that is 1/3 total height of QRS
  • wider than 40 ms
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73
Q

What pathology is described and shown on the ECG below:

QRS > 120 ms

rSR’ pattern V1-V2

slurred S-wave in I and V6

A

Right Bundle Branch Block

  • QRS > 120 ms
  • Axis is RAD or normal
  • rsR’ pattern V1-V2
  • slurred S-wave in I and V6
  • NSSTT changes in V1 and V2

Describe the specific diagnostic criteria for Bundle branch blocks.

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74
Q

Analyze the basic ECG components required to assess pathology to include, heart rate, rhythm, axis, and intervals

Axis Determination

A
  • on the ECG look at Limb Lead 1 and determine if the net deflection of the QRS complex is positive, negative or equal
  • on the ECG look at Limb Lead aVF and determine if the net deflection of the QRS complex is positive, negative or equal
  • determine where the lines cross
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75
Q

Analyze the basic ECG components required to assess pathology to include, heart rate, rhythm, axis, and intervals

ECG: Right Axis Deviation

A
  • right bundle branch block
  • right ventricular hypertrophy
  • high lateral wall MI
  • right anterior fascicular block
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76
Q

ECG Waveforms

(PQRST)

A

P wave: atrial depolarization

QRS wave: ventricular depolarization, also atrial repolarization occurs

J Point: end of the QRS wave and start of the ST segment

T Wave: ventricular repolarization

U Wave: late repolarization variant, can be a normal variant or assoicated with hypokalemia or hypomagnesiumemia

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77
Q

R-Wave Progression

A
  • uses the precordial chest leads V1-V6
  • r-wave (myocardial rotation) progresses from V1 through V6
  • start small V1
  • transition occurs V3,V4
  • get big V6
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78
Q

Identify the common variances within normal ECGs.
Describe the specific diagnostic criteria for normal ECGs .

“Normal” ECG

A
  • P waves upright in: I, II, V2-V6
  • Small Q waves in: I, aVL, V4-V6
  • Deep Q waves in: aVR occassionally III and V1
  • T waves upright in: I, II, V3-V6
  • T waves inverted in: aVR
  • T waves variable in: III, aVL, aVF, V4-V6
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79
Q

Identify the pathology described below and shown on the ECG:

PR interval < 120 ms, normal P waves

Wide QRS complex

Presence of “delta-wave”

A

Wolff Parkinson White

“delta-wave” intial slurring of QRS

can also have secondary ST-T changes

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80
Q

What pathology is present?

Rate: 140-250 bpm

Rhythm: regular

P-Wave: not typically observed

PR: not measurable

QRS - normal (narrow < 0.12 sec)

A

Paroxysmal Supraventricular Tachycardia

Differentiate between atrial fibrillation, atrial tachycardia, and atrial flutter.

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81
Q

Analyze the basic ECG components required to assess pathology to include, heart rate, rhythm, axis, and intervals

QT Interval

A

QT

  • measures a complete ventricular cycle (depolarization and repolarization)
  • start of QRS to end of T wave
  • normal is heart rate dependent
    • HR of 60 - 400 ms
    • HR of 100 - 320 ms
  • as HR increases, QT interval decreases
  • QT is probably prolonged if it exceeds more than HALF of the R-R interval
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82
Q

Analyze the basic ECG components required to assess pathology to include, heart rate, rhythm, axis, and intervals

QRS Interval

A

QRS

  • normal < 3 boxes)
  • beginning of QRS to end (J-Point)
  • length of time for ventricular contraction
  • prolonged interval
    • bundle branch blocks
    • IVCD
    • WPW
    • LVH
    • RVH
    • ventricular tachycardia
    • PVCs
    • idoventricular rhythm
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83
Q
  • Develop a simple method that will allow you to consistently assess unknown ECGs for common pathologies.*
  • *
A
  • Gestalt - general impression (i.e. this is bad)
  • Determine the Heart Rate
  • Determine the Rhythm
  • Measure the Longest Interval (PR, QRS, QT) in the limb leads
  • Determine the Axis
  • Asses the R-Wave Progression
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84
Q

Evaluate this rhythm strip:

A

Differentiate between atrial fibrillation, atrial tachycardia, and atrial flutter.

Paroxysmal Supraventricular Tachycardia

Rate: 140 - 250 bpm*
Rhy: Very Regular
P-wave: Lost in the T-wave, not typically observed on rhythm strip
PR: Not measurable
QRS: Normal (narrow,

Reentry process, presents abruptly for numerous reasons

Symptoms: light-headedness, syncope, racing heart; worsen angina and heart failure

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85
Q

Analyze the basic ECG components required to assess pathology to include, heart rate, rhythm, axis, and intervals

ECG: Left Axis Deviation

A
  • left bundle branch block
  • left ventricular hypertrophy
  • inferior wall MI
  • left anterior fascicular block
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86
Q

How to differentiate between atrial fibrillation, atrial tachycardia, and atrial flutter.

A

Is the rhythm regular?

  • yes: PVST or atrial flutter
  • no: atrial fibrillation or atrial flutter

Are P-waves (F-waves) present?

  • yes: atrial flutter
  • no: PVST or atrial fibrillation
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87
Q

Criteria for Diagnosis of MI: Ischemia

A
  • ST segment depression (2 mm or greater)
  • T wave inversion (symmetrical)
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88
Q

What pathology is described and shown on the ECG below?

QRS > 120 ms

Wide S waves V1-V4

Wide R waves in I and V6

A

Left Bundle Branch Block

  • QRS > 120
  • Axis is normal or LAD
  • wide monomorphic S waves V1-V4
  • wide monomorphic R waves in I and V6
  • NSSTT changes in most leads

Describe the specific diagnostic criteria for Bundle branch blocks.

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89
Q

Identify the common variances within normal ECGs.
Describe the specific diagnostic criteria for normal ECGs.

what to note/evaluate on each ECG lead

A
  • location and morphology of P waves
  • QRS pattern (presence of Q-waves)
  • ST segment (elevation or depression)
  • T wave changes

**Review all leads except aVR

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90
Q

Differential Diagnosis of ST-Elevation

A
  • Acute STEMI
  • Printzmetal’s Angina
  • Ventricular Aneurysm
  • Pericarditis
  • Normal Variant - early repolarization
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91
Q

Evaluate this rhythm strip:

A

Atrial Flutter

Rate: Atrial rate 250 – 400 Ventricular rate Varies
Rhythm: Regular or Irregular
P-waves: Saw tooth deflection (F waves)
PR: Not measurable
QRS: Typically normal

Differentiate between atrial fibrillation, atrial tachycardia, and atrial flutter.

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92
Q

Evaluate this Rhythm Strip:

A

Atrial Fibrillation

Rate: Variable, usually fast > 100 bpm
Rhy: Irregularly irregular (chaotic)
P-wave: Not consistently present or reproducible
PR: Not measurable
QRS: Normal (narrow,

Symptoms: palpitations, SOB, fatigue, DOE, CP, edema

Signs: irregular pulse, variable BP, crackles edema

Causes: organic heart disease, valvular disease, thyroid, HTN

Differentiate between atrial fibrillation, atrial tachycardia, and atrial flutter.

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93
Q

System to Evaluate Rhythm Strips

A
  • Determine Heart Rate
  • Determine Rhythm
  • Presence of P-wave (location and morphology)
    • a single P-wave should proceed each QRS complex
    • should bear a family resemblance to all other P-waves
  • Measure PR and QRS intervals
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94
Q

Analyze the basic ECG components required to assess pathology to include, heart rate, rhythm, axis, and intervals

Heart Rate Determination on an ECG

A

Paper speed is 25 mm/sec or 300 big boxes per second

take 300 divided by the number of big boxes from 1 QRS to the next

i.e. in this example: 300/3.8 = ~80

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95
Q

Analyze the basic ECG components required to assess pathology to include, heart rate, rhythm, axis, and intervals

PR Interval

A

PR:

  • normal: 120-200 ms (3-5 boxes)
  • beginning of P wave to the beginning of the QRS complex
  • best measured in limb lead 2
  • conduction through the AV node
  • short PR interval:
    • pre-excitation syndrome (WPW, LGL)
    • PACs
  • long PR interval - lots of causes
  • refered to as “First Degree AV Block”
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96
Q

Reduced Sodium Intake

Describe the management of HTN according to lifestyle modifications including recommendations and objective support.

A
  • Recommend moderate restriction:
    • 2400 mg/day (2.5-5 grams)
    • 6 grams of Na/Cl (normal 6-12)
    • < 1500 mg is ideal
  • greatest benefit in: African Americans and elderly
  • read food labels
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97
Q

Prevention of HTN

5 Ways:

Describe the management of HTN according to lifestyle modifications including recommendations and objective support.

A
  1. reduction of salt intake
  2. diet rich in fruits, vegetables, low-fat dairy products, reduce saturated fat, total fat and cholesterol
  3. reduction of excess body weight
  4. regular physical exercise
  5. moderation of alcohol intake
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98
Q

HTN Retinopathy

A
  • Keith-Wagner Barker System
  • can determine the level of retinopathy caused by HBP
  • features
    • hemorrhage
    • exudates
    • papilledmia
  • HTN retinopathy has some reversibility
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99
Q

Relative Risk of HTN for CAD, CHF, CVA

A

Normal BP: 1x

140-160/90: 2x

>160/95: 4x

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100
Q

Renovascular Hypertension

Summarize the pathophysiology, secondary causes, and differential diagnosis of HTN.

A
  • unilateral or bilateral stenosis of renal artery
  • clinical clues:
    • abdominal bruit
    • rapid new onset of HTN
    • rapid loss of renal function
    • difficult to control HTN
  • screening studies: MRI, CT
  • confirmatory: renal arteriography
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101
Q

Role of Renin in HTN

Summarize the pathophysiology, secondary causes, and differential diagnosis of HTN.

A

volume status (as related to changes in dietary sodium intake) affects the amount/rate of renin secreted

Angioteninogn —–RENIN——-> Angiotensin 1 —– ACE —-> Angiotensin 2 (vasoconstricts and increases BP)

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102
Q

Definition of Hypertension

Describe the classification and definition of blood pressure

A

any of the following:

Systolic BP > 140 mm Hg

Diastolic BP > 90 mm Hg

taking antihypertensive medications

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103
Q

Blood Pressure Technique

A
  • measure after 5 minutes of rest in a seated position
  • patient should refrain from smoking or ingesting caffeine 30 minutes prior to measurement
  • appropriate cuff size (bladder of cuff ~ 80% of arm)
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104
Q

Weight Loss HTN

Describe the management of HTN according to lifestyle modifications including recommendations and objective support.

A
  • direct linear relationship to increasing BP
  • 1-2 mm Hg fall in BP seen with each kg of weight loss
  • weight regain accompanied with elevated BPs
  • overweight patients: 2-6x increase risk of developing HTN
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105
Q

Pseudohypertension

Summarize the pathophysiology, secondary causes, and differential diagnosis of HTN.

A

increased stiffness of larger arteries = artificially elevated systolic blood pressure

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106
Q

Pathophysiology of HTN

Summarize the pathophysiology, secondary causes, and differential diagnosis of HTN

A
  • cause of primary HTN unknown
  • hemodynamic fault of established hypertension - INCREASED PERIPHERAL VASCULAR RESISTANCE
  • renal defect in sodium excretion
  • heredity
  • abnormal CV or renal development

**EXACERBATING FACTORS:

  • obesity
  • sleep apnea
  • alcohol
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107
Q

Isolated Systolic HTN

Summarize the pathophysiology, secondary causes, and differential diagnosis of HTN.

A
  • defined as a systolic > 160 mmHg while diastolic is < 90 mmHg
  • common among older persons
  • SBP is a better predictor of CV events than DBP
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108
Q

Renal Parenchymal Disease

Summarize the pathophysiology, secondary causes, and differential diagnosis of HTN.

A
  • most common secondary cause
  • responsible for 20% of end stage renal disease in whites; 50% - African Americans
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109
Q

HTN High Risk Groups

A
  • Prehypertension
  • Family history
  • African-Americans
  • Overweight
  • Excess consumption of sodium
  • Physical inactivity
  • Alcohol consumption
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110
Q

Describe the impact hypertension has on individuals and populations.

JNC 7 Goals for Specific Group Management of HTN:

patients < 60

patients > 60

diabetics or kidney disease

A

patients < 60 140/90

patients > 60 150/90

diabetes or kidney disease 140/90

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111
Q

Exercise

Describe the management of HTN according to lifestyle modifications including recommendations and objective support.

A
  • regular isotonic exercise 40 min, 4x/week
  • avoid isometric exercise -may cause reflex rise
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112
Q

Evaluation of Hypertension: History

Describe the clinical presentation, history, PE, and diagnostic work-up of HTN.

A
  • risk factors for CAD
  • social history
    • diet (salt)
    • alcohol
    • caffeine
    • smoking
    • exercise
  • drugs
    • OTC (anti-histamines)
    • prescription
  • past medical and family histories
  • ROS to secreen for secondary causes
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113
Q

DASH Diet

Describe the management of HTN according to lifestyle modifications including recommendations and objective support.

A

Dietary Approaches to Stop Hypertension

  • consume a diet rich in fruits, vegetables and low-fat dairy products
  • 8-14 mmg Hg reduction in BP
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114
Q

JNC 7 - High Blood Pressure Prevention, Detection, Evaluation and Treatment Recommendations

Normal, Prehypertension, Hypertension (Stage 1 and 2)

Describe the classification and definition of blood pressure

A

Normal

  • Systolic < 120
  • Diastolic < 80

Prehypertension

  • Systolic 120-139
  • Diasstolic 80-89
  • at risk (50% will develop HTN within 4 years)

Stage 1 Hypertension

  • Systolic 140-159
  • Diastolic 90-99

Stage 2 Hypertension

  • Systolic > 160
  • Diastolic > 100

*use the highest risk group

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115
Q

Diagnostic Tests HTN

Describe the clinical presentation, history, PE, and diagnostic work-up of HTN.

A
  • Hematocrit & Hemoglobin
  • electrolytes, glucose, BUN, creatinine, cholesterol, calcium
  • lipid profile
  • urinalysis: dipstick and microalbumin (kidney issues)
  • EKG
  • As Indicated
    • CXR
    • TSH (esp. in patients over 50)
    • 24 hr urine for protein (kidney issues)

** can identify secondary causes of hypertension

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116
Q

Clinical Objectives for Diagnosing HTN

Describe the clinical presentation, history, PE, and diagnostic work-up of HTN.

A
  • appropriate diagnosis - BP on 2 or more separate occasions
  • assess for secondary causes
  • determine presence of end-organ disease
  • assess other coronary risk factors
  • institute appopriate managment to control BP
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117
Q

HTN in African Americans

Describe the impact hypertension has on individuals and populations.

A
  • develops earlier
  • average BP is higher
  • higher rates of stage 2 disease
  • 80% higher stroke, 50% higher heart disease mortality
  • screen early and often
  • ? response with ACE, ARBs, BetaBlockers
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118
Q

Factors Implicated in HTN

Summarize the pathophysiology, secondary causes, and differential diagnosis of HTN

A
  • salt intake
  • obesity
  • occupation
  • alcohol intake
  • family size
  • crowding
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119
Q

Types of Hypertension

Summarize the pathophysiology, secondary causes, and differential diagnosis of HTN

A
  • Primary, Essential or Idiopathic (95%)
  • Secondary (5%)
    • look at secondary causes if the patient is young, has unusual symptoms, or doesn’t respond to conventional therapy
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120
Q

Secondary Causes of Hypertension

Summarize the pathophysiology, secondary causes, and differential diagnosis of HTN.

A

Renal Diseases

  • Renal Parenchymal Disease (2-3%)
    • acute glomerulonephritis
    • polycystic disease
    • diabetic neuropathy
  • Renovascular (1%)
    • renal artery stenosis

Endocrine Disorders

  • hypo/hyperthyroidism
  • hyperparathyroidism
  • adrenal
  • exogenous hormones
  • acromegaly

Coarctaton of Aorta

Primary Hyperaldosteronism

Alcohol

  • excessive consumption

Drugs

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121
Q

Lifestyle Modifications

Describe the management of HTN according to lifestyle modifications including recommendations and objective support.

A

Documented Efficacy:

  • weight loss
  • DASH diet
  • reduced sodium intake
  • reduced alcohol intake

Limited Efficacy:

  • stress management
  • potassium
  • fish oil
  • clacium
  • magnesium
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122
Q

Pheochromocytoma

Summarize the pathophysiology, secondary causes, and differential diagnosis of HTN.

A
  • rare
  • wildly episodic hypertension
  • peculiar spells: profuse sweating, tremor, palpitations, headache and other symtpoms
  • lab: single voided urine metanephrine, CT of abdomen
  • tx: surgery
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123
Q

Management of HTN

A
  • Goals: BP < 140/90 (60)
  • reverse end organ manifestations
  • maintain quality of life
  • improve risk stratification for CAD
  • lifestyle modifications
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124
Q

Evaluation of Hypertension: Exam

Describe the clinical presentation, history, PE, and diagnostic work-up of HTN.

A
  • vital signs:
    • bp x 3 and leg
    • pulse
    • weight
    • height
  • fundoscopic exam on all HTN patients
  • bruits:
    • carotid
    • renal
    • aortic
  • heart and lungs
  • extremities:
    • edema
    • pulse
    • signs of PVD
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125
Q

White Coat HTN

Summarize the pathophysiology, secondary causes, and differential diagnosis of HTN.

A
  • many patients have higher blood pressure levels when taken in the office than when out of the office
  • may explain as much as 20% of elevated diastolic BPs in office
  • utilize home monitoring or ambulatory monitoring to further define HTN
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126
Q

Describe the impact hypertension has on individuals and populations.

A
  • 78 million Americans affected - 1000 deaths/year
  • African Americans >> Caucasians
  • frequency increases with age
    • diastolic doesn’t change much after 45
  • level of BP direct risk factor for premature CV disease
  • earlier onest - greater likelihood of CV dieases
  • men >> women
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127
Q

Primary Essential HTN

Summarize the pathophysiology, secondary causes, and differential diagnosis of HTN

A

increased arterial blood presssure with no definable cause

common presentation - asymptomatic

readily detectable

easily treated

often leads to lethal complications if untreated

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128
Q

Pathogenesis of Chest Wall Pain

A
  • irritation
  • trauma
  • compression of structures
  • muscles
  • cartilaginous structures
  • nerves
  • bones
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129
Q

Gastroesophageal Reflux

*Describe the presentation and characteristics of gastrointestinal causes of chest pain *

A
  • substernal burning and pain
  • starts in epigastrium and radiates upward
  • related to consuming large meal, lying down, or bending over
  • relieved by antacid or food
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130
Q

Treatment Algorithm: strongly suspicious for injury

A

start adjunctive treatments

  • B-adrenergic receptor blockers
  • nitroglycerine
  • heparin
  • ACE inhibitors

time from onset of symptoms

  • < 12 hours - select a reperfusion strategy
    • angiography
    • PCI
    • CT surgery
    • fibrinolytic therapy
  • > 12 hours - not candidate for fibrinolytics
    • treat as non-ST elevated AMI (cath, revascularization)
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131
Q

Chest Pain - Musculoskeletal or Nerve Origin

Describe the presentation and characteristics of chest pain that is musculoskeletal or nerve origin

A
  • lasts few seconds to days, months, maybe longer
  • sharp, dull or aching
  • aggravated by deep breathing or cough
  • point-tenderness on palpation
  • may be dermatomal
  • occurs with movement
  • bone pain is well localized
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132
Q

Costochondritis

*Describe the presentation and characteristics of chest pain that is musculoskeletal or nerve origin *

A
  • sharp, well localized pain
  • most intesne at costochondral junction
  • palpation reproduces pain
  • warmth, erythema and swelling
  • aggravated by deep breathing and cough
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133
Q

Pulmonary Embolism

*Describe the presentation and characteristics of pulomonary causes of chest pain *

A

Risk Factors:

  • immobility
  • recent surgery
  • pregnancy or oral contraceptive use
  • large bone fracture
  • malignancy
  • DVT or prior PE
  • CHF
  • COPD
  • obesity
  • hypercoagulability

Presentation:

  • pleuritic chest pain
  • sudden onset dyspnea
  • tachypnea and tachycardia
  • hypotension
  • hemoptysis possible

Examination:

  • rales (crackles) and pleural friction rub
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134
Q

Absolute Contraindications to Fibrinolytic Therapy

List the indications and contraindications for thrombolytic therapy

A
  • history of intracranial hemorrhage
  • known intracranial neoplasm or vascular lesions
  • active bleeding or known bleeding disorder
  • embolic stroke within 3 months
  • suspected aortic dissection
  • significant facial or head trauma within 3 months
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135
Q

Options for testing of CAD

A
  • treadmill - exercise tolerance test (ETT)
  • stress myocardial perfusion imaging
  • stress echo
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136
Q

NSTEMI

Describe the classification of Acute Coronary Syndrome and the inital evaluation based upon 12-lead ECG findings

A
  • occluding thrombus sufficient to cuase tissue damage and mild myocardial necrosis
  • ECG:
    • can look normal
    • ST depression +/- T wave inversion
  • Elevated cardiac enzymes
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137
Q

non-invasive testing for chest pain

Describe common non-invasive tests used to evaluate chest pain.

A
  • Electrocardiogram
  • Exercise Treadmill Testing
  • Stress Myocardial Perfusion Imaging
    • Nuclear stress testing
    • Pharmacologic stress
      • adenosine, dipyridamole, dobutamine
      • sestamibi
  • Stress Echocardiography
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138
Q

History and Physical Exam of patients with Chest Pain

  • Describe the diagnostic evaluation of patients with chest pain including H & P, diagnostic tests, initial management and patient education*
A

History

  • if emergent brief targeted history, get more details later
  • OLD CHARTS

Physical Exam

  • asses level of stress and anxiety
  • BP in both arms (doppler if needed)
  • postural BP
  • skin
    • pallor, cyanosis
    • jaundice
    • herpes zoster rash
  • eyes - fundoscopic exam
  • neck
    • lymphadenopathy
    • thyromegaly
    • tracheal shift
    • JVD
    • carotid bruits
  • chest wall
    • signs of trauma
    • heaves or lifts
    • palpate for tenderness
  • complete heart exam
    • extra heart sounds
    • murmurs, clicks, hums, rubs
    • irregularities
    • arrhythmias
  • lungs
    • equal breath sounds, plerual rub
    • crackles
    • ronchi
    • wheezes
  • Abdomen
    • bowel sounds and bruits
    • tenderness, masses
    • organomegaly
    • ascitis
  • Lower Extremities
    • femoral and peripheral pulses
    • cyanosis
  • Musculoskeletal and Neurological
    • patients with pain on motion
    • focus on focal tenderness
    • motor or sensory deficits
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139
Q

Cardiopulmonary or Vascular Differential Diagnosis of Chest Pain

Give a broad differential diagnosis of chest pain listed by organ system.

A
  • MI
  • Aortic Dissection
  • Pericarditis
  • Pulmonary Embolism
  • Valvular Disease
    • Aortic Stenosis
    • Mitral Valve Prolapse
  • Bacterial Endocarditis
  • Hypertrophic Obstructive Cardiomyopathy
  • Myocarditis
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140
Q

Classification of Acute Coronary Syndromes

Describe the classification of Acute Coronary Syndrome and the inital evaluation based upon 12-lead ECG findings

A
  • Unstable angina pectoris
  • non-ST segment elevation MI (NSTEMI)
  • ST segment elevation (STEMI)
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141
Q

Pleural Causes of Chest Pain

Describe the presentation and characteristics of chest pain that is pleural in origin

A
  • worsened by deep inspiration or coughing
  • spasm secondary to:
    • cold weather
    • increased activity
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142
Q

gastrointestinal causes of chest pain

give a broad differential diagnosis for chest pain listed by organ system

A
  • Gastroesophageal reflux
  • Esophageal spasm
  • Cholecystitis
  • Peptic ulcer disease
  • Pancreatitis

GI Disorders are associated with eating, relief with antacids.

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143
Q

Fibrinolysis Indications

List the indications and contraindications for thrombolytic therapy

A
  • ST segment elevation > 1 mm in two contagious leads
  • new LBBB
  • symptoms consistent with ischemia
  • symptom onset less than 12 hours prior to presentation
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144
Q

Unstable Angina

Describe the classification of Acute Coronary Syndrome and the inital evaluation based upon 12-lead ECG findings

A
  • non-occlusive thrombus
  • ECG: non-specific ECG; ECG can look normal
  • normal cardiac enzymes
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145
Q

Nerve Root Compression

Describe the presentation and characteristics of chest pain that is musculoskeletal or nerve origin

A
  • results in pain and motor/sensory deficits
  • numbness or tingling in neck, chest, upper arm
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146
Q

AMI Symptoms in African Americans

A
  • abdominal pain
  • absence of chest pain
  • dizziness/weakness
  • fatigue
  • hot and flused
  • indigestion
  • palpitations
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147
Q

AMI Symptoms in the Elderly

A
  • absence of chest pain
  • diaphoresis
  • dyspnea
  • faintness
  • syncope
  • nausea
  • vomiting
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148
Q

Diagnostic Testing in patients with Chest Pain

Describe the diagnostic evaluation of patients with chest pain including H & P, diagnostic tests, initial management and patient education

A

based on the data from the H &P

  • pulse oximetry
  • cardiac enzymes
  • CBC and complete metabolic panel
  • 12 lead ECG
  • chest x ray
  • others to consider
    • echocardiogram
      • mitral valve prolapse
      • valvular disorders
    • aortic aneurysm or dissection
      • CT with contrast
      • TE echo
      • aortic angiography
    • cardiac catheterization
    • stress echo
    • spiral CT
      • pulmonary embolism
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149
Q

“Atypical” Chest Pain

A
  • doesn’t fit a common pattern
  • no abnormal exam or diagnostic findings
  • usually self-limited and resolves on own
  • diagnosis of exclusion
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150
Q

AMI Symptoms in Women

A
  • absence of chest pain
  • nausea
  • vomiting
  • hypotension with tachycardia
  • right arm, neck, jaw pain
  • back pain
  • dyspnea
  • headache
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151
Q

Treatment Algorithm: suspicious for ischemia

A
  • NOT candidates for fibrinolytic therapy
  • Adjunctive treatment
    • heparin
    • aspirin
    • glycoprotein receptor inhibitors
    • nitroglycerin
    • B-adrenergic receptor blockers
  • Assess clinical status
    • ischemia
    • depressed LB function
  • condiser cardiac cath and revascularization
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152
Q

Pathogenesis of gastrointestinal problem chest pain

A

Structural Defects

  • lumen laxity
  • obstruction
  • distension

Mucosal or organ irritation, inflammation or infection

  • esophagus
  • abdominal organs
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153
Q

*Describe the presentation and characteristics of psychiatric or mental disorder causes of chest pain *

A
  • Psychogenic Chest Pain
    • generalized, constant
    • aggravated by any effort
    • present in times of stress, absent at non-stress time
  • Associated Symptoms
    • Dyspnea
    • Fatigue
    • Headache
    • Hyperventilation
    • somatic symptoms
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154
Q

Spontaneous Pneumothorax

*Describe the presentation and characteristics of pleural causes of chest pain *

A
  • secondary to trauma or disease
  • more common in: young men, smokers, COPD
  • pain pattern
    • acute unilateral, stabbing pain
    • dyspnea
  • examination
    • decreased breath and voice sounds

** beware of mediastinal shift and Tension Pneumothorax

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155
Q

Myocardial Infarction

Describe the characterisitics of chest pain due to various cardiac conditions

A
  • chest pain
  • other symptoms
    • dyspnea
    • diaphoresis
    • anxiety
    • palpitations
    • nausea
    • vomiting
  • lasts 20-30 minutes or longer
  • unrelieved or only partial relief with nitro or MS
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156
Q

Mitral Valve Prolapse

Describe the characterisitics of chest pain due to various cardiac conditions

A
  • patients are asymptomatic; symptoms may occur (15%)
    • chest pain - sharp, not relieved by nitro, unrelated to exertion
    • fatigue
    • shortness of breath
    • palpitations when lying on left side
    • lightheadedness
    • dizziness
    • hedache
    • mood swings
  • auscultatory feature:
    • midsystolic click or multiple clicks
    • midsystolic to late systolic murmur at the apex of left ventricl over teh mital area
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157
Q

Chest Pain due to Cardiac Disease

A
  • mild to severe
  • transient, exertional pain
  • often radiates to jaw or arms
  • may be associated with
    • weakness
    • dyspnea
    • diaphoresis
    • nausea
    • vomiting
    • palpitations
    • anxiety
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158
Q

Plan and Management in patients with Chest Pain

Describe the diagnostic evaluation of patients with chest pain including H & P, diagnostic tests, initial management and patient education

A

Pain relief - nitro or MS - relieve to a 0 of 10

Ischemic Heart Disease/Acute Coronary Syndrome

  • thrombolytic therapy
  • cardiac cath

Other cardiac or pulmonary problems

  • treatment based upon establishing diagnosis

Psychogenic Problems

  • reassurance
  • appropriate referral
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159
Q

Factors that Increase Risk of AMI

A
  • hypotension
  • tachycardia
  • pulmonary crackles
  • JVD
  • pulmonary edema
  • new murmurs
  • heart sounds
  • diminished peripheral pulses
  • signs of stroke
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160
Q

Diagnosis of STEMI/NSTEMI

A

2 of the following

  • ischemic symptoms
  • diagnostic ECG changes
  • serum cardiac marker elevation
  • wall motion abnormalitiy on echo
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161
Q

AMI Symptoms with Comorbidities

(Diabetes, Heart Failure)

A
  • Diabetes
    • silent MI
  • Heart failure
    • less likely to have CP
    • may have atypical symptoms
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162
Q

Cardiac Care Goals

A
  • decrease amount of myocardial necrosis
  • preserve LV function
  • prevent major adverse cardiac events
  • treat life threatening complications
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163
Q

Dissecting Aortic Aneurysm

Describe the characterisitics of chest pain due to various cardiac conditions

A

pain:

  • excruciating, tearing, knifelike pain; sudden onset, lasts hours
  • anterior chest
    • may be abdomen or back pain
    • often radiates to thoracic back

risk factors:

  • hypertension
  • connective tissue disease
  • pregnancy
  • arteriosclerosis
  • cigarette smoking

common signs:

  • lowered or elevated BP - widened pulse pressure
  • dissociation of arm BP
  • absent pulses
  • paralysis
  • pulsus paradoxus
  • aortic insufficiency murmur
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164
Q

Mechanical and Revascularization Therapy for Ischemic Heart Disease

A
  • Coronary Angioplasty
    • Percutaneous Interventions - balloon angioplasty, stent placement
  • CABG - Coronary Artery Bypass Grafting
  • Enhanced External Counterpulsation
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165
Q

Cocaine-Induced Chest Pain

Describe the presentation and characterisitcs of chest pain that is non-cardiac.

A
  • severe, sharp, pressure-like or squeezing substernal pain
  • associated symptoms
    • euphoria
    • mydriasis
    • hyperstimulation
    • paranoia
    • delusions
    • nausea
    • muscle twitching
    • depression
  • complications
    • myocardial ischemia and infarction
    • arrythmias
    • respiratory failure
    • circulatory collapse
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166
Q

Panic Disorder

*Describe the presentation and characteristics of psychiatric or mental disorder causes of chest pain *

A

chest pain with intesne fear

  • tachypnea
  • palpitations
  • diaphoresis
  • trembling
  • nausea
  • dizziness
  • syncope or near syncope
  • chills or hot flashes
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167
Q

STEMI Cardiac Care

A

Assessment

  • Time since onset: 90 minutes for PCI/ 12 hours for fibrinolysis
  • Determine if fibrinolysis candidate
    • < 3 hours from onset
    • PCI unavailable or delay
    • if no contraindications
    • door to needle goal < 30 minutes
  • Determine if PCI candidate
    • if available
    • door to ballon < 90 minutes
    • if fibrinolysis is contraindicated
    • late presentation > 3 hours
    • STEMI is in doubt
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168
Q

Education for patients with Chest Pain

Describe the diagnostic evaluation of patients with chest pain including H & P, diagnostic tests, initial management and patient education

A
  • cardiology consult if indicated
  • cardiovascular risk reduction
  • recognition of cardiac chest pain - seek medical attention 911
  • proper use of medication
    • nitro for angina
    • other prescribed meds
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169
Q

Pericarditis

Describe the characterisitics of chest pain due to various cardiac conditions

A
  • Paroxysmal pain
  • Pain decreased with sitting and leaning forward
  • Friction Rub
  • May be associated with:
    • fever
    • tachycardia
    • pulus paradoxus
    • cardiac tamponade
    • elevated ESR and leukocytosis
  • Risk factors: infection, autoimmune disease, recent MI, cardiac surgery, malignancy uremia
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170
Q

Pathogenesis of lungs and adjacent structures chest pain

A
  • irritation/inflammation of lung tissue, pleura, diaphragm
  • infection
  • chronic disease
  • neoplasm
  • reactive airway/bronchospasm
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171
Q

Relative Contraindications to Fibrinolytic Therapy

List the indications and contraindications for thrombolytic therapy

A
  • uncontrolled severe hypertension
  • prolonged cardiopulmonary resuscitation or recent surgery or noncompressive vascular puncture
  • current anticoagulation
  • streptokinase
    • prior exposure to the drug
    • hx of allergic reaction
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172
Q

Pathogenesis of Cardiac Chest Pain

A
  • low-flow states of myocardium (CAD)
  • spasm
  • tissue hypoxia
  • anaerobic metabolism
  • lactic acidosis
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173
Q

Angina Pectoris

Describe the characterisitics of chest pain due to various cardiac conditions

A
  • Usually lasts less than 10 minutes
  • Relieved by rest or with nitroglycerine
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174
Q

Pleural Effusion

Describe the presentation and characteristics of chest pain that is pleural in origin

A
  • Transudates
    • congestive heart failure
    • acute atelectasis
    • pulmonary embolism
  • Exudates
    • pneumonia
    • cancer
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175
Q

Bacterial Pneumonia

Describe the presentation and characteristics of chest pain that is pleural in origin

A
  • most common cause of pleuritic pain
  • fever
  • chills
  • cough
  • leukocytosis
  • localized physical exam - chest x-ray findings
176
Q
  • Emergency Department approach to a patient presenting with chest pain*
  • initial assessment and life-saving treatment of chest pain patients in the ED*
A

RULE OUT greatest life threat first

Treat to prevent potential complications

Intitial Assessment

  • measure vital signs
  • measure oxygen saturation
  • obtain IV access
  • administer O2
  • monitor

Brief, targeted H&P

  • eligibility for fibrinolytic therapy

Initial Diagnositc Studies

  • 12-lead ECG
  • serum cardiac marker levels
  • electrolytes and coagulation studies
  • portable CXR

Targeted Phsyical

  • vitals
  • cardiovascular system
  • respiratory system
  • abdomen
  • neurological status

Emergent Care

  • aspirin
  • nitrates
177
Q

AMI Symptoms in Hispanics

A
  • abdominal pain
  • chest pain
  • cough
  • cramping or burning chest pain
  • palpitations
  • upper back pain
178
Q

Treatment Algorithm: NOT unstable angina and troponin is negative

A
  • if further evidence of ischemia or infarction
    • persistent symptoms
    • depressed LV function
  • consider cardiac catheterization
  • anatomy suitable for revascularization: PCI, CABG
179
Q

Pharmacologic Management - Therapy for Ischemic Heart Disease

List common classes of drugs used to treat chest pain in the emergency setting

A
  • Nitrate Therapy
    • Sublingual PRN
    • Chronic therapy: oral/transdermal
    • Emergency: IV
  • B-Blockers
  • Ca Channel Blockers
  • Antiplatelet Agents
    • Aspirin
    • Clopidrogrel (Plavix)
180
Q

STEMI

Describe the classification of Acute Coronary Syndrome and the inital evaluation based upon 12-lead ECG findings

A
  • complete thrombus occlusion
  • ECG:
    • ST elevations on ECG or new LBBB
  • cardiac enzymes: elevated
181
Q

Pathogenesis of psychogenic disorder chest pain

A
  • secondary to anxiety, depression, other psych disorder
  • illicit drug use
182
Q

Esophageal Spasm

*Describe the presentation and characteristics of gastrointestinal causes of chest pain *

A
  • intesne, substernal, sharp pain
  • may radiate to interscapular region
  • may be relieved by nitroglycerine
183
Q

Pitting Edema

A
  • 1+: slight pitting, no visible distortion, disappears rapidly.
  • 2+: somewhat deeper pit than 1+, disappears in 10- 15 seconds.
  • 3+: pit is noticeably deep, lasts more than 1 minute, the dependent extremity looks full and swollen
  • 4+: pit is very deep, lasts 2-5 minutes, extremity is grossly distorted.
184
Q

Echocardiogram

Diagnostic Studies in Heart Failure Patients

A

identify:

  • existence and extent of LV dysfunction
  • valvular or pericardial disease
  • amyloidosis

differentiate systolic versus diastolic heart failure

distinguish regional from global LV dysfunction

185
Q

Stages of Heart Failure - C

A

Patients who have current or prior symptoms of HF associated with underlying structural heart disease

186
Q

Prognosis of Heart Failure

A
  • five year survival < 50%
  • mortality rate in stage d > 30%/year
  • men have poorer prognosis
  • slight improvement due to use of ACE inhibitors and beta-blockers
187
Q

Diagnostic Studies in Heart Failure Patients

A
  • Chest X-ray
  • EKG
  • LAB: BNP
  • Echocardiogram
  • Cardiac catheterization
188
Q

Systolic Heart Failure: Low Output

Classification of Heart Failure

A
  • present with fatigue and loss of mean muscle mass
  • present with dyspnea
189
Q

Stages of Heart Failure - B

A

Patients who have developed structural heart disease that is strongly associated with the development of HF but who have never shown signs or symptoms of HF.

190
Q

Systolic Heart Failure

Classification of Heart Failure

A
  • most common form
  • impaired myocardial contractility and low ejection fraction
  • assoicated with: CAD, MI, idiopathic dilated cardiomyopathy, HTN, valvular disease
191
Q

Physical Exam in Heart Failure Patients

A

not highly sensitive nor highly specific, most sensitive signs:

  • S3 (systolic heart failure)
  • distended jugular veins
  • laterally displaced PMI
  • pulmonary crackles that do not clear with cough
  • peripheral edema

determining the severity of disease and etiology:

  • narrow pulse pressure
  • hypotension with cool extremeties
  • pulsus alternans (regular rhythm but alternating strong and weak peripheral pulses)
192
Q

Physical Exam in Heart Failure Patients

A

See chart below:

193
Q

pathophysiology of heart failure

A

Compensatory Mechanisms: activated when CO falls maintain BP and perfusion to vital organs via

  • Frank-Starling Mechanism
  • Myocardial hypertrophy
  • neurohormonal activation
    • SNS
    • Renin-Angiotensin-Aldosterone System
    • Hormones
      • vasopressin
      • endothelium-derived relaxing factor (nitric oxide)
      • natriuertic peptides
      • cytokines
      • endothelin
      • prostaglandins
194
Q

Systolic Heart Failure: Biventricular Failure

Classification of Heart Failure

A
  • both systemic and pulmonary congestion present
  • bilateral reduced contractility
195
Q

Diastolic Heart Failure

Classification of Heart Failure

A
  • compromised myocardial relaxation with NORMAL contractility and ejection fraction
  • associated with: CAD, HTN, aging, infiltrative cardiomyopathy
196
Q

Systolic Heart Failure: High Output

Classification of Heart Failure

A
  • demand for blood exceeds capacity of a normal heart to meet demand
  • anemia
  • hyperthyroid
197
Q

Electrocardiogram

Diagnostic Studies in Heart Failure Patients

A

Evaluate for:

  • old arrhythmias
  • old MI’s
  • conduction delays
  • left ventricular hypertrophy
  • repolarization abnormality
198
Q

define heart failure:

A

Complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.

199
Q

Pathophysiology - factors that worsen heart failure

A
  • increased metabolic demand
  • increased afterload or preload
  • drugs
    • negative inotropic drugs
    • disopyramide
    • Ca blockers
  • arrhythmias
  • toxins
  • hypothyroidism
  • lack of compliance
200
Q

Stages of Heart Failure - D

A

Patients with advanced structural heart disease and marked symptoms of HF at rest despite maximal medical therapy and who require specialized interventions.

201
Q

Systolic Heart Failure: Right Heart Failure

Classification of Heart Failure

A
  • Most common cause of right heart failure is left heart failure
  • secondary to long-standing increase in pulmonary pressure caused by LV failure
  • signs: **peripheral edema **
  • other cuases
    • mitral stenosis
    • COPD
    • sleep apnea
    • pulmonary emboli
    • pulmonary hypertension
202
Q

B-Type Natriuretic Peptide (BNP)

Diagnostic Studies in Heart Failure Patients

A
  • < 50 pg/mL HF is unlikely
  • >150 pg/mL moderately helpful
  • helps diagnose cardiac vs. non cardiac shortness of breath
  • screening for asymptomatic LV dysfunction
  • risk stratification and prognosis
  • monitoring treatment
203
Q

Goals of Heart Failure Treatment

A
  • improve symptoms
  • prolong survival
  • halt progression of myocardial dysfunction
  • reverse myocardial process
204
Q

Systolic Heart Failure: Left Heart Failure

Classification of Heart Failure

A
  • reduced left-sided contractility
  • pulmonary congestion resulting in dyspnea
  • etiology
    • CAD
    • HTN
    • idopathic dilated cardiomyopathy
    • toxin (alcohol, cocaine, meth)
    • valvular heart disease
    • congenital heart disease
    • viral cardiomyopathy (coxsackie, HIV, CMV)
    • obesity
    • peri-partum cardiomyopathy
    • vitamin/mineral deficiency
205
Q

Stages of Heart Failure

A

At Risk for Heart Failure

  • A: high risk of developing HF
  • B: asymptomatic LV dysfunction

Heart Failure

  • C: past or current symptoms of HF
  • D: end-stage HF

emphasize the preventability of heart failure

can only move A to D due to cardiac remodeling

206
Q

History in Heart Failure Patients

A

History is important to help

  • establish HF as the cause of symtpoms
  • determine etiology
  • establish severity and functional class
207
Q

Functional Classification of Heart Failure

A

NYHA Classification of HF

Class I: No limitation of physical activity

Class II: Slight limitation of activity. Dyspnea and fatigue with moderate activity (walking up stairs quickly)

Class III: Marked limitation of activity. Dyspnea with minimal activity (slowly walking up stairs)

Class IV: Severe limitation of activity. Symptoms are present even at rest

can move bi-directionally

208
Q

Cardiac Catheterization

A

indicated if further evaluation of cardiac function is necessary - extent of vascular disease, CAD and possible revascularization

209
Q

Thearpy for Heart Failure

A

cardiac surgery with ischemic cardiomyopathy

eliminate/correct reversible causes and/or aggrevating factors

  • ischemia
  • HTN
  • arrhythmias
  • thyroid disease
  • anemia
  • vitamin deficiency
  • sleep apnea
  • drugs with negative inotropic effect
  • NSAIDs
  • alcohol
  • obesity

restrict Na intake < 2 grams/day

210
Q

Stages of Heart Failure - A

A

Patients at high risk of developing HF because of the presence of conditions that are strongly associated with the development of HF.

Such patients have no identified structural or functional abnormalities of the pericardium, myocardium, or cardiac valves and have never shown signs or symptoms of HF.

211
Q

Chest X-Ray

Diagnostic Studies in Heart Failure Patients

A
  • information on size and shape of cardiac silhouette
  • cardiomegaly
  • evidence of pulmonary venous hypertension
    • dilation of veins
    • perivascular edema
    • interstitial edema
  • pleural effusions
212
Q

Jugular Venous Pressure

A
  • indicator of volume and pressure in the right side of the heart
  • pulsations absent when patient is upright
213
Q

Systole

*Describe the cardiac cycle including its components: S1, S2, systole, and diastole. *

A

Contraction.

Pressure increases closure of AV valves S1

ventricles empty pressure decreases closure of semilunar valves S2

214
Q

Diastole

*Describe the cardiac cycle including its components: S1, S2, systole, and diastole. *

A

Relaxation

ventricular pressure < atrial pressure, AV valves open, ventricles filling

S3: May occur during late filling of ventricles.

S4: Can occur as atria contract late to complete emptying of atria into ventricles.

215
Q

Cardiac Exam: Vital Signs

A
  • Heart Rate
  • Respiratory Rate
  • Blood Pressure
    • both upper extremity
    • one lower extremity
  • Spot oximetry
216
Q

Cardiac Exam: Inspection

A

General Appearance: nutritional status, genetic abnormalities, nail clubbing

Color: pink, cyanotic, pale

Comfort: dyspnea, diaphoresis

Breathing Pattern: tachypnea, grunting, nasal flaring, bulging or retractions

Venous Distension

217
Q

Cardiac Exam: Palpation

A

Chest:

  • Thrills
  • PMI

Abdomen:

  • Hepatomegaly
  • Splenomegaly

Pulses:

  • rate and rhythm
  • Brachio-Femoral dealy
  • absence of distal pulses
  • bounding pulses
218
Q

Cardiac Exam: Auscultation

Describe the auscultatory process and the areas of auscultation.

A

Auscultatory Process: listen in 3 positions: sitting, supine, left lateral recumbent, take the time to isolate individual sounds

Areas of Ascultation

  • Aortic: 2 ICS RSB
  • **Pulmonic: ** 2 ICS LSB
  • **2nd Pulmonic - Erb’s point: ** 3ICS LSB
  • **Tricuspid: ** 4ICS LSB
  • **Mitral or apical: ** 5ICS MCL
219
Q

First Heart Sound

*Describe the cardiac cycle including its components: S1, S2, systole, and diastole. *

A
  • results from closing of AV valves
  • indicates beginning of systole
  • best heard at apex
  • lower pitch, longer
220
Q

Second Heart Sound

*Describe the cardiac cycle including its components: S1, S2, systole, and diastole. *

A
  • closure of semilunar valves
  • indicates end of systole
  • best heard at the (base) aortic and pulmonic areas
  • higher pitch, shorter duration
  • usually heard as a single sound, can be split
221
Q

Splitting of Heart Sounds

Describe the abnormal extra heart sounds: S3, S4, and splitting.

A
  • occurs due to asynchrony between valves
    • A2P2 - aortic closes slightly earlier
  • heard best at peak of inspiration
  • often normal but may be pathologic
222
Q

Third Heart Sound

Describe the abnormal extra heart sounds: S3, S4, and splitting.

A
  • occurs normally in diastole
  • normally heard to hear
  • physiologic in kids
  • pathologic after age 35
  • due to rapid filling of the ventricles
  • low pitch sound, time sequence “Ken-tuc-key”
  • best heard: left lateral recumbent at apex
223
Q

Fourth Heart Sound

Describe the abnormal extra heart sounds: S3, S4, and splitting.

A
  • pathologic
  • occurs in diastole, later than S3 before S1
  • **low pitched heard best with bell in left lateral recumbant **
  • timing: “Tenn-es-see”
  • heard with decreased ventricular compliance
    • HTN
    • cardiomyopathy
    • aortic stenosis
224
Q

define Heart Murmur

Describe heart murmurs and the characteristics used to evaluate them.

A

disruption in the flow of blood into, through or out of heart

225
Q

Causes of Heart Murmurs

Describe heart murmurs and the characteristics used to evaluate them.

A

diseased valves - don’t open/close properly

high output demands that increase the speed of blood:

  • thyrotoxicosis
  • anemia
  • pregnancy

structural defects

  • ASD
  • PDA

diminished strength of myocardial contraction

altered blood flow in the major vessels near heart

226
Q

Characteristics of Murmurs: Timing

Describe heart murmurs and the characteristics used to evaluate them.

A
  • Systolic Murmurs: between S1 and S2
  • Diastolic Murmurs: between S2 and S1
227
Q

Characteristics of Murmurs:** Location**

Describe heart murmurs and the characteristics used to evaluate them.

A
  • where is it best heard i.e. aortic area
228
Q

Characteristics of Murmurs: Intensity

Describe heart murmurs and the characteristics used to evaluate them.

A

loudness is graded on a six point scale

  1. Grade I: barely audible with careful concentration
  2. Grade II: faint but readily detected
  3. Grade III: prominent, easily detectable
  4. Grade IV: louder still; palpable thrill associated
  5. Grade V: audible with only **rim of stethoscope touching chest wall. ** Thrill easily palpable.
  6. Grade VI: **loud enough to be heard without stethoscope. ** Thrill palpable and visible.
  • grade 3 or greater - significant
229
Q

Characteristics of Murmurs: Pitch

Describe heart murmurs and the characteristics used to evaluate them.

A
  • high tone or low tone
  • depends on pressure and rate of blood flow
  • low tones best heard with the bell
  • high tones best heard with the diaphragm
230
Q

Characteristics of Murmurs: Pattern

Describe heart murmurs and the characteristics used to evaluate them.

A
  • crescendo: progressively gets louder
  • decrescendo: progressively gets softer
  • crescendo-decrescendo: gets louder than softer
  • sustained: maintains constant loudness
231
Q

Characteristics of Murmurs: Radiation

Describe heart murmurs and the characteristics used to evaluate them.

A
  • ability to hear murmur in sites other than the primary or loudest site
  • listen to carotids (aortic stenosis) and axilla
232
Q

Coarctation of Aorta

Review specific heart disease that present as a murmur in children, including: Coarctation

A
  • Systolic ejection murmur in midback, also LUSB
  • May have continuous murmur in back (older)
  • Increased BP in arms
  • Lower BP with weak to absent pulses in legs
  • LV heave
  • RVH (infant) or LVH (older) on EKG
  • May have cardiomegaly, abnormal aortic contour, or rib notching on CXR
233
Q

Aortic Stenosis

Describe the common adult heart murmurs associated with AS, AR, MS, and MR.

A
  • most common fatal valvular heart lesion
  • cause: degenerative calcification
  • age: typically 60+
  • long latent period prior to symptoms

symptoms (prognosis):

  • angina (5 years)
  • syncope (3 years)
  • heart failure (2 years)

harsh, mid-systolic ejection murmur

best heard: aortic area

diagnostic studies

  • ECG: LVH, LBBB
  • CXR: aortic valve calcification
  • Echo: determine LV dimensions, pressure gradient, estimate valve area and ejection fraction

tx: valve replacement

234
Q

Mitral Regurgitation

Describe the common adult heart murmurs associated with AS, AR, MS, and MR.

A

Causes

  • mitral vavle prolapse
  • ischemic heart disease
  • cardiomyopathy
  • infective endocarditis
  • connective tissue disorders
  • congenital defect
  • trauma

Chronic

  • asymptomatic
  • fatigue and mild dyspnea on exertion
  • progresses to DOE, PND, PE, hemoptysis

Acute

  • symptomatic
  • LHF - DOE, PND, pulmonary congestion, cardiogenic shock

Murmur

  • holosystolic
  • blowing
  • heard at apex, radiates to axilla
  • no changes in intensity

Diagnostics

  • ECG: LA enlargment, LV/RV hypertrophy
  • CXR: LA and LV enlargment
  • Echo: confirms dx, chamber dimensions, LA/LV function

Management

  • ACE inhibitors
  • surgery in symptomatic patient, EF below 50%
235
Q

Small Ventricular Septal Defect

Review specific heart disease that present as a murmur in children, including: VSD

A
  • most common form of CHD
  • typically close by 1 year
  • inverse relationship with newborns age
  • no SBE prophylaxis

Murmur

  • High-pitched Holosystolic murmur @ LMSB to LLSB
  • May or may not have a thrill
  • Generally no LV heave or RV lift
  • Normal S2
  • No diastolic murmur
  • Normal EKG and chest x-ray
236
Q

Large Ventricular Septal Defect

Review specific heart disease that present as a murmur in children, including: VSD

A
  • perimembranous or membranous
  • pulmonary overcirculation
  • often require surgical closure 4-6 months

Murmur

  • Low pitched Holosystolic murmur @ LMSB to LLSB
  • Diastolic flow rumble @ apex
  • Increased precordial activity
  • Increased P2 intensity
  • May have RVH +/- LVH on EKG
  • May have cardiomegaly and pulmonary plethora on x-ray
237
Q

Atrial Septal Defect

Review specific heart disease that present as a murmur in children, including: ASD

A
  • usually asymptomatic - no murmur
  • rSR’ pattern on EKG
  • recommend closure when large or RA and RV enlargment
  • no SBE prophylaxis

Murmur

  • Systolic ejection murmur @ LUSB
  • Diastolic flow rumble @ LLSB
  • No palpable thrill
  • RV heave
  • Fixed Split S2
  • May have RVH on EKG
  • May have cardiomegaly and pulmonary plethora on x-ray
238
Q

Innocent Murmurs: Pulmonary Branch Murmur of Infancy

Describe the evaluation of heart murmurs in children, being able to differentiate between pathologic and innocent murmurs: branch pulmonary stenosis

A

Timing: Systolic ejection

Intensity: 1-3/6

Location: LUSB, RUSB, to axillae and back

Pitch: Medium

Character: Blowing

Helpful Maneuvers: None

239
Q

Innocent Murmurs: Venous Hum

Describe the evaluation of heart murmurs in children, being able to differentiate between pathologic and innocent murmurs: venous hum

A

Timing: Continuous

Intensity: 1-3/6

Location: RUSB, occasionally LUSB

Pitch: Medium

Character: Machinery-like

Helpful Maneuvers: Supine to sitting, Head position, Compression of jugular vein

240
Q

Innocent Murmurs: Pulmonary Flow Murmur

Describe the evaluation of heart murmurs in children, being able to differentiate between pathologic and innocent murmurs: pulmonary flow murmur

A

Timing: Systolic ejection

Intensity: 1-3/6

Location: LUSB

Pitch: Low to medium

Character: Blowing

Helpful Maneuvers: Inspiration, Standing

241
Q

Aortic Stenosis

Review specific heart disease that present as a murmur in children, including: Aortic Stenosis

A
  • Bicuspid Aortic Valve
  • No SBE prophylaxis

Murmur

  • Systolic ejection murmur @ RUSB to Neck
  • May have thrill @ RUSB or SSN
  • Usually with ejection click
  • May have LV heave
  • May have assoc diastolic murmur if valve leaks
  • May have LVH on EKG
  • May have cardiomegaly, or prominent aortic shadow on x-ray
242
Q

Aortic Regurgitation

Describe the common adult heart murmurs associated with AS, AR, MS, and MR.

A

Chronic - asymptomatic for decades

  • degnerative disorders
  • dilation of ascending aorta
  • bicuspid aortic valve
  • rheumatic fever
  • syphilis
  • connective tissue disorder

Acute - develop LV failure abruptly resulting in symptoms

  • aortic dissection
  • infective endocarditis
  • trauma
  • valve rupture
  • hypertension

high frequency blowing decrescendo diastolic murmur along LSB

high pulse pressure

echo: valve morphology, LV dimension, aortic root size, ejection fraction

tx: surgery when ejection fraction below 55%

243
Q

Mitral Disease

A
  • require ACE inhibitor and anti-arrhythmic
  • no SBE prophylaxis

Murmur

  • Non-ejection Click, Late Systolic Murmur
  • May have Diastolic Rumble @ Apex
  • May have of Palpitations, Arrhythmias,
  • Chest Pain
  • May have Nonspecific ST-T Wave Changes
  • May have Cardiomegaly on CXR
  • May have LVH or LAE on EKG
  • Marfan, Ehlers-Danlos, Stickler’s, Fragile X, Connective Tissue Syndromes
244
Q

Diagnostic Criteria for Innocent Murmur

Understand how to identify innocent vs. pathologic murmurs murmurs

A
  • classic findings for a specific innocent murmur
    • grade 1/2, changes with position, LLSB
  • no history/complaints to suggest disease
  • no additional physical findings to suggest disease
245
Q

Mitral Stenosis

Describe the common adult heart murmurs associated with AS, AR, MS, and MR.

A

sequela of rheumatic heart disease develops years-decades after rheumatic fever

clinical features:

  • chronic fatigue - low cardiac output
  • decreased exercise tolerance
  • SOB
  • orthopnea
  • hemoptysis
  • palpitations

exam

  • opening snap with diastolic rumble heard at apex
  • loud S1 and P2
  • JVD
  • **edema, **hepatic congestion

treatment

  • heart rate control
  • diuretics if pulmonary congestion
  • warfarin if atrial fibrillation
  • surgery: ballon valvotomy or valvuloplasty
246
Q

Patent Ductus Arteriosus

Review specific heart disease that present as a murmur in children, including: PDA

A
  • very common
  • increased incidence in premature babies
  • tx: surgical ligation, device, coil
  • no SBE prophylaxis

Murmur

  • Continuous murmur @ LUSB to left infraclavicular region
  • Wide pulse pressure, bounding pulses
  • May have increased LV impulse
  • Largest may have diastolic thrill @ LUSB
  • May have LVH on EKG
  • May have cardiomegaly and pulmonary plethora on x-ray
247
Q

Pulmonary Stenosis

Review specific heart disease that present as a murmur in children, including: Pulmonary Stenosis

A
  • systolic gradient across valve > 25 mmHG
  • mildly thickened valve in neonate can resolve with time

Murmur

  • Systolic Ejection Murmur @ LUSB with radiation to back
  • May have systolic thrill
  • May have increased RV impulse
  • Usually with ejection click
  • May have RVH on EKG
  • May have prominent MPA on X-ray
248
Q

Innocent Murmurs: Stills Murmur

Describe the evaluation of heart murmurs in children, being able to differentiate between pathologic and innocent murmurs: Still’s murmur

A

Timing: Systolic Ejection

Intensity: 1-3/6

Location: Several cm lateral to LLSB

Pitch: Low

Character: Vibratory, Musical

Helpful Maneuvers: Standing vs. Supine

249
Q

Mild Congenital Heart Disease

Describe the physiologic categories of congenital heart disease and provide examples of each type.

A

Small Ventricular Septal Defect (VSD)

Small Patent Ductus Arteriosus (PDA)

Mild Pulmonary Stenosis (PS)

Bicuspid Aortic Valve (BAV) w/o AS or AI

Small Atrial Septal Defect (ASD)

250
Q

Moderate Congenital Heart Disease

Describe the physiologic categories of congenital heart disease and provide examples of each type.

A

Aortic Valve Disease: mild or moderate stenosis or insufficiency

Moderate Pulmonary Stenosis

Non-Critical Coarctation

Large ASD

Complex VSD: membranous, perimembranous, non-pressure restrictive, etiology of pulmonary HTN…

251
Q

Severe Congenital Heart Disease: CYANOTIC

Describe the physiologic categories of congenital heart disease and provide examples of each type.

A

Tetralogy of Fallot (TOF)

Transposition of Great Arteries (TGA)

Hypoplastic Right Heart: Tricuspid Atresia, Pulmonary Atresia – IVS, Ebstein’s Anomaly

Hypoplastic Left Heart: Aortic Atresia, Mitral Atresia

Single Ventricle

Double Outlet Right Ventricle (DORV)

Truncus Arteriosus

Total Anomalous Pulmonary Venous Return (TAPVR)

Critical Pulmonary Stenosis

252
Q

Severe Congenital Heart Disease: ACYANOTIC

Describe the physiologic categories of congenital heart disease and provide examples of each type.

A

Atrio-Ventricular Septal Defect

Large VSD

Large PDA

Critical/Severe Aortic Stenosis

Severe Pulmonary Stenosis

Critical Coarctation

253
Q

Tetraology of Fallot

Describe the fetal and post-natal circulation systems and the anatomic defects associated with following disorders: Tetralogy of Fallot

A
  1. Large, mal-aligned VSD
  2. Overriding aorta
  3. RVOT obstruction/pulmonary atresia
  4. RVH

most common cyanotic CHD lesion

associated with genetic syndromes: Trisomy 21, 18, 13; DiGeorge’s, 22q11 deletion, Algille’s syndrome

intermittent spells of extreme cyanosis: Hypercyanotic Spell

Chest X-Ray: boot shaped heart, small MPA, upturned apex

Treatment:

  • Medical: PGE1 to maintain ductus
  • Surgical: systemic-to-pulmonary shunt

Risks:

  • RV failure
  • Arrhythmia
  • prolonged chest tube drain
  • long term risk: sudden death
254
Q

Transposition of Great Arteries

  • Describe the fetal and post-natal circulation systems and the anatomic defects associated with following disorders: Transposition*
A

D-Transposition: aorta arises from RV, pulmonary artery arises from LV

L-Transposition: congenitally corrected transposition, ventricular inversion, may remain asymptomatic

Diagnostics:

  • cyanosis without murmur
  • EKG: RAD
  • CXR: egg on string

Treatment

  • Palliative: PGE1, Ballon atrial septostomy
  • Surgical: Mustard/Senning (left - used in L-TGA) Arterial Switch operation (right - used in D-TGA)

Complications

  • prolonged bypass
  • myocardial dysfunction
  • mobilization of coronary arteries
  • risk of aortic insufficiency and ventricular arrhythmias
255
Q

Truncus Arteriosus

Describe the fetal and post-natal circulation systems and the anatomic defects associated with following disorders: Truncus Arteriosus.

A

Single, arterial trunk arsing from the heart; large VSD below truncal valve

Murmur: occasionally systolic ejection click, singl loud S2

Signs and Symptoms: tachypnea, diaphoresis, cough

Treatment

  • Oxygen therapy (75-85% oxygen)
  • Complete repair
  • complications due to truncal valve
256
Q

Coarctation of the Aorta

Describe the fetal and post-natal circulation systems and the anatomic defects associated with following disorders: Coarctation

A

Narrowing of the lumen of the aorta - shelf like protrusion in the juxtaductal region

often associated with Bicuspid Aortic Valve

males > females

How is it found?:

  • acute decompensation: CHF, poor distal organ perfusion
  • Hypertension: >10 mmHg gradient from upper to lower extremity
  • Murmur - continuous
  • Echo - maybe inconclusive

Complications

  • shock, acidosis
  • poor perfusion = neurologic injury, myocardial infarction
  • LV dysfunction

Treatment:

  • medical: PGE1
  • interventional: balloon aortoplasty, stent placement
  • surgical: end-to-end repair, left subclavian flap repair, subclavian translocation, patch angioplasty
    • post-op concerns:
      • systemic HTN
      • rebound HTN
      • recoarctation
257
Q

Hypoplastic Left Heart Syndrome

Describe the fetal and post-natal circulation systems and the anatomic defects associated with following disorders: Hypoplastic left heart syndrome.

A

Spectrum of abnormalities - fatal within first life if no intervention

Systemic blood flow is dependent on PDA at ASD

Signs and Symptoms:

  • Cyanosis
  • Respiratory Distress - tachypnea and dyspnea
  • Hypothermic
  • poorly perfused systolic pressures < 40 mmHg
  • metabolic acidosis, hypoglycemia, hyperkalemia
  • soft, systolic ejection murmur

Treatment:

  • PGE1
  • Balloon Atrial Septostomy
  • Norwood Procedure
    • Stage 1: BT Shunt v. Sano Shunt
    • Stage 2: Bidirectional Glenn
    • Stage 3: Fontan Completion

Complications

  • AV valve dysfunction
  • Myocardial dysfunction
  • Transplant may be required
258
Q

Goals for Treating Congenital Heart Disease

A
  1. Feed and Grow
  2. Protect the Lungs
  3. Perfuse the rest of the body
259
Q

Barium Enema

Describe the diagnostic work-up involved with GI disorders and identify preferred diagnostic testing

A

barium inserted into colon and radiographs taken

helpful to diagnose: diverticulitis, polyps, tumors

limitations: abnormalities need to be followed up by colonoscopy, patient discomfort

260
Q

CT Scan

Describe the diagnostic work-up involved with GI disorders and identify preferred diagnostic testing

A

incremental images

helpful to diagnose: acute abdominal conditions, tumors

limitations: radiation exposure, cost

261
Q

Esophagogastroduodenoscopy (EGD)

Describe the diagnostic work-up involved with GI disorders and identify preferred diagnostic testing

A

scope inserted through patient’s mouth, down esophagus to stomach and part of small intestine

helpful to diagnose: mucosal ulcerations or abnormalities; visualiztion and biopsy

limitations: unable to determine reflux or swallowing problems

262
Q

Colonoscopy

Describe the diagnostic work-up involved with GI disorders and identify preferred diagnostic testing

A

** gold standard ** - scope visualizes the entire colon, can also perform biopsies

helpful to diagnose: polyps, mucosal abnormalities, diverticula, tumor

limitations: limited if stool present, chance of perforation

263
Q

GI History

Identify and describe key elements of history and physical exam in the diagnostic approach to GI disorders

A

History of Present Illness

  • OLD CHARTS
  • Significance - relationship to life events, stress

Past Medical History

  • Significant Illness: DM
  • Previous Surgeries: adhessions
  • Preventative Care: EKG, colonoscopy
  • Allergies

Family History

  • Cancer
  • Somatic pain conditions
  • Aneurysm
  • Polyposis

Social History

  • life stress
  • eating
  • sleeping
  • working
  • coping ability
  • family/support
  • recent travel
  • addictions: tobacco, alcohol, drugs
264
Q

GI Physical Exam

Identify and describe key elements of history and physical exam in the diagnostic approach to GI disorders

A
  • OBSERVE: patient’s gait, guarding, ability to climb on table
  • POSITION: patient supine with knees slightly flexed
  • INSEPECT
  • AUSCULTATE
  • PERCUSS
  • PALPATE
  • may need to perform pelvic and rectal exam, hemoccult
265
Q

Ultrasonography

Describe the diagnostic work-up involved with GI disorders and identify preferred diagnostic testing

A

safer test - no inoizing radiation

helpful to diagnose:

  • cholecystitis/cholelithiasis
  • cholangitis
  • abscesses
  • diverticulitis
  • SB inflammation

limitations:

  • blind to many areas of the abdomen
266
Q

Flexible Sigmoidoscopy

Describe the diagnostic work-up involved with GI disorders and identify preferred diagnostic testing

A

done in the office - scope inserted through anus and inspects distal 1/3 of colon, capable of visualization and biopsy

helpful to diagnose: abnormalities of mucosa (polyps, diverticula, tumors, ulceration)

limitations: max 60 cm, grin and bear it, difficult if stool is present, patient comfort, chance of peforation

267
Q

Common GI Symptoms

A
  • Dyspepsia
  • Nausea
  • Vomiting
  • Constipation
  • Diarrhea
  • GI Gas
268
Q

GI Diagnostic Work-Up: Laboratory

Describe the diagnostic work-up involved with GI disorders and identify preferred diagnostic testing

A
  • CBC with differentials
  • Electrolytes
  • BUN, Creatinine
  • Liver Enzymes
  • Lipase
  • Amylase
  • TSH
  • hCG
  • Urinalysis
  • Stool Cultures
  • Hemoccult
  • H. Pylori
269
Q

Biopsychosocial Factors & GI Disorders

Describe the role of biopsychosocial factors in GI disorders

A
  • affect the clinical expression of GI illness and disease
    • genetic predisposition
    • early learning
    • cultural background
270
Q

Plain Film X-Rays

Describe the diagnostic work-up involved with GI disorders and identify preferred diagnostic testing

A

usefulness:

  • bowel gas pattern
  • intrabdominal free air
  • air-fluid levels
  • densities
  • tumors
271
Q

Enteric Nervous System (ENS)-Central Nervous System (CNS) Axis

A
  • brain-gut interaction
  • CRF, VIP, 5-hydroxytryptamine, serotonin derivatives, nitric oxide, cholecystokinin
    • regulate gastric motility, secretion, sensation and inflammation
272
Q

Esophageal Manometry

Describe the diagnostic work-up involved with GI disorders and identify preferred diagnostic testing

A

tube from nose to esophagus - measures esophageal function by pressure readings of muscle contractions (motility)

helpful to diagnose: motility disorders

limitations: no visualization

273
Q

Barium Swallow

Describe the diagnostic work-up involved with GI disorders and identify preferred diagnostic testing

A

radiologist visualizes stomach and esophagus under fluroscopy

helpful to diagnose: stricture, hiatal hernia, swallowing problems

limitations: unable to visualize or biopsy

274
Q

24-hour pH probe

Describe the diagnostic work-up involved with GI disorders and identify preferred diagnostic testing

A

tube from the nose to esophagus to LES, pH sensor at tip determines acid expsoure

or can “clip” the probe to the esophagus, eventually detaches and passes in the stool

helpful to diagnose: GERD *gold standards

limitations: inconvenient

275
Q

Tummy Aches - associated symtpoms

A
  • weight loss
  • decreased appetitie
  • nausea
  • intestinal gas
  • diarrhea
  • cough
  • wheezing
  • horase voice
276
Q

HEADSS mnemonic

A

Home

Education

Activities

Drugs

Sexuality

Suicide/Depression

277
Q

Identify this condition and describe the management:

patient is a 6 year old male with a “tummy ache”

history reveals that all he eats are poptarts and milk and only stools once a week, he doesn’t like going at school

he is otherwise normally active

A

CONSTIPATION

exam:

  • general exam
  • abdominal exam (may be able to palpate hard stool)
  • rectal exam - visualize external exam, anal wink, digital rectal exam
  • neuro exam - lower extremity reflexes, cremasteric reflexes, tip toe/heel walking

diagnostic studies:

  • flat plate of abdomen

tx/management:

  • adequate clean-out;
  • education, maintenance, behavioral and dietary components

Stool guiac test: infants and children with abdominal pain, FTT, diarrhea or FHX of colorectal cancer

278
Q

Encopresis

A

lack of voluntary control over defecation

develops as a result of long-standing constipation with enlargement of rectal vault

sensation prompting the urge to defecate is lost

large fecal masses accumulate, allowing only liquid stoll to pass

279
Q

Treatments for Functional Constipation

A

GOAL: one soft stool daily, no fecal incontinence

TX: reduce after 6 months of stability, slowly taper dose

Dietary Changes

  • increase fiber and fluids

Bowl Evacuation

  • manual disimpaction
  • enema
  • laxatives
  • cathartics
  • infants: glycerin suppositories

Stool Softeners

  • smaller, more frequent stooling

Behavioral Modification

  • establish stooling routine soon after meals
  • praise successful elimination of stool
280
Q

GERD Manifestations in Infants

A
  • fussiness
  • arching
  • feeding refusal or some feed more frequently
  • congestion
  • wheezing
281
Q

GERD Manifestations in Preschool

A
  • on/off abdominal pain
  • decreased food intake
  • discomfort after eating
  • cough
  • wheezing
282
Q

GERD Manifestations in Older Children Adolescents

A
  • burning epigastric pain
  • regurgitation
  • chest pressure
  • early satiety
  • nausea
  • bad taste in mouth (especially in AM)
283
Q

Identify this condition and describe the management:

pt is a 16 year old female

she reports stomach pain usually after dinner and it wakes her up at night

she also notes that this gets worse before her AP history exams

A

GERD

other clinical manifestations

  • can be triggered by viral illness
  • can have dysphagia/odynophagia
  • hoarseness and stridor can occur

possible testing based on symptoms and severity

  • endoscopy
  • esophageal pH monitoring

treatment: acid supression medication

  • Ranitidine
  • Omeprazole
  • Lansoprazole
  • treat aggresively
  • trial 2 weeks, if it works 1-6 months
284
Q

Suggested Approach for Common Clinical Scenarios:

Recurrent Vomiting or Regurgitation (older than 18 months)

A
  • upper GI series
  • upper endoscopy
  • acid supression trial
285
Q

Suggested Approach for Common Clinical Scenarios:

Heartburn

A
  • treat empirically and do lifestyle changes
  • persistnent or recurrent symptoms should prompt referral endoscopy with biopsy
286
Q

Suggested Approach for Common Clinical Scenarios:

Dysphagia or Odynophagia

A
  • barium esophagram - looking for anatomic abnormailities
  • NO empiric treatment
  • upper endoscopy is necessary
287
Q

Suggested Approach for Common Clinical Scenarios:

Recurrent Pnemonia

A
  • insufficient research - trial empiric treatment
  • video fluoroscopy?
288
Q

Identify this condition and describe the management:

patient is a 8 year old, he complains of umbilical pain that has been going on for over a year

he has soft stools each day

he just is bullied at school, but otherwise enjoys his classes

A

Irritable Bowel Syndrome/Functional Abdominal Pain

nonorganic abdominal pain, associated with stress

often diagnosed by GI specialists after organic causes are ruled out

can be a cry for help - consider abuse

TX:

  • Eliminate Secondary Gain
  • Treat underlying negative stress
  • Relaxation techniques
289
Q

Abdominal Alarm Findings

A
  • involuntary weight loss
  • deceleration of linear growth
  • GI blood loss
  • significant vomiting
  • chronic severe diarrhea
  • persistent RUQ or RLQ pain or tenderness
  • unexplained fever
  • family history of IBD
  • localized fullness or mass effect
  • Hepatomegaly or Splenomegaly
  • Costovertebral angle tenderness
  • Tenderness over the spine
  • Perianal abnormalities
  • Abnormal or unexplained physical findings
290
Q

Diarrhea

Signs of Volume Depletion

A
  • thirst
  • tachycardia
  • lethargy
  • orthostasis
  • oliguria
  • tachypnea
  • dry mucous membranes
  • weight loss
  • decreased tear production
  • decreased skin turgor
291
Q

Diarrhea

Etiologic Risk Factors

A
  • recent travel to an underdeveloped area
  • other family members affected
  • daycare attendance or employment
  • pets in home (turtles, snakes)
  • visiting farm or petting zoo
  • recent or regular medications
  • occupation as food handler or caregiver
  • sexual contact
  • underlying medical conditions
292
Q

Diarrhea

Diagnostic Studies & Microscopic Exam

A

Diagnostic Studies

  • gross or occult blood
  • undigested vegetable matter
  • mucus present
  • color

Microscopic Exam

  • Leukocytes - bacterial or inflammation
  • Lymphocytes - inflammatory
  • Eosinophils - food sensitivities
  • Fat - malabsorption or pancreatic enzyme insufficiency
  • O&P - ova and parasites

Labs:

  • CBC, BMP, BUN, creatinine, and UA
  • stool studies
  • rapid rotovirus test
293
Q

Identify this condition and describe the management:

patient is a 1 year old reporting on Friday Jan. 30

he vomited on Monday and has had a temp of 99 and watery, foul-smelling diarrhea, no blood is present

A

Acute Diarrhea: Viral Gastroenteritis

Rotovirus is most common

  • peaks in winter
  • can live outside body longer

Norwalk Virus (norovirus)

Adenovirus

fecal-oral route

self limited; tx administer oral rehydration solution

294
Q

Identify this condition and describe the management:

patient was on a camping trip last weekend

he reports abdominal pain, increased flatulence, and diarrhea

stool analysis reveals cysts

A

Acute Diarrhea: Parasitic Gastroenteritis

Giardia Lamblia

fecal-oral transmission

other symptoms: malabsorption, failure to thrive

at risk groups: IgA deficient, CF patients

tx: Flurazolidone, Metronidazole

295
Q

Identify this condition and describe the management:

patient has loose, bloody, mucoid stools

abdominal exam revealed hepatic abscess

A

Acute Diarrhea: Infectious Gastroenteritis

Entamoeba Histolytica

diagnosed via: stool examination and immunoassays

tx: Furazolidone, Albendazole, Metronidazole

296
Q

Acute Diarrhea: Infectious Gastroenteritis

Cryptosporidum

A

frequent, watery stools

common in day cares

self-limited in healthy kids

can become chronic in the immunocompromised

no effective therapy

297
Q

Acute Diarrhea: Infectious Gastroenteritis

Isospora Belli

A

protozoan infection cuasing diarrhea in AIDS patients

treated with TMP-SMZ

298
Q

Identify this condition and describe the management:

patient ate a cream-filled donut that was leftover from yesterday for breakfast

at lunch time patient reports: nausea, vomiting, abdominal cramping

A

Acute Diarrhea: Infectious Gastroenteritis

Staphylococcus Aureus

symptoms resolve spontaneously within 24 hours

299
Q

Identify this condition and describe the management:

patient went out to the new sketchy sushi resturant for two nights ago

she now complains of nausea, vomiting and diarrhea

she is worried becuase her vision has been blurry lately

A

Acute Diarrhea: Infectious Gastroenteritis

Clostridium Botulinum

other CNS symptoms: dry mouth, dysphagia, blurry vision, paralysis of respiratory muscles

tx: specific antitoxin, ventilatory sport

300
Q

Identify this condition and describe the management:

patient is a 5 month old

mom gave baby some honey and now the baby has not been stooling, has a weak sucking reflex and weak cry

A

Acute Diarrhea: Infectious Gastroenteritis

Infantile Botulism

Floppy Baby Syndrome

  • hypnatremia
  • pooled oral secretions
  • cranial nerve deficits
  • generalized weakness
  • apnea
301
Q

Identify this condition and describe the management:

patient is a 10 year old has a headache, nausea, abdominal pain, water diarrhea

patient just got a pet turtle

A

Acute Diarrhea: Infectious Gastroenteritis

Salmonella

  • enterocyte invasion into small bowel, can also cause bacteremia
  • can have an asymptomatic carrier state
  • fecal-oral transmission
  • sources: reptiles, eggs, poultry, meat
  • infants: fever, vomiting, diarrhea
  • older kids: HA, nausea, abdominal pain
  • stools: watery, may have mucus & blood
  • diarrhea - subsides 4-5 days
  • WBC: PMN leukocytosis
  • TX: uncomplicated - no antibiotics
  • TX: Azithromycin, Ciprofloxacin or SMZ-TMP if < 3 months, immunocompromised, hemaglobinopathies
302
Q

E. Coli 0157:H7

A
  • hemorrhagic colitis
  • self-limited
  • source: undercooked beef and fruit juices
  • toxin can cuase HUS
  • no antibiotics
303
Q

Identify this condition and describe the management:

patient is a 4 year old

patient complains of diarrhea and a tummy ache, he recently started taking clindamycin

A

Acute Diarrhea: Infectious Gastroenteritis

C. Difficile

need to order C. Difficile specific culture

tx: stop antibiotic

304
Q

To Treat or Not to Treat . . .

that is the question

Salmonella

Shigella

E. Coli

E. Coli 0157:h7

Campylobacter

C. Difficile

A

Salmonella: no treatment, S. Typhi (typhoid fever), sepsis, bactermia

Shigella: 3rd generation cephalosporin

E. Coli: only in infants < 3 months

E. Coli 0157:h7: do not treat

Campylobacter: macrolide within first 5 days

C. Difficile: if severe treat with metronidazole or vancomycin

305
Q

Identify this condition and describe the management:

patient is 18 months

patient is well-nourished, and at the 75% percentiles of height, weight and head circumfrence

patient has had increased watery BM’s for the past 2 months

A

Chronic non-specific diarrhea (Toddler’s Diarrhea)

ages: 6-24 months

can be caused by excessive fruit juice intake

stool contains particles of undigested food

typically resolves by age 2-4 or by changing beverages

306
Q

Identify this condition and describe the management:

patient is 2 months

patient is failing to thrive

patient has had diarrhea for a month, stools have no O/P and cultures are negative

A

Protracted Diarrhea of Infancy

  • significant malabsorption can occur
  • tx: administering elemental formulas, providing parental nutrition if necessary
307
Q

Short Bowel Syndrome

A
  • resection of significant protions of intestine (congenital anomalies of GI tract, infalammatory or ischemic disorders)
  • malabsorption
  • diarrhea
  • growth failure
  • remaining bowel eventually adapts to maintain adequate absorption
308
Q

Management of Diarrhea

A

ORAL REHYDRATION

  • oral or IV
  • fluid should have appropriate concentrations of glucose and electrolytes (Pedialyte)
  • contraindicated
    • severe dehydration
    • hemodynamic instability
    • stool output
    • ileus

REFEEDING

  • after hydration is normalized
  • re-introduction of food
    • stimulation of intestinal enzymes
    • increased mucosal cell growth
  • advance diet as tolerated
309
Q

Inflammatory Bowel Disease

A
  • Ulcerative Coliits
  • Chron Disease
  • chronic and recurrent
310
Q

Crohn’s Disease

A

transmural inflammation - fibrosis, obstruction, sinus tracts, fistulas

skip lesions - disease is not continuous

involves entire GI tract

familial

increased risk due to: smoking, western diet, NSAIDS?

diagnosed by colonoscopy, increased inflammatory markers

increases risk for colon cancer - colonoscopy annually

tx:

  • well balanced diet,
  • mesalamine,
  • oral antibiotics,
  • corticosteroids (symptom improvement);
  • cholestyramine for binding bile salts (diarrhea)
  • methotrexate
  • anti-TNF drugs

prognosis: intermittent exacerbation and periods of remission

311
Q

Identify this condition and explain the management:

patient complains of abdominal pain and fluctuating diarrhea

patient has felt fatigued lately and has been loosing weight

patient has a skin tag abover his anus and has noticed increased joint stiffness and a rash (see below)

A

Crohn’s Disease

  • abdominal pain - fibrotic strictures result from the transmural disease
  • diarrhea is common, but fluctuates
  • other symptoms: fatigue, weight loss, fever

Clinical Presentation

  • chronic inflammatory disease
  • intestinal obstruction
  • penetrating disease and fistulae
  • perianal disease
  • extraintestinal manifestations: arthralgias, arthritis, iritiis, uveitis, pyoderma gangernosum, erthema nodusm (rash on front of slide)

Diagnosed by:

  • colonoscopy
  • LAB: CBC, blood chem, ESR, CRP, Iron, B12
312
Q

Ulcerative Colitis

A

inflammatory condition of mucosa - primarily the rectum

recurrent

BLOODY DIARRHEA

symptoms: bloody diarrhea, frequent stooling, cramps, abdominal pain, tenesmus, fever, weight loss

increases risk of colon cancer

colonoscopy every 1-2 years

tx:

  • 5-ASA Agents
  • Steroids
  • Immunomodulating Agents
  • Severe: hospitalization, NPO, TPN; steroids, anti-TNF, cyclosporine, surgery
313
Q

Identify this condition:

patient has UC confined to the rectum, intermittent bleeding, mild diarrhea

A

Mild Ulcerative Colitis

314
Q

Identify this condition:

patient has UC in the rectum, distal colon, proximally to the splenic flexure, bloody diarrhea 5/day, anemia, abdominal pain and a low grade fever

A

Moderate Ulcerative Colitis

315
Q

Identify this condition:

patient has diarrhea 7/day, severe cramping and rapid weight loss

colonoscopy reveals patient has UC extending all the way to the cecum

A

Severe Ulcerative Colitis

316
Q

Fulminant Colitis

A
  • type of severe UC
  • rapid progression
  • severe S&S
  • risk of perforation
  • broad-spectrum antibiotics
317
Q

Toxic Megacolon

A
  • dilation of colon
  • risk of perforation
  • surgery to remove colon
  • risk of death
318
Q

Irritable Bowel Syndrome

A

**functional GI disorder - **absence of organic pathology

abdominal pain

**altered bowel habits **

  • IBS-C, IBS-D or mixed
  • constipation
  • diarrhea
  • postprandial urgency

chronic, relapsing condition

319
Q

Irritable Bowel Syndrome - Pathophysiology

A

small bowel dysmotility

  • delayed meal transit IBS-C (constipation dominant)
  • accelerated meat transit IBS-D (diarrhea dominant)
  • can also have mixed

visceral hyperalgesia

  • enhanced perception of motility and visceral pain

pscyhopathology

  • association not clearly defined
320
Q

Irritable Bowel Syndrome - History

A

Abdominal Pain

  • diffuse or LLQ
  • acute sharp pain episodes, underlying dull ache

Abdominal Distension - bloated/gas

Associated Symptoms

  • dyspepsia/heartburn
  • nausea and vomiting
  • urinary frequency and urgency

**NO: >40, progressively worsening, weight loss, anorexia, fever, rectal bleeding, steatorreha

321
Q

Irritable Bowel Syndrome - Exam

A
  • patient looks healthy
  • mild, diffuse tenderness or LLQ tenderness
  • rest of exam - insignficant
322
Q

Irritable Bowel Syndrome - Diagnostic Work Up

A
  • CBC - screen for anemia, infection, inflammation
  • Chemistries - electrolytes, BUN, Cr, Ca
  • TSH
  • Hemoccult
  • ESR - non specific for inflammation
  • CRP - non specific for inflammation
  • Hydrogen Breath Test - lactose/fructose intolerance
  • Stool Culture
  • Lactose-free diet
  • Flex Sig or Colonoscopy - if bleeding, anemia, wt loss, anorexia, chronic diarrhea, age > 40
  • EGD -weight loss dyspepsia
323
Q

ROME III Criteria for Diagnosis of IBS

A

recurrent abdominal pain or discomfort for at least 3 days per month; 3 months; associated with 2 or more

  • pain/discomfort relieved w/ defecation
  • onset associated with change in stool frequency
  • onset associated with change in stool form or appearance

supporting symptoms

  • altered stool frequency
  • altered stool form
  • altered stool passage (straining/urgency)
  • stool with mucus
  • abdominal bloating or distension
324
Q

Identify this condition:

onset: 15-35 years

bloody diarrhea with mucus, fever, abdominal pain, weight loss, tensmus

colonoscopy: mucousal erythema, ulcers

A

Ulcerative Colitis

inflammatory disease of mucosa and sub mucosa

325
Q

Identify this condition:

onset 15-35 and 70-80 years

fever, abdominal pain, diarrhea (no blood), weight loss

anorectal fissures and abscesses

colonoscopy: nodularity, rigidity, ulcers, strictures, fistulas

A

Crohn’s Disease

can involve ANY part of GI tract, inflammation extends through intestinal wall from mucosa to serosa (small bowel, colon common)

326
Q

Identify this condition:

chronic diarrhea with cramps

blood and mucus can be present in stool

malaise and weight loss common

recent travel

A

Infectious Diarrhea

can be bacterial, viral, or parasitic

consider stool culture

327
Q

Identify this condition:

pain LLQ

fever

change in bowel habits

leukocytosis

colonoscopy reveals diverticula

A

diverticulitis - diverticular (pockets/hernias) or colonic mucosa through muscularis become occlude and inflammed

328
Q

Identify this Condition:

abdominal distension and bloating

diarrhea occassionally constipation

symptoms exacerbated by intake of diary products

positive hydrogen breath test

A

Lactose Intolerance

329
Q

Identify this condition

diarrhea (frothy, tan, foul smelly), flatulence, wt loss, abdominal distension, failure to thrive in children

A

Celiac Disease: inflammatory disorder characterized by malabsorption precipitated by gluten; genetic disorder

330
Q

Irritable Bowel Syndrome Treatment

A

behavior modification, stress reduction, treat symptoms

Anticholinergics: antispasmodics inhibit intestinal smooth muscle depolarization at muscarinc receptor

  • Dicyclomine HCL
  • Hycosamine Sulfate

Antidiarrheals: non-absorbable synthetic opioids, prolong transmit time and decrease secretion

  • Lomotil
  • Immodium (Loperamide)

Tricyclic Antidepressants: visceral analgeisc effect, increasing pain threshold of gut, prolong oral-cecal transit time

  • Imipramine
  • Amitriptyline

GC-C Agnoist: alleviates abdominal pain and increases bowel movement frequency

  • Linzess

Prokinetics: promotility for constipation dominant

  • Propulsid
  • Tegaserod

Bulk Forming Laxatives: fiber supplementation to improve symptoms of constipation and diarrhea

  • Methylcellulsoe
  • Psyllium
331
Q

External Hemorrhoids

A
  • below dentate or pectinate line
  • covered by squamous epithelium
  • sensory innervation
  • acute pain when thrombosed
    • if thrombosed typically bluish in color
    • excise clot if necessary
    • NSAIDs, analgeics, stool softeners, preparation H, Tucks
332
Q

Anorectal Abscess

A

secondary to infection originating in the anal glands

presentation: anorectal, drainage of blood/pus

*early sepsis can result

physical exam: hot, red, tender area; adjacent to anus

treatment: I&D, broad spectrum antibiotics

333
Q

Internal Hemorrhoids

A
  • ABOVE dentate (pectinate) line
  • covered by mucosa - no sensory innervation
  • asymptomatic bleeding
  • bright red spotting on toilet paper; dripping into toilet
334
Q

Classification of Internal Hemorrhoids

A

First Degree: small size, bleeding only

Second Degree: medium size, prolapse under pressure, reduce spontaneously

Third Degree: large size, permanent prolapse, reduce manually

Fourth Degree: large size, proplaspe can’t be reduced - refer to colorectal surgeon

335
Q

Management of Hemorrhoids

A

Conservative:

  • decrease straining
  • avoid prolonged sitting
  • symptomatic treatment for pruitis/irritation
    • steroid creams
    • suppositories
    • analgesic cream
    • sitz bath

Office Based:

  • rubber band ligation (1, 2, 3 degree)
  • infrared coagulation (1, 2, 3 degree)

Surgery:

  • when hemorrhoid is unreducable (4 degree)
336
Q

Rectal Carcinoma

A

painless mass or palpable mass on rectal exam

337
Q

Identify key history elements for anorectal disorders

A

HPI: OLD CHARTS + ICE

PMH:

  • similar problems in past
  • hx of IBD, IBS
  • hx of radiation, cancer
  • recent pregnancy
  • chronic constipation
  • bowel habits
  • liver disease
  • medications

FH:

  • hemorrhoids

SH:

  • sexual history
  • anal intercourse (preferences, practices, protection)
  • abuse
  • drug use (cocaine)
338
Q

Proctitis

A

inflammation of the lining of the rectum

causes:

  • IBD
  • infectious: C. dif salmonella, N. gonorohoeae, chlamydia trachomatis, HSV, HPV
  • icschemia
  • radiation

symtpoms:

  • rectal pain
  • mucopurulent discharge
  • fecal urgency or tenesmus
  • constipation

physical exam:

  • DRE may be difficult
  • HSV may have vesicles

diagnosis:

  • CBC
  • stool culture
  • gonoccal swabs
  • endoscopy

treatment:

  • treatment based on underlying cause
339
Q

Identify key physical exam findings and diagnostic tests for anorectal disorders

A

PHYSICAL EXAM

Age - peaks 45-65 years

GU Exam

  • inspect rectal area
  • DRE
  • anoscopy

Abdominal Exam - if colonic etiology

DIAGNOSTICS

Laboratory - CBC for anemia, infection

Diagnostic Tests - anoscopy, colonoscopy

340
Q

Pruritis Ani

A

causes:

  • fecal soilage
  • perspiration
  • hemorrhoids
  • infection, malignancy

treatment:

  • bulk forming agent
  • sitz baths
  • witch hazel pads
  • steroid creams
  • good hygiene
341
Q

Rectal Prolapse

A
  • protrusion of mucosa or entire thickness of rectum
342
Q

Anal Fissure

A

laceration or tear in anal canal distal to dentate line (posterior midline)

painful with defecation; usually due to passing hard stool

viewed on inspection

treatment: topical analgesia, soften stool, may need surgery

343
Q

Pathophysiology &

Causes of Symptomatic Hemorrhoids

A

Pathophysiology: usually secondary to increased intra-abdominal pressure

Causes

  • aging
  • chronic diarrhea or constipation
  • pregnancy/child birth
  • prolonged sitting
  • straining
  • heavy lifting
  • anal intercourse
  • pelvic tumors
344
Q

Condyloma Accuminata

A
  • anogenital warts from HPV
345
Q

Anal Skin Tag

A
  • pervious thrombosed hemorrhoid
346
Q

Strangulated Hernia

A

not reducible

vascular supply compromised

surgical emergency

347
Q

Hernia Causes

A
  • congenital defect
  • obesity
  • pregnancy
  • chronic cough
  • constipation
  • heavy lifting
  • family history
348
Q

Reynolds Pentad

A
  1. Pain
  2. Fever/chills
  3. Jaundice
  4. Altered Mental Status
  5. Hypotension
349
Q

Ventral and Umbilical Hernia

A

frontal wall of abdomen

secondary to tears or seperation of muscle

  • pregnancy
  • surgical incisions
  • congential weakness

TX:

  • attempt to reduce & assess for danger signs
  • surgical referral
  • hernia belt or binder
350
Q

Diverticulitis

A

microperforation of the diverticula: inflammation & infection

SYMPTOMS:

  • lower abdominal pain
  • constipation or loose stools are common
  • nausea and vomiting
  • can be mild (microperforation) to severe (macroperforation - abscess)

PHYSICAL EXAM

  • low grade fever
  • LLQ tenderness and palpable mass
  • rectal exam - + occult blood
  • Lekocytosis
  • perforation would have more dramatic peritonal signs (Obturator, Psoas, Markle)

IMAGING TREATMENT

  • Abdominal CT - more severe symptoms or not responsive to antibiotics

TREATMENT

  • MILD: liquid diet & oral antibiotics
  • MODERATE: admit to hospital, NPO, IV fluids, IV ABX
  • SEVERE: surgery

COMPLICATIONS

  • fistula formation
  • bowel obstruction
  • abscess
  • perforation
351
Q

Hernia

A

protrusion of intra-abdominal contents through a weakness or abnormal fascia opening in abdominal wall

352
Q

Diverticulosis

A

presence of diverticula (pockets/puches) of intestinal mucosa and submucosa

PATHOPHYSIOLOGY:

  • sigmoid and descending colon
  • lack of fiber in the diet
  • patients with connective tissue disorders are predisposed

PHYSICAL EXAM:

  • often an incidental finding
  • LLQ discomfort on exam, thickened palpable sigmoid and descending colon

IMAGING: None

TREATMENT: high fiber diet

353
Q

Epididymitis

A

STD: men

UTI and Prostatitis: older men; gram negative rods

pain in FLANK or ABDOMEN

urinary retention, urgency

nausea/vomiting, fever

EXAM: tender and swollen epididymis, scrotum inflamed, warm, and red

354
Q

Cholecystitis

A

INFLAMMATION & DISTENSION of the GALLBLADDER

CAUSES:

  • obstruction
  • acalculus cholecystitis - due to biliary stasis from fasting, TPN, trauma
  • infection: CMV, cryptosporidosis, vsculitis

PATHOGENESIS

  • gallbladder inflammed, lysolecithin is released due to trauma to gallbladder wall

SYMPTOMS

  • RUQ pain may radiate to back or R shoulder
  • pain is constant and severe
  • nausea
  • vomiting
  • anorexia
  • fever

PHYSICAL

  • RUQ + guarding
    • Murphy’s sign
  • fever
  • tachycardia

LABS

  • complete blood count
  • metabolic panel
  • amylase (may be elevated), lipase

DIAGNOSTIC

  • ultrasound - can detect stones, thinckened wall and sonographic murphy’s sign

TREATMENT

  • GI rest - NPO
  • IV pain medications, anti-emetics, hydration,
  • surgery?
  • IV antibiotics - 2nd or 3 rd generation
355
Q

Reducible Hernia

A

can be manually of spontaneously repositioned into abdominal cavity

356
Q

Charcot Triad

A
  1. Pain
  2. Fever/chills
  3. Jaundice
357
Q

Testicular Torsion

A

MEDICAL EMERGENCY

acute, severe unilateral testicular pain

pain on palpation

most common 12-18 yo; left

358
Q

Indirect Hernia

A

passes THROUGH inguinal ring

LATERAL TO EPIGASTRIC A.

occurs in younger males and females

359
Q

Testicular Tumor

A

painless enlargment of testis

negative urinalysis

360
Q

Cholelithiasis

A

GALLSTONES

classified according to chemical composition

RUQ episodic pain due to stones moving, no infection, inflammation or blockage; often eating fatty or fried foods

no fever, no elevated WBC/liver enzymes

EXAM

  • RUQ tneder to palpation
    • Murphy’s sign

LAB

  • CBC, LFT, chemisty, amylase, lipase - usually normal

IMAGING

  • ULTRASOUND gold standard
  • HIDA scan

TREATMENT

  • Pain medication
  • IV hydration
  • Elective laprascopic cholecystectomy
361
Q

Direct Hernia

A

passes through abdominal wall

MEDIAL TO EPIGASTRIC A.

more common in older men; uncommon in females

362
Q

Gallbladder Disease Prevalence

A
  • 9x greater prevalence in Native American women
  • 5.5% in men
  • 8.6% in women

Special Populations

  • family hx of gallbladder
  • cystic fibrosis patients
  • pancreatic disease
  • patients on TPN
  • male/female > 60
363
Q

Risk for Gallbladder Disease (5 F’s)

A
  • Female
  • Fat
  • Fair
  • Fertile
  • Forty

other risks:

  • estrogen/progesterone replacement tx
  • rapid weight loss
  • dyslipidemia
  • DM2/glucose intolerance/insulin resistance
  • medications
364
Q

Incarcerated Hernia

A

cannot be reduced

can lead to bowel obstruction but no vascular compromise

365
Q

Choledocholithiasis

A

Bile Duct Stones

Features:

  • hx of recurrent RUQ pain
  • chills and fever w/ pain episode
  • jaundice w/ pain episode

Charcot Triad

  1. Pain
  2. Fever/Chills
  3. Juandice

Reynolds Pentad - acute cholangitis - EMERGENCY

  1. Pain
  2. Fever/Chills
  3. Jaundice
  4. Altered Mental Status
  5. Hypotension

EXAM

  • hepatomegaly
  • tenderness of RUQ or epigastrium
  • charcot triad or tirad + lab evidence of inflamation, elevated liver enzymes or biliary dilation on imaging

TREATMENT:

  • surgery
366
Q

Hydrocele

A

painless accumulation of fluid in the tunica vaginalis or along spermatic cord (bag of worms)

tx: aspiration (temporary), surgery

367
Q

Murphy’s Sign

A

when palpating at the edge of the gallbladder fossa just beneath the liver edge, ask patient to inspire deeply

+ patient stops inspiration or has increased pain

368
Q

Causes of Pain by Location:

Suprapubic

A
  • UTI
  • Bladder Cancer
  • Uterine Fibroids
  • Bacterial Vaginosis
  • Cervicitis
  • Advanced Pregnancy
369
Q

Peritonitis

A

inflammation of the peritoneum

signs:

  • distended or rigid abdomen
  • fever and chills
  • fluid in abdomen
  • passing few or no stools or gas
  • excessive fatigue
  • low urine output
  • nausea and vomiting
370
Q

Character: Colicky or Crampy

A

distension or stretching

371
Q

Diarrhea

A

watery: gastroenteritis - medical conditions
blood: inflammatory bowel (Chron’s; UC)

372
Q

Mesenteric Intestinal Ischemia

  • Cause
  • Signs
  • Risk Factors
  • Diagnosis
  • Treatment
A

abrupt onset of pain out of proportion to examination

CAUSE

  • emboli/thrombi

SIGNS

  • nuaea and vomiting common
  • acidosis common

RISK FACTORS:

  • > 50
  • A FIB
  • Atherosclerotic Disease
  • Hypercoagulability

DIAGNOSIS:

  • CT - CTA or MRA
  • Angiography ** Gold Standard **
  • Elevated Serum lactate
  • Heme positive stool
  • Early surgical consult

TREATMENT:

  • IV fluids
  • surgical removal
  • IV ABX
  • Pain control
373
Q

Pancreatitis

A
  • acute upper abdominal pain
  • band-like radiation to the back
  • alcohol, gallstones
  • nausea, vomiting
  • toxic apearing - febrile
  • patient is restless
  • elevated: serum lipase and amylase
374
Q

Appendicitis

A
  • pain begins at umbilicus, shifts to right lower quadrant
  • anorexia
  • may have vomiting
  • tenderness at McBurney’s point
  • rebound tenderness
    • obturator
    • iliospsoas

diagnostics

  • CT with contrast
  • Ultrasound can rule in or rule out
375
Q

Causes of pain by location:

Left Lower Quadrant

A
  • Diverticulitis
  • Ovarian Cyst
  • Ectopic Pregnancy
  • PID
  • Renal Stones (L flank)
  • Ovarian Torsion
  • Inguinal Hernia
  • Referred Hip Pain
376
Q

Immediately Life Threatening Abdomen Conditions

A
  • AAA
  • Mesenteric Ischemia
  • Perforation GI tract
  • Acute bowel obstruction
  • Volvulus
  • Ectopic Pregnancy
  • Placental Abruption
  • MI
  • Splenic Rupture
377
Q

Character: Burning

A

ulcer

378
Q

define: Acute Abdomen

A

sudden, spontanoues non-traumatic disorder whose chief manifestation is in the abdominal area and for which urgent operation may be necessary

delay in tx will adversly affect outcomes

25% discharged vs. 35-40% admitted

elderly - higher mortality rates

kids - 2/3 surgical appendectomy

379
Q

Obstipation

A

absence of both stool AND flatus

indicative of mechanical bowel obstruction

380
Q

Abdomen Imaging

A

Plain Film - low yield

Ultrasound - AAA, gallbladder, female GU

CT - acute abdomen

Angiography - mesenteric ischemia, AAA

381
Q

Ruptured Ectopic Pregnancy

A

TRIAD

  1. Amenorrhea
  2. Crampy, unilateral abdominal pain
  3. Vaginal bleeding

Need transvaginal US or serial HCG - pelvic exam is non-diagnostic

382
Q

Diagnostic Clues for Abdominal Disorders

A
  • CXR - free air = perforation
  • ABD XR - multiple air-fluid levels = obstruction
  • CT scan - determine cause and site of obstruction more accurately
383
Q

Bowel Obstruction

  • Signs
  • Risks
A

most often the small bowel

SIGNS:

  • crampy/peristaltic pain
  • distension
  • vomiting
  • absence of flatus

RISKS:

  • pervious surgery
  • elderly
  • Chron’s
384
Q

Acute Paralytic Ileus

A

Neurogenic failure or loss of peristalsis

common in hospitalizated patients

DX: CT & ABD films - gas filled loops

TX - treat primary cause

385
Q

Acute Cholecysitis

A

5F predisposition

RUQ pain with nausea and vomiting

RUQ tenderness; guadring; + Murphy’s sign

386
Q

Abdominal Pain by Location:

Diffuse

A
  • Ulcerative Colitis/Crohn’s Disease
  • Endometriosis
  • Gastroenteritis
  • Peritonitis
  • Constipation
  • Mesenteric Ischemia
  • Diabetic Ketoacidosis
  • Porphyria
  • Malaria
387
Q

Abdomen Physical Exam: Inspection

A
  1. Insepction
  • essentially well or globally ill
  • writhing or motionless
  • distension
  • scars
388
Q

Volvulus

A

anatomic obstruction; malrotation is common in pediatrics

SIGNS:

  • gradual lower abdominal cramping pain
  • chronic pain in kids
  • distension

DIAGNOSIS:

  • barium enema
  • plain film
  • sigmoidoscopy
  • US
389
Q

severe uncontrollable retching

A

pancreatitis

390
Q

Abdomen Physical Exam: Percussion

A

3. Perucssion

  • tenderess on percussion
  • rebound tenderness
  • tympany midline: distended bowel loops
  • shifting dullness = free peritoneal fluid
391
Q

GI Perforation

A

causes: peptic ulcer, NSAIDS

signs & symptoms:

  • abrupt onset of severe, diffuse abdominal pain
  • board rigid abdomen
  • free air under the diaphrgam
  • quiet bowel sounds
392
Q

Abdomen Physical Exam: Auscultation

A

2. Auscultation

  • hyperactive - gastroenteritis, dysentery, cholera
  • hypoactive - constipation
  • high pitched - bowel obstruction
  • absent - peritonitis, end stage obstruction, mesenteric ischemia
393
Q

bilious vomit

A

lesion in proximal small bowel

394
Q

Causes of pain by location:

Periumbilical

A
  • Early appendicitis
  • Small bowel obstruction
  • Colitis
  • Umbilical Hernia
395
Q

Toxic Appearing Child

A
  • pale or cyanotic
  • lethargic or inconsolably irritable
  • tachypnea
  • tachycardia
  • poor capillary refill
396
Q

Diverticulitis

A
  • pain for several days
  • change in bowel habits common
  • tenderness, mass may be felt
  • more common > 50
  • fever and malaise
  • may be constipated
  • low grade leukocytosis
397
Q

Abdomen Physical Exam

other locations to check out

A

Digital Rectal Exam

  • frank blood or occult blood
  • lesions, masses, level of bleeding
  • hemorrhoids
  • prostate enlargment

Female Pelvic Exam

  • PID vs. ovarian cyst, abscess or appendicitis

Male GU

  • testicular/ scrotal/ hernia exam

EXTRA-ABDOMINAL

  • Heart & Lungs
  • CVA tenderness
  • Eyes - Icterus
  • Skin
  • Musculoskeletal (hip pain)
398
Q

Causes of Pain by Location

Left Upper Quadrant

A
  • Splenic infarct/rupture
  • Myocardial infarction
  • Pericarditis
  • Pneumonia
  • Diverticulitis (occassionally)
  • Pyelonephritis (L flank)
  • Renal stones (L flank)
399
Q

Testicular Torsion

A
  • sudden onset of severe, unilateral scrotal pain
  • typically follows vigorous activity
  • school age and adolescents
  • exam
    • high-riding, transversley oreinted testis, loss of cremasteric reflex
  • SURGICAL EMERGENCY
400
Q

Abdomen Physical Exam: Palpation

A

4. Palpation

  • “board rigid” patient is dying
  • start light and away from pain
  • check for masses and organomegaly
401
Q

Causes of Pain by Location:

Right Upper Quadrant

A
  • cholecystitis
  • cholelithiasis
  • liver abscess
  • hepatitis
  • cancer of liver or gallbladder
  • pnemonia
  • pyelonephritis
  • renal stones
402
Q

Causes of Pain by Location:

Epigastrium

A
  • GERD
  • Myocardial Infarction
  • Gastritis
  • Gastric Ulcer or Peptic Ulcer
  • Pancreatitis
  • Pancreatic Cancer
  • Abdominal or Thoracic Aortic Aneurysm/Dissection
403
Q

Abdomen Diagnostic Studies

A
  • CBC
  • Pregnancy Test
  • Liver Panel
  • Amylase & Lipase
  • Glucose
  • UA
404
Q

Shock

(Toxic Adults)

A
  • Anxiety or agitation
  • Hypotension
  • Cool, clammy skin
  • Confusion
  • Decreased or no urine output
  • General weakness
  • Pale skin color (pallor)
  • Tachypnea
  • Unconsciousness
405
Q

Intussception

A

telescoping of bowel segments - segment of intestine invaginates into the adjoining intestinal lumen, causing bowel obstruction

common: ILIEOCECAL Valve

TRIAD of Symptoms

  1. Vomiting
  2. Abdominal Pain
  3. Blood in Stool

Pain - colicky every 15-20 minutes

406
Q

Abdominal Aortic Aneurysm

  • Risk Factors
  • Evaluation
A

focal dilation of at least 50% compared to normal or > 3 cm

abdominal, back or flank pain

rupture = unstable hypotension

RISK FACTORS

  • Males
  • > 60
  • COPD
  • PVD
  • HTN
  • smoking
  • family hx

EVALUATION

  • Abdominal Ultrasound
  • CT when planning repair
  • surgery if > 5.5 cm
  • routine for follow up depends on size/growth
407
Q

HepatoBiliary Disease

A
  • localized RUQ pain - radiation to right shoulder/back
  • nausea, vomiting and anorexia
408
Q

Right Lower Quadrant

A
  • Appendicitis (usually later)
  • Ovarian Cyst
  • Ectopic Pregnancy
  • PID
  • Renal Stones (R flank)
  • Ovarian Torsion
  • Inguinal Hernia
  • Referred Hip Pain
409
Q

Pain 1st >> Vomit 2nd

vs.

Vomit 1st >> Pain 2nd

A

Pain 1st >> Vomit 2nd (surgical)

vs.

Vomit 1st >> Pain 2nd (medical)

lesion indicated by vomiting character

410
Q

Spleen

A
  • LUQ pain
  • consider signs and symptoms of infectious mononucleosis
411
Q

Evaluation of Acute Abdomen

A

History

  • pain: type, location, onset, progression
  • associated symptoms
  • other: GYN, social, travel, surgical, family

Exam

  • inspect
  • auscultation
  • percussion
  • palpation

Diagnostic Test

Management

412
Q

Differential Diagnosis Pediatrics Acute Abdomen

A

Most Common

  • Appendicitis
  • Infectious Gastroenteritis
  • Colic

Less Common

  • Pancreatitis
  • Gallbladder Disease
  • Lymphoma
413
Q

Esophageal Cancer

A
  • progressive dysphagia
  • (rapid) weight loss
  • GI bleeding
414
Q

Dyspepsia Physical

A
  • Age
  • Weight/BMI
  • Vitals
  • Inspection: pale
  • Abdominal Exam
    • epigastric tenderness
    • rigidity
    • bowel sounds
    • massess
    • organomegaly
    • abdominal mass
    • weight loss
  • Rectal Exam
    • fecal occult blood
    • rectal tenderness
    • masses
415
Q

Peptic Ulcer Disease

A

GI Bleed

  • hematemesis, hematochezia, anemia
  • hospitalize
  • more common > 60 years old

Perforation

  • abdominal pain, rigidity, NO bowel sounds
  • abdominal x-rays (EGD and Barium contraindicated)
  • hospitalize, surgical treatment

Penetration

  • erodes into adjacent organs
  • abdominal or back pain
  • nausea and vomiting

Gastric Outlet Obstruction

  • secondary to inflammation and scarring
  • abdominal pain, vomiting
416
Q

Dyspepsia

A

epigastric pain or burning, early satiety, or postprandial fullness

associated with: heartburn, refulx, regurgitation, indigestion, bloating, post prandial fullness

alarm symptoms: weight loss, dysphagia, recurrent vomiting, evidence of bleeding or anemia **refer for an endoscopy**

417
Q

Gastroesophageal Reflux Disease (GERD) Presentation

  • Typical Symptoms
  • Atypical Symptoms
  • Alarm Symptoms
A

Heartburn: retrosternal burning or discomfort after eating

Regurgitation: effortless return of esophageal contents to posterior pharynx

Atypical Symptoms

  • coughing or wheezing
  • chest pain
  • laryngitis
  • OM
  • enamel decay

Alarm Symptoms

  • Anorexia
  • Weight loss
  • Blood in vomit and/or stool
  • Pain produced by swallowing (odynophagia)
  • Difficulty swallowing (dysphagia)
  • Anemia
418
Q

Peptic Ulcer Disease Treatment

A
  • Discontinue NSAIDs, Aspirin
  • Smoking cessation
  • Minimize alcohol intake
  • Stress reduction

< 45 with NO alarm symptoms

  • Test for H. pylori
      • erradicate
      • empiric treatment

> 45 or with alarm symptoms

  • EGD indicated
419
Q

H. Pylori Eradication (Positive)

A

Current 2014 treat for 14 days:

  • Triple Therapy
    • PPI
    • bismuth
    • Clarithromycin
    • Amoxicillin
  • Quadruple Therapy - preferred in areas with high resistnace, pencillin allergy
    • Bismuth
    • PPI
    • tetracycline
    • metronidazole or tindazole

Follow-up/retest to determine efficacy

  • 4 weeks urea breath test
  • 8 weeks stool antigen
420
Q

Dyspepsia: ALARM SYMPTOMS

A
  • weight loss
  • bleeding
  • older age
  • anorexia
  • fever
  • chest pain
  • early satiety
421
Q

Gastroesophageal Reflux Disease (GERD)

A

symptoms of mucosal damage produced by abnormal reflux of gastric contents into esophagus

chronic, relapsing

pts may self-treat with OTCs

422
Q

Gastroesophageal Reflux Disease (GERD) Pathophysiology

A

Lower Esophageal Sphincter (LES) Relaxation most common mechanism for GERD, nueral reflex thru the brain stem

Foods ↓ pressure

Medications ↓ pressure

Hormones ↓ pressure

Obesity ↑ pressure due to ↑ intra-abdominal pressure

Hiatal Hernia

423
Q

Peptic Ulcer Disease

A

mucosal break 3 mm or greater

usually occurs in areas exposed to acid and pepsin

common cause of dyspepsia and GI bleed

most common patients: GI bleeding - older adults on NSAIDs

424
Q

Gastroesophageal Reflux Disease (GERD) Aggravating & Alleviating Factors

A

Aggravating

  • meals
  • laying down
  • bending over

Alleviating

  • sitting up
  • standing
  • antacids

Contributing Factors

  • fatty foods
  • chocolate
  • tomato-based products
  • alcohol
  • caffeiene
  • citrus fruits
  • onion
  • garlic
  • peppers
  • overweight
425
Q

Zollinger-Ellison Syndrome

A
  1. Peptic Ulcer Disease
  2. Gastric Acid Hypersecretion
  3. Non beta-cell gastrin producing tumor of pancreas
426
Q

Peptic Ulcer Disease

A

Test for H. pylori

  • urea breath test
  • stool antigen
  • serum IgG antibodies

Labs

  • CBC (anemia, infection)
  • LFTs
  • Amylase/Lipase (pancreatitis)
  • Chem profile

Diagnostic Tests

  • EGD - test of choice can biopsy as well
  • Double contrat barium study
427
Q

Peptic Ulcer Disease: Pathophysiology

A
  1. ** H. pylori **
  • continuous gastric inflammation
  • forms ulcers once there is a defect in the mucosa
  1. NSAIDS and Aspirin
  • damage mucosa by direct action
  • inhibiting prostaglandin synthesis
  1. Cigarrette Smoking
    * increases gastric acid secretion
  2. Stress
  3. Diet - exacerbates symptoms
  4. Associated Disease States
  • COPD
  • cirrhosis
  • renal failure
428
Q

Functional Dyspepsia (Non-Ulcer Dyspepsia = NUD)

A

patients with chronic epigastric pain without:

  • evidence of organic lesions
  • reflux symptoms
  • dysphagia

treatment:

  • symptomatic: PPIs or H2 blockers prn
  • address psychosocial and lifestyle factors
429
Q

Gastroesophageal Reflux Disease (GERD) Diagnostics

A

Labs: typically not needed

Diagnostics Needed if:

  • > 50
  • alarm symptoms
  • Barium Study
  • EGD
  • Esophageal Manometry
  • 24-hr pH probe
430
Q

Gastroesophageal Reflux Disease (GERD) Treatment

A

Lifestyle Modifications

  • lose weight
  • avoid: caffeine, chocolate, citrus, tomato, alcohol
  • wait 3 hours after eating to lay down
  • elevate bed 4-6 inches
  • smoking cessation

Remove Offending Agents

  • NSAIDs
  • Aspirin

Pharmacologic Therapy

  • Anatacids
  • **H2 Recptor Antagonists: **Rantidine (Zantac), Cimetidine, Famotidine (Pepcid), Nizatidine
  • **Proton Pump Inhibitors: **Omeprazole, Lansoprazole, Dexlansoprazole, Raberprazole, Esomeprazole, Pantoprazole
  • Prostaglandin E1 Analogue: Misoprotsol
  • Prokinetics: Metaclopramide
431
Q

Gastroesophageal Reflux Disease (GERD) Compications

A
  • Esophagitis
  • Barret Esophagitis: squamous epithelieum of esophagus replaced by intestinal columnar epithelium
  • Respiratory complications: asthma, pneumonia, fibrosis
432
Q

Peptic Ulcer Disease Physical Exam

A
  • epigastric tenderness
  • guaiac positive stool
433
Q

Dyspepsia History

A

PMI:

  • OLD CHARTS
  • look out for alarm symptoms: weight loss, dysphagia, recurrent vomiting, evidence of bleeding or anemia

PMH:

  • illness
  • prior ulcers
  • medications (NSAIDs, steroids, abx, anticoagulants)

FH:

  • 1st degree relative with peptic ulcer disease

SH:

  • lifestyle, stressors
  • diet/current weight (BMI)
  • alcohol
  • smoking
434
Q

Peptic Ulcer Disease Symptoms

A
  • epigastric pain: gnawing, burning; 15 mins-3 hours after meals
  • nausea and vomiting
  • heartburn
  • chest discomfort
  • belching
  • bloating
  • distension
  • anorexia
  • weight loss
  • hematemesis
435
Q

H. Pylori (Negative)

A
  • Proton Pump Inhibitors (PPI)
  • H2 Receptor Antagonists
  • Misoprotosol (Cytotec)
    • inhibits gastric secretion

Adult/Ped Medicine Cumulative Final (6 decks)

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