Exam 4 Flashcards

Question

*modifiable cardiac risk factors*

Answer 1

* hyperlipidemia * smoking * hypertension * insulin resistance and diabetes * sedentary lifestyle * obesity * unhealthy diet

Answer 2

* 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

Answer 3

lowers LDL by \> 50% * Atrovastatin * Rosuvastatin

Answer 4

lowers LDL by 30-49% * Atrovastatin * Rosuvastatin * Simvastatin * Pravastatin * Lovastatin * Fluvastatin * Pitavastatin

Answer 5

* 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%

Answer 6

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

Answer 7

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

Answer 8

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

Answer 9

* 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

Answer 10

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

Answer 11

* 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

Answer 12

present in every stage of atherothrombosis * hs-CRP * ICAM-1 * IL-6 * TNF-a

Answer 13

**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

Answer 14

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

Answer 15

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

Answer 16

**Acute Arterial Occlusion** treatment: * emergent referral * immediate anticoagulation * embolectomy

Answer 17

* 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

Answer 18

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

Answer 19

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

Answer 20

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

Answer 21

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

Answer 22

**Carotid Artery Stenosis** * medical and surgical treatment

Answer 23

* dysfunction of valves in the superficial and/or communicating veins * dysfunction of valves * deep venous outflow obstruction * muscle dysfunction

Answer 24

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

Answer 25

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

Answer 26

* common in smokers * tissue necrosis more common * rest pain more common * more common in older individuals

Answer 27

* 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

Answer 28

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

Answer 29

* 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

Answer 30

* blood sugar * lipid profile * ankle/brachial index * duplex ultrasound * arteriography

Answer 31

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

Answer 32

* Venous Stasis * Endothelial Damage * Hypercoagulability

Answer 33

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

Answer 34

* smoking * increasing age * sex M \> F * diabetes * hyperlipidemia * hypertriglyceridemia * hyperhomocystinemia * hypertension

Answer 35

* CHF * MI * Stroke * Malignancy * Major Surgery * Trauma * Immobilization * Obesity * Age * Pregnancy * Oral Contraceptives * Smoking

Answer 36

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

Answer 37

* common in diabetics * tissue necrosis * older individuals * most difficult to treat * amputation common

Answer 38

* 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

Answer 39

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

Answer 40

**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.*

Answer 41

**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.*

Answer 42

**Atrial Fibrillation** *Differentiate between atrial fibrillation, atrial tachycardia, and atrial flutter.*

Answer 43

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

Answer 44

**Atrial Flutter** *Differentiate between atrial fibrillation, atrial tachycardia, and atrial flutter.*

Answer 45

Is the distance between one QRS complex the same as the others? If yes - the rhythm is regular If no - the rhythm is irregular

Answer 46

* do not meet the criteria for significance * typically found in leads: I, aVL, V4-V6

Answer 47

* ST segment elevation (1 mm or greater) * T wave peaks initially then inverts later

Answer 48

Presence of SIGNIFICANT Q WAVES * Q wave that is 1/3 total height of QRS * wider than 40 ms

Answer 49

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.*

Answer 50

* 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

Answer 51

* right bundle branch block * right ventricular hypertrophy * high lateral wall MI * right anterior fascicular block

Answer 52

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

Answer 53

* 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

Answer 54

* 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

Answer 55

Wolff Parkinson White "delta-wave" intial slurring of QRS can also have secondary ST-T changes

Answer 56

**Paroxysmal Supraventricular Tachycardia** *Differentiate between atrial fibrillation, atrial tachycardia, and atrial flutter.*

Answer 57

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

Answer 58

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

Answer 59

* 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

Answer 60

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

Answer 61

* left bundle branch block * left ventricular hypertrophy * inferior wall MI * left anterior fascicular block

Answer 62

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

Answer 63

* ST segment depression (2 mm or greater) * T wave inversion (symmetrical)

Answer 64

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.*

Answer 65

* 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

Answer 66

* Acute STEMI * Printzmetal's Angina * Ventricular Aneurysm * Pericarditis * Normal Variant - early repolarization

Answer 67

**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.*

Answer 68

**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.*

Answer 69

* 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

Answer 70

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

Answer 71

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"

Answer 72

* 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

Answer 73

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

Answer 74

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

Answer 75

Normal BP: 1x 140-160/90: 2x \>160/95: 4x

Answer 76

* 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

Answer 77

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)

Answer 78

any of the following: Systolic BP \> 140 mm Hg Diastolic BP \> 90 mm Hg taking antihypertensive medications

Answer 79

* 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)

Answer 80

* 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

Answer 81

increased stiffness of larger arteries = artificially elevated systolic blood pressure

Answer 82

* 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

Answer 83

* 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

Answer 84

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

Answer 85

* Prehypertension * Family history * African-Americans * Overweight * Excess consumption of sodium * Physical inactivity * Alcohol consumption

Answer 86

patients \< 60 140/90 patients \> 60 150/90 diabetes or kidney disease 140/90

Answer 87

* regular isotonic exercise 40 min, 4x/week * avoid isometric exercise -may cause reflex rise

Answer 88

* **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

Answer 89

Dietary Approaches to Stop Hypertension * consume a diet rich in fruits, vegetables and low-fat dairy products * 8-14 mmg Hg reduction in BP

Answer 90

**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

Answer 91

* 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

Answer 92

* 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

Answer 93

* 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

Answer 94

* salt intake * obesity * occupation * alcohol intake * family size * crowding

Answer 95

* 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

Answer 96

**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**

Answer 97

Documented Efficacy: * weight loss * DASH diet * reduced sodium intake * reduced alcohol intake Limited Efficacy: * stress management * potassium * fish oil * clacium * magnesium

Answer 98

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

Answer 99

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

Answer 100

* **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

Answer 101

* **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

Answer 102

* 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

Answer 103

**increased arterial blood presssure with no definable cause** common presentation - asymptomatic readily detectable easily treated often leads to lethal complications if untreated

Answer 104

* irritation * trauma * compression of structures * muscles * cartilaginous structures * nerves * bones

Answer 105

* 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

Answer 106

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)

Answer 107

* 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

Answer 108

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

Answer 109

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

Answer 110

* 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

Answer 111

* treadmill - exercise tolerance test (ETT) * stress myocardial perfusion imaging * stress echo

Answer 112

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

Answer 113

* Electrocardiogram * Exercise Treadmill Testing * Stress Myocardial Perfusion Imaging * Nuclear stress testing * Pharmacologic stress * adenosine, dipyridamole, dobutamine * sestamibi * Stress Echocardiography

Answer 114

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

Answer 115

* MI * Aortic Dissection * Pericarditis * Pulmonary Embolism * Valvular Disease * Aortic Stenosis * Mitral Valve Prolapse * Bacterial Endocarditis * Hypertrophic Obstructive Cardiomyopathy * Myocarditis

Answer 116

* Unstable angina pectoris * non-ST segment elevation MI (NSTEMI) * ST segment elevation (STEMI)

Answer 117

* worsened by deep inspiration or coughing * spasm secondary to: * cold weather * increased activity

Answer 118

* Gastroesophageal reflux * Esophageal spasm * Cholecystitis * Peptic ulcer disease * Pancreatitis GI Disorders are associated with eating, relief with antacids.

Answer 119

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

Answer 120

* non-occlusive thrombus * ECG: non-specific ECG; ECG can look normal * normal cardiac enzymes

Answer 121

* results in pain and motor/sensory deficits * numbness or tingling in neck, chest, upper arm

Answer 122

* abdominal pain * absence of chest pain * dizziness/weakness * fatigue * hot and flused * indigestion * palpitations

Answer 123

* absence of chest pain * diaphoresis * dyspnea * faintness * syncope * nausea * vomiting

Answer 124

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

Answer 125

* doesn't fit a common pattern * no abnormal exam or diagnostic findings * usually self-limited and resolves on own * diagnosis of exclusion

Answer 126

* absence of chest pain * nausea * vomiting * hypotension with tachycardia * right arm, neck, jaw pain * back pain * dyspnea * headache

Answer 127

* 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

Answer 128

Structural Defects * lumen laxity * obstruction * distension Mucosal or organ irritation, inflammation or infection * esophagus * abdominal organs

Answer 129

* 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

Answer 130

* 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

Answer 131

* 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

Answer 132

* 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

Answer 133

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

Answer 134

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

Answer 135

* hypotension * tachycardia * pulmonary crackles * JVD * pulmonary edema * new murmurs * heart sounds * diminished peripheral pulses * signs of stroke

Answer 136

2 of the following * ischemic symptoms * diagnostic ECG changes * serum cardiac marker elevation * wall motion abnormalitiy on echo

Answer 137

* Diabetes * silent MI * Heart failure * less likely to have CP * may have atypical symptoms

Answer 138

* decrease amount of myocardial necrosis * preserve LV function * prevent major adverse cardiac events * treat life threatening complications

Answer 139

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

Answer 140

* Coronary Angioplasty * Percutaneous Interventions - balloon angioplasty, stent placement * CABG - Coronary Artery Bypass Grafting * Enhanced External Counterpulsation

Answer 141

* 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

Answer 142

chest pain with intesne fear * tachypnea * palpitations * diaphoresis * trembling * nausea * dizziness * syncope or near syncope * chills or hot flashes

Answer 143

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

Answer 144

* 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

Answer 145

* 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

Answer 146

* irritation/inflammation of lung tissue, pleura, diaphragm * infection * chronic disease * neoplasm * reactive airway/bronchospasm

Answer 147

* 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

Answer 148

* low-flow states of myocardium (CAD) * spasm * tissue hypoxia * anaerobic metabolism * lactic acidosis

Answer 149

* Usually lasts less than 10 minutes * Relieved by rest or with nitroglycerine

Answer 150

* Transudates * congestive heart failure * acute atelectasis * pulmonary embolism * Exudates * pneumonia * cancer

Answer 151

* most common cause of pleuritic pain * fever * chills * cough * leukocytosis * localized physical exam - chest x-ray findings

Answer 152

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

Answer 153

* abdominal pain * chest pain * cough * cramping or burning chest pain * palpitations * upper back pain

Answer 154

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

Answer 155

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

Answer 156

* complete thrombus occlusion * ECG: * ST elevations on ECG or new LBBB * cardiac enzymes: elevated

Answer 157

* secondary to anxiety, depression, other psych disorder * illicit drug use

Answer 158

* intesne, substernal, sharp pain * may radiate to interscapular region * may be relieved by nitroglycerine

Answer 159

* 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.

Answer 160

identify: * existence and extent of LV dysfunction * valvular or pericardial disease * amyloidosis differentiate systolic versus diastolic heart failure distinguish regional from global LV dysfunction

Answer 161

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

Answer 162

* 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

Answer 163

* Chest X-ray * EKG * LAB: BNP * Echocardiogram * Cardiac catheterization

Answer 164

* present with fatigue and loss of mean muscle mass * present with dyspnea

Answer 165

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.**

Answer 166

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

Answer 167

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)

Answer 168

See chart below:

Answer 169

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

Answer 170

* both systemic and pulmonary congestion present * bilateral reduced contractility

Answer 171

* compromised myocardial relaxation with NORMAL contractility and ejection fraction * associated with: CAD, HTN, aging, infiltrative cardiomyopathy

Answer 172

* demand for blood exceeds capacity of a normal heart to meet demand * anemia * hyperthyroid

Answer 173

Evaluate for: * old arrhythmias * old MI's * conduction delays * left ventricular hypertrophy * repolarization abnormality

Answer 174

**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.**

Answer 175

* increased metabolic demand * increased afterload or preload * drugs * negative inotropic drugs * disopyramide * Ca blockers * arrhythmias * toxins * hypothyroidism * lack of compliance

Answer 176

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

Answer 177

* **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

Answer 178

* \< 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

Answer 179

* improve symptoms * prolong survival * halt progression of myocardial dysfunction * reverse myocardial process

Answer 180

* 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

Answer 181

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

Answer 182

History is important to help * establish HF as the cause of symtpoms * determine etiology * establish severity and functional class

Answer 183

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

Answer 184

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

Answer 185

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

Answer 186

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._**

Answer 187

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

Answer 188

* indicator of volume and pressure in the right side of the heart * pulsations absent when patient is upright

Answer 189

Contraction. Pressure increases **closure of AV valves S1** ventricles empty pressure decreases **closure of semilunar valves S2**

Answer 190

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.

Answer 191

* Heart Rate * Respiratory Rate * Blood Pressure * both upper extremity * one lower extremity * Spot oximetry

Answer 192

**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**

Answer 193

Chest: * Thrills * PMI Abdomen: * Hepatomegaly * Splenomegaly Pulses: * rate and rhythm * Brachio-Femoral dealy * absence of distal pulses * bounding pulses

Answer 194

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

Answer 195

* results from **closing of AV valves** * indicates **beginning of systole** * best heard at **apex** * lower pitch, longer

Answer 196

* **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

Answer 197

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

Answer 198

* 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**

Answer 199

* 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

Answer 200

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

Answer 201

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

Answer 202

* Systolic Murmurs: between S1 and S2 * Diastolic Murmurs: between S2 and S1

Answer 203

* where is it best heard i.e. aortic area

Answer 204

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

Answer 205

* 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

Answer 206

* crescendo: progressively gets louder * decrescendo: progressively gets softer * crescendo-decrescendo: gets louder than softer * sustained: maintains constant loudness

Answer 207

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

Answer 208

* **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**

Answer 209

* 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**

Answer 210

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%

Answer 211

* 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**

Answer 212

* 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

Answer 213

* 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**

Answer 214

Timing: Systolic ejection Intensity: 1-3/6 Location: LUSB, RUSB, to axillae and back Pitch: Medium Character: Blowing Helpful Maneuvers: None

Answer 215

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

Answer 216

Timing: Systolic ejection Intensity: 1-3/6 Location: LUSB Pitch: Low to medium Character: Blowing Helpful Maneuvers: Inspiration, Standing

Answer 217

* 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**

Answer 218

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%**

Answer 219

* 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**

Answer 220

* 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

Answer 221

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

Answer 222

* 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**

Answer 223

* 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

Answer 224

Timing: Systolic Ejection Intensity: 1-3/6 Location: Several cm lateral to LLSB Pitch: Low Character: Vibratory, Musical Helpful Maneuvers: Standing vs. Supine

Answer 225

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)

Answer 226

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…

Answer 227

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

Answer 228

Atrio-Ventricular Septal Defect Large VSD Large PDA Critical/Severe Aortic Stenosis Severe Pulmonary Stenosis Critical Coarctation

Answer 229

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

Answer 230

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

Answer 231

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

Answer 232

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

Answer 233

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

Answer 234

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

Answer 235

barium inserted into colon and radiographs taken **helpful to diagnose:** diverticulitis, polyps, tumors **limitations:** abnormalities need to be followed up by colonoscopy, patient discomfort

Answer 236

incremental images **helpful to diagnose:** acute abdominal conditions, tumors **limitations:** radiation exposure, cost

Answer 237

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

Answer 238

\*\* 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

Answer 239

**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

Answer 240

* 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

Answer 241

safer test - no inoizing radiation **helpful to diagnose:** * cholecystitis/cholelithiasis * cholangitis * abscesses * diverticulitis * SB inflammation **limitations:** * blind to many areas of the abdomen

Answer 242

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

Answer 243

* Dyspepsia * Nausea * Vomiting * Constipation * Diarrhea * GI Gas

Answer 244

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

Answer 245

* affect the clinical expression of GI illness and disease * genetic predisposition * early learning * cultural background

Answer 246

usefulness: * bowel gas pattern * intrabdominal free air * air-fluid levels * densities * tumors

Answer 247

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

Answer 248

tube from nose to esophagus - measures esophageal function by pressure readings of muscle contractions (motility) **helpful to diagnose:** motility disorders **limitations:** no visualization

Answer 249

radiologist visualizes stomach and esophagus under fluroscopy **helpful to diagnose**: stricture, hiatal hernia, swallowing problems **limitations**: unable to visualize or biopsy

Answer 250

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

Answer 251

* weight loss * decreased appetitie * nausea * intestinal gas * diarrhea * cough * wheezing * horase voice

Answer 252

Home Education Activities Drugs Sexuality Suicide/Depression

Answer 253

**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

Answer 254

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

Answer 255

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

Answer 256

* fussiness * arching * feeding refusal or some feed more frequently * congestion * wheezing

Answer 257

* on/off abdominal pain * decreased food intake * discomfort after eating * cough * wheezing

Answer 258

* burning epigastric pain * regurgitation * chest pressure * early satiety * nausea * bad taste in mouth (especially in AM)

Answer 259

**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

Answer 260

* upper GI series * upper endoscopy * acid supression trial

Answer 261

* treat empirically and do lifestyle changes * persistnent or recurrent symptoms should prompt referral endoscopy with biopsy

Answer 262

* barium esophagram - looking for anatomic abnormailities * NO empiric treatment * upper endoscopy is necessary

Answer 263

* insufficient research - trial empiric treatment * video fluoroscopy?

Answer 264

**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

Answer 265

* 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

Answer 266

* thirst * tachycardia * lethargy * orthostasis * oliguria * tachypnea * dry mucous membranes * weight loss * decreased tear production * decreased skin turgor

Answer 267

* 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

Answer 268

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

Answer 269

**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

Answer 270

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

Answer 271

Acute Diarrhea: Infectious Gastroenteritis **Entamoeba Histolytica** diagnosed via: stool examination and immunoassays tx: Furazolidone, Albendazole, Metronidazole

Answer 272

frequent, watery stools common in day cares self-limited in healthy kids can become chronic in the immunocompromised no effective therapy

Answer 273

protozoan infection cuasing diarrhea in AIDS patients treated with TMP-SMZ

Answer 274

Acute Diarrhea: Infectious Gastroenteritis **Staphylococcus Aureus** symptoms resolve spontaneously within 24 hours

Answer 275

Acute Diarrhea: Infectious Gastroenteritis **Clostridium Botulinum** other CNS symptoms: dry mouth, dysphagia, blurry vision, paralysis of respiratory muscles tx: specific antitoxin, ventilatory sport

Answer 276

Acute Diarrhea: Infectious Gastroenteritis **Infantile Botulism** Floppy Baby Syndrome * hypnatremia * pooled oral secretions * cranial nerve deficits * generalized weakness * apnea

Answer 277

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**

Answer 278

* hemorrhagic colitis * self-limited * source: undercooked beef and fruit juices * toxin can cuase **HUS** * **no antibiotics**

Answer 279

Acute Diarrhea: Infectious Gastroenteritis **C. Difficile** need to order C. Difficile specific culture tx: stop antibiotic

Answer 280

**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: i**f severe treat with metronidazole or vancomycin

Answer 281

**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

Answer 282

**Protracted Diarrhea of Infancy** * significant malabsorption can occur * tx: administering elemental formulas, providing parental nutrition if necessary

Answer 283

* 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

Answer 284

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

Answer 285

* Ulcerative Coliits * Chron Disease * chronic and recurrent

Answer 286

**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 cance**r - 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**

Answer 287

**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

Answer 288

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

Answer 289

Mild Ulcerative Colitis

Answer 290

Moderate Ulcerative Colitis

Answer 291

Severe Ulcerative Colitis

Answer 292

* type of severe UC * **rapid progression** * **severe S&S** * risk of perforation * broad-spectrum antibiotics

Answer 293

* **dilation of colon** * risk of perforation * surgery to remove colon * risk of death

Answer 294

**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

Answer 295

**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

Answer 296

**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

Answer 297

* patient looks healthy * mild, diffuse tenderness or LLQ tenderness * rest of exam - insignficant

Answer 298

* **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

Answer 299

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

Answer 300

Ulcerative Colitis inflammatory disease of mucosa and sub mucosa

Answer 301

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

Answer 302

Infectious Diarrhea can be bacterial, viral, or parasitic consider stool culture

Answer 303

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

Answer 304

Lactose Intolerance

Answer 305

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

Answer 306

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

Answer 307

* **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

Answer 308

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

Answer 309

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

Answer 310

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

Answer 311

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)

Answer 312

painless mass or palpable mass on rectal exam

Answer 313

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)

Answer 314

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

Answer 315

**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

Answer 316

causes: * fecal soilage * perspiration * hemorrhoids * infection, malignancy treatment: * bulk forming agent * sitz baths * witch hazel pads * steroid creams * good hygiene

Answer 317

* protrusion of mucosa or entire thickness of rectum

Answer 318

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

Answer 319

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

Answer 320

* anogenital warts from HPV

Answer 321

* pervious thrombosed hemorrhoid

Answer 322

not reducible vascular supply compromised surgical emergency

Answer 323

* congenital defect * obesity * pregnancy * chronic cough * constipation * heavy lifting * family history

Answer 324

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

Answer 325

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

Answer 326

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

Answer 327

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

Answer 328

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

Answer 329

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

Answer 330

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

Answer 331

can be manually of spontaneously repositioned into abdominal cavity

Answer 332

1. Pain 2. Fever/chills 3. Jaundice

Answer 333

MEDICAL EMERGENCY acute, severe unilateral testicular pain pain on palpation most common 12-18 yo; left

Answer 334

passes THROUGH inguinal ring LATERAL TO EPIGASTRIC A. occurs in younger males and females

Answer 335

painless enlargment of testis negative urinalysis

Answer 336

**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

Answer 337

passes through abdominal wall MEDIAL TO EPIGASTRIC A. more common in older men; uncommon in females

Answer 338

* 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

Answer 339

* **Female** * **Fat** * **Fair** * **Fertile** * **Forty** **other risks:** * estrogen/progesterone replacement tx * rapid weight loss * dyslipidemia * DM2/glucose intolerance/insulin resistance * medications

Answer 340

cannot be reduced can lead to bowel obstruction but no vascular compromise

Answer 341

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

Answer 342

**painless** accumulation of fluid in the tunica vaginalis or along spermatic cord (bag of worms) tx: aspiration (temporary), surgery

Answer 343

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

Answer 344

* UTI * Bladder Cancer * Uterine Fibroids * Bacterial Vaginosis * Cervicitis * Advanced Pregnancy

Answer 345

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

Answer 346

distension or stretching

Answer 347

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

Answer 348

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

Answer 349

* 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

Answer 350

* 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

Answer 351

* Diverticulitis * Ovarian Cyst * Ectopic Pregnancy * PID * Renal Stones (L flank) * Ovarian Torsion * Inguinal Hernia * Referred Hip Pain

Answer 352

* AAA * Mesenteric Ischemia * Perforation GI tract * Acute bowel obstruction * Volvulus * Ectopic Pregnancy * Placental Abruption * MI * Splenic Rupture

Answer 353

**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

Answer 354

absence of both stool AND flatus indicative of mechanical bowel obstruction

Answer 355

Plain Film - low yield Ultrasound - AAA, gallbladder, female GU CT - acute abdomen Angiography - mesenteric ischemia, AAA

Answer 356

TRIAD 1. Amenorrhea 2. Crampy, unilateral abdominal pain 3. Vaginal bleeding Need transvaginal US or serial HCG - pelvic exam is non-diagnostic

Answer 357

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

Answer 358

most often the small bowel SIGNS: * crampy/peristaltic pain * distension * vomiting * absence of flatus RISKS: * pervious surgery * elderly * Chron's

Answer 359

Neurogenic failure or loss of peristalsis common in hospitalizated patients DX: CT & ABD films - gas filled loops TX - treat primary cause

Answer 360

5F predisposition RUQ pain with nausea and vomiting RUQ tenderness; guadring; + Murphy's sign

Answer 361

* Ulcerative Colitis/Crohn's Disease * Endometriosis * Gastroenteritis * Peritonitis * Constipation * Mesenteric Ischemia * Diabetic Ketoacidosis * Porphyria * Malaria

Answer 362

1. Insepction * essentially well or globally ill * writhing or motionless * distension * scars

Answer 363

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

Answer 364

pancreatitis

Answer 365

**3. Perucssion** * tenderess on percussion * rebound tenderness * tympany midline: distended bowel loops * shifting dullness = free peritoneal fluid

Answer 366

causes: peptic ulcer, NSAIDS signs & symptoms: * abrupt onset of severe, diffuse abdominal pain * board rigid abdomen * free air under the diaphrgam * quiet bowel sounds

Answer 367

**2. Auscultation** * hyperactive - gastroenteritis, dysentery, cholera * hypoactive - constipation * high pitched - bowel obstruction * absent - peritonitis, end stage obstruction, mesenteric ischemia

Answer 368

lesion in proximal small bowel

Answer 369

* Early appendicitis * Small bowel obstruction * Colitis * Umbilical Hernia

Answer 370

* pale or cyanotic * lethargic or inconsolably irritable * tachypnea * tachycardia * poor capillary refill

Answer 371

* 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

Answer 372

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)

Answer 373

* Splenic infarct/rupture * Myocardial infarction * Pericarditis * Pneumonia * Diverticulitis (occassionally) * Pyelonephritis (L flank) * Renal stones (L flank)

Answer 374

* 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

Answer 375

**4. Palpation** * "board rigid" patient is dying * start light and away from pain * check for masses and organomegaly

Answer 376

* cholecystitis * cholelithiasis * liver abscess * hepatitis * cancer of liver or gallbladder * pnemonia * pyelonephritis * renal stones

Answer 377

* GERD * Myocardial Infarction * Gastritis * Gastric Ulcer or Peptic Ulcer * Pancreatitis * Pancreatic Cancer * Abdominal or Thoracic Aortic Aneurysm/Dissection

Answer 378

* CBC * Pregnancy Test * Liver Panel * Amylase & Lipase * Glucose * UA

Answer 379

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

Answer 380

**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

Answer 381

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

Answer 382

* localized RUQ pain - radiation to right shoulder/back * nausea, vomiting and anorexia

Answer 383

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

Answer 384

Pain 1st \>\> Vomit 2nd (surgical) vs. Vomit 1st \>\> Pain 2nd (medical) lesion indicated by vomiting character

Answer 385

* LUQ pain * consider signs and symptoms of infectious mononucleosis

Answer 386

History * pain: type, location, onset, progression * associated symptoms * other: GYN, social, travel, surgical, family Exam * inspect * auscultation * percussion * palpation Diagnostic Test Management

Answer 387

Most Common * Appendicitis * Infectious Gastroenteritis * Colic Less Common * Pancreatitis * Gallbladder Disease * Lymphoma

Answer 388

* progressive dysphagia * (rapid) weight loss * GI bleeding

Answer 389

* 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

Answer 390

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

Answer 391

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\*\*

Answer 392

**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

Answer 393

* 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

Answer 394

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

Answer 395

* weight loss * bleeding * older age * anorexia * fever * chest pain * early satiety

Answer 396

symptoms of mucosal damage produced by **abnormal reflux of gastric contents into esophagus** chronic, relapsing pts may self-treat with OTCs

Answer 397

**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**

Answer 398

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

Answer 399

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

Answer 400

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

Answer 401

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

Answer 402

1. ** H. pylori ** * **continuous gastric inflammation** * forms **ulcers** once there is a defect in the mucosa 2. NSAIDS and Aspirin * **damage mucosa** by direct action * inhibiting **prostaglandin synthesis** 3. Cigarrette Smoking * increases gastric acid secretion 4. Stress 5. Diet - exacerbates symptoms 6. Associated Disease States * COPD * cirrhosis * renal failure

Answer 403

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

Answer 404

Labs: typically not needed Diagnostics Needed if: * \> 50 * alarm symptoms * Barium Study * EGD * Esophageal Manometry * 24-hr pH probe

Answer 405

**_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

Answer 406

* Esophagitis * Barret Esophagitis: squamous epithelieum of esophagus replaced by intestinal columnar epithelium * Respiratory complications: asthma, pneumonia, fibrosis

Answer 407

* epigastric tenderness * guaiac positive stool

Answer 408

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

Answer 409

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

Answer 410

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

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Exam 4 Flashcards

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