Final Flashcards
Where does pleuritic pain localize to?
distribution of an intercostal nerve
T/F: Pleuritic pain may or may not be made worse by taking a deep breath
TRUE
Do shingles outbreaks occur unilaterally or bilaterally?
unilaterally
What is the first symptom of shingles?
pain (it can occur before rash erupts)
What is a key symptom for intercostal neuralgia?
increased pain when bending toward the side of involvement
What is a key symptom for pleurisy?
increased pain when bending away from the side of involvement
What can sometimes be an extremely good mimic of angina/ACS/MI?
non-cardiac chest pain
What is costochondritis?
aka costosternal syndrome. Intermittent unilateral pain at one or more of the costosternal junctions/costochondral junctions. Pain can radiate across the anterior chest and increases with inspiration.
What is Tietze’s syndrome?
idiopathic costochondritis with painful enlargement of the costal cartilage. Usually the 2nd costochondral junction.
What is sternalis syndrome?
pain over midline of sternum. Can radiate bilaterally. Pain is less intense but more constant than costosternal syndrome
What is xyphoidalgia?
pain over xyphoid process. Increased by lifting, deep breathing, or heavy meals
What is rib tip syndrome?
aka slipping rib. Hypermobility of anterior costal cartilage in a lower rib. Movement of rib increases pain and causes clicking or snapping sound
Where are most rib fractures?
angle of the rib via blunt trauma
what are the most commonly damaged ribs?
ribs 4 -9
What are some common concerns about first rib injury?
significant chest damage, injury to lungs, aorta, subclavian, or brachial plexus
What can a lower rib fx damage?
Liver or spleen
what can floating ribs damage?
kidneys
what is the main complication with rib fx?
compromised ventilation (more prone to hyperventilation)
What can fragmented rib fx lead to?
pneumothorax or hemothorax
what can flail chest lead to?
decreased excursion and ventilatory insufficiency
What are some conditions that have been associated with cervical pseudo-angina?
spondylolisthesis, osteophytes, discopathy involving lower Cx spine, cervical NR compression (usually c7)
what is cervicobrachial syndrome?
pain arising from a cervical spine dz, NR compression, or TOS. Might be mistaken for angina pectoris
what is cervicogenic angina?
pain that very closely resembles true cardiac angina but originates from the cervical spine
what must always be ruled out in a pt with cervicogenic angina?
coexisting CAD
what are the mechanisms in cervical pseudo-angina?
- radicular pain d/t NR compression 2. compression of ventral motor root 3. referred pain from ALL, PLL, disc, or facets 4. autonomic Sx mediated by sympathetic nervous system
what are the possible symptoms of cervical pseudo-angina?
- angina-type pain 2. autonomic/sympathetic sx (SOB, diaphoresis, dyspnea, nausea, pallor, vasoconstriction)
what could trigger a Prinzmetal angina?
vasoconstriction mediated by autonomic/sympathetic nervous system and/or pain
What does functional chest pain have a close association with?
GERD
What is functional chest pain?
characterized by recurrent episodes of unexplained chest pain that are usually midline, of visceral quality, and therefore potentially of esophageal origin. The pain is often debilitating.
how many americans suffer from GERD every year?
100 million
What is spontaneous passive movement of some gastric contents into the esophagus called?
normal asymptomatic reflux (some degree occurs in almost everyone multiple times/day)
What is symptomatic functional heartburn?
reflux symptoms are present. Acid levels are not elevated, esophageal mucosa appears normal upon endoscopy
What is non-erosive reflux dz?
reflux symptoms. Acid levels elevated. Esophageal tissue appears normal upon endoscopy
What is gastro-esophageal reflux dz?
aka erosive esophagitis. Reflux symptoms present. Acid levels elevated. Esophageal damage on endoscopy/biopsy
what are the physical anti-reflux barriers?
mucosal rosettes, gastro-esophageal angle (weak barriers)
what are the physiological anti-reflux barriers?
stronger defense mechanisms, positive pressure gradient between lower esophageal sphincter and the stomach, positive intra-abdominal pressure, appropriate LES basal tonus
how does weight loss affect intra-abdominal pressure?
decreases
What are the factors that decrease LES basal pressures and increase risk of reflux?
gastric acidification, citrus, nicotine, alcohol, fried or fatty foods, caffeine, chocolate, peppermint, spearmint. Sometimes: potatoes, tomatoes, sweet and hot peppers, eggplant, tomatillos, tamarillos, pepinos, pimentos, paprika, cayenne, tabasco.
what is considered the first line of Tx for GERD?
avoid foods that can contribute GERD
what has shown to consistently work better than dietary modification for GERD?
weight loss and elevating the head of the bed
along with laying down, how can LES basal pressure also be decreased?
pregnancy, meds, hiatal hernia
what is the incidence of heartburn in US adults?
monthly = 40% weekly = 20% daily = 10%
What is a typical heartburn?
substernal burning pain located b/t xyphoid process and episternal notch
where are the two places that heartburn can have referred pain?
midthoracic spine b/t shoulder blades = 40% of cases, left shoulder/arm = 5% of cases
what is acid regurgitation that can burn the throat?
acid brash
what is excess salivation?
water brash
what is the time frame for classic heartburn to occur?
30-60 mins after offending meal
what often provokes heartburn?
lying down or bending over after meals
T/F: the severity of heartburn often correlates with the degree of damage
false - does not correlate
T/F: older pts with verified GERD may not experience “heartburn”.
TRUE
in a pt with stomach problems, what might dr feel when palpating Tx spine?
“rubbery” between shoulder blades
What are the warning signs that suggest complicated GERD?
- chest pain that can mimic angina pectoris (motility disorders such as esophageal spasm) 2. dysphagia 3. odynophagia 4. weight loss 5. anemia/gastrointestinal bleeding/blood in stool
What should GERD pts with alarm symptoms undergo?
prompt endoscopy
what could be a concern for pts with very chronic GERD?
potential barretts esophagus
what can hyperventilation induce?
vasoconstriction
what is a common concern with hyperventilation syndrome?
coexisting CAD
what is hyperventilation syndrome classically associated with?
hypocalcemia
what are some possible nms findings for hyperventilation syndrome?
latent tetany or neuromuscular irritability
What are the 2 provocative tests for latent tetany?
- Chvostek’s sign 2. Trousseau’s sign
What is Chvostek’s sign?
facial twitching via stimulation of CN VII. (tap over TMJ/parotid gland/masseter) low sensitivity
What is Trousseau’s sign?
carpal spasm/obstetrician’s hand (inflate BP cuff until pulse disappears and hold for 5 min.) decent sensitivity, low false-positive rate
describe the atypical chest pain assoc. with HVS?
pain may last for hours, pain often relieved by exercise
what are the characteristics of HVS paresthesias?
usually bilateral, upper extremity. If unilateral, 80% are left-sided
what is a possible result when minute ventilation exceeds metabolic demands?
“perceived dyspnea”
what do HVS pts tend to breathe using?
upper thorax instead of diaphragm (can lead to chronically over-inflated lungs)
What causes acute primary hyperventilation?
no organic cause identified
how common is acute primary hyperventilation?
1% of HVS cases
what are 2 characteristics that make chronic/compensated primary ventilation difficult to Dx?
- no organic cause identified 2. chest wall tenderness
What are some of the characteristics of secondary hyperventilation?
organic cause identified, pain, mild bronchospasm, asthma
how does pursed lip respiration affect breathing?
slows respiration rate and reduces work of breathing
what is a panic disorder commonly caused by?
spontaneous sudden onset of fear or discomfort (seen in up to 30% of college students)
What does a non-productive cough during a dyspnea attack indicate?
advanced small airways dz
T/F: productive cough would be seen after airways are reopened
TRUE
what is chronic bronchitis?
centrilobular emphysema and increased airways resistance
what is classic emphysema?
panlobular emphysema and decreased elastic recoil
what are the two forms of COPD?
chronic bronchitis (more common) and pulmonary emphysema. Most COPD pts have combination of both conditions
What is the definition of COPD?
chronic, incompletely reversible airflow obstruction on forced expiration
What is the primary risk for COPD?
cigarette smoking
What is the risk involved with secondhand smoke?
might be a factor in pulmonary emphysema. (not considered a direct factor for chronic bronchitis)
what is a common side effect for COPD pts?
more susceptible to infection (bronchitis, pneumonia, etc)
What is the clinical definition of chronic bronchitis?
long term cigarette smoking and a mucus producing cough that occurs on most days and lasts for at least 3 months per year for 2 years in a row
In end stage chronic bronchitis, what is physically obstructed?
greatly increased small airways resistance
what is grade 3 dyspnea?
dyspnea with ADLs (common in end stage chronic bronchitis)
what is a common complication of end stage chronic bronchitis?
cor pulmonale/ “right sided heart failure”
what are some characteristics of end stage chronic bronchitis?
- prolonged expiration 2. excessive use of accessory msls of respiration 3. pursed lip respiration 4. noisy breathing
What is a “blue bloater” associated with?
end stage chronic bronchitis (“can’t catch my breath and I cough all the time”)
What are 3 common causes of pulmonary emphysema?
- inflammatory response 2. alpha-1 antitrypsin deficiency 3. relative obstruction
What is most strongly linked to pulmonary emphysema?
lack of alpha-1 antitrypsin
how does pulmonary emphysema affect respiration?
very prolonged expiration
what lobes are most affected by emphysema associated with cigarette smoking?
upper lobes
how can emphysema occur in a non-smoker?
congenital lack of AAT (more severe in lower lobes)
What does a loss of elastic recoil lead to?
very prolonged expiration
What kind of pt often presents underweight, in a tripod posture when seated, and with a possible expiratory grunt?
pulmonary emphysema
what is a “pink puffer” associated with?
pulmonary emphysema
what is the method of choice for dxing copd?
spirometry
what is the most effective preventitive measure against chronic bronchitis?
smoking cessation
what is pneumoconiosis?
lung dust d/t inhalation of asbestos, coal dust, or crystalline silica
What is an important cofactor for pneumoconiosis?
smoking
What is the most common pneumoconiosis in the US?
silicosis and “sand blasters lung”
What is defined as an asthma-like reaction to the inhalation of cotton dust?
byssinosis
what is the classic early asthmatic response?
a rapid-onset IgE mediated bronchoconstriction right after exposure to a specific trigger
what is the classic late asthmatic response?
mucosal edema d/t inflammatory response that occurs 6-24 hours after exposure to the specific trigger
what are activated in the lungs of asthmatic pts?
eosinophils
what alteration takes place in the epithelium of chronic asthma pts?
increase in number of mucus secreting cells (=> dramatic increase in mucus production)
what can inflammation and tissue alterations in asthmatic pts result in?
an asthmatic response upon exposure to non-specific irritants
what is classically associated with allergic asthma?
exogenous/extrinsic asthma
what are common causes of endogenous asthma?
GERD, viral respiratory infections, emotional stress, obesity, exposure to cold or dry air
what are some examples of conditions that can involve wheezing?
asthma, bronchitis, neoplasm, pulmonary edema/CHF, respiratory foreign bodies, hyperventilation syndrome
T/F: severity of symptoms and intensity of wheezing sounds usually correlate with the actual degree of airway obstruction
false - does not correlate
what is an acute asthmatic exacerbation that’s unresponsive to bronchodilators?
status asthmaticus
what are the signs of respiratory distress?
- increased RR 2. increased HR 3. diaphoresis 4. excessive use of accessory msls of respiration
what is a commonly used benchmark for CHF?
left ventricle ejection fraction
What are two types of late stage mitral stenosis?
- tight mitral stenosis (TMS) 2. pulmonary vascular dz (PVD)
What is the most common symptom in heart failure?
dyspnea (usually d/t elevated left atrial pressure)
What percentage of heart failure pts have glucose abnormalities?
40%
how is neurohumoral stimulation a compensation for a failing heart?
sympathetic stimulation elevates HR, increases strength of cardiac contraction, and may be accompanied by diaphoresis
what are catecholamines thought to be toxic to?
cardiac myocytes
what does compensated heart failure cause?
hypertrophy
what does decompensated heart failure cause?
apoptosis
how does retention of sodium and water compensate for a failing heart?
helps maintain BP, increases preload to make use of Frank Starling mechanism
how does cardiac remodeling compensate for a failing heart?
dilation of ventricle OR hypertrophy
what is a problem associated with dilation of the ventricle during cardiac remodeling?
eventually stretched msl becomes weakened, leading to overt systolic dysfunction (balloon analogy)
what is a problem associated with hypertrophy during cardiac remodeling?
msl becomes stiff and can no longer relax or stretch, leading to overt diastolic dysfunction
what results in increased left atrial pressure?
left backward heart failure
what is the classic symptom progression in pulmonary venous congestion?
exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, dyspnea at rest, acute pulmonary edema
what is the cardinal sign of left ventricular failure?
breathlessness
what is the classic association with left forward heart failure?
fatigue and exercise intolerance
what does left forward heart failure result in?
decreased cardiac output
what is the most common cause of right heart failure?
left ventricular failure
what is the second most common cause of right ventricular failure?
lung dz (cor pulmonale)
what is considered a minor criterion in the dx of CHF?
edema
what is compensated heart failure?
heart failure with a relatively normal cardiac output/ejection fraction
what is decompensated heart failure?
CHF with grossly inadequate cardiac output (death)
what is the NYHA classification of heart failure based upon?
amt of effort needed to produce heart failure symptoms
what is class I CHF?
comfortable at rest and NO limitation of ADLs
what is class II CHF?
comfortable at rest with SLIGHT limitation of ADLs
what is class III CHF?
comfortable at rest with MODERATE limitation of ADLs
what is class IV CHF?
Uncomfortable at rest with SEVERE limitation of ADLs (decompensation)
what is the most common form of heart failure?
dilated cardiomyopathy
Does dilated cardiomyopathy cause systolic or diastolic failure?
systolic
does hypertrophic cardiomyopathy cause systolic or diastolic failure?
diastolic
how may a compensated pts appear at rest?
comfortable
what commonly precedes dilated cardiomyopathy?
systemic hypertension
what kind of therapy is very effective in preventing the development of CHF?
anti-hypertensive therapy
What is a common cause of sudden cardiac death in young competitive athletes?
hypertrophic cardiomyopathy
what are some morphologic changes that occur in response to training?
increased left ventricular wall thickness, increased interventricular septal thickness, increased left ventricular end-diastolic dimension
after the first week of detraining, how much physiologic hypertrophy is lost?
up to 60%
within the first 3 weeks of detraining, how much does maximal cardiac output during exercise decrease?
8% (VO2 max decreases 8% also)
What is the most common cause of sudden cardiac death in athletes over 35?
CAD
what is the most common cause of sudden cardiac death in athletes under 35?
hypertrophic cardiomyopathy
What is S1?
closure of the mitral and tricuspid valves. Marks start of ventricular systole
What are the different names for mitral valve systolic murmurs?
mitral regurgitation, mitral imcompetence, systolic regurgitant murmurs, holosystolic murmurs
what are the two problems with acute mitral regurgitation?
dyspnea and decreased systemic perfusion
what is the key clinical feature for acute mitral regurgitation?
dyspnea
What usually occurs 10 years after acute MR is dxed?
90% of pts die or undergo surgical procedure
What does dilation of the left atrium imply?
chronic mitral regurgitation
what does rupture of a papillary msl imply?
acute mitral regurgitation
What has mitral regurgitation classically been associated with?
rheumatic heart dz
what is mitral valve prolapse?
an abnormal upward systolic displacement of the one or both mitral valve leaflets
what are the 3 categories of mitral valve prolapse?
- “click” 2. syndrome 3. “click-murmur”
is mitral valve prolapse syndrome more common in men or women?
women
what age range has a peak incidence of mitral valve prolapse syndrome?
30-40
Is leaflet approximation good or bad in mitral valve prolapse syndrome? Why?
good, the valve still closes and there is no murmur or regurgitation
How does mitral valve prolapse present in many pts?
benign and asymptomatic
Describe the regurgitation associated w/ MVP click-murmur?
some degree of regurgitation - valve does not fully close
What is the peak incidence for MVP click murmur?
45-60
is MVP click-murmur more common in males or females?
males
what are potential complications of mitral valve prolapse?
mitral valve regurgitation, infective endocarditis, cerebrovascular accidents
what causes congenital aortic stenosis?
small/unicuspid/bicuspid aortic valve (more susceptible to wear and tear)
with a congenital aortic stenosis, when do symptoms develop?
during growth spurts
what is the first problem with adult onset aortic valve stenosis?
left ventricular hypertrophy and diastolic failure
what is the eventual problem with adult onset aortic valve stenosis?
left ventricular dilation and overt heart failure
what are the 2 most important clinical features of adult onset aortic stenosis?
- late appearance of symptoms 2. dyspnea on exertion
What is S2?
closure of the aortic and pulmonic valves. End of ventricular systole
what does classic chronic aortic regurgitation lead to?
diastolic regurgitant murmur, increased stroke volume, combined hypertrophy and dilation of left ventricle
what is a common first symptom of chronic aortic regurgitation?
uncomfortable awareness of the heart beat
what is the key feature of classic mitral stenosis?
elevated left atrial pressure
what is mitral stenosis most often due to?
rheumatic fever
what is the first symptom of mitral stenosis?
dyspnea on exertion (almost all heart valve dzs)
When does S3 occur?
mid diastole during rapid passive ventricular filling
what is the abnormal variant of S3?
ventricular gallop (s1, s2, s3)
When does S4 occur?
late diastole during period of atrial contraction
What does S4 imply?
decreased ventricular compliance/remodeling
What is the abnormal variant of S4?
atrial gallop (s4, s1, s2)
when is a “soft” s4 common?
in pts with no overt signs of heart dz
