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Family Medicine > FM Cardiovascular Review > Flashcards

FM Cardiovascular Review Flashcards

1
Q

HTN

A
  • two different reading & two separate visits
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2
Q

Primary HTN

A
  • 95% are idiopathic
  • Between ages of 25-55 years old
  • often family history
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3
Q

Seconadry HTN

A
  • Often related to correctable underlying cause
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4
Q

Renal stenosis

A
  • renal stenosis lead to hypertension ( body think it is going through hypotension thus activates RAS system)
  • suspected when:
    1. HTN onset younger than 20 years or older than 50
    2. Severe HTN
    3. Resistance to 3 anti-hypertensive drugs

Underlying cause:
- atherosclerosis in elderly
- fibromuscular dysplasia in females

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5
Q

Other causes of secondary HTN

A
  1. Hyperaldosteronism
  2. Pheochromocytoma
  3. Cushing syndrome
  4. Coarctation of the aorta
  5. Obstructive sleep apnea
  6. ETOH
  7. Oral contraceptive
  8. Cox-2 inhibitors (NSAIDs)
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6
Q

Complication of HTN

A
  1. Coronary artery disease
  2. Heart failure
  3. Heart attach or MI
  4. Aortic dissection
  5. Stroke
  6. Ruptured aneurysm
  7. Renal disease
  8. Retinal hemorrhage
  9. Blindness

Note:
- papilloedema in fundoycopic exam —> is indicative of advanced stage of malignant HTN

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7
Q

Treatment of HTN

A
  1. Diuretics: (decrease Blood Volume, thus pressure by excreting more Na & H2O)
    - thiazide (hydrochlorothiazide & chlorthalidone) —> initial therapy in uncomplicated HTN
    - loop (furosemide)
    - potassium-sparing
  2. ACE-i/ARBs
  3. Dihydropyridine CCB
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8
Q

Strict vegan diet (avoid all animal-derived product)

A

Expected deficiency in:

  1. vitamin B 12 (cobalamin)
    - lead to megaloblastic anemia or subacute combined degeneration
  2. vitamin D
    - lead to osteomalacia or osteoporosis
  3. Calcium, iron, zinc
    - need to be supplemented in children & menstruating women
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9
Q

Types of ulcerative colitis (Proctitis, left-sided colitis, pancolitis, acute severe UC)

( diarrhea with blood/pus +pain/cramp + fever + N/V + dehydration + anemia )

A

Proctitis:
- inflammation of the 12 cm of rectum
- only bleeding

Left -sided colitis
- inflammation of the left side of the colon (rectum, sigmoid, transverse, descending colon)
- bloody diarrhea + cramp + weight loss

Pancolitis
- inflammation of the entire colon

Acute severe UC:
- Is Fulminant colitis
- more than 10 bowel motion per day
- continuous bleeding + pain + fever + anorexia
- high risk for: toxic megacolon + bowel perforation

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10
Q

Management of food protein-induced allergic proctocolitis (FPIAP)

(Symptoms: loose stool + presence of mucus in stool + infants < 6 months) (blood-streaked, mucoid stool in early infancy)

(Suspected in well-appearing infant with painless, bloody stool)

A

Infant with presumed FPIAP

  1. Breastfeeding
    - eliminate common trigger from maternal diet ( diary, soy)
  2. Formula-feeding
    - switch to hypoallergenic (hydrolyzed) formula
    - switch to amino-acid based (elemental) formula —> to prevent persistence bleeding
  • does symptoms resolve ?
  1. Yes: FPIAP confirmed, reintroduce offending protein around age 1
  2. No: consider evaluation of alternative diagnosis ( via flexible sigmoidoscopy)
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11
Q

GI problem in children and diagnosis

A
  1. Meckel diverticulum:
    - perform meckel scan
    - intestinal obstruction: ill-appearing child (> 6 months) + vomiting + abdominal distention
  2. Intussusception:
    - perform air contrast enema
    - present at age 6-36 months + intermittent/colicky abdominal pain + irritability + vomiting + current jelly stool
  3. Intestinal obstruction (malrotation with midgut volvulus or necrotizing enterocolitis) :
    - perform abdominal x-ray
    - ill-appearing child + hematochezia + abdominal distention
  4. Infectious gastroenteritis
    - perform stool culture
    - bloody diarrhea + fever + vomiting
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12
Q

Celiac disease
( deficiency in: protein, fat, iron, D, K, A)

A

Present with:

  1. Abdominal pain + distention + bloating + diarrhea ( bulky, foul smelling, floating)
  2. Fatigue and weight loss due to Iron-deficiency anemia
  3. Arthritis, osteomalacia/rickets due to vitamin D deficiency
  4. Dermatitis herpetiform rash (intense itchy; on extensor surface knee/elbow)
  5. Failure to thrive (low percentile)

Diagnosis:
1. Elevated tissue transglutaminase IgA antibody
2. Elevated IGA anti-endomysial
2. Proximal intestinal biopsy (villous atrophy, crypt hyperplasia, intraepithelial lymphocytosis)
3. Endoscopy to proximal small intestine changes

Treatment:
1. Gluten-free diet
2. Dapsone for dermatitis herpetiformis

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13
Q

Streptococcal pharyngitis infection

A

Symptoms:
1. Painful + non itchy nodule on the shin ( erythema nodosum)
2. Positive antistreptolysin O antibodies

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14
Q

Systemic lupus erythematous (SLE)

A

Symptoms:
1. Fatigue + weight loss + photosensitivity + malar rash
2. Normocytic anemia due to chronic disease
3. Positive antinuclear antibody

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15
Q

Lactose intolerance
(Due to lactase deficiency)

A

Precipitated by:
1. Primary: lactase deficiency
2. Secondary: Inflammatory disorders affecting brush border: infectious gastroenteritis, celiac disease, crohn disease

Symptoms:
1. Postprandial Abdominal pain + bloating + watery diarrhea

Diagnosis:
1. Resolution of symptoms on diary-restricted diet
2. Lactose breath hydrogen test

Management:
1. Dietary restriction of lactose
2. Lactase replacement if diary ingested

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16
Q

Carbohydrate (lactose) malabsorption due to secondary lactase deficiency

A
  • patient present with worsening watery diarrhea when introduced to whole milk, after few days from resolution of infectious gastroenteritis symptoms ( fever + vomiting + diarrhea)

Management:
- no intervention
- symptoms resolves within weeks as the intestinal mucosa heals

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17
Q

Functional constipation in infants

A
  • usually presents after introduction of solid food ( low fiber + decreased fluids)
  • no alarm signs ( poor growth, severe abdominal distention)
  • treatment: nondigestible osmotically active carbohydrates ( fruit juice/puree)
18
Q

Infant constipation

A

Pathologic causes:

  1. Risk factor:
    - down syndrome
    - abnormal physical finding ( displaced anus, tuft at gluteal cleft)
  2. Clinical feature:
    - delayed passage of meconium
    - fever + vomiting
    - ribbon (narrow) stools
    - poor growth
    - severe abdominal distention
  3. Management:
    - workup for serious organic cause
    - Hirschsprung disease ( barium enema)
    - cystic fibrosis ( sweat chloride test)
    - spinal dysraphism ( MRI)

Functional:
1. Risk factor:
- introduction of solid food
- decrease water intake
- decrease fiber diet

  1. Clinical:
    - infrequent defecation
    - hard + painful stool
    - large-caliber or pellet-like stool
    ± anal fissure
  2. Management:
    - add undigestible osmotically active carbohydrate ( prune or apple juice/puree)
19
Q

Water-soluble vitamin

A

B1 (Thiamine)

  1. Beriberi (peripheral neuropathy, heart failure)
  2. Wernicke-korsakoff syndrome ( ataxia + confusion+ opthalamoplagia)

B2 ( riboflavin)
- angular cheilosis + stomatitis + glossitis
- normocytic anemia
- seborrheic dermatitis

B3 (niacin)
-pellagra ( dermatitis, diarrhea, delusion/delirium, glossitis)

B6 (Pyridoxine)
- cheilosis, somatitis, glossitis
- irritability, confusion, depression

B9 (folate)
- megaloblastic anemia
- neural tube defect (fetus)

B12 (cobalamin)
- megaloblastic anemia
- neurologic symptoms ( ataxia + confusion paresthesia)

C (ascorbic acid)
- scurvy ( punctate hemorrhage, gingivitis, corkscrew hair, easily bruising & poor wound healing)

20
Q

Zenker diverticulum (false diverticulum)

A

Symptoms:
1. Progressive Dysphagia + regurgitation of undigested food + bad mouth breath + changes in voice
2. Halitosis (retained food within diverticulum) + gurgling sound
3. Age > 60
4. Can lead to aspiration pneumonia due to regurgitated food
5. Caused by motor dysfunction (of cricopharyngeus muscle) during swallowing

Diagnosis:
- contrast swallow study

Treatment:
- surgical ( cricopharyngeal myotomy or diverticulectomy or diverticulotomy)

21
Q

Metabolic abnormalities such as iron-deficiency anemia

A
  • lead to esophageal web (plummer-vinson syndrome) that causes insidious onset of dysphagia
22
Q

Chest pain work up

A
  1. ECG
  2. Chest x-ray
  3. Laboratory ( cardiac enzymes, D-dimer, BNP, CBC, CMP)
  4. Chest CT
  5. Upper endoscopy
23
Q

Diffused esophageal spasm

(episodes of dysphagia, regurgitation, &/or chest pain precipitated by emotional stress, cold, or hot food)

(Resolves with nitrates, diagnosed with esophageal manometry)

A

Symptoms:
- spontaneous pain
- odynophagia for cold & hot food & emotional stress
- resolution of chest pain with nitroglycerin (or CCB)

Diagnosis:
- esophageal motility studies (manometric reading) —> shows repetitive, nonperstaltic, high-amplitude contraction either spontaneous or after ergonovine stimulation

Note:
- nitrates can relax myocytes in coronary vessels & smooth muscle of esophageal

24
Q

Management of GERD

A
  • Alarm feature:
    1. Dysphagia/odynophagia
    2. Iron deficiency anemia
    3. GI bleed
    4. Unexplained weight loss
    5. Persistent vomiting
    6. Family history of GI cancer

**Barrett esophagus risk factors:
1. Age > 50
2. Male sex
3. Smoking history
4. GERD > 5 years
5. Obesity
6. Family history
7. White ethnicity
8. Hiatal hernia

Protocol:

  1. GERD symptoms ( substernal burning + regurgitation)
  2. Presence of alarm feature* or barrett esophagus risk factor **
    - yes: perform upper GI endoscopy
  • No: symptoms severity
    1. Mild < 2 time/week —> antacids ( calcium carbonate) or H2 receptor antagonist + lifestyle changes
    2. Severe > 2 times/week —> PPI + lifestyle changes
25
Q

Upper GI endoscopy can assess with GERD complication

A
  1. Esophageal adenocarcinoma
    - (results from barrett esophagus)
    - associated with alarm symptoms: dysphagia + weight loss + positive family history
  2. Esophageal stricture
    - present with dysphagia (mainly for solid, not liquid) + no weight loss
  3. Esophageal ulcer
    - present with odynophagia + iron deficiency anemia

Note:
- GERD is only substernal burning + regurgitation, but if other alarm feature presents —> need to perform upper GI endoscopy to rule GERD complication

26
Q

Diagnose esophageal disorder

A

Esophageal monometry
- diagnosis of achalasia ( regurgitation + impaired peristalsis + dysphagia to liquid & fluid)

Esophageal pH monitoring:
- diagnosis of refractory GERD (does not respond to PPI or antacid)

27
Q

Peptic ulcer disease (PUD)

A
  • epigastric discomfort + melena (dark stool)
  • ulceration of stomach or duodenum caused by H.pylori or NSAID use

Symptoms:
1. Epigastric pain + Nausea + early satiety
2. Stomach ulcer: worse with food
3. Duodenal ulcer: better with food

Diagnosis:
1. Upper GI endoscopy

28
Q

Irritable bowel syndrome (IBS)

A
  • recurrent abdominal pain/discomfort > 1 day per week for past 3 months & > 2 of the following :
    1. Improves or get worse with delectation
    2. Change in stool frequency
    3. Change in stool form (constipation/diarrhea)

Note:
- IBS can be exacerbated by pregnancy
- pregnant women with dilutional (normocytic) anemia do not require colonoscopy

29
Q

Secondary causes of constipation

A

In Down syndrome evaluate causes for hypothyroidism, diabetes, hypercalcemia

30
Q

Proctalgia fugax

A

Caused by:
1. Spastic contraction of anal sphincter
2. Pudendal nerve compression

Risk factor:
1. IBS
2. Stress, anxiety

Clinical:
1. Rectal pain not related to defecation
2. Lasting seconds to minutes (< 30 min)
3. No pain between episode

Evaluation: (diagnosis of exclusion)
1. Normal physical examination (digital rectal, prostate, pelvic)
2. No laboratory abnormalities

Management:
1. Reassurance
2. Nitroglycerin cream ± biofeedback therapy for refractory symptoms

31
Q

Approach to straining infant ( constipation? )

A

Straining in infants

  1. Ill-appearing or red flag signs*
    - hirschsrung disease (abdominal distention + increase rectal tone + delayed passage of meconium)
    - cystic fibrosis
    - spinal dysraphism
    - hypothyroidism (delayed meconium + enlarged fontanelle + protrude tongue + constipation + prolonged jaundice + dry skin + hypotonia + poor feeding & growth)
  2. Well-appearing
  • loos stool ± mucus/blood —> food induced protein enterocolitis
  • normal stool —> infant dyschezia ( resolves spontanously after age of 9 month)
  • hard or pellet-like stool —> functional constipation (± anal fissure if blood presents) —> treat with lactulose

Note:
1. Red flag signs:
- severe abdominal distention
- abnormal rectal tone
- sacral finding
- delayed passage of meconium
- failure to thrive

32
Q

IgE & non-IgE mediated food allergies

A

IgE mediated
1. Anaphylaxis
- any age
- immediate (<1 hr) symptoms: urticaria + vomiting + wheezing + angioedema + hypotension

Non IgE- mediated:
1. Food protein-induced allergic proctocolitis (to cow mil or soy)
- less than 6 months
- insidious symptoms: painless, bloody stool + well-appearing

  1. Food protein-induced enterocolitis syndrome
    - less than 12 months
    - within hours symptoms: profused vomiting + diarrhea (±blood) + dehydration + lethargy + ill-appearing
33
Q

Anorectal fistula

A
  • caused by rupture of perianal abscess with formation of a persistence sinus tract
  • symptoms: pain with defecation + chronic discharge (foul-smelling) + pruritus
  • management requires surgical intervention
34
Q

Pediatric constipation

A
35
Q

Gonococcal proctitis

A
  • occurs in adolescence or young adult practicing unprotected sex
  • rectal infection occurs via receptive of anal intercourse or spread from vagina
  • symptoms: tenesmus, constipation, rectal pain, itchy, mucopurulent discharge, bleeding.
  • treatment: ceftriaxone + doxycycline (to cover chalamydia)
36
Q

Giardiasis
(Transmitted fecal-oral & spread from person to person)

A
  • disruption of the epithelium tight junction & leading to symptoms of malabsorption
  • signs: weight loss + profused, oily, nonbloody diarrhea after a recent lake vacation
  • treatment:
    1. Tinidazole or nitazoxanide
    2. Pregnant (1st trimester): paromomycin
    3. Refractory/recurrent: evaluation for immunodeficient
37
Q

Hepatitis B status (serological markers)

A

HBsAg:
Anti-HBs
Anti-HBc
HBeAg
Anti-HBe

Note:
1. Immune due to natural HBV infection (resolved hepatitis B infection): positive anti-HBs & positive IgG anti-HBc & negative HBsAg
2. Vaccinated for HBV: positive anti-HBs
3. Acute hepatitis B infection: positive HBsAg & positive IgM anti-HBc
4. Chronic hepatitis B infection: positive HBsAg in serum for > 6 months
5. Recovery phase of hepatitis B: positive anti-HBs & positive IgG anti-HBc & positive anti-HBe

38
Q

Risk factors vs. protective factors in colon cancer

A
  1. Protective factors:
    - aspirin or NSAIDS use
    - high-fiber diet
  2. Risk factor:
    - red meat
    - smoking
    - family history of colon cancer (early screening)
    - diabetes
    - obesity
    - ulcerative colitis (early screening)
    - prior abdominal radiation (4 times, early screening)

Note:
- exposure to abdominal radiation in childhood ( to treat lymphoma, wilms tumor, neuroblastoma, sarcoma) —> significantly increase risk for colon adenocarcinoma
- this warrant colon cancer screening at age (30-40) earlier than what is typically recommended
- screening via:
1. Colonoscopy
2. Fecal occult blood test
3. Fecal DNA test

  • childhood cancer survivor treated with abdominal radiation are at increased risk for developing colorectal adenocarcinoma
39
Q

Gilbert syndrome
( shows signs of liver disease with no

A
  • most common disorder of bilirubin metabolism
  • decrease hepatic UDP enzyme activity —> decrease conjugation of bilirubin

Symptoms:
1. Recurrent episodes of mild jaundice (yellow eyes)
2. Provoked by stress ( febrile illness, fasting, dehydration, exercise, menstruation, surgery)

Diagnosis:
- increased unconjugated bilirubin
- normal CBC, Blood smear, reticulocyte count
- normal ALT, AST, alkaline phosphatase

Treatment:
- benign, no treatment required

Note:
- a patient can have yellow eyes & increased unconjugated bilirubin after upper respiratory tract infection

40
Q

Other causes of liver disease:

A
  1. Alcohol-mediated hepatitis
  2. Infection-mediated hepatitis
  3. Vir

Family Medicine (5 decks)

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