FM Cardiovascular Review Flashcards
HTN
- two different reading & two separate visits
Primary HTN
- 95% are idiopathic
- Between ages of 25-55 years old
- often family history
Seconadry HTN
- Often related to correctable underlying cause
Renal stenosis
- 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
Other causes of secondary HTN
- Hyperaldosteronism
- Pheochromocytoma
- Cushing syndrome
- Coarctation of the aorta
- Obstructive sleep apnea
- ETOH
- Oral contraceptive
- Cox-2 inhibitors (NSAIDs)
Complication of HTN
- Coronary artery disease
- Heart failure
- Heart attach or MI
- Aortic dissection
- Stroke
- Ruptured aneurysm
- Renal disease
- Retinal hemorrhage
- Blindness
Note:
- papilloedema in fundoycopic exam —> is indicative of advanced stage of malignant HTN
Treatment of HTN
- Diuretics: (decrease Blood Volume, thus pressure by excreting more Na & H2O)
- thiazide (hydrochlorothiazide & chlorthalidone) —> initial therapy in uncomplicated HTN
- loop (furosemide)
- potassium-sparing - ACE-i/ARBs
- Dihydropyridine CCB
Strict vegan diet (avoid all animal-derived product)
Expected deficiency in:
- vitamin B 12 (cobalamin)
- lead to megaloblastic anemia or subacute combined degeneration - vitamin D
- lead to osteomalacia or osteoporosis - Calcium, iron, zinc
- need to be supplemented in children & menstruating women
Types of ulcerative colitis (Proctitis, left-sided colitis, pancolitis, acute severe UC)
( diarrhea with blood/pus +pain/cramp + fever + N/V + dehydration + anemia )
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
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)
Infant with presumed FPIAP
- Breastfeeding
- eliminate common trigger from maternal diet ( diary, soy) - Formula-feeding
- switch to hypoallergenic (hydrolyzed) formula
- switch to amino-acid based (elemental) formula —> to prevent persistence bleeding
- does symptoms resolve ?
- Yes: FPIAP confirmed, reintroduce offending protein around age 1
- No: consider evaluation of alternative diagnosis ( via flexible sigmoidoscopy)
GI problem in children and diagnosis
- Meckel diverticulum:
- perform meckel scan
- intestinal obstruction: ill-appearing child (> 6 months) + vomiting + abdominal distention - Intussusception:
- perform air contrast enema
- present at age 6-36 months + intermittent/colicky abdominal pain + irritability + vomiting + current jelly stool - Intestinal obstruction (malrotation with midgut volvulus or necrotizing enterocolitis) :
- perform abdominal x-ray
- ill-appearing child + hematochezia + abdominal distention - Infectious gastroenteritis
- perform stool culture
- bloody diarrhea + fever + vomiting
Celiac disease
( deficiency in: protein, fat, iron, D, K, A)
Present with:
- Abdominal pain + distention + bloating + diarrhea ( bulky, foul smelling, floating)
- Fatigue and weight loss due to Iron-deficiency anemia
- Arthritis, osteomalacia/rickets due to vitamin D deficiency
- Dermatitis herpetiform rash (intense itchy; on extensor surface knee/elbow)
- 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
Streptococcal pharyngitis infection
Symptoms:
1. Painful + non itchy nodule on the shin ( erythema nodosum)
2. Positive antistreptolysin O antibodies
Systemic lupus erythematous (SLE)
Symptoms:
1. Fatigue + weight loss + photosensitivity + malar rash
2. Normocytic anemia due to chronic disease
3. Positive antinuclear antibody
Lactose intolerance
(Due to lactase deficiency)
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
Carbohydrate (lactose) malabsorption due to secondary lactase deficiency
- 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
Functional constipation in infants
- 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)
Infant constipation
Pathologic causes:
- Risk factor:
- down syndrome
- abnormal physical finding ( displaced anus, tuft at gluteal cleft) - Clinical feature:
- delayed passage of meconium
- fever + vomiting
- ribbon (narrow) stools
- poor growth
- severe abdominal distention - 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
- Clinical:
- infrequent defecation
- hard + painful stool
- large-caliber or pellet-like stool
± anal fissure - Management:
- add undigestible osmotically active carbohydrate ( prune or apple juice/puree)
Water-soluble vitamin
B1 (Thiamine)
- Beriberi (peripheral neuropathy, heart failure)
- 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)
Zenker diverticulum (false diverticulum)
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)
Metabolic abnormalities such as iron-deficiency anemia
- lead to esophageal web (plummer-vinson syndrome) that causes insidious onset of dysphagia
Chest pain work up
- ECG
- Chest x-ray
- Laboratory ( cardiac enzymes, D-dimer, BNP, CBC, CMP)
- Chest CT
- Upper endoscopy
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)
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
Management of GERD
- 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:
- GERD symptoms ( substernal burning + regurgitation)
- Presence of alarm feature* or barrett esophagus risk factor **
- yes: perform upper GI endoscopy
- No: symptoms severity
- Mild < 2 time/week —> antacids ( calcium carbonate) or H2 receptor antagonist + lifestyle changes
- Severe > 2 times/week —> PPI + lifestyle changes
Upper GI endoscopy can assess with GERD complication
- Esophageal adenocarcinoma
- (results from barrett esophagus)
- associated with alarm symptoms: dysphagia + weight loss + positive family history - Esophageal stricture
- present with dysphagia (mainly for solid, not liquid) + no weight loss - 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
Diagnose esophageal disorder
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)
Peptic ulcer disease (PUD)
- 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
Irritable bowel syndrome (IBS)
- 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
Secondary causes of constipation
In Down syndrome evaluate causes for hypothyroidism, diabetes, hypercalcemia
Proctalgia fugax
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
Approach to straining infant ( constipation? )
Straining in infants
- 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) - 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
IgE & non-IgE mediated food allergies
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
- Food protein-induced enterocolitis syndrome
- less than 12 months
- within hours symptoms: profused vomiting + diarrhea (±blood) + dehydration + lethargy + ill-appearing
Anorectal fistula
- 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
Pediatric constipation
Gonococcal proctitis
- 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)
Giardiasis
(Transmitted fecal-oral & spread from person to person)
- 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
Hepatitis B status (serological markers)
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
Risk factors vs. protective factors in colon cancer
- Protective factors:
- aspirin or NSAIDS use
- high-fiber diet - 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
Gilbert syndrome
( shows signs of liver disease with no
- 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
Other causes of liver disease:
- Alcohol-mediated hepatitis
- Infection-mediated hepatitis
- Vir
