Midterm Flashcards
Angina Pectoris:
Discomfort induced by exertion and relieved with rest or nitroglycerin.
Due to ischemia of the heart or obstruction of coronary arteries.
Stable Angina:
Anginal symptomatology that occurs with the same degree of exertion and resolves with the same decree of rest and same dosage and strength of nitroglycerine
Unstable Angina:
Angina that occurs with more frequent occurrence of angina episodes, longer lived ones, or more easily proved not relieved by nitroglycerine
Prientz Metal/ Atypical
Angina at rest not relieved by Nitroglycerine
Acute Coronary Syndrome:
Symptoms that suggest high risk
*pressure/squeezing quality, pain similar to prior mi or angina, radiation to neck, shoulders, jaw or left arm, associated dyspnea and could have nausea and sweating
Most often due to endothelial injury and plaque formation and rupture
Acute Coronary Syndrome:
Pneumothroax:
Tension Pneumothorax: present when there is significant impairment of respiration and/or blood circulation.
Emergency!!
PE: Broncophony will be diminished and it will be hyper-resonant on percussion. Increased heart rate, rapid breathing and displacement of windpipe away from affected side
Acute Coronary Syndrome:
Aortic Dissection:
Unequal pulses, radiating pain to the back, new onset murmur
Acute Coronary Syndrome:
Pulmonary Embolism:
Consider in any patient who presents with chest pain that is pleuritic in nature or dyspnea that is not explained by: *Clinical evaluation
- Radiograph
- Electrocardiogram.
- JVD w/lungs clear to auscultation->Pulmonary embolism, Cardiac Tamponade, RCHF
- SX: Dyspnea, anxiety, pleuritic chest pain, cough, hemoptysis. Low pulse ox and arterial gasses
- Tests: CT pulmonary angiography, D-dimer testing & conventional pulmonary angiography.
- D-dimer also used with suspicion of Deep Vein Thrombosis, Pulmonary Embolism and intravascular coagulation
Acute Coronary Syndrome:
Cardiac Tamponade:
SX: Becks Triad= Low BP, JVD, Decreased Heart Sounds
*JVD w/lungs clear to auscultation->Cardiac Tamponade, RCHF, Pulmonary embolism
Occurs as a result of chest trauma, cancer, uremia, pericarditis or cardiac surgery
Acute Coronary Syndrome:
Aortic Aneurysm:
Any swelling of the aorta greater than 1.5 x normal, representing an underlying weakness in the wall of the aorta at that location.
Sx: pain radiating to the mid back, hoarse voice and left due to left recurrent laryngeal nerve being stretched *Matching of where pain goes
Acute Coronary Syndrome: Myocardial Infarction *Sx's *Blood Markers *Tx (MONA)/STEMI (LAD-Widow Maker)
Sx onset is usually gradual over minutes and chest pain is the mc sx. Sensation of tightness, squeezing, pressure.
Nitric Oxide is given to increase oxygen load to the heart and by dilating the vessels.
Blood Markers: creatinin Kinase –MB (CKMB) and Troponin
Troponin: late marker, rise at 3 hours . Carbon monoxide poisoning/ cyanide poisioning can also release troponin since it can damage the heart
Primary pulmonary hypertension/pulmonary embolism/obstructive pulmonary disease puts right ventricular strain on the heart leading to an increase in ischemia and tension, therefore increased troponin
Treatment: oxygen, aspirin and sublingual nitroglycerin but STEMI’s need reperfusion therapy,
MONA: morphine, oxygen, nitroglycerine, aspirin.
Clopidogrel: 600 mg for STEMI or 300 for non-STEMI. It is a platlet aggravation inhibitor that is given with aspirin as an additive effect.
Stemi use Percutaneous intervention, thrombolysis with IV alteplace, steptoinase or tenectoplace or CABG
Pneumonia:
Sx: Crackles (rales)
Chest pain but with fever, cough, and dyspnea
Chest Xray for CHF can look the same as pneumonia
Use (B-type Natriuretic Peptide) BNP lab test to check for CHF not Pneumonia
BNP is secreted from the ventricles or lower chambers of the heart in response to changes in pressure that occur when heart failure develops and worsens.
Clues that Suggest Gi Sources of Chest Pain
Pain persisting for more than one hour Typically occurs post-prandially (after meals) Lack of radiation of pain Associated with esophageal symptoms Relieved by antacid ingestion
Nitroglycerin relieving chest pain does not = angina always, you also want to think about esophageal spasms
GI Cocktail
Antacid with oral zylocaine or Benadryl or Tylenol (artificially sweetened so it tastes better)
Musculoskeletal chest wall pain
SX: diffuse pain with multiple areas of tenderness.
Upper costal cartilages are most frequently involved
Diagnosis is based on reproduction of pain with palpation
Tietze’s Syndrome:
painful, non-suppurative localized swelling of the costosternal sternoclavicular or costochondral joints most often involving the area of the second and third rib
Commonly post viral
What criteria are used to rule in an MI?
Signs and symptoms
Patients with typical myocardial infarction may have the following prodromal symptoms in the days preceding the event (although typical STEMI may occur suddenly, without warning):
(STEMI)=>Anterior ST elevation myocardial Infarction
Fatigue
Chest discomfort
Malaise
- Anterior STEMI results from occlusion of the left anterior descending artery (LAD).
- Anterior myocardial infarction carries the worst prognosis of all infarct locations, mostly due to larger infarct size.
S&sx’s used to rule in an MI!
Typical chest pain in acute M.I. has the following characteristics:
- Intense and unremitting for 30-60 minutes
- Retrosternal, often radiates to neck, shoulder, jaw & down to the ulnar aspect of the left arm
- Substernal pressure characterized as squeezing, aching, burning, or even sharp
- In some pt’s, the sx is epigastric, w/a feeling of indigestion or fullness & gas
S&sx’s used to rule in an MI!
Vital signs demonstrated in myocardial infarction:
- Inc. Hrt. rate
- Inc. Pulse
- Inc. BP (Rt ventricular M.I. or Sev. Lt ventricular dysfxn.=>hypotension is seen)
- Inc. Resp.
- Fever
- Coughing, wheezing, & frothy sputum
Hrt rate often increased 2nd to sympathoadrenal d/c
Pulse may be irregular bc of ventricular ectopy, an accelerated idioventricular rhythm, ventricular tachycardia, atrial fibrillation or flutter, or other supraventricular arrhythmias; bradyarrhythmias may be present
Pt’s blood pressure is initially elevated bc of peripheral arterial vasoconstriction resulting from an adrenergic response to pain and ventricular dysfunction
However, with right ventricular myocardial infarction or severe left ventricular dysfunction, hypotension is seen
Respiratory rate may be increased d/t pulmonary congestion or anxiety
Coughing, wheezing, and the production of frothy sputum may occur
Fever is usually present within 24-48 hours, with the temperature curve generally parallel to the time course of elevations of creatine kinase (CK) levels in the blood. Body temperature may occasionally exceed 102°F
Diagnosis
Laboratory tests used in the diagnosis of myocardial infarction include the following:
Do a BNP to differentiate from pneumonia.
- Troponin->only when myocardial necrosis occurs
(3-12Hrs->New Gold Standard) - Creatine kinase=> CK-MB levels increase w/in 3-12 hrs (Doesn’t exclude inc. of CK from skeletal Mm trauma)
- Urine myoglobin rises w/in 1-4 hrs chest pain onset.
Other labs: Complete blood count Chemistry profile Lipid profile C-reactive protein and other inflammation markers
Cardiac biomarkers/enzymes: The American College of Cardiology/American Heart Association (ACC/AHA) guidelines on unstable angina/NSTEMI (non–ST-segment elevation myocardial infarction) recommend that in patients with suspected myocardial infarction, cardiac biomarkers should be measured at presentation
Troponin levels: Troponin is a contractile protein that normally is not found in serum; it is released only when myocardial necrosis occurs
Creatine kinase (CK) levels: CK-MB levels increase within 3-12 hours of the onset of chest pain, reach peak values within 24 hours, and return to baseline after 48-72 hours
Myoglobin levels: Myoglobin is released more rapidly from infarcted myocardium than is troponin; urine myoglobin levels rise within 1-4 hours from the onset of chest pain
Diagnosis
Dx of M.I. include the following:
Confirms Dx in approximately 80% of cases.
Electrocardiography (ECG)
The ECG is the most important tool in the initial evaluation and triage of patients in whom an acute coronary syndrome (ACS), such as myocardial infarction, is suspected.
Diagnosis
Cardiac imaging to definitively diagnose or rule out coronary artery disease
Coronary angiogram:
It’s done to find out if your coronary arteries are blocked or narrowed, where and by how much.
For individuals with highly probable or confirmed ACS (acute coronary syndrome), a coronary angiogram can be used to definitively diagnose or rule out coronary artery disease.
Determine the location of a myocardial infarction based on which chest leads are abnormal.
Leads with ST elevation
- Anterior wall MI: V3/V4
- Lateral wall MI: I and avL
- Inferior wall MI: II, III, avF (bradycardia)
Go over MONA for MI
MONA: morphine, oxygen, nitroglycerine, aspirin.
Review Beck’s triad
Cardiac Tamponade:
Low Blood Pressure, Muffled Heart Sounds and JVD
The Wells Criteria is used for DVT: (scoring)
- Active cancer (treatment within last 6 months or palliative): +1 point
- Calf swelling ≥ 3cm compared to asymptomatic calf (measured 10cm below tibial tuberosity): +1 point
- Swollen unilateral superficial veins (non-varicose, in symptomatic leg): +1 point
- Unilateral pitting edema (in symptomatic leg): +1 point
- Previous documented DVT: +1 point
- Swelling of entire leg: +1 point
- Localized tenderness along the deep venous system: +1 point
- Paralysis, paresis or recent cast immobilization of lower extremities: +1 point
- Recently bedridden ≥ 3days, or major surgery requiring regional or general anesthetic in the past 12 weeks: +1 point
10. Alternative diagnosis at least as likely as a diagnosis of DVT: minus (-)2 points* (only minus)
The Wells Criteria is used for DVT Interpretation:
Probability
- High if greater than two (2)
- Moderate if one or two (1-2)
- Low if less than one (0)
Wells Pulmonary Embolism Scoring:
- (3 pts) Clinically suspected DVT: 3 points
- (3 pts) Alternative diagnosis is less likely than PE: 3.0 points
- (1.5 pts) Tachycardia (HR > 100): 1.5 points
- (1.5 pts) Immobilization (≥ 3d)/surgery in previous four weeks: 1.5 points
- (1.5 pts) History of DVT or PE: 1.5 points
- (1 pt) Hemoptysis: 1.0 points
- (1.pt) Malignancy (with treatment within 6 months) or palliative treatment: 1.0 points
Traditional interpretation of Well’s score for PE
- Score of > 6.0 = High probability of PE (probability 59% based on pooled data)
- Score of 2.0 to 6.0 = Moderate probability of PE (probability 29% based on pooled data])
- Score of
Alternative interpretation of Well’s score for PE
- Score > 4 = PE is likely. Consider diagnostic imaging.
* Score 4 or less = PE is unlikely. Consider D-dimer testing.
Salicylate Poisoning:
SX: tinnitus, abdominal discomfort, dizziness, nausea and hyperventilation, Vertigo, tachycardia, and hyperactivity.
Worsening:
As toxicity progresses, agitation, delirium, hallucinations, convulsions, lethargy, and stupor may occur.
Toxicity Tx include: activated charcoal, intravenous dextrose and normal saline, sodium bicarbonate, and dialysis.
Exam Findings of a Respiratory Emergency:
- Breath sounds
- JVD
- Crackles (rales)
- Inspiratory Stridor
- Expiratory Stridor
Absent or diminished breath sounds-> pneumothorax
JVD with lungs that are clear to auscultation->R CHF, Cardiac Tamponade, Pulmonary embolism
Crackles (rales):
A. “ADHF”->Acute decompensated heart failure,
B. “ARDS”->Adult respiratory distress syndrome
C. “Pneumonia”
D. “Pulmonary Edema” (crackling/wheezing->Acute Pulmonary Edema)
Inspiratory Stridor-> obstruction of air flow above the vocal cords->(Croup, bacterial tracheitis->Staph. aureus)
Expiratory Stridor-> Obstruction of air below the vocal cords: ->DDX: foreign body (may be inspiratory (most common), expiratory, or biphasic)
Resp. Emerg. DDX: COPD, CHF, Pneumonia, Asthma
Signs of worsening CHF:
“Crackling/wheezing”
Anxiety, restlessness, dyspnea, rapid labored breathing, cyanosis, blood tinged sputum, distended jugular veins, rapid pulse,cool clammy skin
JVD with lungs that are clear to auscultation-> RCHF, Cardiac Tamponade, Pulmonary embolism
Blood test for CHF VS Pneumonia
Brain Natriuretic peptide (BNP) secreted by the heart when there is large changes of blood pressure.
- Use (B-type Natriuretic Peptide) BNP lab test to check for CHF not Pneumonia.
- Chest Xray for CHF can look the same as pneumonia.
BNP is secreted from the ventricles or lower chambers of the heart in response to changes in pressure that occur when heart failure develops and worsens.
Acute Decompensated Heart Failure:
Do a BNP to differentiate from pneumonia.
- Sudden worsening of the S&Sx’s of heart failure, caused by severe congestion of multiple organs by fluid that is inadequately circulated by the failing heart.
- An attack of decompensation can be caused by underlying medical illness, such as myocardial infarction, infection, or thyroid disease.
Sx: Pulmonary edema, enlarged heart size, apivascular redistribution circle and bilateral pleural effusions, JVD, Pedal edema.
*Crackles (rales)
Acute decompensated heart failure,
Adult respiratory distress syndrome or
Pneumonia
