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Project - USMLE Step 3 > Symptom To Diagnosis - Dyspnea > Flashcards

Symptom To Diagnosis - Dyspnea Flashcards

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USMLE® Step 1 flashcards
1
Q

MCCs of dyspnea:

A
  1. Heart.
  2. Lung.
  3. Anemia.
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2
Q

3 tests that are mandatory in the initial evaluation of dyspnea:

A
  1. Chest radiograph.
  2. ECG.
  3. Ht.
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3
Q

Diagnostic approach of dyspnea - Cardiac etiologies - History:

A

Valvular heart disease –> Rheumatic heart disease.
Arrhythmia –> Palpitations.
HF –> CAD or risk factors, HTN, alcohol abuse, PND.
Acute coronary syndrome –> Chest pain, CAD risk factors.

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4
Q

Diagnostic approach of dyspnea - Cardiac etiologies - Physical findings:

A

Valvular heart disease –> Significant murmur.
Arrhythmia –> Irregular pulse.
HF –> S3, JVD, crackles on exam.
Acute coronary syndrome –> S3, JVD, crackles on exam.

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5
Q

Diagnostic approach to dyspnea - Cardiac etiologies - Tests:

A

Valvular heart disease –> Echo.
Arrhythmia –> ECG, holter, event monitor.
HF –> Chest radiography, BNP, echocardiography.
Acute coronary syndrome –> ECG, troponin, stress test, angiography.

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6
Q

Diagnostic approach of dyspnea - Pulmonary etiologies:

A
  1. COPD.
  2. Asthma.
  3. PE.
  4. Pneumonia (CAP, TB, PCP).
  5. ILD.
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7
Q

Pulmonary etiologies - History:

A

COPD –> >20pack years tobacco.
Asthma –> Cold +/- exercise –> Symptoms; + family history.
PE –> Sudden onset, pleuritic pain, cancer, surgery, immobilization, estrogen.
Pneumonia –> Fever, productive cough, high-risk sexual exposures, injection drug use.
ILD –> Known connective tissue disease, Raynaud, vocational, occupational exposure.

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8
Q

Pulmonary etiologies - Physical findings:

A 
COPD --> Decr. breath sounds, wheezing.
Asthma --> Wheezing.
PE --> Unilateral leg swelling.
Pneumonia --> Crackles, fever, thrush, Kaposi sarcoma, skin pop marks.
ILD --> Diffuse lung crackles.
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9
Q

Pulmonary etiologies - Tests:

A

COPD –> CXR, PFTs.
Asthma –> PFTs, bronchodilator response, methacholine induced.
PE –> D-dimer, CTA, V/Q scan, Leg duplex.
Pneumonia –> CXR, HIV, CD4 (when appropriate).
ILD –> PFTs, High res chest CT.

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10
Q

Anemia as a cause of dyspnea - History, physical findings, and tests:

A

History –> Menorrhagia, melena, rectal bleeding.
Physical findings –> Pale conjunctiva.
Echo –> Ht.

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11
Q

Mortality in patients with SHF and DHF?

A

Similar.

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12
Q

Progression of HF:

A
  1. Heart failure often triggers maladaptive neurohormonal changes including increased activation of the SNS and the RAA.
  2. These neurohormonal changes promote Na retention –> Incr. afterload –> Progressive HF.
  3. Therapies that interrupt these responses reduce mortality.
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13
Q

NYHA:

A

I –> Asymptomatic.
II –> Symptoms on ordinary exertion (climbing stairs).
III –> Symptoms with less than ordinary exertion (walking on flat surface).
IV –> Symptoms at rest.

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14
Q

4 STAGES OF HF - ACC/AHA:

A

A –> At risk for HF.
B –> Structural changes (LV hypertrophy or decr. EF) but no symptoms.
C –> Structural changes and symptoms.
D –> Structural changes and refractory symptoms despite therapy.

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15
Q

HF complication - Stroke and thromboembolism:

A

2-4% annual incidence.

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16
Q

Death in HF:

A

Symptomatic mild to moderate HF –> 20-30%/y.

Symptomatic severe HF –> Up to 50%/y.

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17
Q

HF - Mechanism of death:

A

Sudden in 50% - Secondary to V-tach or asystole.

Progressive in 50%.

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18
Q

Evidence-based diagnosis - History in HF:

A

Should assess risk factors:

  1. HTN.
  2. CAD.
  3. Alcohol.
  4. Illicit drug use.
  5. Adiamycin.
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19
Q

EBD - Physical exam - Clinical signs and symptoms may be affected by:

A
  1. Patient’s CURRENT volume status.

2. Chronicity –> CHRONIC HF is frequently asymptomatic.

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20
Q

EBD - S3 gallop:

A

Occurs when large volume of blood rushes from the LA into the LV at the start of diastole (just after S2).

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21
Q

EBD - S3 - Is it an important finding?

A

Virtually PATHOGNOMONIC of volume overload and occurs most commonly in patients with decompensated HF.

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22
Q

EBD - S4 gallop:

A

Occurs when the LA contracts and sends blood into the LV (just before S1).

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23
Q

EBD - S4 importance:

A

An S4 gallop may be heard in some normal patients and in many patients with HTN and LV hypertrophy.
–> NOT SPECIFIC FOR HF.

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24
Q

EBD - JVD:

A

> 3cm of elevation above the sternal angle.

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25
Q

EBD - JVD importance:

A

Highly specific for HF (>95%) –> May occur in RV or LV failure.

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26
Q

Importance of classic signs/symptoms (orthopnea, PND, crackles, gallops, and edema) in the diagnosis of HF:

A

NOT SENSITIVE - Their absence does NOT RULE OUT HF.

Even in severe CHRONIC HF –> 42% of patients did NOT have crackles, increased JVP, or edema.

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27
Q

Most sensitive CXR finding in HF?

A

Cardiomegaly in CXR –> 74%. Its absence decreases the likelihood of HF (LR- 0.33).

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28
Q

Most specific CXR findings for HF:

A

Pulm. venous congestion and interstitial+alveolar edema –> 96-97%. When present, strongly suggest HF (LR+12).

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29
Q

Pleural effusions are seen in …% of patients with HF.

A

26%.

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30
Q

When is BNP secreted?

A

FROM LV/RV –> In response to increased volume or pressure or both.

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31
Q

BNP

A

Sens: 87-93%.
Spec: 66-72%.
LR+ 2.7-3.1.
LR- 0.11-0.12.

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32
Q

BNP

A

Sens: 35%.
Spec: 90%.
LR+2.6.
LR-0.05.

33
Q

BNP in COPD patients:

A 
May not rule out HF in patients with coexistent COPD:
Sens: 35%.
Spec: 90%.
LR+ 3.5.
LR- 0.72.
34
Q

BNP>250:

A

Sens: 89%.
Spec: 81%.
LR+ 4.6.
LR- 0.14.

35
Q

BNP and PE?

A

BNP is elevated due to RV dilatation:
34% –> BNP=88-487.
33% –> BNP=527-1300.

36
Q

Some authorities use the following criteria to interpret BNP levels:

A

HF unlikely.
100-500 –> Indeterminate.
>500 –> LR+ 6 –> HF most likely diagnosis.

37
Q

Test of choice to diagnose HF:

A

2D echo.

38
Q

HF is frequently present but UNSUSPECTED in patients in whom COPD is diagnosed:

A

Studies report unsuspected HF in 25% of patients with COPD.

–> Fewer years of tobacco use than patients without HF (9.6 vs 22.7).

39
Q

MR - Textbook presentation:

A

Patients with MR may be identified due to an asymptomatic holosystolic murmur at the apex or during an evaluation of:
1. Shortness of breath.
2. Dyspnea on exertion.
3. Orthopnea.
4. Fatigue.
Alternatively –> During evaluation of patients with AF.

40
Q

MR diagnosis - Average delay from diagnosis to symptoms is …?

A

16y.

41
Q

In patients with severe MR, annual mortality is?

A

5%.

42
Q

EBD of MR - Physical exam - Grade 3 or louder systolic murmur:

A

Sens: 85%.
Spec: 81%.
LR+ 4.5.
LR- 0.19.

43
Q

EBD - S3 gallop in MR?

A

May be heard due to increased flow across the mitral valve.

44
Q

EBD of MR - Role of ECG and chest radiograph:

A

May demonstrate LA or LV enlargement –> NEITHER is sensitive/specific for the diagnosis.

45
Q

EBD of MR - Test of choice?

A

Echo –> Diagnosis + Quantification of MR.

Transesophageal echo –> More details.

46
Q

Chronic AR - Textbook presentation:

A

Typically complain of progressive dyspnea on exertion or the sensation of a pounding heart.
Alternatively, may be asymptomatic, and the diagnosis may be suspected when an EARLY DIASTOLIC murmur is detected by a careful examiner.

47
Q

Chronic AR - Progression to symptoms or LV dysfunction in patients with normal LV function develops in …% of patients per year.

A

4%.

48
Q

EBD of chronic AR - Why is the pulse pressure wide?

A

2 processes:

  1. Large SV increases the SBP.
  2. Regurgitation of blood back into the LV rapidly lowers the DBP.
49
Q

EBD - Are wide pulse pressures specific for chronic AR?

A

NOT SPECIFIC.

  1. Anemia.
  2. Fever.
  3. Pregnancy.
  4. Large AV fistulas.
  5. Cirrhosis.
  6. Thyrotoxicosis.
  7. PDA.
50
Q

EBD of chronic AR - Auscultation:

A

May demonstrate an EARLY decrescendo DIASTOLIC murmur following S2. Best heard at the left sternal border.

51
Q

EBD in chronic AR - Auscultation sens/spec?

A
  1. More sensitive for moderate to severe AR.
  2. 0-64% sens among students and residents.
  3. 80-95% sens among experienced cardiologists.
52
Q

EBD in chronic AR - Importance of diastolic murmur finding?

A

Highly specific –> 98%.

53
Q

EBD in chronic AR - Systolic murmur?

A

A systolic murmur suggesting AS may be heard.
–> Regurgitation results in increasing end diastolic volumes –> Stroke volumes increase to maintain forward flow –> Incr. CO may exceed the capacity of even a normal AV to accommodate flow –> High flow systolic murmur across the aortic valve.

54
Q

EBD in chronic AR - One study reported that …% of patients with mild to moderate AR had a SYSTOLIC murmur (…% in moderate AR and …% in mild AR).

A

51%.

86%, 50%.

55
Q

Bottom line about murmurs in chronic AR:

A

Although a diastolic murmur strongly suggests AR, systolic murmurs are often the only murmur heard in patients with AR.

56
Q

EBD in chronic AR - Austin Flint murmur:

A
  1. Aortic regurgitant streams may impact the MV leaflets during diastole resulting in functional mitral stenosis and a late diastolic murmur over the apex.
  2. Sensitivity varies from 0-100%.
57
Q

EBD in chronic AR - Test of choice:

A

Doppler echo.

58
Q

AF - Textbook presentation:

A

Classically –> Palpitations.
Abrupt onset often prompts patients to be seen emergently. Patients may also complain of shortness of breath and dyspnea on exertion.
Occasionally, AF is detected during a routine office visit when an irregularly irregular pulse is noted and evaluated.

59
Q

MC clinical arrhythmia:

A

AF –> Incidence increases with AGE: 3.8% of patients >60yr to 9% in those >80yr.

60
Q

AF - MC etiologies:

A
  1. HTN.
  2. CAD.
  3. HF.
61
Q

Annual stroke rate in AF patients not receiving anticoagulation is …%.

A

4.3%.

62
Q

AF accounts for … of all strokes at an annual cost of … billion.

A

1/6.

6.6.

63
Q

Stroke is more common in patients with AF who have other clinical risk factors:

A
  1. Valvular heart disease.
  2. Prior transient ischemic attack or stroke.
  3. Increasing age.
  4. HTN
  5. DM.
  6. HF.
  7. Gender (women 1.5-3x more than men).
64
Q

AF - Worsen HF?

A

AF –> Loss of atrial kick –> Especially important in patients with stiff LV (ie diastolic dysfunction).

65
Q

EBD about AF:

A
  1. Easily recognized on ECG.

2. Episodic AF can be detected with Holter or event recorders.

66
Q

…% of patients with PE have DVT.

A

80%.

67
Q

…% of patients with DVT have PE (often asymptomatic).

A

48%.

68
Q

PE - 3-month mortality is …%.

A

17.5%.

69
Q

MC thrombophilia?

A

Factor V Leiden - 11% of patients with DVT.

70
Q

EBD - Classic presentation of PE:

A

20-33% –> Chest pain with dyspnea or chest pain, dyspnea, and hemoptysis.
12-25% –> Isolated dyspnea.
80% –> Have risk factors.

71
Q

EBD of PE - Tachypnea has been reported in …-…% of patients and an accentuated P2 in …-…%.

A

54-85%.

15-57%.

72
Q

EBD of PE - One study reported that …% of patients with an unexplained exacerbation of COPD actually had a PE.

A

25%.

73
Q

Bottom line about EBD of PE:

A

The classic presentation of PE is actually the exception. Patients may have very few symptoms.
A high index of suspicion must be maintained for the diagnosis of PE.

74
Q

EBD of PE - CXR:

A
  1. Normal in 50% of patients with PE.

2. Focal oligemia (45%), wedge-shaped infiltrate (15%), or pleural effusions (45%).

75
Q

EBD of PE - ABG:

A

May demonstrate hypoxemia and hypocarbia, but findings are neither sensitive nor specific for PE.
PaO2

76
Q

EBD of PE - Bottom line about ABG:

A

Patients with PE may NOT be hypoxic.

Therefore normal arterial O2 does NOT rule out PE.

77
Q

EBD of PE - Troponin?

A

Elevated in up to 57% of patients with documented PE.

78
Q

Diagnostic approach of dyspnea - Cardiac etiologies - Diagnostic hypothesis:

A
  1. Valvular heart disease.
  2. Arrhythmia.
  3. HF.
  4. Acute coronary syndrome.

Project - USMLE Step 3 (82 decks)

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