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Clinical Medicine > Test 1 > Flashcards

Test 1 Flashcards

1
Q

EOD Occlusive aorta & iliac arteries

A
  1. Claudication in calf, thigh or hip
  2. Diminished femoral pulses
  3. Tissue loss (ulceration, gangrene) or rest pain
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2
Q

EOD superficial & common femoral & popliteal arteries

A
  1. Cramping pain or tiredness in calf w/ exercise
  2. Reduced popliteal or pedal pulses
  3. Foot pain at rest, relieved by dependency
  4. Foot gangrene/ulceration
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3
Q

EOD lower leg & foot arterial occlusion

A
  1. Severe pain of the forefoot relieved by dependency
  2. Pain/numbness of the foot w/ walking
  3. Ulceration or gangrene of the foot or toes
  4. Pallor when the foot is elevated
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4
Q

What is the most common cause of cardiac thrombus formation?

A

Afib

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5
Q

In acute arterial occlusion of a limb, what should you do ASAP?

A
  1. Revascularization
  2. IV heperin

from thrombus/emboli

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6
Q

EOD acute arterial occlusion of a limb

A
  1. Sudden pain in extremity
  2. Generally assoc. w/ some element of neurologic dysfunction w/ numbness, weakness or complete paralysis
  3. Absent extremity pulses
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7
Q

Where do emboli come from in occlusive cerebrovascular disease w/o stroke?

A

proximal internal carotid artery

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8
Q

Unilateral blindness from occlusive cerebrovascular disease is called?

A

amaurosis fugax

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9
Q

EOD occlusive cerebrovascular disease

A
  1. Sudden onset weakness & numbness of an extremity, aphasia, dysarthria or unilateral blindness (amaurosis fugax)
  2. Bruit heard loudest in the neck
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10
Q

What is chronic syndrome of intestinal angina?

A

adequate perfusion for the viscera at rest but ischemia occurs w/ severe abdominal pain when flow demands inc. w/ feeding

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11
Q

EOD visceral artery insufficiency

A
  1. Severe postprandial abdominal pain
  2. Wt loss w/ a fear of eating
  3. Acute mesenteric ischemia - severe abdominal pain yet minimal findings on physical exam

may also be acute mesenteric vein occlusion but rare

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12
Q

Which vessels are usually affected w/ thromboangiitis obliterans (Buerger disease)?

A

plantar & digital vessels of foot & lower leg

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13
Q

What are the DDx w/ Buerger disease?

A
  1. Atherosclerotic peripheral vascular disease
  2. Raynaud disease
  3. Atheroemboli
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14
Q

EOD thromboangiitis obliterans (Buerger disease)

A
  1. Typically male cigarette smokers
  2. Distal extremities involved w/ severe ischemia, progressing to tissue loss
  3. Thrombosis of the superficial veins may occur
  4. Amputation required unless stop smoking
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15
Q

How big is an abdominal aortic aneurysm?

A

3 cm

usually ruptures >5cm

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16
Q

What is the ratio of men:female w/ abdominal aortic aneurysm?

A

4:1

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17
Q

Which vessels are usually involved in abdominal atherosclerotic aneursyms?

A

aortic bifurcation or common iliac arteries

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18
Q

When do you screen for abdominal aortic aneurysms?

A

US for 65-75 y/o men w/ Hx of smoking

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19
Q

EOD abdominal aortic aneurysm

A
  1. Most asymptomatic until rupture
  2. AAA 5cm are palpable in 80% of Pts
  3. Back or abdominal pain w/ aneurysmal tenderness may precede rupture
  4. Rupture is catastrophic (HOTN, excruciating abdominal pain that radiates to the back)
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20
Q

What is 1st line if suspected thoracic aneursym?

A

CT scanning

shows anatomy & size
excludes lesions that can mimic aneurysms (ex. neoplasm, goiter)

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21
Q

EOD thoracic aneurysm

A
  1. Widened mediastinum on CXR

2. w/ rupture, sudden onset CP radiating to back

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22
Q

What are the Sx of peripheral artery aneurysms due to?

A

peripheral embolization & thrombosis

silent until critically symptomatic

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23
Q

What is the most common peripheral artery aneurysm?

A

popliteal

does not cause ischemia due to parallel arterial supply to foot

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24
Q

EOD peripheral artery aneurysm

A
  1. Widened, prominent pulses

2. Acute leg or foot pain & paresthias w/ loss of distal pulses

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25
Q

Type A vs. Type B aortic dissection

A

A - arch proximal to L subclavian
worse prognosis, surgery!

B - proximal descending thoracic aorta usually just beyond the L subclavian

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26
Q

What is absolutely necessary w/ aortic dissection?

A

control BP!
systolic to 100-120 mmHg

DO NOT GIVE ASPIRIN!

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27
Q

What are the DDx for aortic dissection?

A
  1. MI

2. Pulmonary embolism

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28
Q

EOD aortic dissection

A
  1. Sudden searing CP w/ radiation to the back, abdomen, or neck in a HTN Pt
  2. Widened mediastinum on CXR
  3. Pulse discrepancy in extremities
  4. Acute aortic regurgitation may develop
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29
Q

What is the biggest risk factor for varicose veins?

A

women after pregnancy

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30
Q

Which veins are usually affected w/ varicose veins?

A

greater saphenous veins

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31
Q

EOD varicose veins

A
  1. Dilated, tortuous superficial veins in lower extremities
  2. May be asymptomatic or assoc. w/ aching discomfort or pain
  3. Often hereditary
  4. Inc. frequency after pregnancy
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32
Q

What are the causes of superficial venous thrombophelbitis?

A
  1. Cath
  2. PICC lines

spontaneously in

  1. Pregnant/postpartum women
  2. Varicose veins
  3. Thromboangiitis obliterans
  4. Trauma, systematic hypercoagulability secondary to abdominal CA
  5. Assoc w/ DVT in 20% of cases
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33
Q

What are the DDx of superficial venous thrombophlebitis?

A
  1. Cellulitis
  2. Erythema nodosum
  3. Erythema induratum
  4. Panniculitis
  5. Fibrositis
  6. Lymphangitis & Deep thrombophlebitis
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34
Q

How do you treat simple superficial venous thrombophlebitis?

A

Local heat

NSAIDS

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35
Q

EOD superficial venous thrombophlebitis

A
  1. Induration, redness & tenderness along a superficial vein (usually the saphenous vein)
  2. Induration, redness & tenderness at the site of a recent IV line

Significant swelling of the extremity may NOT be seen

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36
Q

EOD chronic venous insufficiency

A
  1. Hx of prior DVT/leg injury
  2. Edema, stasis (brawny) skin pigmentation, subQ liposclerosis in the lower leg
  3. Large ulcerations at or above the ankle common (stasis ulcers)
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37
Q

What are the common causes of superior vena cava obstruction?

A
  1. Neoplasms
  2. Chronic fibrotic mediastinitis
  3. DVT
  4. Aneurysm of aortic arch
  5. Constrictive pericarditis
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38
Q

EOD superior vena cava obstruction

A
  1. Swelling of the neck, face & upper extremities

2. Dilated veins over the upper chest & neck

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39
Q

What bacteria commonly cause lymphangitis/lynphadenitis?

A

Hemolytic streptococci

S aureus

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40
Q

DDx of lymphangitis/lynphadenitis

A
  1. Superficial thrombophlebitis
  2. Cat-scratch fever (Bartonella henselae)
  3. Strep hemolytic gangrene
  4. Necrotizing fasciitis
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41
Q

EOD lymphangitis/lynphadenitis

A
  1. Red streak from wound or area of cellulitis toward regional lymph nodes, which are usually enlarged & tender
  2. Chills, fever & malaise may be present
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42
Q

Primary vs. secondary lymphedema

A

1 - congenital

2 - Inflammatory or mechanical

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43
Q

EOD lymphedema

A
  1. Painless persistent edema of one or both lower extremities
  2. Primarily in young women
  3. Pitting edema w/o ulceration, varicosities or stasis pigmentation
  4. May be episodes of lymphangitis & cellulitis
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44
Q

What is syndrome X?

A

angina w/ normal coronary arteries w/o other identifiable causes
most likely due to inadequate flow in microvasculature

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45
Q

ECG & angina

A

Neg cardiac enzymes
horizontal or downsloping ST-segment depression

reverses after ischemia disappears

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46
Q

What is the definitive diagnostic procedure for CAD?

A

coronary angiography

LV function is a major determinant of prognosis in coronary heart disease

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47
Q

What is the drug Tx for angina?

A

nitroglycerin

if pain not relieved/improving after 5 mins call 911

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48
Q

EOD angina

A
  1. Precordial CP, usually pptd by stress or exertion, relieved rapidly by rest or nitrates
  2. ECG or scintigraphic evidence of ischemia during pain or stress testing
  3. Angiographic demonstration of significant obstruction of major coronary vessels
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49
Q

Describe ECG & characteristics of Prinzmetal’s angina

A

spasm
ST-segment elevation
women <50 y/o
usually occurs in am, awakening Pts from sleep
assoc. w/ arrythmias or conduction defects

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50
Q

EOD angina w/o CAD (ex. Prinzmetal’s angina)

A
  1. Precordial CP, often occuring at rest during stress or w/o known precipitant, relieved rapidly by nitrates
  2. ECG of ischemia during pain, sometimes w/ ST-segment elevation
  3. Angiographic demonstration of no significant obstruction of major coronary vessels, coronary spasm that responds to intra-coronary nitroglycerin or CCBs
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51
Q

TIMI risk score

A
  1. > 65 y/o
  2. 3 or + cardiac risk factors
  3. Prior coronary stenosis 50%
  4. ST-segment deviation
  5. 2 anginal events in prior 24 hours
  6. ASA in prior 7 days
  7. Elevated cardiac markers
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52
Q

EOD NSTEMI

A
  1. Distinction in acute coronary syndrome btwn Pts w/ & w/o ST-segment elevation at presentation is essential to determine need for reperfusion therapy
  2. Fibrinolytic therapy is harmful in acute coronary syndrome w/o ST-segment elevation
  3. Antiplatelet & anticoagulation therapies & coronary intervention are mainstays of Tx
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53
Q

What should you avoid w/ STEMI?

A

NSAIDS

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54
Q

EOD STEMI

A
  1. Sudden but not instantaneous development of prolonged (>30 mins) anterior chest discomfort (sometimes felt as “gas” or pressure
  2. Seomtimes painless, masquerading as acute HF, syncope, stroke or shock
  3. ECG: ST-segment elevation or LBBB
  4. Immediate reperfusion Tx w
  5. Primary PCI w/in 90 mins of 1st medical contact is the goal & superior to thrombolysis
  6. Thrombolysis w/in 30 mins of hosptial presentation & 6-12 hrs of onset of Sx reduces mortality
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55
Q

A high morning BP is a sign of???

A

inc. risk of cerebral hemorrhage

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56
Q

HTN risk factors

A
  1. Age/gender
  2. Race (blacks)
  3. FH
  4. Obesity
  5. Sedentary lifestyle
  6. Low K diet
  7. High salt diet
  8. Tobacco use
  9. Alcohol
  10. Stress
  11. Sleep apnea
  12. Endocrine diseases
  13. Kidney disease
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57
Q

HTN Sx

A

Mostly asymptomatic

  1. HA
  2. Fatigue
  3. End organ damage
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58
Q

HTN Pts at risk for?

A
  1. Stroke
  2. MI
  3. Peripheral arterial disease
  4. CHF
  5. LV hypertrophy
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59
Q

When should you start BP meds?

A

if 20S/10D higher from the target

if >140/90 start to get concerned

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60
Q

Work up w/ HTN Dx

A
  1. Renal function
  2. Glucose
  3. Lipid panel
  4. EKG
  5. UA
  6. Electrolytes
  7. CBC
  8. ECHO

must have 2 high BP readings at two diff. times

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61
Q

Causes of secondary HTN

A

Renal artery stenosis - #1!

  1. Abdominal bruits
  2. Primary hyperaldosteronism
  3. Pheochromocytoma
  4. Cushing’s
  5. Sleep apnea
  6. Coarctation of aorta
  7. Meds
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62
Q

May have secondary HTN if?

A
  1. Severe or resistant to Tx
  2. Acute rise in BP
  3. <30 y/o, nonobese, no FH, no other risk factors
  4. Malignant or accelerated w/ end organ damage
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63
Q

Work up of secondary HTN

A
  1. Renal imaging
  2. Plasma renin activity
  3. Plasma & urine catecholamines
  4. MRA, duplex US
  5. CTA
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64
Q

What is the most underestimated cause of secondary HTN?

A

sleep apnea

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65
Q

What is a HTN urgency?

A

> 180 >120
no Sx or just HA

common causes - not taking meds, too much salt

gradual reduction to 160/100

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66
Q

What is a HTN emergency?

A

> 180 >120 w/ end organ damage

  1. Encephalopathy
  2. Retinal hemorrhage
  3. Papilledema
  4. Acute renal failure
  5. CP, EKG changes
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67
Q

Genetic disorders of secondary HTN

A
  1. Glucocorticoid remediable aldosteronism - dominant
  2. Syndrome of apparent mineralocorticoid excess - recessive
  3. HTN exacerbated in pregnancy - dominant
  4. Liddle syndrome - dominant
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68
Q

When is renal vascular HTN suspected?

A
  1. Onset before 20/after 50
  2. HTN resistant to 3 or more drugs
  3. Epigastric or renal artery bruits present
  4. Atherosclerotic disease of the aorta or peripheral arteries
  5. Abrupt inc. in level of serum creatinine after administration of ACEi
  6. Episodes of pulmonary edema are assoc. w/ abrupt surges in BP
69
Q

BP HTN

A

140-159, 90-99

70
Q

BP Stage 2 HTN

A

> 160 , >100

71
Q

AB vs CD drugs

A

ACEi/ARBs -& beta-blockers - interrupt the renin angiotensin system
more effective in young, white people where renin is usually higher

CCBs & diuretics - more effective in old or black people

72
Q

Risk factors of orthostatic HOTN

A

autonomic reflexes are impaired or intravascular volume is depleted

  1. Old people
  2. Meds
  3. Diabetic neuropathy
  4. Autonomic dysfunction
  5. Parkinoson
  6. Paraneoplastic
  7. FH
73
Q

DDx orthostatic HOTN

A
  1. Aortic stenosis
  2. Arrhythmia
  3. Postural tachycardia syndrome
  4. Postprandial HOTN
74
Q

Dx of orthostatic HOTN

A

Fall 20S or 10D 2-5 mins after supine position

75
Q

Work up of orthostatic HOTN

A
  1. CBC
  2. Renal function
  3. Glucose
76
Q

Tx of orthostatic HOTN

A
  1. Avoid/treat primary reason
  2. Fluids
  3. Arise slowly
  4. Avoid long standing
  5. Avoid coughing, hot weather, straining
  6. Elastic stocking extended to the waist
  7. Tensing legs
  8. Inc. salt water
  9. Avoid large meals
77
Q

Meds for orthostatic HOTN

A
  1. Fludrocortisone
  2. Midodrine alpha-1 adrenergic
  3. Caffeine
78
Q

Risk factors of CAD & peripheral artery disease

A
  1. Smoking!!!!!!!!
  2. Dyslipidemia
  3. HTN
  4. Diabetes
  5. Abdominal obesity
  6. Psychosocial factors
  7. Physical activity
  8. FH
  9. Age >50
  10. Gender - men (women after menopause 55+)
  11. Collagen vascular disease
  12. Infections
  13. Sleep apnea
  14. Homocysteine
  15. Cocaine
  16. Meth
  17. Takotsubo stress cardiomyopathy
79
Q

Sx of MI

A
  1. CP
  2. SOB
  3. GI
  4. Diaphoresis
  5. Dizziness
  6. Fatique
  7. Sudden death
  8. Inc. HR
  9. Change in BP
  10. New murmurs/heart sounds
  11. Chest congestion
  12. Irregular heart beat
80
Q

Dx MI

A
  1. EKG
  2. Cardiac enzymes
  3. CXR
  4. CBC
  5. Renal function
  6. Electrolytes
  7. Transthoracic echo
  8. Stress test/coronary angiogram
81
Q

Anterior leads

A

V1-V6

LAD - worst!

82
Q

Anterioseptal leads

83
Q

Lateral leads

A

V4, V6, aVL, I

84
Q

Inferior leads

A

II, III, aVF

R coronary occlusion

85
Q

Immediate mgmt for MI

A
  1. Monitor
  2. O2
  3. IV access
  4. Chew ASA
  5. Nitrate/morphine
  6. EKG
  7. Airways
  8. Quick H&P
86
Q

Complications of MI

A
  1. Arrhythmias
  2. CHF
  3. Rupture
  4. Aneurysm
  5. Acute pulmonary edema
  6. Mitral regurgitation
87
Q

Risk factors of aortic aneurysm

A
  1. Old age
  2. Male (women rupture more)
  3. Caucasian
  4. FH
  5. Smoking
  6. Presence of other large aneurysm
88
Q

Clinical findings of thoracic aortic aneurysm

A

Pressure on

  1. Trachea
  2. Esophagus
  3. Superior vena cava
89
Q

Clinical findings of abdominal aortic aneurysm

A

Most Pts have no Sx

  1. Pulsatile mass
  2. Abdominal, back pain
  3. Limb ischemia w/ embolization
  4. Fever/malaise due to inflammation, infection
  5. Discovered by imaging studies as a coincidental findings
90
Q

Risk factors of aortic dissection

A
  1. HTN!!!
  2. Inflammatory changes
  3. Marfan syndrome, Ehler-Danlos syndrome
  4. Aortic coarcation
  5. Turner syndrome
  6. CABG (coronary artery bypass grafting)
  7. Cardiac cath
  8. High intensity wt lifting
91
Q

Sx of aortic dissection

A
  1. Syncope
  2. CVA
  3. MI
    Painless in cases like diabetes
92
Q

Imaging for aortic dissection

A
  1. CXR
  2. CT scan
  3. MRI
  4. Aortogram
  5. TTE
93
Q

What is erectile dysfunction common with?

A

common iliac disease

94
Q

Risk factors of chronic venous insufficiency

A
  1. Trauma
  2. DVT
  3. Obstruction
95
Q

Risk factors of DVT

A
  1. CA
  2. Immobilization
  3. Coagulopathy
  4. Birth control
  5. Major surgery
96
Q

Dx of DVT

A
  1. Duplex US
  2. D-Dimer
  3. Venogram
  4. Serial US
97
Q

Pulsus Paradoxus

A

Dec. in systolic BP upon inspiration >10mmHg

seen in pericarditis

98
Q

Electrical alternans

A

alternation of QRS amplitude or axis

seen in pericarditis

99
Q

HACEK organisms

A 
Haemophilus
Actinobacillus
Cardiobacterium hominis
Eikenella corrodens
Kingella

infective endocarditis

100
Q

What is the most common bacteria & location of infective endocarditis w/ IV drug users?

A

S. Aureus

Tricuspid valve

101
Q

EOD Myocarditis

A
  1. Often follows a URI
  2. May present w/ CP (pleuritic or nonspecific) or signs of heart failure
  3. Echo documents cardiomegaly & contractile dysfunction
  4. Myocardial Bx may reveal a characteristic inflammatory pattern
102
Q

EOD Rheumatic fever

A
  1. Uncommon in US, more common in developing countries

2. Diagnosis based on Jones criteria & confirmation of streptococcal infection

103
Q

EOD Acute inflammatory pericarditis

A
  1. Anterior pleuritic CP that is worse supine than upright
  2. Pericardial rub
  3. ESR usually elevated
  4. ECG shows diffuse ST segment elevation w/ PR depression
104
Q

EOD constrictive pericarditis

A
  1. Evidence of R heart failure w/ an elevated JVP, edema, hepatomegaly & ascites
  2. No fall or an elevation of the JVP w/ inspiration (Kussmaul sign)
  3. Echo shows septal bounce & reduced mitral inflow velocities w/ inspiration
  4. Cath shows RV-LV interaction, a square-root sign, equalization of diastolic pressures, normal PA pressure & discordance of RV/LV systolic pressures w/ inspiration (RV systolic rises, LV systolic falls)
  5. Area of RV/LV pressure tracing ratio that dec. w/ inspiration
105
Q

EOD infective endocarditis

A
  1. Fever
  2. Preexisting organic heart lesion
  3. Positive blood cultures
  4. Evidence of vegetation on echo
  5. New or changing heart murmur
  6. Evidence of systemic emboli
106
Q

Virulence vs. Pathogenicity

A

V - magnitude of the infection by virulence factors

P - ability to cause infection

107
Q

What are the ways infection can be established?

A
  1. Direct inoculatin
  2. Inhalation or respiratory droplets/aerosols
  3. Contiguous spread
  4. Hematogenous dissemination
  5. Mucosal barriers
  6. Disruption of normal flora (C. diff)
108
Q

What bacteria causes Rheumatic Fever & who commonly gets it?

A

Strep pyogenes - group A beta-hemolytic strep

gram + bacilli in pairs & chains

usually happens 2 weeks after strep pharyngitis infection
uncommon in US, most common in 5-15 y/o

109
Q

Which valve is usually infected w/ Rheumatic Fever?

A

mitral valve

then aortic, tricuspid & pulmonary

110
Q

How is Rheumatic Fever diagnosed?

A

Jones criteria
2 major/1 major & 2 minor

Major

  1. Carditis
  2. Erythema Marginatum
  3. Sydenham chorea
  4. Polyarthritis (symmetric & migratory)

Minor

  1. Polyarthralgias
  2. Elevated CRP
  3. Prolonged PR interval
  4. +throat culture
  5. ASO titer
111
Q

DDx of Rheumatic Fever

A
  1. Endocarditis
  2. Myocarditis
  3. Juvenile rheumatoid arthritis
  4. Lupus
  5. Lyme’s disease
  6. Kawasaki’s disease
  7. Osteomyelitis
  8. Disseminated Gonococcal Disease
112
Q

Tx of Rheumatic Fever

A
  1. Bedrest until fever goes away
  2. Salicylates - ASA
  3. PCN Benzathine 1.2 mil units IM once
    Maybe corticosteroids

PCN IM monthly until 21 y/o

113
Q

What are the causes of pericarditis?

A
  1. Coxsackie
  2. Echovirus
  3. EBV
  4. Influenza
  5. HIV
  6. Varicella
  7. Mumps
  8. Hepatitis
  9. B burgdoferi, pneumococci
  10. TB
  11. Uremic/severe hypothyroidism
  12. CA
  13. Dressler’s syndrome, SLE
  14. Radiation, drugs
114
Q

S/S pericarditis

A
  1. Pleuritic CP relieved w/ leaning forward
  2. Dyspnea, cough, weakness, fatigue
  3. Triphasic friction rub
  4. +/- fever if infectious
  5. R sided CHF if severe
  6. Pulsus Paradoxus
115
Q

Dx pericarditis

A
  1. Leukocytosis if infectious
  2. Elevated ESR & CRP
  3. EKG findings
    - diffuse ST-segment elevation
    - PR depression
    - Low QRS amplitude
    - Electrical alternans
  4. Echo - pericardial fluid
  5. Pericardiocentesis
116
Q

Tx pericarditis

A

Depends on underlying cause

  1. Viral - NSAIDS/ASA
  2. Dressler’s - ASA
  3. Uremic - dialysis
  4. Neoplastic - pericardiocentesis/pericardial window
  5. Antibiotics
117
Q

Who most commonly gets pericarditis?

A

males under 50 y/o

inflammation of pericardial sac

118
Q

What commonly causes constrictive pericarditis?

A
  1. Radiation therapy
  2. Cardiac surgery
  3. Histoplasmosis infection
  4. Chronic viral pericarditis
119
Q

What is constrictive pericarditis?

A

Chronic inflammatory process leading to thickened, fibrotic & adherent pericardium
Restricts diastolic filling leading to elevated venous back pressure

120
Q

S/S constrictive pericarditis

A
  1. Progressive dyspnea
  2. Weakness
  3. Edema
  4. Hepatomegaly
  5. Elevated JVP
  6. Kussmaul sign
121
Q

What is Kussmaul sign?

A

failure of JVP to fall w/ inspiration

122
Q

Dx constrictive pericarditis

A
  1. CXR - occasional calcifications around pericardium
  2. Echo - may reveal septal bounce
  3. Cardiac CT - need 4 mm pericardial thickening to be diagnostic
  4. Cardiac cath
    - evidence of RV-LV interaction
    - square root sign
123
Q

What are the ECG changes associated w/ pericarditis?

A
  1. Diffuse ST-segment elevation
  2. PR depression
  3. Low QRS amplitude
  4. Electrical alternans
124
Q

Tx constrictive pericarditis

A
  1. Aggressive diuresis w/ attention to electrolyte balance

2. Pericardiectomy if diuresis fails

125
Q

What are the causes of myocarditis & what is it?

A

Cardiac dysfunction due to acute viral infection & post viral immune response, leading to chronic myocyte injury

Many causes - mostly viral in US but can be autoimmune, drugs, venom, systemic diseases, other

126
Q

S/S myocarditis

A
  1. Pleuritic CP
  2. Dyspnea
  3. PVC/VTach
  4. Edema
  5. Sudden hemodynamic compromise
    may mimic STEMI w/ normal coronaries
    Microaneurysm may lead to Vtach

shows few days/weeks after acute febrile illness

127
Q

What should you suspect in a Pt w/ new CHF, arrhythmia, or conduction block w/o previous heart disease?

A

Myocarditis

128
Q

Dx myocarditis

A
  1. Cardiac MRI w/ Gadolinium
    - areas of spotty enhancement throughout the myocardium indicating injury & necrosis
  2. Endomyocardial Bx
    - histology

if no virus/bacteria present, may want to start immunosuppression

129
Q

Tx acute myocarditis

A
  1. Correct hemodynamic compromise

2. IV pressors, IABP, LVAD, ECMO, IVIG

130
Q

Tx chronic myocarditis

A
  1. Treat EF <40% as you would for CHF
  2. BB, ACEi
    w/ severe dilated cardiomyopathy
    Consider long-term LVAD/heart transplantation
131
Q

What is contained in the mediastinum?

A
  1. Great vessels
  2. Heart
  3. Vagus & Phrenic nerves
  4. Lymph nodes
  5. Trachea
  6. Esophagus
132
Q

What are the common causes of mediastinitis?

A

Cardiac surgery is main cause
Spreads from deep neck space facial planes from untreated retropharyngeal abscess
Others:
1. Esophageal rupture
2. Contiguous spread from oropharyngeal, lung

133
Q

What risk factors inc. your chances of mediastinitis during cardiac surgery?

A
  1. Morbidity prior to surgery
  2. Length of the procedure
  3. Artificial materials used
  4. Previous sternotomy
134
Q

What bacteria most commonly cause mediastinitis?

A

Often polymicrobial & bacteria from the mouth

  1. Viridans group strep
  2. Peptococci
  3. Peptostreptococci
  4. Bacteroides
  5. Fusobacterium
135
Q

S/S mediastinitis

A
  1. Primary infection - odontogenic signs
  2. CP, SOB, dysphagia
  3. PE, tachycardia, crepitus over the chest wall, Hamman’s sign, precordial crepitus
  4. Sepsis
  5. Cardiothoracic surgery - abnormal wound appearance, bubbling from the site, abnormal pain, wound or sternotomy dehiscence
    usually 2 wks out or sooner if gram -
136
Q

Dx mediastinitis

A

1, CT scan of thorax - soft tissue swelling, pleural effusion, air collection, sternal errosion
2. Cultures
epicardial wires, purulent material, blood, aspirate
3. May do Indium 111 tagged WBCs

137
Q

Hammon’s sign

A

crunching sound synchronous with heartbeat

seen w/ mediastinitis

138
Q

Tx mediastinitis

A
  1. Most require surgical drainage & debridement
  2. Broad-spectrum antibiotics
    Duration may be months
139
Q

Which valve is most commonly infected w/ infective endocarditis?

A

Mitral valve

then AV, TV, PV

140
Q

What are the risk factors for native valve endocarditis?

A
  1. Rheumatic Heart Disease
  2. Congenital heart disease
  3. IVDU - TV
  4. Poor dental hygiene
  5. On hemodialysis
  6. Diabetes
141
Q

What are the risk factors for prosthetic valve endocarditis?

A
  1. Mechanical valve
  2. Bioprosthetic valve if <6 mo of surgery
  3. Bacteremia/fungemia from lines
142
Q

What are the causes of infective endocarditis?

A
  1. Strep sp. Viridans group
  2. S. aureus
  3. CoNS
  4. Enterococci
  5. Gram neg bacillis
  6. HACEK organisms
  7. Diptheroids
  8. Polymicrobial
  9. Or from previous abx exposure - Bartonella sp, meitensis, Legionella pneumophila, Chlamydia psittaci, Tropheryma whippeli, Coxiella burnetii
143
Q

S/S infectious endocarditis

A
  1. Fever
  2. Murmur
  3. Emboli
  4. Splenomegaly
  5. Metastatic focus of infection
  6. Retinal lesion
  7. Petechiae
  8. Splinters
  9. Osler’s node
  10. Janesway lesions
144
Q

What are Osler’s nodes?

A

painful nodes on finger pads from immune complexes

characteristic of infectious endocarditis

145
Q

What are Janesway lesions?

A

painless red lesions of the palms or soles

characteristic of infectious endocarditis

146
Q

How do you diagnose infective endocarditis?

A

Duke criteria

+histopath/cultures from tissue
2 major
1 major & 3 minor
5 minor

Possible
1 major & 1 minor
3 minor

Rejected
Firm alternative Dx
Resolution of illnes <4 days w/ abx therapy
No supportive pathology

147
Q

What are the components of the Duke criteria?

A

Major

  1. Pathogens from 2 cultures
  2. Antibody titer IgG >1:800
  3. New valvular regurgitation
  4. Positive echo

Minor

  1. Predisposing conditions (ex. IVDU)
  2. Fever
  3. Vascular phenomena (emboli, infarct, mycotic aneurysm, hemorrhage)
  4. Immunologic phenomena (glomerulonephritis, Osler’s nodes, Roth’s spots, RF)
148
Q

What are the complications of infective endocarditis?

A
  1. Systemic embolic (greater w/in first 2-4 wks of abx therapy)
  2. Periannular extension: abscess, fistula
  3. Splenic abscess
  4. Mycotic aneurysms
149
Q

Tx infective endocarditis

A
  1. ID & surgical consult
  2. PICC line - vanco +/-gentamicin
    Test of Cure - blood cultures
150
Q

What is the problem w/ VAD?

A

induced CD4 T cells to induce apoptosis leading to immunocompromise

common infection in drive line

must get transplant

151
Q

What is chronic Rheumatic Heart Disease?

A

from single/repeat attacks of RF that produce rigidity & deformity of valve cusps, fusion of the commisures or shortening & fusion of the chordae tendinae
valvular stenosis or regurgitation can occur

152
Q

What should you use to treat recurrent/refractory cases of pericarditis?

A

colchicine

153
Q

What should you look for if a Pt has enterococci endocarditis?

A

Gastric CA

154
Q

What is the best test for endocarditis?

155
Q

Who & when should receive prophylaxis Tx to prevent endocarditis?

A

Pts w/ predisposing congenital/valvular anomalies

Select dental procedures, operations w/ respiratory tract, infected skin, skin structure or musculoskeletal tissue

156
Q

Which heart sound is present during active MI?

A

S4

due to the lack of ATP production impairing left ventricular relaxation

157
Q

Killip Classification

A

Used to predict mortality in STEMI

I - No evidence of heart failure
II - Mild to moderate heart failure (S3 gallop, rales 1/2-way up lung fields of elevated jugular venous pressure)
III - Pulmonary edema
IV - Cardiogenic shock (Systolic BP <90 mmHg & signs of hypoperfusion such as oliguria, cyanosis & sweating)

158
Q

What is Carey Coombs?

A

murmur suggestive of valvulitis

seen with Rheumatic Fever

159
Q

What is the most common cause of pericarditis?

A

Coxsackie virus

160
Q

What is Dressler’s syndrome?

A

inflammatory process 2-5 days after an MI causing pericarditis

treat w/ ASA

161
Q

What is effusive-constrictive pericarditis?

A

pericardial tamponade + constrictive pericarditis

162
Q

What is metabolic syndrome & what is it associated with?

A

HTN, coronary heart disease

  1. Truncal obesity
  2. Hyperinsulinemia & insulin resistance
  3. Hypertriglyceridemia
163
Q

What HTN meds are commonly used in men w/ BPH?

A

alpha - adrenergic antagonists

164
Q

What is Levine’s sign?

A

a clenched fist over the sternum & clenched teeth when describing chest pain

165
Q

What is commonly used to measure the extent of an MI?

A

MRI w/ gadolinium contrast

also used to Dx myocarditis

166
Q

What is seen w/ a perivascular granuloma w/ vasculitis?

A

Rheumatic fever

167
Q

What is the most common cause of aortic dissection?

A

atherosclerosis

most occur in the abdomen

168
Q

What cholesterol level significantly inc. your risk of CAD?

A

> 200 mg/dL

Clinical Medicine (11 decks)

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