1
Q
a 48-year-old male with type I diabetes mellitus and end-stage renal disease currently on hemodialysis with dyspnea, cough, and chest pain. He describes the pain as worse during inspiration and when he is lying on his back. The patient reports significant relief of his chest pain by sitting up or leaning forward.
A
pericarditis
2
Q
PE findings for pericarditis
-often leads to??
A
- pleuritici CP—–worse with inspiration and laying down— better when pt sits up or leans forward
- pericardial friction rub–heard when upright/leaning forward
- diffuse ST seg elevations in precordial leads
often will lead to pericardial effusion *****
3
Q
MCC of percarditis
A
MC=idiopathic
-SLE
-Uremia
-viral infection—– coxsackie MC
-TB
-RA
-neoplasms
-drugs
POST MI PERICARDITIS 2-5 days post op= DRESSLER
4
Q
how to diagnose percarditis
A
need two of the following
- typical CP—- sharp and pleuritic, improved when sit up/leaning forward
- pericardial friction rub—best heard over left sternal boarder
- suggestive EKG changes–widespread ST elev in precaridoals and T wave inversion
- new or worsening pericardial effusion
5
Q
type of breathing pattern seen with pt in restrictive percarditis
A
kussmauls sign ——-obstruction to R ventric outflow—— elevating jugular venous and right atrial pressures with inspiration
6
Q
tx pericarditis
A
ID cause— tx it
- NSAIDs, ASA— 7-14 days
- corticos for >48 hrs of s/s
- ABs for bacerial
- pericardiocetesis if effusion
- Head at 45 degrees
- Pericardial window——– pt can develop tamponade or effusion—- window is cut on the pericardium to allow drainage of fluid
7
Q
bacterial invovled in endocarditis
- acute
- IVDU
- subacute
- prosthetic valve
A
acute=staph A
IVDU=staph A
subacute=S. viridans
prosthetic= staph epidermidis
8
Q
dukes criteria vs jones criteria
A
DUKE is for endocarditis
JONES for rheumatic fever
9
Q
tx for Candida endocarditis
A
Amphotericin B
10
Q
MCC overall of endocarditis
A
Strep viridans
**late complication of valve replacement
11
Q
PE findings for endocarditis
A
- splinter hemorrhages in fingernail beds
- osler nodes—paiful lesions on fleshy portions of extremities
- roth spots– retinal hems
- janeway lesions– cutaneous evidence of septic emboli
- palatal or conjunctival petechiae
- splenomegaly
- hematuria
neuro findings— CVA—visual loss, motor weakness, aphasia
12
Q
diagnosis for endocarditis
-GS?
A
blood cultres— 3 sets 1 hour apart
EKG
LABS— CBC, ESR, RF
transesophageal echocardiogram is GOLD STANDARD
MODIFIED DUKES CRITERIA
- *definite= 2 major criteria or 1 major + 3 minor OR 5 minor
- *Possible= 1 major and 1 minor or 3 minor
MAJOR CRITERIA
- blood cultures
- single positive blood culture for C. burnetii or antiphase iGG antibody titer >1:800
- positive echo showing vegetation, abscess or new partial dehiscence of a prosthetic valve
- new valvular regurgitation– simple change in pre-exist murmur not sufficient
MINOR
- predisposing heart condition or IVDU
- Fever > 38C or 100.4F
- Vascular phenom: arterial emobli, septic pulmonary infarcts, janeway, conjunct hem,
- immunologic pheomena: glomerulonephritis, Osler nodes, Roth spots, rheumatoid factor (RF) Microbiologic evidence: positive blood culture, but not a major criterion (excluding single positive cultures for coagulase-negative staphylococci and organisms that do not cause endocarditis) or serologic evidence of infection likely to cause IE
13
Q
who should get AP before dental work
A
- prosthetic valves
- hx of IE
- unrepaired cyanotic congenitial HD or repaired with shunts
- cardiac transplant with valvue regurg
14
Q
tx for IE
- with a native valve and is IVDU
- with prosthetic valve
- IVD abusers
A
IVDU= ampicillin 500 mg/h + nafcillin 2 g IV q 4 hr + gentamicin 1 mg/kf
PROSTHETIC= vanco 15 mg/kg + gentamicin 1 mg/kg + rifampin 300 PO
15
Q
valve affected in IVDU and non IVDU
A
IVDU= tricuspid non= mitral
16
Q
def diag for stable angina
most sensitive clinical signs to diagnose
tx for stable angina
A
angiography =GS—- useed only for severe cases bc costly
-stress test= most useful and cost effective
horizontal or downslopping ST-segment depression on ECG during attack
stable angina
-BB + nitro
SEVERE= angioplasty and bypass
17
Q
what is considered a + stress test
A
st seg depression of 1 mm
18
Q
unstable angina vs NSTEMI vs STEMI
A
unstable= ischemic changes, NO ELEV in troponins, with or without EKG changes for ischemia
NSTEMI= same manifestations as unstable angina, but with elevated troponins—— subendocardial —–ekg changes include ST seg depressions, T wave inversion or BOTH. NO ST ELEVATIONS
SSTEMI= same manifestations as those in unstable angina but with elevations in troponins and EKG Changes—– TRANSMURUAL (full thickness of myocardium)— ST ELEVS
19
Q
diagnosis of unstable angina
-GS??
A
- ekg normal— then do a stress test
ANGIO to diagnose CAD— done if PCI or CABG being considered
20
Q
tx for unstable angina
A
- mod of RF– smoking, BP, lipids
- antiplatelet drugs— ASA and/or clopidogrel or ticagrelor
- BB
- nitro and CCB for symptoms
- revasc if s/s persist despite medical tx
- ACE and statins
21
Q
number 1 RF for printzmetal angina
A
smoking
second is cocacine
22
Q
how to diagnose printzmetal angina
A
- ***HX of smoking (or no hx of CAD, DM, HTN, HCOL)
- *** preservation of exercise capacity
- **EKG: can show inverted U waves, ST seg or T wave abnormals
- *pain can sligtly be relieved with nitro
- Positive troponins
- **CP provoked by IV ergonovine
23
Q
GS to diagnose vasospastic angina
A
angio with IV provoactive agents like ergonovine into coronary artery
24
Q
prophylaxtic tx for prinztmetal angina
-what is contraindicated
A
CCB– tx the vasopsasms like amlodipine + long acting nitrates
CONTRA= use of BB like propranlol
25
AFIB
- mc in who
- tx
- elderly
- etoh
RATE CONTROL
-goal= under 110
drugs= CCB (diltiazem********** or verap) or BB (metoprolol)
RHYTHM CONTROL
- unstable= synchronize cardiovert **************
- AFIB > 48 days---- anticoagulate for 21 days before cardioversion
- <48 hours---- cardiovert--- get a TEE before to see if clot present
ANTICOAGULATE
-warfarin
target INR=2.5
26
wide QRS + short PR interval + delta wave =
WPW
27
what is contraindicated for tx of WPW
-CCB and BB
28
causes of cardiac tamponade
```
ACUTE ONSETS
trauma
MI
aortic disection
pericadial effusion
```
```
SLOW ONSETS
CA
chronic inflammation
uremic pericarditis
hypothyroid
CT disease
```
29
becks triad
distant heart sounds (muffled heart sounds)
distended jugular veins (JVD)
decreased atrial pressure (hypotension)
***cardiac tamponade
30
pulsus paradoxus
drop 10 mmHg in SPB on inspiration
| ---- cardiac tamponade
31
PE findings for cardiac tamponade
becks triad-- hypot, JVD, muff heart sounds
pulsus paradoxus
electrical alternans--- QRS height alternates high to low
CXR--- water bottle heart---
32
diagnosis for cardiac tamponade
| -GS
GS= echo---- shows diastolic collapse of RV (how to differentaite b/w tamponade and effusion)
effusion= fluid w/o RV collapse
CXR-- water bottle heart
EKG-- elec alternans
****tamponade is a clinical diagnosis---- echo shows an enffusion and if the RV is collapsed in diastole than tamponade is DX
33
tx for tamponade
- IVF
- pericardiocentesis=therapeutic
- balloon pericardiotomy and pericardial window
34
pericardial effusion
-PE
-tx
-presents similar to percarditis (CP worse laying down.. better leaning forward)
PE
- distant hear sounds
- EKg=low voltage QRS and electrical alternans
- echo shows pericardial fluid WITHOUT RV Collapse in diastole
- CCR= water bottle heart
tx
- percardiocentesis if large
- tx underlying cause
35
5 DDX for CP in the ED
1. pericarditis
2. ACS---- CP + SOB + rad to back/shoulders/jaw/arms
3. PE--- pleuritic CP + dyspnea (spiral CT for TOC)
4. pneumothorax--- ipsilateral CP and dyspnea, decr tactile fremitus, deviated trachea, hyperresonance, diminish BS
5. Thoracic anerusysm/dissection---- tearing, CP rad to back
36
Absolute contraindications for fibrinolytic use in STEMI include the following:
- prior ICH
- known stuctural cerebral vasc lesion
- malignant cerebral CA
- ischemic stroke within 3 MO
- suspected aortic dissection
- active bleeding or bleeding diathesis (exluding menses)
37
GS for STEMI tx
other tx
Beta Blockers + NTG + Aspirin + Heparin + ACEI + REPERFUSION
PCI withint 3 hours of s/s onset (esp 90 mins)
PCI >>>>>>> thrombolytics
thrombolytics
- done is no access to cath lab or surgery is contra
- TPA
- streptokinase
PT SENT HOME ON
- bb
- ACEI
- statin
- NTG PRN
38
what drugs can cause edema
CCD and alpha 1 blockers-- bc they vasodilate
39
MCC of HF
- CAD
- HTN
- MI
- DM
HF= LV remodeling, dilation, thinning, mitral valve incomptence, RV remodeling
40
type of breathing pattern seen with HF
cheyene stokes ---- periodic cyclic respirations
41
S4 heart sound
diastolic HF--- EF is normal
42
S3 heart sound
* hypertrophic cardiomyopathy
| * HF--- systolic--- reduced EF with volume overload
43
best test for diagnosis of HF
echo
44
systolic LHF tx
ACEI + BB + Loop diuretic
45
Diastolic HF tx
ACEI + BB or CCB (do not use diuretics in stable chronic diastolic failure)
46
GS to diagnose RHF
right heart cath
47
what is the BEST test for diagnosig CHF
echo
48
three specific beta blocekrs used in reducing mortality in HF
BETA 1 BLOCKERS
- metoprolol
- carvedilol
- bisprolol
49
HTN emergency
>180/120 WITH impending or progressing end organ damage
tx
- red bp by 25% in 1 hour
- IV sodium nitropurissde
50
HTN urgency
- define
- tx
>180/120 without end organ damage
| -clonidine
51
Malignant HTN
- define
- tx
diastolic reading >140 assoc with papilledema and encephalopathy or nephopathy
tx
-sodium nitropurisside/hydralazine/Clevidipine
52
MCC of cardiogenic shock
MI
HF
cardiac tamponade
53
what happens to pulmonary cap wedge pressure in cardiogenic shock
it increases
| >15 mmHg
54
define orthostatic hypotension
Drop of > 20 mm Hg systolic, 10 mmHg diastolic, 15 BPM increase in pulse 2-5 minutes after a change from supine to standing
55
ankle brachial index results for periph vascular disease
<0.9
56
PE findings for PVD
- LE hair loss
- birttle nails
- pallor
- cyanosis
- shiny atrophic skin
- claudication
- hypothermia
- ulcers=pale to black, well circumscribed and PAINFUL, laterally and distally
57
DX for PVD
| -GS?
arteriography/ angiography for PAD
58
tx for PAD
1. RF control--- stop smoking, DM/HTN/hyperlidi controlled
2. exercise--walk to the point of claudication
3. platelet inhibs--- ASA/Clopidogrel/cilostazol
4. ACEI/statins
5. exercise
if all that fails-- revasc with PTA, bypass grafts, stenting
59
PE findings for venous insufficiency
RF
DX
TX
Stasis deramtitis
non healing ulcers at medial malleolus
discomofrt, edema
RF
advancing age, family history of venous disease, ligamentous laxity (eg, hernia, flat feet), prolonged standing, increased BMI, smoking, sedentary lifestyle, lower extremity trauma, prior venous thrombosis (superficial or deep), high estrogen states, and pregnancy
DX
- clinical
- get US to R/O DVT
- DD
TX
-compression, wound care and rarely surgery
-elevate legs
leg exercies
60
opening snap
Mitral stenosis
61
mid systolic click
MVP
| MR
62
when do surigcal repair for AAA
> 5.5 or expands >0.6 cm per yr
63
monitoring for AAA
PT should be on what med
annually if > 3 cm
every 6 MO if > 4cm
BB*****
64
AAA vs dissection
```
AAA= all 3 layers
disection= inner layer
```
65
sudden tearing CP b/w scapula and diminished pulses
Aortic dissection
66
older male >60 YO with severe back or abd pain
+syncope
+hypotension and tender abd mass
AAA
67
aortic dissection
| -ascending vs descending
ascending ---- surgical emergency
| descending--- medical tx-- BB unless complicated present
68
Type A aortic dissection
Proximal
| -surgical managmenet
69
Type B aortic dissection
Distal
| -medical management
70
GS for evaluation of aortic dissection
MRI angio
71
variation in pulse b/w r and l arm
aortic dissection
72
CXR shows widened mediastinum
aortic dissection
73
GS For eval of AAA
angiography
74
screening for AAA
one-time screening for abdominal aortic aneurysm by ultrasonography in men ages 65 to 75 years who have ever smoked
75
test of choice for throacic anuerysm
CT
76
What size should you refer AAA to vascular surgeon?
>4.5 cm
77
when is immediate surigcal repair needed for AAA
>5.5 or >0.5 cm expansion in 6 MO
| ***even if asymptomatic***
78
GS for diagnosis of aterial embolism/thrombosis
angioraphy
79
GS for diagnosis pheblitis/thrombophelbitis
venous duplex US
80
Virchows triad
DVT
- stasis
- enodthelial damage (surgery).
- hypercoag state
81
sprain =
| strain =
sprain=liagments
| strain=muscles+tendons
82
+spurling test
cervical sprain
+sitff
+pain in neck
+paraspinal muscle tenderness and spasm
83
tx for cervical sprain
c collar for 2-3 days, ice, heat, analgesics, gentle ROM
84
back strain
thoracic and lumbar
-lifiting, twisting or strenuous activity
NO RADICULAR S/S ********
no neuro changes----- NO PAIN BELOW KNESS
tx= NSAIDs, heat, ice PT, exercise, bed rest <2 days
85
pain with direct pressure on knee (when PT kneels it hurts)
| swelling over patella
prepatellar bursitis
86
what is common in wrestlers
prepatellar bursitis
| **also worry about septic bursitis---- get aspiraiton with gram staining+ culture
87
tx for prepatellar bursitis
NSAIDs, compressive wraps
| +/- aspiration and immobilization
88
atheletes who particiapte in jumping activitis
patellar tendinitis
| -anterior knee pain with patellar tendon tenderness
89
pain at biceps groove
| -pain with resisted supination of elbow
biceps tendonitis
90
how to diagnose caudia equina
-emergent MRI
if MRI not available--- then CT myelography
91
CP worse with deep breaths or coughing
CP worse with upper body movement
UNILATERAL cp
costochronditis
92
costochronditis
- dx
- tx
DX
- reproducible CP
- XR, bone scan, vit D levels, bipsyp ECG--- to R/O other stuff if necessary
- re-consider this if absence of local tenderness to palpation
- PT > 35 YO work up for CAD---EKg, troponins
- PE can mimic this---------
TX
- anti-inflammatories----NSAIDs, tylenol
- apply heat with compression
- PT, local steroid injectios
93
GS for DVT DX
venography
| --- been largelt replaced with US
94
Shoulder dislocation
| -mc?
MC= anterior---> FOOSH-->abduction + eternally rotated
95
assoc conditions with shoulder dislocations
BANKART LESIONS---- fx of anterior inferior glenoid following impact of humeral head against glenoid
HILL SACHS LESIONS---- dent in the humeral head--- compression chrondral injury of posterior superior humereal head
axillary nerve injury*** C5-6
labrum tear
96
direct fall onto the shouler
clavicular fx
97
mc assoc condition with anterior shoulder dislocation
hill sac lesion
98
MC type of claviular fx
middle third (right in the middle basically)
99
tx for claviuclar fx
-simple arm sling or figure 8 sling for 4-6 weeks
| consult ortho is proximal 1/33 fx
100
fall on the shoulder
| PE Deformity: elevation of clavicle and point tenderness and pain with cross chest testing
AC joint separation
101
DX for AC joint separation
XR with patient holding a weight to assess level of injury
102
Shoulder pain with overhead activity or at night when lying on arm
rotator cuff tear
103
dx for rotator cuff tear
MRI
104
list muscles of rotator cuff
suprasinatus
subscapularis
infraspinatus
teres minor
105
humeral fracture
- mc in who
- mc involve what else injured?
- elderly who fall
| - MC site for radial nerve injury
106
xray shows posterior fat pad sign
supracondylar fracture
107
supracondylar fracture
| -worry about
compartment syndrome
| brachial artery
108
anterior fat pad sign
supracondylar fracture
109
posterior fat pad sign
distal humeral fx
110
pt punched a wall or generally punch with clenched fist
boxers fx
111
insidious onset of dull aching pain localized to groin, lateral hip or butt
AVN
112
RF for AVN
- sickle cell
- trauma
- steroid use
EORs
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