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Flashcards in Final Deck (185)
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1

Where does pleuritic pain localize to?

distribution of an intercostal nerve

2

T/F: Pleuritic pain may or may not be made worse by taking a deep breath

TRUE

3

Do shingles outbreaks occur unilaterally or bilaterally?

unilaterally

4

What is the first symptom of shingles?

pain (it can occur before rash erupts)

5

What is a key symptom for intercostal neuralgia?

increased pain when bending toward the side of involvement

6

What is a key symptom for pleurisy?

increased pain when bending away from the side of involvement

7

What can sometimes be an extremely good mimic of angina/ACS/MI?

non-cardiac chest pain

8

What is costochondritis?

aka costosternal syndrome. Intermittent unilateral pain at one or more of the costosternal junctions/costochondral junctions. Pain can radiate across the anterior chest and increases with inspiration.

9

What is Tietze's syndrome?

idiopathic costochondritis with painful enlargement of the costal cartilage. Usually the 2nd costochondral junction.

10

What is sternalis syndrome?

pain over midline of sternum. Can radiate bilaterally. Pain is less intense but more constant than costosternal syndrome

11

What is xyphoidalgia?

pain over xyphoid process. Increased by lifting, deep breathing, or heavy meals

12

What is rib tip syndrome?

aka slipping rib. Hypermobility of anterior costal cartilage in a lower rib. Movement of rib increases pain and causes clicking or snapping sound

13

Where are most rib fractures?

angle of the rib via blunt trauma

14

what are the most commonly damaged ribs?

ribs 4 -9

15

What are some common concerns about first rib injury?

significant chest damage, injury to lungs, aorta, subclavian, or brachial plexus

16

What can a lower rib fx damage?

Liver or spleen

17

what can floating ribs damage?

kidneys

18

what is the main complication with rib fx?

compromised ventilation (more prone to hyperventilation)

19

What can fragmented rib fx lead to?

pneumothorax or hemothorax

20

what can flail chest lead to?

decreased excursion and ventilatory insufficiency

21

What are some conditions that have been associated with cervical pseudo-angina?

spondylolisthesis, osteophytes, discopathy involving lower Cx spine, cervical NR compression (usually c7)

22

what is cervicobrachial syndrome?

pain arising from a cervical spine dz, NR compression, or TOS. Might be mistaken for angina pectoris

23

what is cervicogenic angina?

pain that very closely resembles true cardiac angina but originates from the cervical spine

24

what must always be ruled out in a pt with cervicogenic angina?

coexisting CAD

25

what are the mechanisms in cervical pseudo-angina?

1. radicular pain d/t NR compression 2. compression of ventral motor root 3. referred pain from ALL, PLL, disc, or facets 4. autonomic Sx mediated by sympathetic nervous system

26

what are the possible symptoms of cervical pseudo-angina?

1. angina-type pain 2. autonomic/sympathetic sx (SOB, diaphoresis, dyspnea, nausea, pallor, vasoconstriction)

27

what could trigger a Prinzmetal angina?

vasoconstriction mediated by autonomic/sympathetic nervous system and/or pain

28

What does functional chest pain have a close association with?

GERD

29

What is functional chest pain?

characterized by recurrent episodes of unexplained chest pain that are usually midline, of visceral quality, and therefore potentially of esophageal origin. The pain is often debilitating.

30

how many americans suffer from GERD every year?

100 million

31

What is spontaneous passive movement of some gastric contents into the esophagus called?

normal asymptomatic reflux (some degree occurs in almost everyone multiple times/day)

32

What is symptomatic functional heartburn?

reflux symptoms are present. Acid levels are not elevated, esophageal mucosa appears normal upon endoscopy

33

What is non-erosive reflux dz?

reflux symptoms. Acid levels elevated. Esophageal tissue appears normal upon endoscopy

34

What is gastro-esophageal reflux dz?

aka erosive esophagitis. Reflux symptoms present. Acid levels elevated. Esophageal damage on endoscopy/biopsy

35

what are the physical anti-reflux barriers?

mucosal rosettes, gastro-esophageal angle (weak barriers)

36

what are the physiological anti-reflux barriers?

stronger defense mechanisms, positive pressure gradient between lower esophageal sphincter and the stomach, positive intra-abdominal pressure, appropriate LES basal tonus

37

how does weight loss affect intra-abdominal pressure?

decreases

38

What are the factors that decrease LES basal pressures and increase risk of reflux?

gastric acidification, citrus, nicotine, alcohol, fried or fatty foods, caffeine, chocolate, peppermint, spearmint. Sometimes: potatoes, tomatoes, sweet and hot peppers, eggplant, tomatillos, tamarillos, pepinos, pimentos, paprika, cayenne, tabasco.

39

what is considered the first line of Tx for GERD?

avoid foods that can contribute GERD

40

what has shown to consistently work better than dietary modification for GERD?

weight loss and elevating the head of the bed

41

along with laying down, how can LES basal pressure also be decreased?

pregnancy, meds, hiatal hernia

42

what is the incidence of heartburn in US adults?

monthly = 40% weekly = 20% daily = 10%

43

What is a typical heartburn?

substernal burning pain located b/t xyphoid process and episternal notch

44

where are the two places that heartburn can have referred pain?

midthoracic spine b/t shoulder blades = 40% of cases, left shoulder/arm = 5% of cases

45

what is acid regurgitation that can burn the throat?

acid brash

46

what is excess salivation?

water brash

47

what is the time frame for classic heartburn to occur?

30-60 mins after offending meal

48

what often provokes heartburn?

lying down or bending over after meals

49

T/F: the severity of heartburn often correlates with the degree of damage

false - does not correlate

50

T/F: older pts with verified GERD may not experience "heartburn".

TRUE

51

in a pt with stomach problems, what might dr feel when palpating Tx spine?

"rubbery" between shoulder blades

52

What are the warning signs that suggest complicated GERD?

1. chest pain that can mimic angina pectoris (motility disorders such as esophageal spasm) 2. dysphagia 3. odynophagia 4. weight loss 5. anemia/gastrointestinal bleeding/blood in stool

53

What should GERD pts with alarm symptoms undergo?

prompt endoscopy

54

what could be a concern for pts with very chronic GERD?

potential barretts esophagus

55

what can hyperventilation induce?

vasoconstriction

56

what is a common concern with hyperventilation syndrome?

coexisting CAD

57

what is hyperventilation syndrome classically associated with?

hypocalcemia

58

what are some possible nms findings for hyperventilation syndrome?

latent tetany or neuromuscular irritability

59

What are the 2 provocative tests for latent tetany?

1. Chvostek's sign 2. Trousseau's sign

60

What is Chvostek's sign?

facial twitching via stimulation of CN VII. (tap over TMJ/parotid gland/masseter) low sensitivity

61

What is Trousseau's sign?

carpal spasm/obstetrician's hand (inflate BP cuff until pulse disappears and hold for 5 min.) decent sensitivity, low false-positive rate

62

describe the atypical chest pain assoc. with HVS?

pain may last for hours, pain often relieved by exercise

63

what are the characteristics of HVS paresthesias?

usually bilateral, upper extremity. If unilateral, 80% are left-sided

64

what is a possible result when minute ventilation exceeds metabolic demands?

"perceived dyspnea"

65

what do HVS pts tend to breathe using?

upper thorax instead of diaphragm (can lead to chronically over-inflated lungs)

66

What causes acute primary hyperventilation?

no organic cause identified

67

how common is acute primary hyperventilation?

1% of HVS cases

68

what are 2 characteristics that make chronic/compensated primary ventilation difficult to Dx?

1. no organic cause identified 2. chest wall tenderness

69

What are some of the characteristics of secondary hyperventilation?

organic cause identified, pain, mild bronchospasm, asthma

70

how does pursed lip respiration affect breathing?

slows respiration rate and reduces work of breathing

71

what is a panic disorder commonly caused by?

spontaneous sudden onset of fear or discomfort (seen in up to 30% of college students)

72

What does a non-productive cough during a dyspnea attack indicate?

advanced small airways dz

73

T/F: productive cough would be seen after airways are reopened

TRUE

74

what is chronic bronchitis?

centrilobular emphysema and increased airways resistance

75

what is classic emphysema?

panlobular emphysema and decreased elastic recoil

76

what are the two forms of COPD?

chronic bronchitis (more common) and pulmonary emphysema. Most COPD pts have combination of both conditions

77

What is the definition of COPD?

chronic, incompletely reversible airflow obstruction on forced expiration

78

What is the primary risk for COPD?

cigarette smoking

79

What is the risk involved with secondhand smoke?

might be a factor in pulmonary emphysema. (not considered a direct factor for chronic bronchitis)

80

what is a common side effect for COPD pts?

more susceptible to infection (bronchitis, pneumonia, etc)

81

What is the clinical definition of chronic bronchitis?

long term cigarette smoking and a mucus producing cough that occurs on most days and lasts for at least 3 months per year for 2 years in a row

82

In end stage chronic bronchitis, what is physically obstructed?

greatly increased small airways resistance

83

what is grade 3 dyspnea?

dyspnea with ADLs (common in end stage chronic bronchitis)

84

what is a common complication of end stage chronic bronchitis?

cor pulmonale/ "right sided heart failure"

85

what are some characteristics of end stage chronic bronchitis?

1. prolonged expiration 2. excessive use of accessory msls of respiration 3. pursed lip respiration 4. noisy breathing

86

What is a "blue bloater" associated with?

end stage chronic bronchitis ("can't catch my breath and I cough all the time")

87

What are 3 common causes of pulmonary emphysema?

1. inflammatory response 2. alpha-1 antitrypsin deficiency 3. relative obstruction

88

What is most strongly linked to pulmonary emphysema?

lack of alpha-1 antitrypsin

89

how does pulmonary emphysema affect respiration?

very prolonged expiration

90

what lobes are most affected by emphysema associated with cigarette smoking?

upper lobes

91

how can emphysema occur in a non-smoker?

congenital lack of AAT (more severe in lower lobes)

92

What does a loss of elastic recoil lead to?

very prolonged expiration

93

What kind of pt often presents underweight, in a tripod posture when seated, and with a possible expiratory grunt?

pulmonary emphysema

94

what is a "pink puffer" associated with?

pulmonary emphysema

95

what is the method of choice for dxing copd?

spirometry

96

what is the most effective preventitive measure against chronic bronchitis?

smoking cessation

97

what is pneumoconiosis?

lung dust d/t inhalation of asbestos, coal dust, or crystalline silica

98

What is an important cofactor for pneumoconiosis?

smoking

99

What is the most common pneumoconiosis in the US?

silicosis and "sand blasters lung"

100

What is defined as an asthma-like reaction to the inhalation of cotton dust?

byssinosis

101

what is the classic early asthmatic response?

a rapid-onset IgE mediated bronchoconstriction right after exposure to a specific trigger

102

what is the classic late asthmatic response?

mucosal edema d/t inflammatory response that occurs 6-24 hours after exposure to the specific trigger

103

what are activated in the lungs of asthmatic pts?

eosinophils

104

what alteration takes place in the epithelium of chronic asthma pts?

increase in number of mucus secreting cells (=> dramatic increase in mucus production)

105

what can inflammation and tissue alterations in asthmatic pts result in?

an asthmatic response upon exposure to non-specific irritants

106

what is classically associated with allergic asthma?

exogenous/extrinsic asthma

107

what are common causes of endogenous asthma?

GERD, viral respiratory infections, emotional stress, obesity, exposure to cold or dry air

108

what are some examples of conditions that can involve wheezing?

asthma, bronchitis, neoplasm, pulmonary edema/CHF, respiratory foreign bodies, hyperventilation syndrome

109

T/F: severity of symptoms and intensity of wheezing sounds usually correlate with the actual degree of airway obstruction

false - does not correlate

110

what is an acute asthmatic exacerbation that's unresponsive to bronchodilators?

status asthmaticus

111

what are the signs of respiratory distress?

1. increased RR 2. increased HR 3. diaphoresis 4. excessive use of accessory msls of respiration

112

what is a commonly used benchmark for CHF?

left ventricle ejection fraction

113

What are two types of late stage mitral stenosis?

1. tight mitral stenosis (TMS) 2. pulmonary vascular dz (PVD)

114

What is the most common symptom in heart failure?

dyspnea (usually d/t elevated left atrial pressure)

115

What percentage of heart failure pts have glucose abnormalities?

40%

116

how is neurohumoral stimulation a compensation for a failing heart?

sympathetic stimulation elevates HR, increases strength of cardiac contraction, and may be accompanied by diaphoresis

117

what are catecholamines thought to be toxic to?

cardiac myocytes

118

what does compensated heart failure cause?

hypertrophy

119

what does decompensated heart failure cause?

apoptosis

120

how does retention of sodium and water compensate for a failing heart?

helps maintain BP, increases preload to make use of Frank Starling mechanism

121

how does cardiac remodeling compensate for a failing heart?

dilation of ventricle OR hypertrophy

122

what is a problem associated with dilation of the ventricle during cardiac remodeling?

eventually stretched msl becomes weakened, leading to overt systolic dysfunction (balloon analogy)

123

what is a problem associated with hypertrophy during cardiac remodeling?

msl becomes stiff and can no longer relax or stretch, leading to overt diastolic dysfunction

124

what results in increased left atrial pressure?

left backward heart failure

125

what is the classic symptom progression in pulmonary venous congestion?

exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, dyspnea at rest, acute pulmonary edema

126

what is the cardinal sign of left ventricular failure?

breathlessness

127

what is the classic association with left forward heart failure?

fatigue and exercise intolerance

128

what does left forward heart failure result in?

decreased cardiac output

129

what is the most common cause of right heart failure?

left ventricular failure

130

what is the second most common cause of right ventricular failure?

lung dz (cor pulmonale)

131

what is considered a minor criterion in the dx of CHF?

edema

132

what is compensated heart failure?

heart failure with a relatively normal cardiac output/ejection fraction

133

what is decompensated heart failure?

CHF with grossly inadequate cardiac output (death)

134

what is the NYHA classification of heart failure based upon?

amt of effort needed to produce heart failure symptoms

135

what is class I CHF?

comfortable at rest and NO limitation of ADLs

136

what is class II CHF?

comfortable at rest with SLIGHT limitation of ADLs

137

what is class III CHF?

comfortable at rest with MODERATE limitation of ADLs

138

what is class IV CHF?

Uncomfortable at rest with SEVERE limitation of ADLs (decompensation)

139

what is the most common form of heart failure?

dilated cardiomyopathy

140

Does dilated cardiomyopathy cause systolic or diastolic failure?

systolic

141

does hypertrophic cardiomyopathy cause systolic or diastolic failure?

diastolic

142

how may a compensated pts appear at rest?

comfortable

143

what commonly precedes dilated cardiomyopathy?

systemic hypertension

144

what kind of therapy is very effective in preventing the development of CHF?

anti-hypertensive therapy

145

What is a common cause of sudden cardiac death in young competitive athletes?

hypertrophic cardiomyopathy

146

what are some morphologic changes that occur in response to training?

increased left ventricular wall thickness, increased interventricular septal thickness, increased left ventricular end-diastolic dimension

147

after the first week of detraining, how much physiologic hypertrophy is lost?

up to 60%

148

within the first 3 weeks of detraining, how much does maximal cardiac output during exercise decrease?

8% (VO2 max decreases 8% also)

149

What is the most common cause of sudden cardiac death in athletes over 35?

CAD

150

what is the most common cause of sudden cardiac death in athletes under 35?

hypertrophic cardiomyopathy

151

What is S1?

closure of the mitral and tricuspid valves. Marks start of ventricular systole

152

What are the different names for mitral valve systolic murmurs?

mitral regurgitation, mitral imcompetence, systolic regurgitant murmurs, holosystolic murmurs

153

what are the two problems with acute mitral regurgitation?

dyspnea and decreased systemic perfusion

154

what is the key clinical feature for acute mitral regurgitation?

dyspnea

155

What usually occurs 10 years after acute MR is dxed?

90% of pts die or undergo surgical procedure

156

What does dilation of the left atrium imply?

chronic mitral regurgitation

157

what does rupture of a papillary msl imply?

acute mitral regurgitation

158

What has mitral regurgitation classically been associated with?

rheumatic heart dz

159

what is mitral valve prolapse?

an abnormal upward systolic displacement of the one or both mitral valve leaflets

160

what are the 3 categories of mitral valve prolapse?

1. "click" 2. syndrome 3. "click-murmur"

161

is mitral valve prolapse syndrome more common in men or women?

women

162

what age range has a peak incidence of mitral valve prolapse syndrome?

30-40

163

Is leaflet approximation good or bad in mitral valve prolapse syndrome? Why?

good, the valve still closes and there is no murmur or regurgitation

164

How does mitral valve prolapse present in many pts?

benign and asymptomatic

165

Describe the regurgitation associated w/ MVP click-murmur?

some degree of regurgitation - valve does not fully close

166

What is the peak incidence for MVP click murmur?

45-60

167

is MVP click-murmur more common in males or females?

males

168

what are potential complications of mitral valve prolapse?

mitral valve regurgitation, infective endocarditis, cerebrovascular accidents

169

what causes congenital aortic stenosis?

small/unicuspid/bicuspid aortic valve (more susceptible to wear and tear)

170

with a congenital aortic stenosis, when do symptoms develop?

during growth spurts

171

what is the first problem with adult onset aortic valve stenosis?

left ventricular hypertrophy and diastolic failure

172

what is the eventual problem with adult onset aortic valve stenosis?

left ventricular dilation and overt heart failure

173

what are the 2 most important clinical features of adult onset aortic stenosis?

1. late appearance of symptoms 2. dyspnea on exertion

174

What is S2?

closure of the aortic and pulmonic valves. End of ventricular systole

175

what does classic chronic aortic regurgitation lead to?

diastolic regurgitant murmur, increased stroke volume, combined hypertrophy and dilation of left ventricle

176

what is a common first symptom of chronic aortic regurgitation?

uncomfortable awareness of the heart beat

177

what is the key feature of classic mitral stenosis?

elevated left atrial pressure

178

what is mitral stenosis most often due to?

rheumatic fever

179

what is the first symptom of mitral stenosis?

dyspnea on exertion (almost all heart valve dzs)

180

When does S3 occur?

mid diastole during rapid passive ventricular filling

181

what is the abnormal variant of S3?

ventricular gallop (s1, s2, s3)

182

When does S4 occur?

late diastole during period of atrial contraction

183

What does S4 imply?

decreased ventricular compliance/remodeling

184

What is the abnormal variant of S4?

atrial gallop (s4, s1, s2)

185

when is a "soft" s4 common?

in pts with no overt signs of heart dz