IM 1 Flashcards
(101 cards)
1
Q
CF-1: 56 yo mane comes to the ER complaining of chest discomfort. He describes the discomfort as severe, retrosternal pressure sensation that had awakened him from sleep 3 hours ealier. He previously had been well but has a medical history of hypercholesterolemia and 40ppy smoking. On exam, appears comfortable and diaphoretic, P-116 BP 166/102, R 22 O2 96% on room air. Jugular venous pressure appears normal. Auscultation of the chest reveals clear lung fields, reg rhythm with S4 gallop, no murmurs or rubs. Chest radiograph shows clear lungs, normal cardiac silhouette. ECG: ST elevations. Dx? next step?
A
Most likely, Acute ST segment elevation MI. Next step in therapy: Morphine (or fentanyl) for pain control, O2, sublingual and/or IV nitroglycerin, soluble aspirin 162-325mg, clopidogrel 300-600 loading dose, IV metoprolol 2-5 mg given every 5 minutes (up
2
Q
acute coronary syndrome
A
spectrum of acute cardiac ischemia: unstable angina- acute MI
3
Q
acute myocardial infarction
A
death of myocardial tissue
4
Q
non-ST-segment elevation myocardial infarction
A
MI, but without ST elevation. May have ST depression or T wave inversion. Represent SUBENDOCARDIAL infarctions.
5
Q
PCI
A
percutaneous coronary intervention
6
Q
ST-segment elevation myocardial infarction
A
MI defined as in acute MI. ST elevation more than 0.1mV in two or more contiguous leads. Represent TRANSMURAL infarctions
7
Q
thrombolytics
A
tPA, streptokinase, reteplase used to restore patency
8
Q
pathophysiology of acute coronary syndromes.
A
caused by in situ thrombosis, occasionally caused by embolic occlusion, coronary vasospasms, vasculitis, aortic root or coronary artery dissection, or coccaine use (both vasospasm and thrombosis)
9
Q
diagnostic criteria for acute MI
A
History: CHEST PAIN, sometimes radiating to the arm or jaw. In contrast to stable angina, lasts more than 30 min and is not relieved by rest. Accompanied by sweating, nausea, vomiting and/or sense of impending doom. Patient older than 70yo diabetic, may
10
Q
physical findings
A
S4 gallop - reflecting myocardial noncompliance because of ischemia. S3 gallop representing severe systolic dysfunction. Apical systolic murmur of mitral regurgitation caused by ischemic papillary muscle dysfunction.
11
Q
ECG evolution
A
Hyper acute T waves, elevation of ST segments, hours-days T wave inversion, Q waves-signify necrosis/scar tissue.
12
Q
ECG localization
A
Inferior heart/RCA 2-3-aVF, Anterior heart/LAD V2-V3, Lateral heart/ left circumflex 1-aVL-V5-V6
13
Q
cardiac enzymes
A
Cardiac specific troponin I rises 2hours peaks 2 days gone in 7. ck-mb rises in 6 hours, peaks in 12 hours, and gone in 24-36. Generally 2 sets of normal troponin 4-6 hours apart exclude MI.
14
Q
diagnosis of MI, made by 2 of the following:
A
chest pain persisting for more than 30min. typical ECG findings, elevated cardiac enzyme levels.
15
Q
main differentials
A
Aortic dissection (unequal pulses, new murmur, widend mediastinum) Acute pericarditis ( diffuse ST segment elevations)
16
Q
when are thrombolytics given?
A
within 3 hours of onset of chest pain.
17
Q
indications for thrombolytic therapy?
A
Clinical complaint is consistent, ST elevation more that 1mm in at least 2 anatomically contigues leads, no contraindications, patient younger than 75.
18
Q
Absolute contraindicatons
A
think bleeding:
surgery, trauma within 2 weeks, aortic dissection, pericarditis, history of cerebral tumor/hemorrhage, arteriovenous mal, allergy, cerebrovascular accident within the past 12 mths. uncontrolled hypertension, recent hepatic/renal biopsy.
19
Q
whe is PCI indicated
A
Prefered method, STEMI within 2-3 hours of onset, within 90 min.
20
Q
complications of MI
A
ventricular arrythmias, ventricular tachycardia, ventricular fibrillation in first 24hrs. Sinus bradycardia - RCA/inferior involvment. First degree block (PR prolonged), Mobitz-I second degree block (gradual prolongation of PR interval before nonconducted
21
Q
treatment of VT
A
direct current cardioversion,
followed by amiodarone.
22
Q
Most severe complication in acute MI
A
Cardiogenic shock/ cardiac pump failure.
23
Q
Evaluation for cardiogenic shock?
A
Evaluate pt with hypotension: Pul Artery Cath
Systolic BP < 80mmHg
reduced cardiac index to less than 1.8L/min/m2
elevated LV filling pressure (Pulmonary cap wedge of >18mmHg)
24
Q
RV infarction symptoms, tx?
A
Hypotensive
clear lungs
marked JVD.
Tx Dobutamine, Dopamine.
25
LV infarction symptoms, tx?
Hypotensive,
wet lungs,
JVD
Tx Volume replacement with saline.
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New holosystolic murmur? DD?
papillary msl dysfunction,
papillary muscle rupture,
ventricular septal rupture.
GET A DOPPLER
27
Most severe complication days after MI?
Ventricular free wall rupture
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ventricular free wall rupture symptoms?
pulselessness, hypotension, loss of conciousness. FATAL
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elevated ST segment elevation persisting weeks after event?
ventricular aneurysm
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Post MI risk Statification
Submaximal exercise stess testing,
evaluation of LV systolic function
(Echo, <35% ejection fraction-risk for sudden death/v arrythmias).
High risk, implant defibrillator.
31
Secondary prevention of ischemic heart dz
1 Most important SMOKING CESSATION
2-Antiplatelet (aspirin, clopidogrel, bb, ACE inhibitors)
3-LDL <70mg/dL -colesterol med
32
36yo has severe burning chest pain that radiates to her neck. The pain occurs particularly after meals, especially when she lies down, and is not precipitated by exertion. She is admitted for observation. Serial ECG and Troponin are normal. Next step?
Initiation of PPI
33
56 yo admitted to the hospital for chest pain of 2 hrs duration. His heart rate is 42bmp, with sinus bradycardia on ECG, as well as ST-segment elevation in leads II, III, and aVF. Dx?
Inferior wall MI
34
59 yo diabetic had suffered an acute anterior wall MI. 5 days later gets into an argument and complains of chest pain. ECG shows no ischemic changes, but troponin is mildly elevated. Next step?
Diabetics can have absent/atypical symptoms
1- O2, nitroglycerin
2-Second set/ serial ECGs! and CK-MB may be used. Troponins are going to still be elevated from 5 days ago, not useful.
35
59 smoker complains of squeezing chest pain of 30 min duration. Paramedics give sublingual nitroglycerin and oxygen by nasal cannula. Blood pressure is 110/70mmHg HR 90bpm on arrival to ER. ECG is normal. Best next step?
Asprin
follow up with serial studies, may be normal initially.
36
CF-2 72yo presents to the office complaining of several weeks of worsening exertional dyspnea. Previously, he had been able to work in his garen and mow the lawn, now feels short of breath after walking 100 ft. He does not have chest pain when he walks, although in the past he has experienced episodes of retrosternal chest pressure with strenuous exertion. Once recently felt lightheaded, as if he were about to fain while climbing a flight of stairs, but the symptom passed after he sat down. He has been having some difficulty sleeping at night and has to prop himself up with 2 pillows. Occasionally, he wakes up at night feeling quite short of breath, which is relieved within minutes by sitting upright and dangling his legs over the bed. His feet have become swollen, especially by the end of the day. He denies any significant medial history, takes no medications, and prides himself on the fact that he has not seen a doctor in years. Denies smoking, and alcohol. PE: afebrile P 86 R 16 BP 115/92. Examination of the head and neck reveals pink mucosa without pallor, a normal thyroid gland and distended neck veins. Bibasilar inspiratory crackles are heard on examination. Heart regular rate and rhythm, normal S1 and a second heart sound that splits during expiration, and S4 at apex, nondisplaced apical impulse, late peaking systolic murmur at the right upper sternal border that radiates to the carotids. Carotid upstroke diminished amplitude. Dx? What would confirm?
Congestive Heart Failure, possibly as a result of aortic stenosis. Next best step? Echocardiogram to assess the aortic valve area as well as the left ventricular systolic function. Elderly px with symptoms and signs of aortic stenosis. Valvular disorder has progressed from previous angina to heart failure, reflecting severity. Urgent evaluation for possible replacement.
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Acute Heart Failure
Acute (hours, days) presentation of cardiac decompensation
- pulmonary edema
- low cardiac output
may proceed to cardiogenic shock.
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Chronic Heart Failure
Months, years
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Diastolic Dysfunction
Increased diastolic filling pressures caused by impaired diastolic relaxation and decreased ventricular compliance.
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Systolic Dysfunction
Low cardiac output caused by impaired systolic function ( low ejection fraction)
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Cardiac remodeling
changes to heart due to increased cardiac loading (pre and after load) leads to cardiac dysfunction.
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Neurohumoral responce to CHF
activation of renin-angio-aldosterone axis
| increased sympathetic activity
43
forward failure
systolic dysfunction (LVEF >40%),
low cardiac output - fatigue, lethargy, hypotension
1-Alcohol, Adriamycin, w-BeriB, Cox B, Chagas, Cocaine, Doxyrub, Dyptheria
2-dilated cardiomyopathy
44
backward failure
```
diastolic dysfunction (LVEF <40%)
-S4 (late diastolic murmur)
```
increased filling pressure - dyspnea, peripheral edema, ascites
1- hypertrophic cardiomyopathy- IHHS-HCOM
2- chronic HTN
45
NYHA classification
HF evaluation by patients exercise tolerance:
1-no limitation
2- slight limitation on physical activity
3-marked limitation on physical activity (mortality 20% yearly)
4-Symptoms at rest (mortality 60%)
46
CHF due to myocardial injury?
Adriamycin, alcohol, cocaine, ishemic cardiomyopathy, rheumatic fever, viral myocarditis
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CHF due to pressure overload?
volume overload?
PO-aortic stenosis, hypertension
VO-mitral regurge
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CHF due to infiltrative dz?
chronic work overload?
amyloidosis, hemochromatotis.
Chronic: tachycardia/bradycardia
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Three major goals for patient with CHF?
relief of symptoms,
prevention of dz progression,
reduction of mortality risk
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Tx
Relief of symptoms: Na restriction, loop diuretics, possible digoxin
Reduce mortality in patients with impaired systolic function: ACE, BB
if ACE non tolerated use hydralazine with nitrates.
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When do you not use ACEI?
non tolerant and blacks, use hydralizine with nitrates.
52
MOA in CHF- BB
prevent and reverse adrenergically mediated intrinsic myocardial dysfunction and remodeling
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MOA in CHF- ACEI
reduce preload and afterload,
reduce: right atrial P, pulmonary arterial P and pul cap wedge P along with SVR
prevent remodeling
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MOA in CHF- Nitrates
reduce preload and clear pulmonary congestion
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MOA in CHF- Diuretics
decrease preload, especially acutely
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MOA in CHF- Digoxin
improve cardiac contractility
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narrow pulse pressure, harsh late peaking systolic murmur radiating to the carotids and delayed slow rising carotid upstroke.
Aortic stenosis, physical findings
58
Aortic stenosis epidimiology
MC valvular abnormality in adults, younger than 30- congenital bicuspid valve, 30-70- congenital stenosis, acuired rheumatic heart dz, >70 degenerative calcific stenosis
59
Aortic stenosis labs, imaging
ECG left hypertrophy, Doppler ECG thickend valve, severity assessed by aortic valve area and transvalvular pressure gradient. As valve orifice narrows, pressure gradient increases in an attempt to maintain cardiac output. Severe- <1cm2 (NL 2-3cm2) Mean
60
55yo noted to have moderately severe CHF with impaired systolic function. Drug that would lower his risk of mortality?
ACEI
61
In the US, what is the most likely cause of CHF in the previous patient?
Atherosclerosis
62
35yo woman noted to have chest pain with exertion, and has been passing out recently. On examination she is noted to have a harsh systolic murmur. Best therapy for her condition?
Valve replacement
63
55yo noted to have CHF and states he is confortable at rest but becomes dyspneic even with walking to bathroom. On echocardiography, he is noted to have an ejection fraction of 47%. Type of dysfunction?
Diastolic Dysfunction
64
CF-3 26yo woman presents to the ER compaining of sudden onset of palpitations and severe SOB and coughing. She reports that she has experianced several episodes of palpitations in the past, often lasting a day or two, but never with dyspnea like this. Reports that she experianced several episodes of palpitations in the past, often lasting a day or two, never with dyspnea like this. Rheumatic fever at age 14. 20 weeks pregnant first child, takes prenatal vitamins. Denies medications, tobacco, alcohol and illicit drugs.
On examination, R 110-130 irregular irregular, BP 92/65 RR 24 O 94% RA. Uncomfortable, labored respirations. Coughing, producing scant amount of frothy sputum with pinkish tint. She appears uncomfortable, labored raspirations. Coughing, producing scant amount of frothy sputum with pinkish tint. Ruddy cheeks, no JVP. Bilateral inspiratory crackles in lower lung fields. Irr Irregular loud S1 and low pitched diastolic murmur at apex. Apical impulse is nondisplaced. Uterine fundus is palpable at the umbilicus, ans she has no peripheral edema. ECG atrial fib. Dx? next step?
ECG- absence of p waves and irregularly irregular responce. Dx- atrial fibrillation, mitral stenosis. Next step? cardiac rate control and IV BB
65
28yo has been told she has RHD, specifically mitral stensis. Murmur most likely present? Other heart sounds?
Mitral Stenosis- Diastolic rumble at the apex of the heart. Other heart sounds AR- early diastolic decrescendo murmur. MR- holostystolic murmur at apex. AS- late peaking systolic murmur at the upper sternal border.
66
48yo is noted to have atrial fibrillation with a ventricular HR of 140bpm. She is slightly dizzy with a systolic blood pressure of 75/48 mmHg. Most appropriate next step?
DC cardioversion. Significant symptoms of hypotension caused by AF and rapid ventricular rate.
67
Atrial Fibriallation epidemiology
MC arrythmia for which px seeks tx. Acute paroxysmal and chronic forms. Morbitity: 1-may trigger rapid ventricular rate leading to MI or exacerbation of HF. 2- thrombus formation in noncontractile atria. Duration of AF longer than 48hrs, higher risk of
68
Most common causes of AF?
HTN and coronary atherosclerosis
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Causes of AF "I SMART CHAP"
Inflammatory dz (pericarditis/myocarditis), Surgery, Medications (theophylline, caffiene, digitalis), Atherosclerotic coronary dz, RHDz, Thyrotoxicosis, CHF, Hypertensive heart dz, Thyrotoxicosis, CHD, Hypertensive HDz, Alcohol, Pulmonary Dz (PE)
70
Goals in tx of AF
Stabilization, Rate control, Conversion to sinus rhythm, Anticoagulation
71
Tx unstable AF? stable AF?
unstable (hypotensive, angina pectoris, pulmonary edema)- DC cardioversion. stable- IV BB, CaCB or digoxin.
72
Cardioverting types, SE
DC-Direct Current, Pharmacological- Procainamide, Sotalol, Amiodarone. SE: clot embolization- stroke, MI. AF >48 hrs, Warfarin therapy 3-4 weeks prior to and after cardioversion. Low risk patients, transesophageal echocardiography. Postcardioversion
73
Prognositc factors for AF
Left atrial dilation (Atrial diameter>4.5 cm predicts failure of cardioversion) and duration of AF (electrical remodeling of the heart). Chronic AF: rate control, anticoagulation (5% chance per year incident, goal INR 2-3)
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lone AF, less than 60yo with no stoke factors
risk of stroke is very low, no anticoagulation is necessary
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clinically significant bleeding while on warfarin
Fresh Frozen Plasma and Vit K.
76
RHD, valve involved, physical signs
Right side of the heart mitral and occasionally mitral with aortic, mitral stenosis- loud S1 and opening snap following S2. Severity-mitral valve opening snap interval narrows. Low pitched diastolic rumble after the opening snap, best at the apex with be
77
WPW syndrome
accessory pathway, preexcitation. Recognized as delta waves, widen QRS and shorten PR interval. Hemodynamically unstable DC cardioversion. Stable, procainamide or ibutilide
78
A third-year medical student has been reading about the dangers of excessive anticoagulation and bleeding potential. He reviews the chart of severeal patients with atrial fibrillation currently taking Coumadin. Which of the following patients is best su
45yo- conditins associated wiht high risk for embolic stroke include dilated left atrium, CHF, prior stroke, thrombus by echocardiogram. "lone atrial fibrillation" has low risk and thus no benefit from anticoagulation.
79
59yo placed on warfarin (Coumadin) after being found to have had chronic atrial fibrillation. She is noted to have an INR of 5.8, is asymptomatic, and has no overt bleeding. Best managment for this patient?
hold warfarin, target INR 2-3 non symptomatic patient just hold warfarin.
80
45 yo noted to have dizziness, pounding of the chest, and fatigue of 3 hours duration. On examination, noted to have a BP of 110/70mmHg and a HR of 180 bmp. She is noted on ECG to have atrial fibrillation with delta waves. The emergency room physician
Procainamide, DC cardioversion is an option; however in a hemodynamically stable patient, procainamide may be used. It will slow the propagation through the accessory pathway. Procainamide SE hypotension, wide QRS and sometimes greater propigation thro
81
CF-4 37yo executive returns to your office for follow-up of recurrent abdominal pain. He initially presented 6 weeks ago, complaining of an increasing frequency and severity of burning epigastric pain, which he has experianced occasionally for more than 2 years. Now the pain occurs three or four times a week, usually when he has an empty stomach., often awakens him at night. Pain usually is relieved within min by food or over the counter antacids but when recurs within 2-3 hours. Admitted that stress at work had recently increased and that because of long working hours, he was drinking more caffeine and eating a lot of take out foods. His medical history and review of systems were otherwise unremarkable and other than the antacids, he takes no medications. PE normal including stool guaiac, neg for occult blood. You advised a change in diet and started him on H2 blocker. Symptoms resolved completely with the diet changes and daily use of the medications. Lab tests performed at his first visit show no anemia, serum H. Pylori ab was positive. Dx? Next step?
Peptic ulcer disease, antibiotic therapy for H. pylori infection. Symptoms suggestive of duodenal ulcer. No "alarm symptoms" (wt loss, bleeding, anemia, age, chronicity)
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Dyspepsia:
Pain or discomfort centered in the upper abdomen, associated with fullness, early satiety, bloating or nausea.
83
Functional (non ulcer) Dyspepsia:
Symptoms like dyspepsia persisting for 12 weeks but without evidence of ulcer on endoscopy.
84
Helicobacter Pylori:
Gram Negative microaerophilic bacillus resides in mucus layer of gastric mucosa. Produces urease enzyme that splits urea, raising local pH and allowing it to survive in acidic enviroment.
85
Peptic Ulcer Disease
Presence of gastric or duodenal ulcers as demonstrated by endoscopy or upper GI barium study
86
burning epigastric, mid chest pain occurring after meals and worstening with recumbency?
GERD "heartburn"
87
acute onset severe pain, right upper quadrant or epigastrium, usually precipitated by meals with high fat content, lasting 30-60 min with spontaneous resolution, more common in women.
Biliary Colic
88
Chronic dysmotility symptoms (bloating, cramping) relieved by defecation, without weight loss or bleeding.
Irritable bowel syndrome
89
Duodenal Ulcer presentation?
pain due to presence of acid without food or buffers, symptoms produced after stomach is emptied but food stimulated acid production persists, 2-5 hours after a meal. May awaken a patient at night, circadian rhythms increase acid producion. Pain relieved with food or antacids.
90
Gastric Ulcer presentation?
Food worsens symptoms, pain not relieved by antacids
91
>45 with new onset dyspepsia. Possible dysphagia, persistent vomiting, early satiety?
Endoscopy!! Gastric Cancer, dysphagia if located around cardiac area. Vomiting if block pyloric channel, Satiety by mass effect. Alarm symptoms: wt loss, evidence of bleeding, anemia.
92
Young, dyspepsia, no alarm features: cause, etiology?
H. pylori antibody test, urea breath test. H. Pylori (more common in older pts, low socio economic, intitutionalized, developing countries) and associate with MALT Mucosa-associated lympoid tissue lymphoma.
93
H. Pylori pos patient, tx?
CAP: Clarithromycin and Amoxicillin (allergic-Metronidazole), and PPI 14days Quadruple theapy for treatment failed px PPI, Bismuth, Metronidazole and Tetracycline
94
NSAIDs induced gastric ulcers:
NSAIDs inhibit gastroduodenal prostaglandin synthesis, reduce secretion of mucus and bicarbonate and decreased mucosal blood flow.
95
Persistent ulcer disease, H. Pylori neg and denies NSAIDS. Along with diarrhea. Suspect?
Zollinger Ellison Sydrome, Gastrin level >1000pg/mL
96
Sever complication of PUD:
Hemorrhage with hematemesis or melena. Free perforationn into abdominal cavity may cocur in association with hemorrhage, sudden onset of pain and devolpment of peritonitis even pancreatitis.
97
Complication of chronic ulcers, presenting with perisistent vomiting and wt loss, but no abdominal distention.
Gastric outlet obstruction.
98
42yo overweight but otherwise healthy woman presents with sudden onset of right upper abdominal colicy pain 45 minutes after a meal of fried chicken. The pain is associated with nausea and vomiting, and any attempt to eat since has caused increased pain.
Cholelithiasis, Right upper abdominal pain of acute onset occring after ingestion of a fatty meal and is associated with nausea and vomiting.
99
Most accurate statement regarding H. pylori? More common in developed than underdeveloped nations. Associated with development of colon cancer. Cause of nonulcer dyspepsia. Route of transmission is thought to be sexual. Common cause of both duodenal
Linked to gastric and duodenal ulcers
100
45yo brought to the ER after vomiting bright red blood. BP 88/46 and HR of 120bpm. Next step?
IV fluid resuscitation and preparation for transfusion
101
Which should be promply referred for endoscopy? 65 new onset epigastric pain and wt loss. 32yo symptoms not relieved by ranitidine. 29yo H-pylori postive wiht dyspeptic symptoms. 49yo intermittent right upper quadrant pain following meals.
65yo new onset epigastric pain and wt loss.
