Module 4 & 5 Flashcards
(108 cards)
1
Q
What are Hypertension?
A
Persistent elevation of SBP at >140mm Hg & DBP at >90mm Hg
2
Q
What are the differential diagnosis of Angina?
A
Vascular: aortic dissection, pericarditis, myocarditis, myocardial infarction
Pulmonary: pleuritis, pulmonary embolism, pneumothorax
Gastroesophageal: gastric reflux, esophageal spasm, peptic ulcer
Musculoskeletal: costochondritis, arthritis, muscle strain, rib fracture
Other: anxiety, psychosomatic, cocaine abuse
3
Q
What are venous ulcers?
A
Chronic skin and subcutaneous lesions usually found on lower extremity between the ankle and knee, thought to occur from intracellular edema or inflammatory processes
4
Q
What is the health history of Malignant Melanoma?
A
Any skin changes/new growths that are of concern to the patient
Ask about person & family history of skin cancer
Inquire regarding history of acute blistering sunburn, chronic sun exposure; use of sun protection
Question about prior radiation exposure, thermal injury, cigarette smoking (current & in past)
5
Q
What is the diagnostic test for Rheumatic Fever?
A
Labs
Throat culture to confirm Group A streptococcal infection
Rapid antigen detection test
ESR is usually elevated
CRP is usually elevated
Imaging
ECG
Chest radiograph
Echocardiology
6
Q
What is the physical examination of Squamous Cell Carcinoma?
A
Examine entire surface of skin for suspicious lesions
Use magnifying glass and cross-illumination to highlight subtle changes in elevation and other surface characteristics.
All pigmented lesions should be carefully evaluated
A hair dryer is helpful in examining the use scalp; use a cotton-tipped applicator to move hair away from scalp
7
Q
What is a red flag for peripheral venous disease?
A
Differentiate if a superficial venous disease vs DVT which requires more active tx
8
Q
What are the differential diagnosis of chronic wounds (e.g. pressure ulcers)
A
Vascular ulcer Arterial ulcer Venous ulcer Pressure ulcer Diabetic foot ulcer Abscess Atypical ulcers Dermatological disorder Necrotizing fasciitis Skin cancers Trauma
9
Q
What is the health history of Deep Vein Thrombosis?
A
PQRST. Ask about common symptoms: pain, tenderness, erythema, warmth, and swelling of involved lower extremity
Ask about systemic symptoms: fever, chills
Ask about risk factors for VTE + fam hx of VTE
Ask about PE symptoms: chest pain, SOB, difficulty breathing, hemoptysis
PMHx + present medium
10
Q
What are the risk factors for Deep Vein Thrombosis?
A
Remember THROMBOSIS:
Trauma, travel
Hypercoagulable, HRT
Recreational drugs (IVDU)
Old (age >60 y/o)
Malignancy
Birth control pill
Obesity, obstetrics
Surgery, smoking
Immobilization
Sickness (CHF, MI, nephrotic syndrome, vasculitis)
11
Q
What diagnostic test can you use for peripheral artery disease?
A
Ankle-Brachial Index
12
Q
What are Peripheral Arterial Disease
A
Any chronic pathologic process causing obstruction or blood flow to the lower extremity arteries that overtime compromises their structure and function, producing leg symptoms of arterial insufficiency
13
Q
What is the physical examination of Dyslipidemia?
A
VS + General appearance
Particular tests/exams- measure Ht and wt, waist circumference, lipid deposits: observe skin for cutaneous xanthomas, premature arcus cornealis., palpate thyroid, CVS and GI exam (assess for hepato +splenomegaly)
Diagnostic tools: CCS Guidelines- patients w/ high CV risk be considered to have a “statin-induced condition”. Other pts should be stratified into 1 to 3 categories of CV risk, using the FRS. Double FRS when there is a family hx of premature CV disease (modified FRS)
Calculate risk (unless statin-indicated condition) using the Framingham Risk Score (FRS) or Cardiovascular Life Expectancy Model (CLEM)repeat screening every 5 yrs for FRS <5% or every yr if FRS ≥ 5%; repeat every 5 years for men and women age 40-75 to guide therapy to reduce major CVS events; complete risk assessment when pt’s expected risk status changes
14
Q
What are the 3-stage process for lacerations and abrasions?
A
clotting, inflammatory, and proliferative stages
15
Q
What are some red flags for referring to a vascular surgeon?
A
Critical Limb Ischaemia/ Rest Pain
Ulceration or Gangrene
Suspected AAA / TIA
16
Q
What is the health history of Rheumatic Fever?
A
Review a recent history (1 – 3 months) of sore throat and the onset, duration, severity and treatment of symptoms
Complete a drug history.
Did the patient finish the prescribed antibiotics? Does the patient take aspirin?
Assess the patient for signs and symptoms of rheumatic and scarlet fever
Discuss the patient’s history of heart problems, chest pain or shortness of breath
Evaluate the onset and complaints of chorea: fidgety, clumsiness, uncoordinated erratic facial movements, tongue movements. Ask if the movements and other symptoms disappear with sleep.
Review symptoms of joint pain
17
Q
What are red flags for Basal Cell Carcinoma?
A
ABCDE Checklist
Asymmetry
Border (irregular and/or indistinct)
Colour (varied)
Diameter (increasing or >6 mm)
Enlargement, elevation, evolution (e.g. change in colour, size, or shape)
18
Q
What is the physical examination of lacerations and abrasions?
A
Always use sterile technique when examining wounds
Vital signs
Inspect wound and surrounding areas
Check for foreign bodies
Assess for circulation, sensation, and movement to distal to wound
Assess ROM, and strength against resistance of all body parts surrounding wound site.
19
Q
What is the health history of lacerations and abrasions? ?
A
Mechanism of injury
How much time elapsed since the wound occurred
Current medication, esp. steroids and/or anticoagulant therapy
Hx of DM or immunodeficiency— affects infection/wound healing.
20
Q
What are red flags for Dyslipidemia?
A
primary hyperlipidemia, metabolic syndrome, derm manifestations (xanthomas), GI (pancreatitis, hepatomegaly, splenomegaly), premature arcus cornea, aortic stenosis, achilles tendinitis, hyperinsulinemia, hyperuricemia, arthritis, cholelithiasis.
21
Q
What is the physical examination of Coronary Artery Disease?
A
Assessment of ankle-brachial index for PAD
Perform a detailed CVS exam including BP in both upper extremities- noting inter-arm asymmetry.
Palpate pulses at the brachial, radial, ulnar, femoral, popliteal, DP, PT.
Assess for leg edema, diaphoresis,
Stress testing
22
Q
What is the diagnostic test for Hypertension?
A
Urinalysis
CBC, K, Na, Creatinine
Fasting glucose or A1c
Fasting lipid panel
Cholestoral, lipoprotein, triglycerides
ECG
Urinary albumin (for diabetes pts)
Consider the following for suspected 2° HTN: creatinine clearance, urinary microalbumin, 24h urinary protein, uric acid, HgA1c, TSH, drug levels, ESR, cortisol level, CRP, brain natriuretic peptide, vascular angiogram, CT scan, U/S of suspected organs, graded exercise test, resting ECG with Doppler flow imaging
Diagnose using the following algorithm Algorithm for diagnosis
Imaging
See above for suspected 2° HTN
23
Q
What are red flags for Congestive Heart Failure?
A
New chest pain (r/o MI), sudden onset increased SOB, worsening edema (flash pulmonary edema), palpitations (arrhythmia)
24
Q
What are Deep Vein Thrombosis?
A
Presence of coagulated blood—a thrombus—in one of the deep venous conduits (most often in lower extremities) that return blood to the heart
25
What is the health history of Congestive Heart Failure?
Previous heart dx (MI, CAD, HTN)
Difficulty with breathing and increased fatigue
How many pillows are needed to sleep comfortably?
Dyspnea on exertion *cardinal sign LHR
PQRST Chest pain
Weight gain
Edema -lower extremities (feet, ankles, legs, lower back, RUQ hepatic congestion) RHF
Associated symptoms- frequent colds with congestion (nocturnal nonproductive cough, orthopnea)
Episodes of syncope, palpitations?
26
What is the physical examination of Angina?
Measure Vitals; complete heart and lung exam
Measure fat distribution, waist-to-hip ration, body mass index.
Evidence of peripheral vascular disease (diminished pulses, bruits).
Examine neck for JVD, thyromegaly and bruits
Abdo exam for organomegaly; mid-epigastric pain may suggest GERD, gastritis or ulcers.
Assess peripheral pulses; assess for presence of bruits and pulses deficits
Assess for edema, cyanosis and clubbing
Ankle-brachial index measurement
27
What is the health history of Angina?
Ask patient to describe pain or discomfortPoorly localized tightness, pressure, or aching in the chest that may radiate to jaw or arm (discomfort or pain lasts 5 min or less; occurs with exertion; relieved by rest or nitro. Hx of Dyspnea, diaphoresis, dizziness, N&V; lightheadedness, weakness, palpitations, presyncope/syncope. Ask about GI upset, indigestion or nausea Ask about physical activity (if tolerance decreased)? Ask if symptoms are controlled by meds or rest and if there is a change in the frequency or pattern of ischemic pain within the preceding 6 weeks. Unstable angina- new onset of angina no longer relived by rest or meds; increase in frequency or duration of occurrences; inability to walk 1-2 blocks or climb a flight of stairs
28
What are the differential diagnosis of Malignant Melanoma?
Actinic Keratosis
Common Nevus
Seborrheic Keratosis
Solar Lentigo
29
What are the risk factors for Rheumatic Fever?
Group A pharyngitis, untreated or inadequately treated
Age 5 to 15 years
Crowded living conditions
Occupational exposure
Most common in tropical countries
Gender: more common in females
30
What is the health history of Squamous Cell Carcinoma?
Any skin changes/new growths that are of concern to the patient
Ask about person & family history of skin cancer
Inquire regarding history of acute blistering sunburn, chronic sun exposure & use of sun protection
Question about prior radiation exposure, thermal injury, cigarette smoking (current & in past)
31
What is the diagnostic test for Coronary Artery Disease?
CBC; lipid profile, thyroid function tests (to exclude thyroid disorders); blood glucose and HBA1C in pts with diabetes; C-reactive protein level; lipoprotein a ; Apolipoprotein A1; Apolipoprotein B; fibrinogen; Urine Albumin/Creatinine Ratio (Ualb/Cr)
Imaging
EKG
Stress test
Echocardiogram
32
What is the health history of Dyslipidemia?
1.Ask about previous or present CVD
2.CHD major risk factors
3.PMH-pancreatitis, renal, liver, vascular, DM, hypothyroidism, Cushing’s, immunologic disorders
4.Fam hx of premature CVD
5.Med hx: focus on drugs that elevate cholesterol levels: thiazide + loop diuretics, BB, progestins, anabolic steroids, corticosteroids, HIV meds
6.Alcohol consumption
7.Phyiscal activity
8.Derm: xanthomas
9.Hx of abdo pain
10.If female: menstrual history/?hormone replmt’ tx
11.Diet in 24hr period: CAGE
33
What are red flags for Deep Vein Thrombosis?
Pts presenting w/ dyspnea, tachycardia, hemoptysis, or chest pain require immediate transport for emergent care
Pts dx’d w/ PE à inpatient care w/ IV continuous anticoagulant tx
34
What is the health history of Myocardial Infarction?
Ask patient to describe pain or discomfortPoorly localized tightness, pressure, or aching in the chest that may radiate to jaw or arm Hx of Dyspnea, diaphoresis, dizziness, N&V; lightheadedness, weakness, palpitations, presyncope/syncope. Ask about GI upset, indigestion or nausea Severe ischemic chest discomfort that lasts morethan 20-30 minutes and is not relieved by rest or nitroglycerin. Elderly patients may have generalized weakenss, stroke, syncope, or change in mental status
35
What are Basal Cell Carcinoma?
Cells of BCC resemble those of the basal layer of the epidermis and grow by direct extension requiring surrounding stroma to support growth
Slow-growing tumor that rarely metastasizes
36
What are red flags for Peripheral Arterial Disease?
If acute onset w/ s/s of acute limb ischemia à transport for emergent care is necessary
37
What are the differential diagnosis of Basal Cell Carcinoma?
Actinic Keratosis
Common Nevus
Seborrheic Keratosis
Solar Lentigo
38
What are the risk factors for peripheral venous disease?
The venous valve fails to function properly with immobility, obesity and DVT
Genetic disposition
Females: hormonal contraceptive use, pregnancy
Prolonged standing
Greater height
39
What are the risk factors for Congestive Heart Failure?
CAD/MI (60-70%)
HTN
Ischemic cardiomyopathy
Alcohol abuse
Cor pulmonale, congenital heart defect
Arrhythmias
DM
Obesity
40
What is the physical examination of Congestive Heart Failure?
VS-hypotension, pulsus alternans, narrow pulse pressure
Skin: peripheral cyanosis, slow cap refill, cool extremities, peripheral edema
Resp: basilar crackles/rales +/- wheeze
CV: S3 gallop, elevated JVP -most prognostic
PMI shift Left and downwards
Abdo: hepatomegaly, ascites, pulsatile liver
41
What are the risk factors for Hypertension?
Diet high in Na+ & fat, low K+Excessive EtOH intakeAge: 30-55ObesityFamily hxAfrican American
42
What are red flags for Squamous Cell Carcinoma?
ABCDE Checklist
Asymmetry
Border (irregular and/or indistinct)
Colour (varied)
Diameter (increasing or >6 mm)
Enlargement, elevation, evolution (e.g. change in colour, size, or shape)
43
What is the health history of Peripheral Arterial Disease
Onset and duration à determine if ALI is present à see red flags
Features of ALI (6Ps), note all may not be present:
Pain: absent in 20% of cases
Pallor: within a few hours becomes mottled cyanosis
Paresthesia: light touch lost first then sensory modalities
Paralysis/Power loss: most important, heralds impending gangrene
Polar/Poikilothermia/’Perishing cold’
Pulselessness: not reliable
Does the pain occur with exercise or is it present with rest?
Ask how far they can walk before developing pain, determine which muscle groups are involved
Ask if erectile dysfunction is present in males
Ask if hair on toes and lower legs has been lost
Obtain PMHx: particularly smoking, diabetes mellitus and dyslipidemia and hypertension
44
What is the health history of Hypertension?
2° HTN symptoms: palpitations, sweating, dizziness, abdominal/back pain
Symptoms of stress, cardiovascular disease, cerebrovascular disease, peripheral vascular disease, renal disease, diabetes, dyslipidemia, gout, sexual dysfunction
Weight control, smoking, physical activity level
Dietary intake of Na, K, alcohol, caffeine, cholesterol, saturated fat, appetite suppressants
Medication hx (illicit and non-illicit) that may cause elevated BP: OCP, steroids, NSAIDS, decongestants, appetite suppressants, cyclosporine, tricyclic antidepressants, MOAIs)
45
What are the risk factors for Peripheral Arterial Disease
Cigarette smoking (**seen in >80% of pts w/ lower extremity PAD)
Diabetes Mellitus
Dyslipidemia
Hypertension
In ALI: Embolism risk: arrhythmias, endocarditis, arterial aneurysms. Thrombosis risk: hypercoagulable states, chronic PAD, previous vascular grafts/reconstructions
46
What is the diagnostic test for chronic wounds (e.g. pressure ulcers)
Ankle brachial index (ABI)
Arterial Doppler
47
What are the risk factors for Squamous Cell Carcinoma?
Chronic cumulative sun exposure e.g outdoor occupation or exposure to forms of radiation & chemicals eg. hydrocarbons, smoking that induce local thermal injury Caucasians w/ fair complexion, combined w/ UVR exposure are at greatest riskIncreasing age –middle age & elderlyHx of actinic keratosis
48
What are arterial ulcers?
Skin ulcers usually found on the medial or lateral foot or ankle; ulcers are non-healing due to inadequate arterial flow
49
What are the differential diagnosis of Hypertension?
Faulty/incorrect BP
2° causes of HTN (p. 466 Uphold)
Helpful algorithm on FM35 of Toronto Notes)
50
What are diabetic ulcer?
Skin ulcers usually found on the plantar surface of the foot, most commonly occurring from trauma or plantar pressure
51
What are red flags of Malignant Melanoma?
ABCDE Checklist
Asymmetry
Border (irregular and/or indistinct)
Colour (varied)
Diameter (increasing or >6 mm)
Evolving
52
What are the differential diagnosis of Dyslipidemia?
r/o all 2◦ causes of hyperlipidemia
53
What are the differential diagnosis of peripheral venous disease?
Investigations
Brodie-Trendelenberg test (in VV)
Labs
None indicated from readings
Imaging
Symptomatic patients with CEAP classifications C3-C6 require a duplex ultrasound examination evaluating both the deep and superficial systems
If peripheral artery disease (PAD) is suspected or when an ulcer if present, has an atypical appearance or location for a venous ulcer, the patient should also undergo concurrent diagnostic evaluation of PAD
54
What are the differential diagnosis of Squamous Cell Carcinoma?
Actinic Keratosis
Common Nevus
Seborrheic Keratosis
Solar Lentigo
55
What are burns?
Scalds (burns from wet heat) most common
Direct burns (flames)
Chemical burns
Electricity burns – sm. deep burns at point of entry – concerning over chest for cardiac problems
Radiation burns (sunlight)
56
What are the risk factors for Basal Cell Carcinoma?
Exposure to ultraviolet radiation esp. in pattern of intense, episodic exposure e.g. outdoor activity on weekends, holidays
Fair skin, red/blond hair, light eyes
Depressed immune system
Age >60, male, location of initial tumor on trunk, presence of superficial rather than nodular subtype
57
What is the physical examination of Malignant Melanoma?
Examine entire surface of skin for suspicious lesions
Use magnifying glass and cross-illumination to highlight subtle changes in elevation and other surface characteristics.
All pigmented lesions should be carefully evaluated
A hair dryer is helpful in examining the use scalp; use a cotton-tipped applicator to move hair away from scalp
Individuals at high risk for melanoma should have careful ocular exam to assess for presence of melanoma in the iris and retina
58
What is the diagnostic test for Peripheral Arterial Disease
Investigations
Ankle-brachial index (ABI)—see Uphold and Graham p. 509 for complete breakdown of test
Labs
Troponin
CBC
PT/INR, PTT
Imaging
ECG
Echocardiogram
CT angiogram
Conventional catheter based angiography
59
What is the health history of peripheral venous disease?
Onset, duration and location of symptoms (OPQRST)
Ask about symptoms of early disease (C0-C3) are limb discomfort (tired, heavy legs) or leg pain, mild ankle swelling or transient edema, telangiesctasias and/or varicose veins may also be present
Ask about s/s of advanced disease (C4-C6): early disease s/s plus skin changes and ulcers of ankle
If pain or ankle swelling present, ask if symptoms are worse with prolonged standing and relieved with elevation or walking
If active ulcerations à determine ulcer characteristics (location and if painful/painless)
PMHx: surgeries, DVT, comorbid conditions
Ask about tobacco use and willingness to try smoking cessation
Ask about treatments tried to control symptoms
Ask about lifestyle and employment and symptoms are affecting quality of life
Red Flags
60
What are the differential diagnosis of Congestive Heart Failure?
COPD, asthma
PE, endocarditis, pericarditis
MI, arrhythmia
Dependent edema
HTN, anemia
Obstructive sleep apnea
Medication noncompliance
Dietary indiscretion
61
What are red flags for burns?
Always ask about potential for smoke inhalation *
Assess for the possibility of abuse and neglect (scald injuries consistent with “dipping”, cigarette or iron burns) **
62
What are the differential diagnosis of Peripheral Arterial Disease
Spinal stenosis
Osteoarthritis
Venous claudication
Mechanical muscle pain
Peripheral nerve pain (e.g. diabetic neuropathy)
Post-thrombotic syndrome
Acute gout
63
What is the physical examination of Deep Vein Thrombosis?
VS: if HR >100 bpm à possibility of PE. Fever is a non-specific finding for DVT and PE
Examine affected extremity for localized tenderness along the distribution of the deep venous system. Assess for warmth and erythema. If pitting edema present à find out if it is confined to symptomatic area (calf) vs whole leg
Determine if inguinal lymph nodes on side of affected leg are enlarged
Calculate pretest probability of VTE using Wells rule (see Investigations)
64
What are the differential diagnosis of Rheumatic Fever?
Differential Diagnoses
Juvenile rheumatoid arthritis
Rheumatoid arthritis
Gonococcal arthritis
Septic arthritis
Sickle cell anemia
Infective endocarditis
Leukemia
Gout
Huntington chorea
Kawasaki disease
Systemic lupus erythematous
Lyme’s disease
Reiter’s syndrome
Scarlet fever
Rhinitis or sinusitis
Epiglottitis
65
What is the diagnostic test for Squamous Cell Carcinoma?
Skin biopsy should be performed on all lesions suggestive of malignancy or when there is diagnostic uncertainty
66
What is the physical examination of chronic wounds (e.g. pressure ulcers)
Vital signs
| Full skin examination
67
What is the physical examination of Myocardial Infarction?
Measure Vitals; complete heart and lung exam
Assess peripheral pulses;
Assess for edema, cyanosis and clubbing.
General: abnormal vital signs including tachycardia or bradycardia, hypertension or hypotension, widened pulse pressure, tachypnea, fever
Neurologic: dizziness, syncope, fatigue, weakness, altered mental status
Cardiovascular: dysrhythmia, jugular venous distention (JVD), new murmur, rub or gallop, diminished peripheral pulses, carotid bruits
Respiratory: tachypnea, increased work of breathing, crackles
Musculoskeletal: Sharp pain reproducible with movement or palpation is unlikely to be cardiac.
Skin: cool skin, pallor, diaphoresis
68
What is peripheral venous disease?
A broad spectrum of diseases affecting the venous system of the lower limbs:
Deep Venous Thromboembolism (DVT) *see next page*, superficial venous thrombosis (SVT), varicose veins (VV), chronic venous insufficiency (CVI)
69
What is the diagnostic test for Deep Vein Thrombosis?
Wells Clinical Prediction Rule for dx of DVT:
Paralysis, paresis, or recent orthopedic casting of lower extremity (1)
Recently bedridden (>3 d) or major surgery within past 4 wks. (1)
Localized tenderness in deep vein system (1)
Swelling of entire leg (1)
Calf swelling >3 cm than other leg (measured 10 cm below the tibial tuberosity) (1)
Pitting edema greater in the symptomatic leg (1)
Collateral non-varicose superficial veins (1)
Active cancer or cancer treated within 6 mo. (1)
Alternative dx more likely than DVT (e.g. Baker's cyst, cellulitis, muscle damage, superficial venous thrombosis) (-2)
Total Score Probability: 0 = Low; 1-2 = Moderate; >3 = High
Labs
D-dimer test
only useful to R/O DVT if (-) in low-mod risk pts. High risk of false (+) in: elderly, infection, recent surgery, trauma, hemorrhage, late in pregnancy, liver disease, cancer
Imaging
Doppler U/S (most useful dx test, but only 73% sensitive for calf DVTà may need to repeat if test is (-) but pt is mod-high risk for DVT)
MRI, Impedence plethysmography
Venography (gold standard, but $$$, invasive + high risk)
CT pulmonary angiography or V/Q scan if PE suspected
70
What is the diagnostic test for peripheral venous disease?
Differential Diagnoses
Lymphedema
Trauma
Soft skin infection
Cellulitis
Arterial ulcer
Diabetic ulcer
71
What is the health history of burns?
What caused the burn?
How long was the skin in contact for with agent?
If electrical if the voltage was known – was consciousness lost
Pt co-morbidities – cardiac hx
Current tetanus status
Alcohol or narcotic abuse
Associated injuries
72
What are the common pathogens causing infections of lacerations and abrasions?
Staphylococcus aureus and b-hemolytic streptococcus
73
What is Congestive Heart Failure?
Inability of heart to pump enough blood to meet metabolic demands of body
Right Heart-Failure (RHF) (backward failure), elevated ventricular filling pressures, vascular congestion in vena cava
Left-Heart Failure (LHF) inability to maintain CO (forward failure) vs. pulmonary congestion (backward failure)
Biventricular Heart Failure- long term LHF leading to RHF
74
What are the risk factors for Malignant Melanoma?
Intermittent, intense exposure to UVR
Fair skinned/sun sensitive, red/blond hair
Family history of melanoma
History of blistering sunburn
Immunosuppression
75
What is the diagnostic test for Angina?
Labs
Serial cardiac troponin to rule out myocardial infarction (MI)
CBC to evaluate for anemia, infectious cause
Fasting lipid profile
Fasting glucose or hemoglobin A1C
Basic metabolic panel to rule out electrolyte abnormalities and assess renal function.
Lipoprotein associated phospholipase A2.
Imaging
EKG; CXR; Echocardiogram
Stress testing is most helpful for patients at intermediate risk of heart disease.
76
What is Angina?
Syndrome characterized by short episodes of deep, poorly localized chest pain or arm discomfort associated with physical exertion or emotional stress and relieved by rest. D/t myocardial ischemia that occurs when the cardiac workload and myocardial oxygen demand exceed the ability of the coronary arteries to supply oxygenated blood. Results from significant underlying CAD. Lactic acidosisàabnormal coronary reactivity (spasms)à chest pain.
77
What is the physical examination of Hypertension?
2 BP readings minimum; sitting down with feet on floor
automated non-invasive ambulatory BP for pts with “white coat” HTN, drug resistance, nocturnal pressure changes, episodic HTN, hypotensive symptoms, carotid sinus syncope, pacemaker syndrome
How to take BP
Height, weight, waist-hip ratio, BMI
Fundoscopic exam
Neck for dilated veins, carotid bruits, thyromegaly
Heart: clicks, murmurs, arrthymias, tachycardia
Lungs: rales, bronchospasm
Abdomen: bruits, enlarged kidneys, masses, abnormal aortic pulsation
Neuro exam
Impedence cardiography (ICG)
78
What is the physical examination of Peripheral Arterial Disease
Integumentary: Lower legs examined for: colour, temperature, skin integrity, signs of active or healed ulcers, distal hair loss, trophic skin changes and hypertrophic nails
Cardio: Perform a detailed cardiovascular examination including upper and lower extremity blood pressures, palpate all pulses, auscultate the femoral artery for bruits
Diminished, absent or asymmetrical pulses help pinpoint exact site of partial or complete occlusion
Anatomic site of the arterial stenosis often assoc. with specific leg symptoms: Iliac occlusion: hip, buttocks and thigh pain
Femoral, popliteal, &; tibial occlusion: calf painTibial: foot pain and numbness
Neuro: Perform a neurologic examination focusing on motor, reflexes and sensation to the lower extremities Particular Tests/ExamsUse of Buerger test may demonstrate elevation pallor in the lower extremities
79
What is the physical examination of peripheral venous disease?
Evaluate femoral, popliteal, posterior tibial and dorsalis pedis pulses
Test lower extremities to light touch and vibratory sensation
Assess for edema (edema extension beyond ankle suggests deep venous disease)
Assess for skin changes—pigmentation, eczema, lipodermatosclerosis, and signs of healed or active ulceration involving the ankle (most common place where changes develop in the majority of patients)
Use the CEAP classification system to determine disease severity
R/O possible systemic causes of lower extremity edema by cardiac and respiratory examinations
80
What is Coronary Artery Disease?
Atherosclerotic narrowing of the major epicardial coronary arteries. Blockages consisting of fats, platelets, other debris that form fatty streaks, fibrous plaques, and complicated lesions in large and medium sized arteries of the heart- changes lead to coronary artery narrowing. Narrowing leads to ischemic heart disease as a result of inadequate blood flow to the myocardium. CAD may manifest insidiously as angina pectoris or as an acute coronary syndrome (ACS) and lead to a myocardial infarction
81
What is the diagnostic test for Myocardial Infarction?
Troponin I and T (cTnI, cTnT) rise 3 to 6 hours after onset of ischemic symptoms.
Myoglobin fraction of creatine kinase (CK-MB): rises 3 to 4 hours after onset of myocardial injury; peaks at 12 to 24 hours and remains elevated for 2 to 3 days; CK-MB adds little diagnostic value in assessment of possible ACS to troponin testing.
Myoglobin: early marker for myocardial necrosis; rises 2 hours after onset of myocardial necrosis, reaches peak at 1 to 4 hours, and remains elevated for 24 hours; myoglobin addslittle diagnostic value in assessment of possible ACS to troponin testing.
Fasting lipid profile, CBC with platelets, electrolytes, magnesium, BUN, serum creatinine, and glucose; international normalized ratio (INR) if anticoagulation contemplated; brain natriuretic peptide (BNP) is elevated in acute MI; may or may not indicate heart failure
Imaging
EKG; ST-segment depression and/or T-wave inversion: left bundle branch block (LBBB); pathologic Q waves on ECG.
CXR
Echocardiogram
82
What are the differential diagnosis of Coronary Artery Disease?
Vascular: aortic dissection, pericarditis, myocarditis, myocardial infarction
Pulmonary: pleuritis, pulmonary embolism, pneumothorax
Gastroesophageal: gastric reflux, esophageal spasm, peptic ulcer
Musculoskeletal: costochondritis, arthritis, muscle strain, rib fracture
Other: anxiety, psychosomatic, cocaine abuse
83
What is the physical examination of burns?
VS
General appearance
Remove clothes and assess all skin
Diagnostic tools: Lund-Browder Burn Chart (palm is 0.4% of TBSA and entire hand is 0.8% of TBSA)
84
What is the diagnostic test for Basal Cell Carcinoma?
Skin biopsy should be performed on all lesions suggestive of malignancy or when there is diagnostic uncertainty.
85
What are Malignant Melanoma?
Arises from cells of the melanocyte system; begins either de novo or develops from a pre-existing lesion Initially grows superficially & laterally, confined to epidermis epidermis & papillary dermis; vertical growth occurs over time w/ penetration of dermis & subcutaneous fat· Arises from cells of the melanocyte system; begins either de novo or develops from a pre-existing lesion Initially grows superficially & laterally, confined to epidermis epidermis & papillary dermis; vertical growth occurs over time w/ penetration of dermis & subcutaneous fat
86
What are red flags for Hypertension?
Papillaedma, retinal hemmorhage
87
What is a red flag for minor lacerations or tears in the skin?
Tetanus – rare, but dangerous complication characterized by Trismus and severe muscular spasm
88
What are pressure ulcers?
Localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear
89
What are the risk factors for Coronary Artery Disease?
Atherosclerosis, PAD
Hypertension (sBP >140, dBP >90) ↓HDL, increased LDL, moderate hypertriglyceridemia (triglyceride level 2.3-9 mmol/L) is an independent risk factor for CAD, smoking, diabetes, insulin resistance, premature CAD in 1st-degree relatives (men <55 years old; women <65 years old), age (>45 for men, >55 for women)
Sedentary lifestyle; Obesity (BMI >27 kg/m2), abnormal ankle-brachial indices, renal disease
Inflammatory disease (rheumatoid arthritis, SLE, psoriatic arthritis, ankylosing spondylitis, inflammatory bowel disease)
HIV infection on highly active anti-retroviral therapy (HAART)
90
What is the health history of chronic wounds (e.g. pressure ulcers)
Location and onset
Associated drainage
Medical and medication history
History of chronic wounds
Previous treatment and outcomes any numbness or tingling in the lower extremities?
Does the patient wake up at night with pain?
Does he or she have any pain with ambulation?
91
What are the differential diagnosis of Deep Vein Thrombosis?
Muscle strain or tear
Lymphangitis or lymph obstruction
Venous valvular insufficiency
Ruptured popliteal cysts
Cellulitis
Arterial occlusive disease
92
What is the physical examination of Rheumatic Fever?
Check temperature, pulse, respirations and blood pressure
Inspect:
Inspect joints for swelling and warmth
Observe for signs of chorea
Conduct a dermal exam, especially the trunk and proximal aspects of the extremities. Individual lesions of erythema marginatum are evanescent, moving over the skin in wavy patterns. The lesions can develop and disappear in minutes, appearing to change shape while being examined
Complete an ear, nose, oral and throat exam. Evaluate tonsillopharyngeal erythema with or without exudates. Observe for beefy, red, swollen uvula.
Auscultate:
Auscultate heart. Note heart murmur, pericardial friction rub or effusion.
Auscultate all lungs fields. Note shortness of breath.
Palpate:
Palpate the neck lymph nodes
Palpate the extremities: apical and radial pulses
Palpate the abdomen
Neuromuscular examination for chorea
Have the patient stick out his or her tongue and note any movements
Have patient grip your hand – with chorea he or she will be unable to maintain a grip and rhythmical squeezing results
Observe for the spooning sign – a flexion a the wrist with finger extension when the hand is extended
Observe for the pronator sign – the palms turn outward when held above the head
93
What are the risk factors for Angina?
Same as for CAD.
Aortic stenosis, hypertrophic cardiomyopathy; HTN; congenital heart defects.
94
What is the health history of Basal Cell Carcinoma?
Any skin changes/new growths that are of concern to the patientAsk about person & family history of skin cancerInquire regarding history of acute blistering sunburn, chronic sun exposure & use of sun protectionQuestion about prior radiation exposure, thermal injury, cigarette smoking (current & in past)
95
What are the risk factors for Dyslipidemia?
1◦ hyperlipidemia- specific inherited traits resulting in defects in lipid metabolism + transport
2◦ hyperlipidemia *(screen all patients w/the following conditions regardless of age): obesity, clinical evidence of atherosclerosis, AAA, Endocrine disorders (DM, Cushing’s, Metabolic Syndrome, hyper/hypoparathyroidism), renal disorders (CKD, uremia, nephrotic syndrome), hepatic disorders, immunologic disorders (lupus), stress, smokers , arterial hypertension, stigmata of dyslipidemia, Fam Hx of premature CVD (Men <55 and women <65 yrs in 1st degree relative), inflammatory disease, HIV, erectile dysfunction, COPD, HTN in pregnancy, alcohol, medications
CHD Risk Factors: (if ≥2, then calculate Framingham risk pg.543 uphold; use medCalc app or CCS app)
+: smoking, HTN (BP≥140/90 or on antihypertensive meds), low HDL (<40mg/dL), fam hx of premature CHD, age (men ≥45; women ≥55)
-: HDL cholesterol ≥60 mg/dL
96
What are the differential diagnosis of burns?
Depends on the intensity of the burning agent and the amount of time in contact with skin
Superficial: minimal epithelial damage, no skin loss; slight erythema, blanches with pressure, can have sm. dry blisters – very painful
Superficial partial-thickness: all epidermis and upper dermis, but spare epidermal appendages (hair follicles, nails, sweat, and sebaceous glands, and sensory nerve cells); tender, erythematous, weeping skin, and clear blisters; blanches with pressure – painful
Deep partial-thickness: epidermis, dermis, and damage to the appendages – patchy areas of injury varying from superficial partial to full thickness; appear pale and waxy with patchy red areas and may have large blisters, no blanching – decreased pinprick sensation
Full-thickness: entire thickness of skin, including underlying subcutaneous fat –sensation absent
Deep: all above plus involves fat, muscle, and bone
97
What is the diagnostic test for Malignant Melanoma?
ABCDEs tend to have greatest diagnostic accuracy when used in combination
98
What is the diagnostic test for Congestive Heart Failure?
Investigations
Goal: to determine underlying cardiac abnormality and ID possible aggravating factors, degree of ventricular impairment and type of cardiac dysfunction
Initial: 12-lead ECG
Labs
BNP (test of choice to dx HF)
CBC, serum glucose, electrolytes+ extended lytes
HbA1C
BUN, Creatinine
TSH
LFTs
Lipid profile
Urinalysis
CRP, troponin, CK, Iron, ferritin, albumin
Imaging
CXR
TTE (transthoracic echocardiogram) + doppler GOLD standard cardiac pump size ax
Stress test or Nonstress test if cannot complete treadmill
99
What are Squamous Cell Carcinoma?
Atypical squamous cells originate in epidermis, proliferate & penetrate epidermal basement membrane, eventually expand to dermis
100
What are the risk factors for Myocardial Infarction?
Same as for CAD.
Aortic stenosis, hypertrophic cardiomyopathy; congenital heart defects.
101
What is the diagnostic test for Dyslipidemia?
Investigations / Labs
Screening: Refer to CCS for screening guidelines
Lipid testing done non-fasting
-men and women ≥40 (consider earlier in ethnic groups at árisk (South Asian/First Nation)
-screen all pts who fit risk factors for 2◦hyperlipidemia regardless of age
For all:
-Hx and physical exam
-standard lipid panel (TC, LDL-C, HDL-C, TG)
-Non-HDL-C (will be calculated from profile)
-Glucose
-eGFR
Optional:
-ApoB
-Urine albumin:creatitine ratio (if eGFR <60 mL/min/1.73m2, HTN, or DM
*if pt has hx of triglyceride levels >4.5 mmol/L then measure lipid + lipoprotein levels fasting
*see CCS guidelines for secondary testing
102
What is the physical examination of Basal Cell Carcinoma?
Examine entire surface of skin for suspicious lesions
Use magnifying glass and cross-illumination to highlight subtle changes in elevation and other surface characteristics.
All pigmented lesions should be carefully evaluated
A hair dryer is helpful in examining the use scalp; use a cotton-tipped applicator to move hair away from scalp
103
What are the risk factors for lacerations and abrasions?
Elderly and undernourished
Immunodeficiency and diabetes mellitus Chemotherapeutic agents
Exposure to accidental or intentional injury
104
What is Rheumatic Fever?
Acute rheumatic fever is an autoimmune inflammatory process that occurs as sequelae of a Group A streptococcal (GAS) tonsillopharyngitis
Inflammatory disease due to antibody cross-reactivity following GAS (Group A streptococcal) infection
Is characterized by inflammatory lesions of the joints, heart, subcutaneous tissue and CNS
105
What are the differential diagnosis of Myocardial Infarction?
Unstable angina
Vascular: aortic dissection, pericarditis, myocarditis, myocardial infarction
Pulmonary: pleuritis, pulmonary embolism, pneumothorax
Gastroesophageal: gastric reflux, esophageal spasm, peptic ulcer
Musculoskeletal: costochondritis, arthritis, muscle strain, rib fracture
106
What is Myocardial Infarction?
Acute coronary syndrome (ACS) is used as a clinical classification for both unstable angina and acute myocardial infarction (AMI) because both present with similar signs and symptoms. Unstable angina involves episodes of chest or arm discomfort severe, prolonged and occur at rest, however of not a sufficient severity to result in necrosis (infarction). AMI is a process with sufficient severity and duration to be considered an infarction-permanent myocardial damage.
107
What is a non-invasive, rapid, quantitative measurement for assessing the arterial circulation?
Ankle-Brachial Index
108
What is the health history of Coronary Artery Disease?
Signs and symptoms develop gradually as the atheroma and narrowing extend in the vessels –typically silent until sclerosis, stenosis, thrombosis, aneurysm, or embolus develops.
Fatigue, mild angina on exertion, and intermittent claudication are often initial complaints.
Ask questions related to risk factors as hyperlipidemia, PVD, PAD, HTN, diabetes- are commonly associated conditions
Ask about chest pain at rest or on exertion, pressure or discomfort in the chest.
Ask about leg pain with exercise or at rest- to investigate for possible PAD (PAD is associated with atherosclerosis and increased rates of CVS ischemic events).
Assess for shortness of breath and may present as dyspnea, orthopnea.
Ask about weakness, tiredness, and reduced exertional capacity, dizziness and palpitations
