Term
| 1. what is your job when the Step 2 exam describes a patient with chest pain? |
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Definition
| Make sure the chest pain is not due to any life-threatening condition. Usually you must try to make sure that the patient has not had a heart attack. |
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Term
| 2. What elements of the history and physical exam steer you away from a diagnosis of MI? |
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Definition
-wrong age: absence of known heart disease, strong FH, or multiple risk factors for coronary artery disease, a patient under the age of 40 is extremely unlikely to have an MI.
-lack of risk factors: a 60 yo marathon runner who eats well and has high level of HDL and no other cardiac risk factors (other than age) is unlikely to have a heart attack.
-physical characteristics of pain: if the pain is reproducible by palpation, it is from teh chest wall, not the heart. The pain a/w an MI is usually not sharp or well localized. The pain should not be related to certain foods or eating.
-for exam, don't just get an EKG if there is an alternative diagnosis and MI is unlikely |
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Term
| 3. What findings on EKG should make you suspect an MI? |
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Definition
| flipped or flattened T waves, ST-segment elevation (depression means ischemia; elevation means injury), and/or Q waves in the leads where the MI was |
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Term
| 4. Describe the classic pattern of chest pain in an MI. |
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Definition
| pain is classically described as a crushing or pressure sensation; it is a poorly localized substernal pain that may radiate to the shoulder, arm, or jaw. Pain is usually not reproducible on palpation and in patients with a heart attack often does not resolve with nitroglycerin (as it often does in angina). The pain usually lasts at least half an hour. |
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Term
| 5. what tests are used to diagnose an MI? |
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Definition
| other than an EKG, get serial CK-MB, troponin I or T, or myoglobin (usually drawn every 8 hours x3 before a heart attack is r/o). Elevated LDH and reversed ratio (LDH1>LDH2) is uncommonly used for late MI b/c troponins stay elevated for more than 24 hrs. Aspartate aminotransferase (AST) usually is elevated, but this parameter is not used clinically for detection of cardiac injury. Radiographs may show cardiomegaly and/or pulmonary congestion; echocardiography may show ventricular wall motion abnormalities. |
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Term
| 6. describe the physical exam findings in a patient with MI. |
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Definition
| diaphoretic, anxious, tachycardic, tachypneic, and pale; they may have n/v. large heart attacks causing heart failure, may have pulmonary rales w/o pneumonia indications, distended neck veins, S3 or S4, new murmurs, hypotension, and/or shock |
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Term
| 7. what in the history should steer you toward a dx of MI? |
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Definition
-h/o angina or previous chest pain
-h/o murmurs
-h/o arrhythmias
-risk factors for CAD, HTN, or DM
-taking digoxin, furosemide, cholesterol meds |
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Term
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Definition
admit to ICU or cardiac care unit.
1. early thrombolysis (less than 6 hrs from pain onset) if pt. meets criteria for use . coronary angiography w/ percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) if thrombolysis is contraindicated.
2. EKGs! If symptomatic ventricular tachycardia or ventricular fibrillation, use lidocaine or amiodarone (but not prophylactically).
3. O2 by nasal cannula, keep sats >90%
4. pain control with MORPHINE (can also improve pulmonary edema)
5. NITROGLYCERIN.
6. BETA BLOCKERS. As long as not contraindicated. Reduces mortality rate of MI as well as incidence of 2nd heart attack. Avoid w/ acute heart failure.
7. ASPIRIN.
8. Consider ACE-I and HMG-COA REDUCTASE INHIBITOR acturely, which can also reduce mortality rate of acute MI. |
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Term
| 9. T or F. With good management, patients with an MI will not die in the hospital. |
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Definition
| F. Even with the best medical management, patients may die from an MI. They also may have a second heart attack during hospitalization. Watch for sudden deterioration! |
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Term
| 10. When is heparin indicated in the setting of chest pain and MI? |
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Definition
| start if unstable angina diagnosed, cardiac thrombus, or severe CHF on echo. Step 2 exam will not ask for any other indications. Do NOT give heparin to patients w/ contraindications to its use (ie, active bleeding). |
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Term
| 11. What clues suggest the common noncardiac causes of chest pain? |
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Definition
-GERD/PUD: pain related to foods (spicy, chocolate), smoking, caffeine, or lying down. relieved by antacids or acid-reducing medications. If peptic ulcer disease, will test + for H. pylori.
-Chest wall pain (costochondritis, bruised or broken ribs): pain is well localized and reproducible w/ chest wall palpation.
-esophageal problems (achalasia, nutcracker esophagus, or esophageal spasm): negative w/u for MI, lack of atherosclerosis risk factors. Abnormal barium swallow (achalasia) or esophageal manometry. Treat achalasia ith pneumatic dilatation or botulism toxin, and treat nutcracker esophagus or esophageal spasm w/ calcium channel blockers. If medical treatments are ineffective, surgical myotomy may be needed.
-Pericarditis: look for viral upper respiratory infection prodrome. EKG shows diffuse ST-segment elevation, ESR elevated, and low-grade fever present. Pain is relieved by sitting forward. The most common cause is infection with coxsackievirus. Also TB, uremia, malignancy, SLE or other autoimmune diseases.
-Pneumonia: chest pain due to pleuritis. also cough, fever, and/or sputum production. Ask about possible sick contacts.
-Aortic dissection: a/w severe tearing or ripping pain that may radiating to back. look for HTN or evidence of Marfan's syndrome (tall, thin pt. w/ hyperextensible joints). Blunt chest trauma can cause aortic laceration and pseudoaneurysm, which are different conditions but managed similarly. |
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Term
| 12. how can you recognize stable angina? |
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Definition
| chest pain of stable angina begins w/ exertion or stress and remits w/ rest or calming down. Pain described as a pressure or squeezing pain in the substernal area and may radiate to the shoulders, neck, and/or jaw. It often is accompanied by SOB, diaphoresis, and/or nausea. Pain relieved by nitroglycerin. EKG during acute attack often shows ST-segment depression, but in absence of pain, the EKG is often nl. Pain should last less than 20 min. or be relieved after a sublingual nitroglycerin; otherwise, there may be progression to unstable angina or MI. |
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Term
| 13. Define unstable angina. How is it diagnosed and treated? |
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Definition
Defined as change from previously stable angina (ex: if usually angina once a week and now once a day, that's unstable angina).
-presents w/ nl or only minimally elevated cardiac enzymes.
-EKG changes (ST depression) and prlonged chest pain that does not respond to nitroglycerin initially (like MI)
-pain often begins at rest.
-rx: similar to MI rx: admit to ICU/CCU, heparin or other anti-coagulant (glycoprotein IIb/IIIa receptor inhibitors), emergent PTCA if pain does not resolve
-usually h/o stable angina and CAD risk factors. |
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Term
| 14. pain at rest and ST elevation, but nl cardiac enzymes and responds to nitroglycerin. what is it, what causes it, and how to treat? |
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Definition
Prinzmetal's angina
-coronary artery spasm
-long term rx: calcium channel blockers (reduces arterial spasm) |
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Term
| 15. patient has no chest pain, but p/w CHF, shock, or confusion and delirium (esp. elderly patients). what is it, and how often does it present and in which patient types? |
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Definition
Silent MI
-25% of MIs
-esp. seen in diabetics w/ neuropathy |
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Term
16a. late diastolic blowing murmur (best heard at apex)
-also opening snap, loud S1, a.fib., left atrial enlargement, pulmonary HTN |
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Definition
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Term
16b. holosystolic murmur radiating to axilla
-also soft S1, left atrial enlargement, pulmonary HTN, left ventricular hypertrophy |
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Definition
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Term
16c. harsh systolic ejection murmur (best heard in aortic area; radiates to carotids)
-slow pulse upstroke, S3/S4, ejection click, LVH, cardiomegaly
-syncope, angina, HF |
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Definition
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Term
16d. early diastolic decrescendo murmur (best heart at apex)
-widened pulse pressure, LVH, LV dilation, S3 |
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Definition
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Term
| 16e. mid-systolic click, late systolic murmur, panic disorder |
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Definition
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Term
| 17. T or F. An understanding of the pathophysiology behind various changes a/w long-standing valvular heart disease is high-yield for Step 2. |
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Definition
| T. For example, it's advisable to understand why right-heart failure may occur w/ long-standing mitral stenosis. This is not memorization but rather the ability to determine rationally which changes are a/w each type of valvular dysfunction. |
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Term
| 18. Who should receive endocarditis prophylaxis? |
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Definition
| People w/ known valvular heart disease (including disease developing after endocarditis) or prosthetic valves. If mitral valve prolapse, use prophylaxis only if murmur heard on exam or patient has h/o previous endocarditis. |
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Term
| 19. Describe protocols for endocarditis prophylaxis. |
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Definition
For oral surgery, use amoxicillin before and after the procedure; clindamycin or azithromycin may be used in patients with penicillin allergy.
For GI or GU procedures, ampicillin plus gentamicin before and amoxicillin after; vancomycin if penicillin allergy. |
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Term
| 20. endothelial damage, venous stasis, hypercoaguable state. what is that and what should you think of? |
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Definition
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Term
| 21. List the common clinical scenarios for development of DVT. |
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Definition
-Surgery
-Malignancy
-Trauma
-Immobilization
-Pregnancy
-Use of birth control pills
-disseminated intravascular coagulation
-lupus anticoagulant
-deficiencies of factor V (Leyden), antithrombin III, protein C, or protein S; thrombin variant |
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Term
| 22. describe the physical signs and symptoms of DVT. how is it diagnosed? |
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Definition
signs and sx include unilateral leg swelling, pain or tenderness, and/or Homan's sign (present in 30% of cases)
-superficial palpable cords imply superficial thrombophlebitis rather than DVT
-dx DVT by Doppler ultrasound or impedance plethysmography of the veins of the extremity. Gold standard is venography, but this invasive test is reserved for when dx not clear. |
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Term
| 23. T or F: superficial thrombophlebitis is a risk factor for pulmonary embolus. |
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Definition
F. superficial thrombophlebitis (erythema, tenderness, edema, and palpable clot in a superficial vein) affects superficial veins and does not cause pulmonary emboli. It is considered a benign condition, although recurrent superficial thrombophlebitis can be a marker for underlying malignancy (eg, Trousseau's syndrome, or migratory thrombophlebitis, is a classic marker for pancreatic cancer).
-treat affected patients w/ nonsteroidal anti-inflammatory drugs (like aspirin) and warm compresses. |
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Term
| 24. how is DVT treated? for how long? |
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Definition
| systemic anticoagulation is necessary, so use IV heparin or SQ low-molecular weight heparin, followed by crossover to oral warfarin. Stay on warfarin for 3-6 mo, and possibly for life if more than one episode occurs. |
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Term
| 25. what is the best way to prevent DVT in patients undergoing surgery? |
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Definition
pneumatic compression boots and early ambulation.
-low-dose heparin if ambulation not possible
-warfarin and heaprin are esp. useful in patients undergoing orthopedic hip or knee surgery. |
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Term
| 26. in what clinical settings does PE occur? Describe signs and sx. |
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Definition
PE commonly follows DVT, delivery of a baby (amniotic fluid embolus), or fractures (fat emboli).
-classic pt.: went on long car ride or long airplane flight
-sx: tachypnea, dyspnea, CP, hemoptysis (if lung infarct occurred), and hypotension, syncope, or death in severe cases.
-rarely, chest radiograph shows a wedge-shaped defect due to pulmonary infarct |
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Term
| 27. T or F. DVT can lead to stroke. |
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Definition
F - w/ one rare exception.
-Embolization of L-sided heart clots (due to a.fib., ventricular wall aneurysm, severe CHF, or endocarditis) causes arterial infarcts (stroke and renal, GI, or extremity infarcts)- NOT pulmonary emboli
-DVT or R-sided heart clots embolize to the lungs- NOT arterially
-EXCEPTION: rarely, pts. w/ R-to-L shunt, such as PFO, atrial or ventricular septal defect, or pulmonary arteriovenous fistula, can have a venous clot embolize and cross over to L-side circulation, causing arterial infarct potentially in the brain. |
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Term
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Definition
use ventilation/perfusion (V/Q) scan or CT pulmonary angiogram to screen for PE.
-if positive test, PE is diagnosed and treatment is started.
-if test is indeterminant, gold standard: a conventional pulmonary angiogram is used to clinch dx, but invasive and carries substantial risk
-if V/Q scan or CT angiogram is negative, it is highly unlikely that the patient has a significant PE; thus no treatment is needed.
-low-probability V/Q scan and high clinical suspicion, a CT angiogram or conventional pulmonary angiogram is needed. |
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Term
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Definition
treated initially w/ IV heparin to prevent further clots and emboli
-patient then switches gradually to oral warfarin for 3-6mo.
-recurrent clots on anticoagulation or contraindications to anticoagulation, an inferior vena cava filter (ie, Greenfield filter) should be used.
-in rare patients w/ massive PE, surgical embolectomy or thrombolytics (ie, t-PA) may be attempted |
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Term
| 30. What is the most imp. side effect of heparin? |
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Definition
causes thrombocytopenia that in some unlucky patients is a/w arterial thrombosis
-easure complete blood counts to monitor for this SE, which usually occurs on day 3 to day 7 of heparin administration.
-d/c heparin immediately if platelet counts begin to fall. |
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Term
| 31. how are the effects of aspirin, heparin, and warfarin monitored? |
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Definition
-heparin is monitored w/ partial thromboplastin time (PTT), a measure of the internal coagulation pathway
-warfarin is monitored w/ prothrombin time (PT), which measures external coagulation pathway
-aspirin prolongs bleeding time, a measure of platelet functions
-clinically, the effect of aspirin is not monitored w/ lab testing, but be aware that it prolongs the bleeding time test |
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Term
| 32. how are the effects of low-molecular weight heparin monitored? |
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Definition
low-molecular-weight heparin's effect is not clinically monitored
-rarely, a special type of factor X assay (anti-Xa) is used to measure the effect |
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Term
| 33. in an emergency, how can you reverse the effects of heparin, warfarin, and aspirin? |
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Definition
Heparin and low-molecular-weight heparin can be reversed with protamine.
Warfarin with fresh frozen plasma (clotting factors) and/or vit. K (takes a few days to work), and aspirin with platelet transfusions. |
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Term
| 34a. Prolonged PTT, with low levels of factor 8, normal PT and bleeding time; X-linked |
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Definition
Hemophilia A
-AXE: Hemophilia A, X-linked, Eight |
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Term
| 34b. Prolonged PTT, with low levels of factor 9, normal PT and bleeding time; X-linked |
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Definition
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Term
| 34c. Prolonged bleeding time and PTT, normal levels of factor 8 and 9, normal PT, autosomal dominant |
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Definition
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Term
| 34d. Prolonged PT, PTT, and bleeding time, with positive D-dimer or FDPs |
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Definition
| DIC (disseminated intravascular coagulation) |
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Term
| 34d. what is associated with DIC? |
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Definition
postpartum, infection, malignancy
peripheral smear: schistocytes and fragmented cells |
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Term
| 34e. Prolonged PT, with PTT normal or prolonged; all factors but 8 are low; no correction with vit. K |
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Definition
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Term
| 34f. Prolonged PT and slightly prolonged PTT; with normal bleeding time, low levels of 2, 7, 9, and 10, proteins C and S |
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Definition
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Term
| 34f. What is vitamin K deficiency a/w? |
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Definition
neonate who did not receive prophylactic vitamin K
malabsorption
alcoholism
prolonged abx use (which kills vit. K-producing bowel flora) |
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Term
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Definition
| platelet defect and vit. C deficiency |
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Term
| 34h. chronic steroids can cause? |
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Definition
| bleeding tendency, with normal coagulation tests. |
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Term
| 35. Fatigue, dyspnea, cardiomegaly on CXR, ventricular hypertrophy on EKG, S3 or S4 on cardiac exam |
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Definition
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Term
| 36a. orthopnea; paroxysmal nocturnal dyspnea; pulmonary congestion (rales); Kerley B lines on CXR; pulmonary vascular congestion and edema, bilateral pleural effusions |
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Definition
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Term
| 36b. peripheral edema, jugular venous distention, hepatomegaly, ascites, underlying lung disease (cor pulmonale) |
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Definition
| right ventricular failure |
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Term
| 37. how is chronic CHF treated? |
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Definition
| outpatient: sodium restriction, ACE-I (reduces mortality rate), beta blockers, diuretics, spironolactone, digoxin (not in diastolic dysfunction), and vasodilators (arterial and venous) |
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Term
| 38. how is acute CHF treated? |
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Definition
inpatient: oxygen, diuretics, positive inotropes
-digoxin if patient is stable
-IV sympathomimetics (dobutamine, dopamine, amrinone) for severe CHF
-beta blockers are contraindicated for patients in acute failure |
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Term
| 39. what factors precipitate exacerbations in previously stable patients with CHF? |
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Definition
noncompliance with diet or medications
-watch out for MI, severe hypertension, arrhythmias, infections and fever, pulmonary embolus, anemia, thyrotoxicosis, and myocarditis |
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Term
| 40. define cor pulmonale. what sx? with what clinical scenarios is it associated? |
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Definition
-definition: R ventricular enlargement, hypertrophy, and failure due to primary lung disease
sx: tachypnea, cyanosis, clubbing, parasternal heave, loud P2, and R-sided S4 in addition to the signs and sx of pulmonary disease.
clinical scenarios:
-seen in pulmonary disease and pulmonary embolus
-if young woman (20-40yo) w/ no PMH or risk factors, think primary pulmonary HTN; rx w/ calcium channel blockers while awaiting heart-lung transplantation
-sleep apnea can cause cor pulmonale- look for obese snorer who is sleepy during the day |
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Term
| 41. what causes restrictive cardiomyopathy? how is it different from constrictive pericarditis? |
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Definition
restrictive cardiomyopathy: problem with the ventricles, usually due to amyloidosis, sarcoidosis, hemochromatosis, or myocardial fibroelastosis
-abnl. ventricular biopsy in all of these conditions
-constrictive pericarditis can be fixed simply by removing an abnl pericardium; look for a pericardial knock on exam, calcification of the pericardium, and nl ventricular biopsy
-watch for S4 (indicates stiff ventricles) and signs of R-sided HF (JVD, peripheral edema) in both conditions.
-these 2 disorders are mentioned together b/c they cause "restrictive" type cardiac physiology, but the treatments are quite different |
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Term
| 42. what is the most common kind of cardiomyopathy? what causes it? |
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Definition
dilated cardiomyopathy, which most commonly is caused by chronic coronary artery disease or ischemia, though by strict definition this is not true cardiomyopathy
-USMLE: think alcohol, myocarditis, doxorubicin as causes of dilated cardiomyopathy |
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Term
| 43. which cardiomyopathy is likely in a young person who passes out or dies while exercising or playing sports and has a FH of sudden death? |
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Definition
hypertrophic CM
-may be AD
-idiopathic, causes asymmetric ventricular hypertrophy that reduces CO (ex. of diastolic dysfunction)
-rx: beta blockers and verapamil (allows ventricular more time to fille)
-avoid competitive sports
-contraindicated b/c worsen condition: positive inotropes (digoxin), diuretics, and vasodilators |
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Term
| 44. rx of atrial fibrillation |
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Definition
in symptomatic patients, 1st slow ventricular rate w/ digoxin, beta blockers, or calcium channel blockers
-if acute (onset <24 hrs): cardiovert w/ amiodarone, procainamide, or DC cardioversion
-f chronic, first anticoagulate, then cardiovert; if fails or a.fib. recurs, leave pt. on digoxin and warfarin |
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Term
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Definition
treat like afib
-can try stopping arrhythmia and vagal maneuvers (ie, carotid massage) |
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Term
| 44c. rx of first degree heart block |
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Definition
| no rx, avoid beta blockers and calcium channel blockers, both of which slow conduction |
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Term
| 44d. second-degree heart block |
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Definition
-for mobitz type I, use pacemaker or atropine only in symptomatic patients
-use pacemaker in all patients w/ Mobitz type II |
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Term
| 44e. rx for third-degree heart block |
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Definition
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Term
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Definition
-procainamide or quinidine
-avoid digoxin and verapamil |
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Term
| 44g. ventricular tachycardia |
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Definition
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Term
| 44h. ventricular fibrillation |
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Definition
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Term
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Definition
usually not treated
-if severe and symptomatic, consider amiodarone or lidocaine |
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Term
| 44j. sinus bradycardia rx |
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Definition
usually not treated
-use atropine if severe and symptomatic (like after heart attack)
-avoid beta blockers, calcium channel blockers, and other conduction-slowing medications |
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Term
| 44k. sinus tachycardia rx |
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Definition
usually none
-correct underlying cause
-if sx: beta blocker, calcium channel blocker |
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Term
| 45. if patient p/w sinus tachycardia or atrial fibrillation, what disease should be considered? |
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Definition
hyperthyroidism
-check TSH as screening test |
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Term
| 46. how does Wolff-Parkinson-White syndrome classically present? |
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Definition
child becomes dizzy or dyspneic or passes out after playing, then recovers and has no other sx
-cause is a transient arrhythmia via the accessory pathway
-EKG shows delta wave |
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Term
| 47a. constant, machine-like murmur in upper left sternal border; dyspnea and possible CHF |
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Definition
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Term
| 47a. how to rx PDA? What is it a/w? |
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Definition
-rx: close w/ indomethacin or surgery if that fails; keep open w/ prostaglandin E1
-a/w congenital rubella and high altitudes |
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Term
| 47b. holosystolic murmur, next to sternum |
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Definition
ventricular septal defect (VSD)
-most common congenital heart defect
-most cases resolve on their own |
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Term
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Definition
| fetal alcohol, TORCH, Down syndrome |
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Term
| 47c. fixed, split S2 and palpitations |
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Definition
atrial septal defect
-often asymptomatic until adulthood |
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Term
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Definition
| usually doesn't require correction unless very large |
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Term
| 47d. patients squatting after exertion |
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Definition
| "tet" spells, a/w Tetralogy of Fallot |
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Term
| 47d. anomalies a/w Tetralogy of Fallot |
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Definition
VSD, RVH, pulmonary stenosis, overriding aorta
-most common cyanotic congenital heart defect |
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Term
| 47e. upper extremity hypertension, radiofemoral delay, systolic murmur over mid-upper back |
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Definition
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Term
| 47e. what is seen on XR with coarctation of aorta, and what is it a/w? |
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Definition
| rib notching on XR; a/w Turner syndrome |
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Term
| 48. what is important to remember about tachycardia in kids? |
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Definition
| heart rates over 100 may be normal in children, as are respiratory rates over 20 |
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Term
| 49. in fetal circulation, where is the highest and lowest oxygen content? |
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Definition
highest: umbilical vein (blood coming from mother)
lowest: umbilical arteries
-also oxygen content is higher in blood going to the upper extremities than blood going to lower extremities |
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Term
| 50. what changes occur in circulation as an infant goes from intrauterine to extrauterine life? |
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Definition
first breath inflates lungs and decreases pulmonary vascular resistance, which increases blood flow to the pulmonary arteries
-this and clamping of the cord leads to increased left-sided heart pressures, causing closure of the foramen ovale
-increased oxygen concentration shuts off prostaglandin production in ductus arteriosus, leading to gradual closure |
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