Clin Med Exam I
Terms
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- RX Tx for HTN
- ACE and Diuretics
- RX Tx for HTN and stable angina
- BB
- angina
- precordial chest pain usually precipitated by stress/exertion; relieved by rest/nitrates
- RX for HTN and unstable angina
- Asprin and heparin; nitrates; BB
- RX for prinzmetal's angina
- nitrates/CCB
- TX in hypertensive emergencies
-
In ER - IV Na nitroprusside(antihypertensive)
[office-oral clonadine(antihypertensive-andrenergic)] - Cardinal sign of HF
-
1. parasternal lift (thrill/heave)
2. enlarged/displaced PMI
3. S3 gallop
4. diminished 1st heart sound -
34 female/exercise/acute SOB/palpitations/hemoptysis
ER: CXR:Interstitial edema -
Mitral stenosis
(due to back up in mitral valve)Curly B lines on CXR are interstitial edema - DVT
- tenderness/edema/redness of Lower extremity = unilateral
- occlusive arterial atherosclerosis
-
pain with ambulation, claudication, femoral bruits, diminished pedal pulses
6P's - pain, pallor, pulseless, parathesia, paralysis, popcicle - Mild chronic CHF
- ACE/Diuretics
- CHF w/COPD
- avoid BB (b/c blocking of beta cells can cause acute asthmatic rxn)
- unequal peripheral pulses/intrascapular pain
- Aortic dissection
- SVT primary RX
- BB, CCB
- BB
- slow HR/increase strength of contraction
- Tamponade classic finding
- pulsus paradoxus
- risk factors for PAD
- **DM and hyperlipidema
- coronary syndromes and MI
- BB
- CCBs used:
- acute HTN or if BB contraind.
- SVT RX
- usually adenosine, then CCB, BB, digoxin(not 1st line b/c of length of action and need for watching bld levels)
- Drug of choice for recurrent SVT attacks
-
digoxin
p362 - CABG most patent artery
-
internal mammary (long term patency/flow)
[saphenous/radial] - AAA
- abdominal US
- Aortic dissection
- unequal pulses; ripping intrascapular chest pain
- Unstable angina surgery cut off
- 75-85% occlusion
- CAD risk factors
- FM, male, hyperlipidemia, DM, HTN, physical inactivity, obesity, cigarette smoking
- TOD
- Brain/Heart
- Tamponade classic findings
- ***pulsus paradoxus, JVD, tachycardia
- Tamponade side of heart involved
- RV bulges into LV
- Beck's triad
- assoc w/tamponade: muffled heart sounds, JVD, hypotension
- Mgt of Tamponade
- drain fluid
- best diag test for tamponade
- echocardiogram
- avoid what RX in CHF (esp w/L sided failure)
- BB
- CHF causes
- ischemic heart dz, HTN, aortic/mitral valve dz, nonischemic (infection, alcoholic, toxic, postpardum, infiltrative, idiopathic), arrythmias
- at risk for failure but w/o structural heart dz
- Stage A
- structural dz w/o Sx of HF
- Stage B
- structural dz w/Sx of HF
- Stage C
- refractory HF w/special interventions (sx at rest)
- Stage D
- normal HTN
- 119/79
- preHTN
- 120-139 / 80-89
- Stage I HTN
- 140-159 / 90-99
- Stage II HTN
- >160 / >100
- DM / HTN
- initial ACE/ARB
- Aortic insuff
-
pul. edema (LV failure)
PF: wide arterial pulse press, lg SV - Mitral insuff
-
lg LA
Clin Char: pansystolic to axilla; LV impluse; carotid upstroke; 3rd heat sound - Marfan's acute Tx RX
- BB
- 3 systems involved in marfan's
- ocular, skel, cardio
- MI heart sounds
- S4 gallop (atrial)
- enzyme test for MI
- CK -
- PSVT Tx RX
- 1st choice - digoxin
- SVT Tx
-
Procedure: radiofrequency ablation
Rx: long term: verapamil, digoxin, BB
Avoid:BB, CCB, digoxin with Afib - Afib RX
-
asprin (with no stroke RF);
w/CHF, LV dysfunc, obstructive valve dz, DM, HTN, >75- warfarin - V tach RX
-
lidocain bolus (w/unstable)
Chronic: ICD (defib) - MVP Tx
- surgury
- Test for new onset murmur
- echo
- Raynauds
-
vasospastic disorder
pallor(white)-cyanosis(blue)-rubor(red)-cold-migraine - Pericarditis
- water bottle chest on CXR
- Pericarditis Gold star test
- echo
- Tamponade Tx
- pericariectomy
- Cor pulmonale
-
RVH - failure due to pul.dz/hyposia/PVD
Common cause: COPD - Corpulmonale Sx
- productive cough, DOE, wheezing, fatigue, weakness
- Corpulmonale signs
- cyanosis, clubbing, distended neck veins, RV heave/gallop, lower sternal/epigastric pulsations, large/tender liver, edema
- Rheumatic fever Dx
- jones criteria
- Major jones criteria
- Carditis, erythema margenatum/subcut. nodules, chorea, arthritis
- Rheumatic fever Tx
- bed rest; salicylates, penicillin, corticosteroids
- aortic stenosis
- splitting of S2; 2nd rt ICS/apex/carotids; midsystolic murmur; harsh/rough
- mitral stenosis
- after S2(middiastolic snap)LSB/apex; Afib is common; low pitch(bell); rumbling
- mitral stenosis found with___
- interstitial edema
- acidotic ABG
- <7.35
- alkalinic ABG
- >7.45
- Metabolic
- direct rel btwn pH and HCO3
- Respiratory
- indirect rel btwn pH and PCO2
- Metabolic acidosis cause
- starvation, excessive diarhhea, ketoacidosis
- Metabolic Acidosis S/Sx
- Kussmaul's respiration - severe, deep, reg, sighing respiration
- Metabolic Alkalosis cause
-
vomiting/nasogastric suctioning, excessive antiacid, prim aldosteronism, diuretic therapy
No char s/sx; orthostatic htn - Metabolic Alkalosis Tx
- correcting fluid imbalance - replace fluid w/NaCL/KCL
- Respiratory acidosis (hypercapnia)
- COPD b/c CO2 build up; acute: confusion, somnolence, asterixis, myoclonis inc intracranial press (papilledema)
- Resp. Alkalosis cause
- **hyperventilation, interstitial lung dz, pneumonia, pul embolism, pul edema
- Resp Alkalosis S/Sx
- light-headed, anxiety, paresthesias, numb mouth, tetany
- Resp Alkalosis Tx in acute hyperventilation
- paper bag to inc pCO2
- mild intermittent asthma
-
<2x/wk; asymp; normal PEF b/w exacerbations
NO daily meds
quick relief: short acting bronchodilator(beta2antagonist) - mild persistant
-
>2/wk <1/day; may affect activity
Rx: 1daily anti-inflammatory(inhaled corticosteroid low dose)
quick relief: short act.broncodilator - moderate persistant
- daily Sx; affect activity; >2/wk
- moderate persistant RX
-
Rx daily: anti-inflam(med dose) OR
inhaled cortico.(low/med) AND long acting brochodil (b2 agonist/theophylline) - Severe persistant
- continual Sx; limited activity; frequent exacerbations
- Severe persistant Rx
- daily antiinflam(inhaled cort high dose)ANDlong acting bronchodilator AND corticsteroid tablets/syrup
- during exacerbations best med
- short acting inhaled Beta adrenergic agonist (albuterol, bitolterol, pirbuterol, terbutaline)
- if pt does not respond to B agonist
- glucocorticoids systemically
- To control COPD Sx
- bronchodilators
- mild COPD
- short acting brochodilator prn
- moderate COPD
- reg tx w/bronchodilator, inhaled glucocorticoid, pul rehab, long term O2, surgury
- O2 decreases mortality
-
1.pO2 <55 or satO2is <89 OR
2.pO2<60 w/sighns or corpulmonale or secodary polythemia or max med therapy or less dyspnic and can inc activity with 2nd therapy - exacerbation tx
- inc dose/freq of bronchodil; combine classes of drugs, use nebulizers, change route of admin, abx (vol reduction surgery - 15%pts)
- pink puffer
- emphysema; dyspnea; no cough, little mucus; THIN; use accessory muscles; NO adventitious breath sounds; NO peripheral edema
- Blue Bloater
- bronchitis, chronic cough, productve mocopurulent sputum; mild dyspnea, OVERWEIGHT; cyanotic, comfortable at rest; PERIPHERAL EDEMA; noisy chest; wheezes
- PFT
- pulmonary function test
- FEV1
- amt of air expired in one second during forceful excertion
- Vital Capacity
- tot amt of gas exhaled following maximal inhalation
- Restriction
-
reduction in lung vol w/inc. FEV1/FVC ratio; reduced FVC=pul restriction
Causes: dec lung compliance (pul fibrosis), reduced mus strenghth, diaphragm dysfunc, neuromus dz, pleural dz - Forced Vital capacity
- tot expired during FEV test
- Obstruction
- ratio decrease; caused by asthma, COPD, bronchiectasis, bronchiolitis, upper airway obstruction
- Sarcoidosis
- systemic - granulomatous inflammation (dx with transbronchial lung biopsy)
- Pul embolism
-
dyspnea, chest pain, tachypnea
study of ch: perfusion lung scan pulmonary arteriograph/angiography **gold std - pul. HTN
-
SYNCOPE, dyspnea, fatigue, chest pain
Dx test: ECG (RVH); CT-pruning of lg pul art - pul effusion
-
CXR: fluid
CT: fluid
thoracentesis to evaluate fluid - transudate
-
watery
3 causes:
HF, nephrosis/nephrotic synd, cirrhosis - exudate
-
less watery / many pr-
all other causes - pleuritis tx
- underlying cause (analgesic/antiinflam) codeine to control cough
- Pleuritis dx test
- CXR/US
- nosocomail pneumon
-
polymicrobial gram neg, pseudomonas aeruginosa, s. aureus
MORE GRAM NEG - commum aquired pneumon
-
strep p, hemophilius influenaza
MORE GRAM POS
DX: CXR (GOLD) - nosocom tx
- broad spec abx: cephalosporin, quinalone, vancomycin
- comm aquired tx
- macrolides: erythromycin, azithromycin, or doxycylin if high macrolide resistance
- TB s/sx
- fatigue, wt loss, fever, night sweats, cough
- TB tests
-
CXR- infiltrates at apices of lungs
PPD - PPD pos
-
>5=HIV, TB pts, organ transplant, immunosupressed
>10=immigrants, Inject users, myobact lab personel, res/employees in high risk
>15 persons with no TB risk