PANCE Precision 4.0 Flashcards

Abdominal aortic aneurysm-

Health Maintenance

Avoiding heavy lifting and vigorous physical activity

Abdominal Aortic Aneurysm-

Using Diagnostic and Laboratory Studies

Initial imaging study of choice in suspected AAA to determine presence, size, & extent; Also used to monitor progression in size (expansion) = Abdominal US and if unstable. Gold Standard = CT with contrast

Abdominal Aortic Aneurysm-

Formulating the Most Likely Diagnosis

White men > 65 YO with a smoking history

Asx until expanding/ruptures; rupture = sudden, severe, constant back/flank/ abdominal/groin pain and/or in shock

Palpable pulsatile abdominal mass on PE

Acute MI-

Pharmaceutical Therapeutics

Acute medications: MONAAnticoagulants = LMWH/unfractionated heparin (usually with + troponin) Clot busters only for STEMISubacute medications - Beta blockers - ACE inhibitors - Statins

Acute MI-

Using Diagnostic and LaboratoryStudies

12-lead EKG within 10 minutes of arrival to EDSTEMI = ST elevation in two anatomically contiguous leads w/reciprocal changesTroponin is positive in STEMI & NSTEMI

Acute MI, Anterior-

Formulating the Most LikelyDiagnosis

ST elevations in V1-V4 on 12-lead EKG with resiprocal changes

Adverse Drug Effect: Antiarrhythmics-

Pharmaceutical Therapeutics

Amiodarone SE's = optic neuritis/thyroid disease/hepatitis/pulmonary fibrosisBeta blockers = bradycardia/bronchospasm Na+ channel blockers OD = wide complex QRS Na+ channel blockers OD = wide complex QRS

Aneurysm, Thoracoabdominal-

Pharmaceutical Therapeutics

SABA (statin/antiplatelet/BB/ACEI)

Angina-

Pharmaceutical Therapeutics

Stable = Nitro/BB/CCBUnstable = "MONA" (morphine, O2, nitro, ASA)

Angina Pectoris-

History Taking and PerformingPhysical Exam

Chest discomfort/pressure/squeezing/burning/fullness +/- radiation to neck/arm/jaw/shoulder/back; usually precipitated by exertion, eating, exposureto cold, or emotional stress that is relieved by rest or NTG; ask patient about frequency/severity/number of NTG pills to subside pain

Angina Pectoris-

Pharmaceutical Therapeutics

MONA for acute. For chronic: NTG, BB and CCB

Aortic Aneurysm-

Clinical Intervention

Surgical revascularization with > 5.5 cm

Aortic Insufficiency-

Formulating the Most LikelyDiagnosis

Diastolic blowing decrescendo murmur best heard in LUSB that increases when pt sits and leans forward, squats, or lays supine and raises leg; decreases with valsalva maneuvers and standing; wide pulse pressure; bounding pulses; definitive diagnosis made on cardiac catheterization

Aortic Insufficiency/ Regurgitation-

History Taking and PerformingPhysical Exam

Holo-diastolic blowing murmur. No radiation.

Aortic Insufficiency/ Regurgitation-

Using Diagnostic and LaboratoryStudies

Echocardiogram. Definitive diagnosis = cardiac catheterization

Aortic Valve Stenosis-

Clinical Intervention

Aortic valve replacement only effective treatment

Arrhythmia atrioventricular block, second degree (mobitz type II)-

Clinical Intervention

Initial: Transcutaneous pacing; Definitive: Permanent pacemaker

Arrhythmia, Atrial Fibrillation-

Clinical Intervention

Unstable (shock) = cardioversion

Arrhythmia, atrial fibrillation-

History Taking and Physical Examination

Always with an irregularly irregular rhythm

Arrhythmia, Atrial Fibrillation-

Pharmaceutical Therapeutics

Anticoagulation usually with NOACs (dabigatran (Pradaxa), rivaroxaban(Xarelto), apixaban (Eliquis).Rate control: BBs/non-dihydropyridine CCBs (arely digoxin)

Arrhythmia, Atrial Fibrillation-

Using Diagnostic and LaboratoryStudies

EKG: irregularly irregular rhythm, no discrete P waves.

Arrhythmia, Atrial Fibrillation-

Formulating the Most LikelyDiagnosis

EKG: irregularly irregular rhythm, no P waves, usually narrow complex QRS Presents as either an arrhythmia or an embolic event (CVA, limb ischemia,mesentery ischemia, renal infarct)

Arrhythmia, atrial flutter-

Using Laboratory and DiagnosticStudies

EKG: "Sawtooth" pattern

Arrhythmia, atrioventricular block, third degree-

Using Laboratory and DiagnosticStudies

Slow heart rate and no coordination between atria and ventricles

Arrhythmia, Bradycardia-

Formulating the Most LikelyDiagnosis

HR < 60bpm. If responsive to atropoine, usually benign. If not responding to atrpoine, probably needs a pacemaker

Arrhythmia, Complete HeartBlock-

Clinical Intervention

Acute/symptomatic: temporary pacing (aka trans-cutaneous pacemaker) Definitive tx: permanent pacemaker

Arrhythmia, JunctionalRhythm-

Using Diagnostic and LaboratoryStudies

P wave is either absent of retro-grade (upside down). If HR is 40-60 bpm =junctional rhythm.If HR is 60-100 bpm = accelerated junctional rhythm and if >100 bpm =junctional tachycardia

Arrhythmia, Paroxysmal Supraventricular Tachycardia (PSVT)-

Formulating the Most LikelyDiagnosis

Heart rate > 100 bpm; rhythm usually regular with narrow QRS complexes; Pwaves hard to discern due to the rapid rate

Arrhythmia, premature atrial contractions-

Formulating the Most LikelyDiagnosis

PAC is a premature atrial beat. There will be an early beat with a P wave

Arrhythmia, PSVT-

Clinical Intervention

Vagal maneuvers

Arrhythmia, PSVT-

Formulating the Most LikelyDiagnosis

HR usually about 150. Narrow QRS complex with a T wave in-between

Arrhythmia, sinus-

Using Laboratory and DiagnosticStudies

Normal varient. There is gradual widening and narrowing of the R to Rinterval with breathing

Arrhythmia, V-tach-

Clinical Intervention

V-tach unstable = synchronized cardioversionV-tach (no pulse): Defibrillate (unsynchronized cardioversion) + CPR

Arrhythmia, V-tach (Torsade's de Pointes)-

Clinical Intervention

If unstable = synchronized cardioversion. V-tach (no pulse): Defibrillate(unsynchronized cardioversion) + CPR

Arrhythmia, VentricularFibrillation-

Clinical Intervention

Always dead (no pulse) - Defibrillate (unsynchronized cardioversion) + CPR

Arrhythmia, VentricularFibrillation-

Formulating the Most LikelyDiagnosis

Patient is in cardiac arrest. Dead. Only treatment is CPR and defibrillation

Arterial Thrombosis-

History Taking and PerformingPhysical Exam

Acute onset of severe pain with no pulses. Clinical diagnosis.

Atrial Fibrillation-

Formulating the Most LikelyDiagnosis

Irregularly irregular rhythm with fibrillatory waves on EKG; atrial rate >250bpm

Atrial Septal Defect-

Applying Basic ScientificConcepts

Oxygenated L-atrium blood crosses the ASD and mixes with deoxygenated in the R-atrium. Blood volume greater in R-atria can lead to R sided CHF. The pulmonic valvue will stay open so have a split S1 that doesn't change with respirations

Atrial Septal Defect-

Formulating the Most LikelyDiagnosis

Systolic crescendo-decrescendo; widely fixed-split S2 that does NOT vary with respiration

Axis Deviation-

Using Diagnostic and LaboratoryStudies

EKG: Leads aVF and I are most closely associated with axis deviation.

Bacterial endocarditis-

Applying Basic ScientificConcepts

Infection seeds itself on the valves. Can be from IV drug use or someone who already has an artificial valve.

Blood pressure monitoring-

History Taking and PhysicalExamination

Sit & relax for >5 minutes, No stimulates (caffeine, exercise, smoking) X 30 minutes before. Cuff to skin. Correct cuff size means bladder encircles 80%of the arm. Check BP in both arms. Deflate the cuff 2 mmHg per second. We use an average of ≥2 readings obtained on ≥2 occasions

Bruits, carotid-

Using Laboratory and DiagnosticStudies

Asculation with a bell, then order a doppler

Cardiac Arrest-

Clinical Intervention

CPR 1stDefibrillate if in V-tach or V-fibAlways give epinephrine first

Cardiac tamponade-

Clinical Intervention

Pericardiocentesis

Cardiac Tamponade-

Formulating the Most LikelyDiagnosis

Beck's Triad (JVD-"distended neck veins", muffled heart sounds, low BP) Pulsus Paradoxus: > 10 mm Hg decrease in SBP w/ inspiration

Cardiac Tamponade-

History Taking and PerformingPhysical Exam

Often trauma induced and can look like a tension pneumothorax (both have hypotension and JVD.) Can be a sequalae from pericarditis.

Cardiac Tamponade-

Using Diagnostic and LaboratoryStudies

ECHO: ventricles collapse in diastole (+ presence of an effusion)

Cardiogenic Shock-

Clinical Intervention

Angioplasty and stenting. Balloon pump. Extracorporeal membrane oxygenation (ECMO)

Cardiogenic Shock-

Formulating the Most LikelyDiagnosis

Hypotension and CHF at the same time.

Cardiomegaly-

Using Laboratory and DiagnosticStudies

EKG: LBBB/Left axis deviation/LVH. CXR: Big heart (cardiomegaly.) ECHO is the best test

Cardiomyopathy-

Pharmaceutical Therapeutics

Beta blocker with HOCM. Treat as CHF with dilated (ACEI or ARB/BB/hydralizine and nitro, spiranalactone)

Cardiomyopathy, Alcoholic-

Formulating the Most LikelyDiagnosis

ETOH causes dilated cardiomyopathy = systolic HF --> S3 gallop + decreasedEF + h/o ETOH; thin ventricular walls on echocardiogram

Cardiomyopathy, Alcoholic-

Pharmaceutical Therapeutics

The primary treatment for alcoholic cardiomyopathy involves cessation of alcohol consumption. Additional pharmaceutical therapies may be used to manage symptoms and include:1. Diuretics: These medications help remove excess fluid from the body, which can improve symptoms such as swelling and shortness of breath.2. ACE inhibitors or ARBs: These medications can help lower blood pressure and reduce the workload on the heart.3. Beta-blockers: These medications can slow the heart rate, reduce blood pressure, and decrease the workload on the heart.4. Anti-arrhythmic medications: These medications can help manage irregular heart rhythms, which can be common in people with cardiomyopathy.5. Anticoagulants: These medications can help prevent blood clots, which can be a risk in people with cardiomyopathy.6. Nutritional supplements: People with alcoholic cardiomyopathy may be deficient in certain nutrients, such as thiamine, which can lead to further heart damage.7. Implantable devices: In some cases, implantable devices such as pacemakers or defibrillators may be necessary to manage heart rhythms or prevent sudden cardiac arrest.It's important to note that the best treatment for alcoholic cardiomyopathies prevention through abstinence from alcohol.

Cardiomyopathy, hypertrophic obstructive-

Formulating Most LikelyDiagnosis

< 35 years old, casue of syncope/sudden cardiac death that occurs during tachycardia. Systolic creshendo decreshendo murmur with S4

Cardiovascular disease-

Health Maintenance

Control risk factors: smoking, DM, cholesterol, HTN. Weight loss.

Carotid artery stenosis-

Using Laboratory and DiagnosticStudies

Doppler

Carotid Stenosis-

Clinical Intervention

Revascularization via carotid endarterectomy if symptomatic and stenosis >50% or if asymptomatic and stenosis > 60%. If 100% blocked we leave it alone and let the other side feed the brain.

Coarctation of the Aorta-

Clinical Intervention

Surgical correction: balloon angioplastyProstiglandin pre-operatively to decrease sxs and improve lower extremity blood flow

Coarctation of the Aorta-

Formulating the Most LikelyDiagnosis

Refractory HTN. Bilateral lower extremity claudication. BP in upper extremities > lower extremities. Delayed or weak femoral pulses

Coarctation of the Aorta-

History Taking and PerformingPhysical Exam

Refractory hypertension

Complete heart block-

Clinical Intervention

Pacemaker

Congestive Heart Failure (CHF)-

Applying Basic ScientificConcepts

The heart just isn't working right. It can be from several causes.Right sided CHF has JVD/HJR/Ascites/Edema. Left sided CHF has S3 and rales in lungs and always has SOB

Congestive Heart Failure (CHF)-

Health Maintenance, Patient Education, and Preventative Measures

Overall health: wt. loss, stop smoking/ETOHRestrict sodium intake to 3 g/day. Daily weight monitoring

Congestive Heart Failure (CHF)-

History Taking and PerformingPhysical Exam

Hx always consists of SOB & DOEPE= JVD/HJR/Ascites/Edema for Right CHF; S3 and rales in lungs for Left CHF

Congestive Heart Failure (CHF)-

Pharmaceutical Therapeutics

Acute CHF tx: Nitro/BiPap and furosemideChronic CHF: ACE/ARB + BB. Hydralizine and NTG if can't tolerate ACEI/ARBand spironolactone in class III/IV CHF

Coronary artery disease-

Applying Basic ScientificConcepts

Build up of plaque on arteries. Usually from risk factors: smoking, advanced age, DM, cholerterol, HTN, family history

Coronary Artery Disease-

Clinical Intervention

Open the artery with a PCI/stent or bypass it with a graft (CABG)

Coronary Artery Disease-

Using Diagnostic and LaboratoryStudies

EKG initial test looking for STEMI. Stress testing for unstable angina. Angiography (aka cardiac cath) = Gold Standard

Coronary Artery Vasospasm-

Formulating the Most LikelyDiagnosis

Variant (Prinzmetal) Angina: coronary spasm leading to transient ST elevations; the chest pain is usually non-exertional, often occurring @ rest (early morning or wakes pt up at night.) Angiography:vasospasm with IV ErgonovineCocaine-induced MI: coronary artery vasospasm we treat with CCB & Nitrates; avoid BB

Deep Venous Thrombosis-

Health Maintenance, Patient Education, and Preventative Measures

Smoking cessation; compression stockings for pts with prolonged periodsof sitting/standing or frequent long-distance traveling; Increase fluid intake;increase exercise. If hypercoagulable, chronic anticoagulation.

Deep Venous Thrombosis-

History Taking and PerformingPhysical Exam

Virchow's Triad: Damage (recent broken bones), Stasis. Hypercoagulability(high estrogen, cancer or genetics)

Deformity, congenital, heart-

Formulating Most LikelyDiagnosis

Think of breast feeding as a stress test. A baby having difficult time feeding could mean cardiac. Look for murmur.

Dextrocardia-

Using Laboratory and DiagnosticStudies

CXR then ECHO

Dilated Cardiomyopathy-

Applying Basic ScientificConcepts

Something poisoned the heart making the muscular wall of the L ventricle is big and weak leading to CHF.

Dilated Cardiomyopathy-

Health Maintenance, Patient Education, and Preventative Measures

Limit alcohol. Manage cardiac risk factors:BP, Lipids, and DM. Cardiac rehab

Dilated Cardiomyopathy-

Pharmaceutical Therapeutics

Acute CHF tx: Nitro/BiPap and furosemideChronic CHF: ACE/ARB + BB. Hydralizine and NTG if can't tolerate ACEI/ARBand spironolactone in class III/IV CHF

Dissecting Aortic Aneurysm-

Using Diagnostic and LaboratoryStudies

CT Scan w/ contrast if stable to go to radiology TEE: accurate, portable. Used if patient is unstable CXR: widening of the mediastinum (screening test)

Dissection, Aorta-

History Taking and PerformingPhysical Exam

Sudden onset of severe CP (ripping/tearing) that radiates through to the backAscending dissection has anterior chest pain. Aortic arch dissection has neck/jaw pain.Descending dissection has interscapular pain

Down syndrome-

Formulating Most LikelyDiagnosis

Physical features: flattened face, especially the bridge of the nose, almond- shaped eyes that slant up, short neck. Amniocentesis, chorionic villus sampling (placenta biopsy) and ultrasound. 50% of Down's congenital heart disease.

Dressler Syndrome-

Pharmaceutical Therapeutics

Aspirin. NSAID and/or Colchicine

Drug effect, adverse:antiarrhythmics-

Pharmaceutical Therapeutics

Amiodarone: optic neuritis, thyrodi dysfunction, hepatitis (elevated AST/ALT,) and pulmonary fibrosis. With Na+ channel blockers there will be a widfe complex QRS

Drug Toxicity, Digoxin-

Pharmaceutical Therapeutics

They will have hyperkalemia. Reversal agent is DigiFab

Effusion, pericardial-

Formulating Most LikelyDiagnosis

Shortness of breath. CP usually when supine

Endocarditis-

Pharmaceutical Therapeutics

Antibiotics. Usually vancomycinProphylaxis: 2g Amoxicillin 60 min before dental procedure (600 mgClindamycin if PCN allergic)

Endocarditis, bacterial-

Applying Basic ScientificConcepts

Mitral > Aortic > Tricuspid > Pulmonary; Acute normal valves: S.aureusSubacute abnormal valves: S.viridansIV drug use: Tricuspid valve + S.aureus MRSA

Endocarditis, bacterial-

Formulating Most LikelyDiagnosis

Look at hands for splinter hemmorhages, Osler's Nodes and Janesway Lesions. In the eye it's Roth spots. Explore IV drug use or anyone who already has an artificial valve

Endocarditis, bacterial-

Health Maintenance

Antibiotics for people with artificial valves anytime bacteria is going to be introducted (ie dental work/abscess)

Endocarditis, bacterial-

Using Laboratory and DiagnosticStudies

TEE and blood cultures

Endocarditis, Infective-

Using Diagnostic and LaboratoryStudies

Blood cultures - 3 sets at least 1 hr apart if stable or from 3 different locationsAND TEE

Endocarditis, unspecified-

Applying Basic ScientificConcepts

Heart valve infection that launches emboli. (Roth sport/splinter hemorrhages/Osler's nodes/Janesway lesions) Endocarditis with negative blood cultures; suspect "HACEK" organisms (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)

Essential Hypertension-

Formulating the Most LikelyDiagnosis

Stage 1: SBP 130-139 mmHg or DBP 80-89 mmHgStage 2: SBP > 140 mmHg or DBP > 90 mmHg

Giant Cell Arteritis-

Applying Basic ScientificConcepts

Vasculitis of branches of carotid artery. Usually elderly women with unilateral head aches. Elevated ESR demands prednisone to prevent blindness.

Giant Cell Arteritis-

Formulating the Most LikelyDiagnosis

Usually elderly female. Unilateral temporal HA with visual disturbance. calp tenderness. Jaw claudication

Giant Cell Arteritis-

Pharmaceutical Therapeutics

High-dose corticosteroids (ex. prednisone 40-60 mg/day x 6 wks) with gradual tapering based on sxs and ESR

Health screening, children, hypertension-

Health Maintenance

Screening all patients at age 3 years

Heart disease, rheumatic-

History Taking and PhysicalExamination

15 year old with a migratory polyarthritis. JONES Criteria (Joints- migratory polyarthritis, carditis, nodules, erythema marginatum, Sydenham Chorea.) They has strep throat 2 weeks ago

Heart failure-

Formulating Most LikelyDiagnosis

SOB - they always has dyspnea on exertion. Look for leg swelling, JVD, HJRand ascites

Heart Failure-

Health Maintenance, Patient Education, and Preventative Measures

Lifestyle modifications (wt. loss, smoking cessation, increasing physical activity, daily weight to monitor fluid status) ACEi/ARBs + BBs for decreased mortality; sacubitril-valsartan is an ACEi/ARB combo drug that reduces mortality