Internal Medicine 02 Aquifer

Describe treadmill exercise stress test w/ imaging

Treadmill Exercise Stress Testing without additional imaging: Some studies have suggested that females have higher rates of false positives than males, however this diagnostic test can be useful for patients who can exercise to the extent needed. Since the patient can exercise and her baseline ECG is normal, this is a reasonable option.

Describe cocaine induced chest pain

- Chest pain after cocaine use from infarction or intense coronary spasm. - Urine tox screen positive for cocaine and drug metabolites. Elevated CPK levels may be seen with associated rhabdomyolysis.

Describe angina pectoris / CAD

- Chest pressure that may radiate to neck/arm/shoulder. May have associated dyspnea. Risk factors include obesity, diabetes, hypertension and hyperlipidemia. - May have abnormal blood pressure, lower extremity edema, cardiac murmurs or normal exam. - May have ST segment abnormalities on EKG.

What should you do to evaluate a suspected angina?

- ECG - Obtaining a CBC is important to evaluate for a low hemoglobin (anemia reduces oxygen capacity). - The basic metabolic panel provides valuable information, including evidence of renal disease, hyperglycemia, and electrolyte imbalances that can lead to cardiac disease. - Lipid levels - Transaminases - Assessment of thyroid function with a TSH level may be valuable in evaluating potential triggers for angina.

Describe aortic dissection

- Longitudinal intimal tear forming a false lumen. Associated with hypertension, bicuspid aortic valve, inherited connective tissue disorders (eg, Marfan syndrome). Can present with tearing, sudden-onset chest pain radiating to the back +/− markedly unequal BP in arms. CXR can show mediastinal widening. Can result in organ ischemia, aortic rupture, death. - Two types: Stanford type A (proximal): involves Ascending aorta. May extend to aortic arch or descending aorta. May result in acute aortic regurgitation or cardiac tamponade. - Treatment: surgery. Stanford type B (distal): involves only descending aorta (Below left subclavian artery). Treatment: β-blockers, then vasodilators.

Describe pneumothorax

- Primary is due to rupture of apical subpleural bleb or cysts. Occurs most frequently in tall, thin, young males and smokers. - Secondary is due to diseased lung (eg, bullae in emphysema, infections), mechanical ventilation with use of high pressures lead to barotrauma.

Describe variant angina

- Vasospastic cause of angina, often younger pt with few risk factors. Risk factors include tobacco use. - Between episodes of chest pain physical exam may be completely normal. - Accompanied by transient ST elevation on EKG.

How do you treat angina?

For relief of stable angina symptoms, beta blockers (BBs), calcium channel blockers (CCBs), and nitrates have all been proven to be effective in the treatment of stable angina.

What are atorvastatin side effects?

Rare cases of rhabdomyolysis with acute renal failure secondary to myoglobinuria; biochemical abnormalities of liver function. Myalgia is a common side effect and sometimes limits compliance.

What are three criteria for stable angina?

1. Substernal chest discomfort with a characteristic duration and features 2. Provoked by exertion or emotional stress 3. Relief with rest or nitroglycerin

What is the imaging workup for suspected angina?

A chest x-ray is a noninvasive and a relatively inexpensive first-line imaging test for evaluating a patient with suspected anginal chest pain. It will screen for some non-cardiac causes of chest pain and may suggest underlying cardiac disease. It may provide important information regarding heart size, lung fields, and bony thorax pathology. A chest CT is not a first-line test in the workup of probable angina. If a patient's describes chest pain that is acute in onset, pleuritic in quality, or associated with persistent dyspnea or a ripping sensation radiating to the back, then the suspicion for pulmonary embolism or aortic dissection would be high enough to warrant a chest CT angiogram as first line imaging.

Describe primary prevention of CVD

Avoiding tobacco, aggressively controlling diabetes mellitus, keeping blood pressure and cholesterol in the normal range, and regular exercise.

Describe tension pneumothorax

Air enters pleural space but cannot exit. Increasing trapped air lead to tension pneumothorax. Trachea deviates away from affected lung . May lead to increased intrathoracic pressure lead to mediastinal displacement lead to kinking of IVC then low venous return low CO. Needs immediate needle decompression and chest tube placement.

What is a secondary prevention of cardio disease?

Among other beneficial effects, losing weight will decrease cardiac risk by decreasing abdominal fat stores and improving hypertension control. Exercise and dietary modification will be important in losing the weight but will also have other advantages. Exercise will increase HDL cholesterol and dietary modification can lower total cholesterol, decrease LDL cholesterol and decrease triglycerides. Decreasing dietary sodium content may improve blood pressure control as well. Referral to a nutrition expert may help patients achieve their weight loss and dietary objectives.

Describe atypical angina

Atypical angina is defined as chest pain having 2 of the 3 features of typical angina noted above. Patients who have diabetes, females, and older adults > 65 years of age are more likely to present with atypical features. Occasionally they will present with only weakness or shortness of breath on exertion.

Describe acute pancreatitis

Autodigestion of pancreas by pancreatic enzymes Causes: Idiopathic, Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune disease, Scorpion sting, Hypercalcemia/Hypertriglyceridemia (> 1000 mg/dL), ERCP, Drugs (eg, sulfa drugs, NRTIs, protease inhibitors). I GET SMASHED. Diagnosis by 2 of 3 criteria: acute epigastric pain often radiating to the back, high serum amylase or lipase (more specific) to 3× upper limit of normal, or characteristic imaging findings. Complications: pseudocyst B (lined by granulation tissue, not epithelium), abscess, necrosis, hemorrhage, infection, organ failure (ALI/ARDS, shock, renal failure), hypocalcemia (precipitation of Ca2+ soaps).

What are clopidogrel side effects?

Bleeding

Describe traumatic pneumothorax

Caused by blunt (eg, rib fracture), penetrating (eg, gunshot), or iatrogenic (eg, central line placement, lung biopsy, barotrauma due to mechanical ventilation) trauma.

Describe chronic pancreatitis

Chronic inflammation, atrophy, calcification of the pancreas. Major causes include alcohol abuse and genetic predisposition (ie, cystic fibrosis); can be idiopathic. Complications include pancreatic insufficiency and pseudocysts. Pancreatic insufficiency (typically when <10% pancreatic function) may manifest with steatorrhea, fat-soluble vitamin deficiency, diabetes mellitus. Amylase and lipase may or may not be elevated (almost always elevated in acute pancreatitis).

What are ACE i side effects?

Cough, renal dysfunction, angioedema, hyperkalemia

What are hydrochlorothiazide side effects?

Dehydration, hyponatremia, hypokalemia, renal dysfunction, increases serum uric acid which may precipitate gouty attack

Describe exercise stress test w/ nuclear or echo imaging

Exercise Stress Testing with nuclear or echocardiographic imaging: Imaging increases the sensitivity and specificity of the test but increases cost too. Nuclear imaging, which utilizes technetium 99m sestamibi or thallium-201, has been reported to result in a high number of false positives in females, possibly due to breast attenuation of smaller heart size. Echocardiography has generally been shown to have the highest diagnostic accuracy for females, but can be technically difficult in the patient with obesity.

What are aspirin side effects?

Gastritis, peptic ulcer disease, bleeding (especially when used with clopidogrel)

What are metoprolol (beta blocker) side effects?

Hypotension, bradycardia, heart block

Describe myocarditis

Inflammation of myocardium high global enlargement of heart and dilation of all chambers. Major cause of SCD in adults < 40 years old. Presentation highly variable, can include dyspnea, chest pain, fever, arrhythmias. Multiple causes: Viral (eg, adenovirus, coxsackie B, parvovirus B19, HIV, HHV-6); lymphocytic infiltrate with focal necrosis highly indicative of viral myocarditis. Parasitic (eg, Trypanosoma cruzi, Toxoplasma gondii) Bacterial (eg, Borrelia burgdorferi, Mycoplasma pneumoniae, Corynebacterium diphtheriae) Toxins (eg, carbon monoxide, black widow venom) Rheumatic fever Drugs (eg, doxorubicin, cocaine) Autoimmune (eg, Kawasaki disease, sarcoidosis, SLE, polymyositis/dermatomyositis) Complications include sudden death, arrhythmias, heart block, dilated cardiomyopathy, HF, mural thrombus with systemic emboli.

Describe pericarditis

Inflammation of the pericardium. Commonly presents with sharp pain, aggravated by inspiration, and relieved by sitting up and leaning forward. Often complicated by pericardial effusion. Presents with friction rub. ECG changes include widespread ST-segment elevation and/or PR depression. Causes include idiopathic (most common; presumed viral), confirmed infection (eg, coxsackievirus B), neoplasia, autoimmune (eg, SLE, rheumatoid arthritis), uremia, cardiovascular (acute STEMI or Dressler syndrome), radiation therapy. Treatment: NSAIDs, colchicine, glucocorticoids, dialysis (uremia)

Describe aspirin recommendations

Initiating low-dose aspirin use for the primary prevention of cardiovascular disease in adults aged 50 to 59 years who have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years. For adults aged 60-69 years of age with a 10% or greater 10 year risk of CVD, the decision to use low dose aspirin for primary prevention must be individualized based on each patient's life expectancy and longterm bleeding risk.

Describe secondary prevention of CVD

Involves avoidance of risk factors, more aggressive cholesterol lowering, and optimizing hypertension and diabetic control. Aspirin and statins are mainstays of secondary prevention for most patients. Certain cardiovascular medications such as beta-blockers and angiotensin converting enzyme (ACE) inhibitors may be used as well, particularly for patients who have suffered a myocardial infarction and/or have reduced ventricular systolic function.

What are risk factors for CAD & Atherosclerosis?

Many risk factors have been independently associated with coronary artery disease. In addition to age > 55 in females or > 45 in males, male sex, family history of sudden death or premature CAD, smoking, dyslipidemia, diabetes mellitus, hypertension, and obesity; other risk factors for coronary artery disease are a sedentary lifestyle, a personal history of peripheral vascular or cerebrovascular disease, estrogen use and chronic inflammation. It's recommend to assess major ASCVD risk factors every 4 to 6 years in adults 20 to 79 years of age who are free from ASCVD.

Describe pharmacologic stress test w/ imaging

Pharmacologic Stress Testing with imaging: This is an alternative if the patient cannot exercise to the degree needed to produce a diagnostic result. Options include dipyridamole or adenosine with nuclear imaging or dobutamine with echocardiography.

Describe panic disorder

Recurrent panic attacks involving intense fear and discomfort +/− a known trigger. Attacks typically peak in 10 minutes with ≥ 4 of the following: palpitations, paresthesias, depersonalization or derealization, abdominal pain, nausea, intense fear of dying, intense fear of losing control, lightheadedness, chest pain, chills, choking, sweating, shaking, shortness of breath. Strong genetic component. High risk of suicide. Diagnosis requires attack followed by ≥ 1 month of ≥ 1 of the following: Persistent concern of additional attacks, worrying about consequences of attack. Behavioral change related to attacks Symptoms are systemic manifestations of fear. Treatment: CBT, SSRIs, and venlafaxine are first line. Benzodiazepines occasionally used in acute setting.

Describe costochondritis

Sharp anterior chest pain occurring at costochondral and costosternal junctions. Tenderness to palpation over chest wall.

What is the metabolic syndrome?

The Metabolic Syndrome is a constellation of risk factors for cardiovascular disease that often occur in the same individual. Together they increase the risk of cardiovascular disease for any given LDL level. Metabolic syndrome has several definitions according to various subspecialty groups; however, all definitions are more alike than they are different.