PANCE Word Association

Murmur in pt with h/o rheumatic heart disease

#1. Mitral stenosis #2. Tricuspid Stenosis

Crushing CP, dyspnea, palpitations, radiation to neck or left arm.

Angina (if lasts minutes) Acute MI if lasts > 30 minutes STEMI if ST elevation at the J point in 2 contiguous leads with reciprocal depression Injury/ischemia - T wave depression Infarct - pathologic Q wave

1. flank pain 2. hypotension 3. pulsatile abdominal mass

AAA

Drug for pt with heart failure and LVH

ACE-I ( survival, prevents development of HF sxs)

Drug for pt with DM and HTN

ACE-I is 1st line; decreased morbidity/mortality

1. Blue extremities --worse with cold --improve with warming

Acrocyanosis

1. dry cough 2. angioedema

Adverse effects of ACE-I

1. diastolic decrescendo blowing murmur best heard at the left upper sternal border 2. lateral displaced PMI 3. wide pulse pressure 4. increased with hand grip 5. decreased with amyl nitrite inhalation

Aortic Regurgitation/Insufficiency Back flow from aorta to left ventricle leads to left ventricular overload

2. canon "a" waves 3. Quincke's pulse (subungual pulsation) 4. Corrigan's pulse (rapid rise and fall) 5. Austin flint murmur (low pitch mid-diastolic rumble murmur at apex) 6. de Musset's sign (rhythmic nodding or bobbing of the head in synchrony with the beating of the heart) 7. water hammer pulse (high pulse volume; sharp rise. ill-sustained; sharp fall.)

Aortic Regurgitation/Insufficiency: Back flow from aorta to left ventricle leads to left ventricular overload

1. sudden onset ripping, tearing CP 2. diminished pulses

Aortic dissection

1. diamond shaped 2. blowing systolic murmur 3. +/- angina/syncope/CHF

Aortic stenosis

1. elderly 2. systolic murmur

Aortic stenosis due to: 1. calcifications: age related 2. bicuspid valve: congenital

1. lower extremity rubor 2. lack of hair 3. brittle nails 4. pallor on elevation 5. calf or LE pain with walking short distances, relieved with rest or in PM

Arterial insufficiency/peripheral artery disease LE rubor, AKA dependent rubor, is a fiery to dusky-red coloration visible when the leg is in a dependent position but not when it's elevated above the heart. The underlying cause is peripheral arterial disease (PAD), so the extremity is cool to the touch.

Ground glass appearance on CXR

Asbestosis (shipbuilders, construction/demolition)

1. PNA 2. decreased mental status 3. poor dental hygiene/dentures 4. foul smelling sputum 5. bronchiectasis 6. patchy infiltrates in dependent lung zones

Aspiration PNA

1. pregnancy 2. thyrotoxicosis 3. anemia 4. beriberi 5. Paget's disease

Associated with high output heart failure

1. ischemic heart disease (IHD) 2. HTN 3. dilated CM 4. valvular dz 5. arrhythmia

Associated with low output heart failure

1. wheezing 2. prolonged expiration

Asthma

Airway edema with eosinophils, neutrophils, & lymphocytes

Asthma

Alcoholic with palpitations, arrhythmia

Atrial fibrillation (Holiday heart)

Irregular irregular

Atrial fibrillation; (if > 48 or chronic - anticoagulate)

Mechanical valve or prosthesis & Dental, GU, GI, or ortho procedure prophylaxis

Bacterial endocarditis (strep. Viridians) prevention

1. intravenous drug abuse (IVDA) 2. new murmur

Bacterial endocarditis: staphylococcus aureus (MSSA > MRSA)

Post MI drug associated with decreased mortality

Beta-blockers

1. infant with dyspnea 2. difficulty feeding 3. holosystolic murmur at LSB, 3rd intercostal space 4. hypertrophy of left and right ventricle

Ventricular septal defect (VSD)

1. dyspnea on exertion (DOE) 2. paroxysmal nocturnal dyspnea (PND) 3. edema 4. echo w/ LVH or RVH and hypokinesis

CHF

S3 heart sound

CHF, dilated cardiomyopathy

1. smoker 2. chronic productive cough 3. NO hemoptysis 4. shortness of breath

COPD Dx: *1. best initial test is CXR (increased AP diameter, air trapping, flattened diaphragm)* *2. most accurate test is PFT (decreased FEV1 and FVC (<70%), increased total lung capacity)* 3. ECG and Echo show RV and RA hypertrophy. Echo also shows pulmonary HTN. 4. Afib or multifocal Atach may develop 5. CBC with increased hematocrit

1. smoker 2. cough 3. dyspnea on exertion

COPD Tx: *Improve mortality:* 1. smoking cessation 2. oxygen therapy *Treat symptoms:* 1. short-acting b-agonists (albuterol) 2. anticholinergics (ipratropium bromide) 3. steroids **give influenza and pneumococcal vaccines

Deep breathing alternating w/ apnea

Cheyne-Stokes breathing - heart failure, brain damage

Reticular to nodular pattern on CXR

Coal miner's lung

Rib notching on CXR

Coarctation of Aorta

1. child with leg pain after physical activity 2. abnormal heart sounds 3. unequal UE & LE pulses 4. rib notching

Coarctation of aorta

Sweat chloride test

Cystic fibrosis

1. child 2. history of recurrent lung infections 3. pancreatitis 4. failure to thrive

Cystic fibrosis (Staph & Pseudomonas infections usually cause of death)

1. dyspnea after surgery/travel (airplane, long car ride) 2. +/-calf pain 3. +/-chest pain

DVT/PE

1. venous stasis 2. vessel wall injury 3. hypercoagulability

DVT/PE (Virchow's triad)

"resting ARMS"

Diastolic murmurs: Aortic Regurgitation and Mitral Stenosis (Systolic murmurs= Aortic Stenosis and Mitral Regurg)

1. EKG changes 2. nausea & vomiting 3. yellow visual disturbances and/or halos of light

Digoxin toxicity (Hypokalemia will make worse)

Pericarditis s/p open heart surgery

Dressler's syndrome. 1st line Tx = ASA (Indomethacin or other NSAID OK.) +/-steroids

1. hyperinflation on CXR 2. tear drop heart

Emphysema

1. drooling 2. sniffing position 3. tripod 4. toxic

Epiglottitis MCC: Haemophilus influenzae type b

Thumbprint sign

Epiglottitis MCC: Haemophilus influenzae type b

Hx angina but no acute sxs. EKG shows no acute changes. Next step?

Exercise stress test.

Patchy fibrosis on CXR

Farmer's lung

Inspiratory stridor

Foreign body or viral croup

1. smoker with COPD 2. PNA

H. influenzae

1. premature infant 2. CXR with hypoexpansion (atelectasis) 3. air bronchograms (tubular outline of an airway made visible by filling of the surrounding alveoli by fluid or inflammatory exudates

Hyaline membrane disease (Infant respiratory distress syndrome) Tx: surfactant

Premature infant with respiratory distress within 24 hours of delivery

Hyaline membrane disease (Infant respiratory distress syndrome) Tx: surfactant

Young athlete with syncope during athletic event or practice. No physical exam abnormalities.

Hypertrophic CM or fatal arrhythmia. EKG (big Q waves) Echo (asymmetrical ventricular septal wall thickening >15mm, and small LV chamber)

Treatment for premature infant with left to right shunt and communication between descending thoracic aorta and pulmonary artery

Indomethacin PDA due to continued prostaglandin E2 production in premature infant. *P*rostaglandins *P*rop open the *P*DA. NSAIDs inhibit prostaglandins to close the defect

Cavitations on CXR

Infections - lung abscess, TB (Ghon focus), septic emboli

1. claudication with rest pain 2. ABI < 0.4

Intermittent claudication Dx: ABI best choice, arteriogram gold standard Tx: arterial bypass

1. PNA 2. DM, immunocompromised, EtOH 3. currant colored sputum

Klebsiella

Rapid, deep labored breathing

Kussmaul breathing - DKA, Metabolic acidosis

1. PNA 2. late summer 3. construction site/old air conditioner/still water 4. diarrhea 5. toxic looking

Legionella

Hilar mass on CXR

Lung cancer

Grossly elevated blood pressure especially w/ signs of end organ damage

Malignant or Urgent HTN

1. mitral valve prolapse 2. aortic regurgitation 3. aortic dissection 4. aortic root dilatation 5. ectopic lentis

Marfan's Syndrome

1. young female (<30yo) 2. palpitations 3. long arms & fingers 4. pectus excavatum 5. flexible joints

Marfan's Syndrome

Pleural thickening on CXR

Mesothelioma

Systolic murmur heard best at apex with radiation to left axilla (apical systolic)

Mitral regurgitation

New systolic murmur at apex after MI

Mitral regurgitation (secondary to papillary muscle rupture)

Diastolic murmur best heart at apex without radiation

Mitral stenosis

Opening snap followed by a rumble

Mitral stenosis

1. connective tissue disorder (Marfan, Ehlers Danlos) 2. chest pain, panic attacks, palpitations, syncope 3. decreased venous return (valsalva, standing, inspiration) leads to earlier click and longer duration of murmur

Mitral valve prolapse

1. young female or post MI 2. systolic murmur heard best at the apex 3. preceded by click without radiation

Mitral valve prolapse

1. <35 y/o 2. fever 3. cough 4. +/- sputum, chills, muscle aches

Mycoplasma pneumonia

Bullous myringitis

Mycoplasma pneumonia

Heart failure after upper respiratory infection

Myocarditis

Lung VQ scan with perfusion defects

PE

1. continuous, harsh, machine-like murmur 2. loudest at pulmonic area

Patent ductus arteriosus (PDA)

1. murmur 2. poor feeding 3. weight loss 4. frequent lower respiratory tract infections 5. pulmonary congestion 6. wide pulse pressure 7. bounding peripheral pulses

Patent ductus arteriosus (PDA)

1. electrical alternans (swinging motion of the heart in the pericardial cavity causing a beat-to-beat variation in QRS axis and amplitude) 2. narrow pulse pressure 3. pulsus paradoxus

Pericardial effusion/tamponade

1. JVD 2. hypotension 3. muffled heart sounds

Pericardial effusion/tamponade (Beck's triad)

Pulsus paradoxus (exaggerated fall in a pt's SBP during inspiration by > 10 mm Hg.)

Pericardial effusion/tamponade, pericarditis, asthma attack, tension pneumothorax, superior vena cava obstruction

Constant, sharp CP worse lying down, better sitting up and leaning forward

Pericarditis

1. PNA 2. HIV/AIDS 3. sxs out of proportion to exam 4. diffuse interstitial & alveolar infiltrates

Pneumocystis jirovecii Tx: TMP-SMX

1. fever 2. cough 3. sputum 4. crackles 5. +egophony, +pectoriloquy

Pneumonia CXR: airspace opacity, lobar consolidation, or interstitial opacities

Problem associated with treating HTN w/ an alpha-blocker (α-adrenoreceptor antagonists)

Postural hypotension Common a-blockers: doxazosin mesylate (Cardura), prazosin hydrochloride (Minipress), and terazosin hydrochloride (Hytrin)

Alcoholic with dyspnea on exertion, heart failure

Primary dilated CM

1. PNA 2. Cystic fibrosis

Pseudomonas aueroginosa causative agent

Systolic ejection murmur heard best at base with radiation to left clavicle

Pulmonary stenosis

1. granulomas 2. inflammation of alveoli 3. small bronchi 4. small blood vessels

Sarcoidosis

Eggshell pattern on CXR

Silicosis (Sandblasters)

1. PNA 2. nursing home/chronic care facility 3. purulent sputum

Staphylococcus aureus

1. >35 y/o with PNA 2. rusty colored or yellow-green sputum 3. acute onset fever and chills

Streptococcal pneumonia

Pt with CHF on diuretic & digoxin

Suspect dig toxicity (hypokalemia from diuretic exacerbates dig tox)

Trendelenburg test of extremities

Tests for veinous insufficiency

1. cyanotic infant 2. systolic thrill heard at LSB 3. systolic ejection murmur +/- click

Tetralogy of fallot

1. right ventricular outflow obstruction: pulmonary artery stenosis 2. right ventricular hypertrophy 3. ventricular septal defect 4. overriding aorta (positioned directly over a VSD instead of over the left ventricle)

Tetralogy of fallot

HTN not responsive to basic HTN meds

Think secondary HTN most likely Renal artery stenosis (infrarenal artery).

1. apical infiltrates 2. fever, chills 3. dry cough

Tuberculosis

1. LE pain after long periods of standing 2. dilated, tortuous, veins

Varicose veins Tx: compression stockings

1. holosystolic murmur at the left sternal border 2. +/- ventricular hypertrophy

Ventricular septal defect (VSD)

Steeple sign

Viral croup (laryngotracheobronchitis) MCC: #1. Parainfluenza, #2. RSV

Atrial fibrillation or prosthetic valve

Warfarin (2 - 3 for Afib; 2.5 - 3.5 for valve) Tx for OD: vit K (takes ~24h)

1. short PR interval 2. wide QRS complex 3. presence of delta wave

Wolff-Parkinson-White Syndrome Avoid Digoxin!

Pediatric wheezing

lower respiratory FB, asthma

1. barking cough 2. coryza (inflammation of nasal mucous membranes) 3. inspiratory stridor

viral croup (laryngotracheobronchitis) Tx: racemic epi, +/- steroids