1 Table of Contents CARDIOVASCULAR – 20% ................................ ................................ ................................ ............... 3 ACS ................................ ................................ ................................ ................................ ................................ ....... 6 Peripheral Artery Disease ................................ ................................ ................................ ................................ . 14 PVD – Peripheral Vascular Disease ................................ ................................ ................................ ................... 19 Cardiomyopathies ................................ ................................ ................................ ................................ ............. 23 Endocarditis ................................ ................................ ................................ ................................ ....................... 30 Heart Failure ................................ ................................ ................................ ................................ ...................... 36 Hypertension ................................ ................................ ................................ ................................ ..................... 42 CHD ................................ ................................ ................................ ................................ ................................ .... 47 Valvular Disease ................................ ................................ ................................ ................................ ................ 55 Arrhythmias ................................ ................................ ................................ ................................ ....................... 62 PULOMONOLGY – 15% ................................ ................................ ................................ ................. 78 Asthma ................................ ................................ ................................ ................................ ............................... 78 Idiopathic Pulmonary Fibrosis ................................ ................................ ................................ ........................... 85 Lung Cancer ................................ ................................ ................................ ................................ ....................... 87 Sleep Disorders ................................ ................................ ................................ ................................ .................. 93 Sarcoidosis ................................ ................................ ................................ ................................ ......................... 95 Pneumonia ................................ ................................ ................................ ................................ ....................... 101 GI/NUTRTITIONAL – 12% ................................ ................................ ................................ ............ 109 Esophagitis ................................ ................................ ................................ ................................ ....................... 110 Acute Cholecystitis ................................ ................................ ................................ ................................ .......... 113 Acute Gastritis ................................ ................................ ................................ ................................ ................. 118 GERD ................................ ................................ ................................ ................................ ................................ 120 Hepatitis ................................ ................................ ................................ ................................ ........................... 122 Pancreatitis ................................ ................................ ................................ ................................ ...................... 128 Anal Fissure ................................ ................................ ................................ ................................ ...................... 132 Inflammatory Bowel Disease ................................ ................................ ................................ .......................... 136 Hepatocellular Carcinoma ................................ ................................ ................................ ............................... 140 ORTHO/RHEUMATOLOGY – 12% ................................ ................................ ................................ 145 Fibromyalgia ................................ ................................ ................................ ................................ .................... 145 Gout ................................ ................................ ................................ ................................ ................................ . 146 Polyarteritis Nodosa ................................ ................................ ................................ ................................ ........ 148 Polymyositis ................................ ................................ ................................ ................................ ..................... 150 Rheumatoid Arthritis ................................ ................................ ................................ ................................ ....... 152 ENDOCRINOLOGY – 8% ................................ ................................ ................................ .............. 160 Adrenal Insufficiency ................................ ................................ ................................ ................................ ....... 160 Hypothyroidism ................................ ................................ ................................ ................................ ............... 169 Diabetes Mellitus ................................ ................................ ................................ ................................ ............. 175 Pituitary Aden oma – Prolactinoma ................................ ................................ ................................ ................. 180 Hypercalcemia ................................ ................................ ................................ ................................ ................. 181 NEUROLOGY – 8% ................................ ................................ ................................ ...................... 188 Headaches ................................ ................................ ................................ ................................ ........................ 189 Meningitis ................................ ................................ ................................ ................................ ........................ 194 Huntington Disease ................................ ................................ ................................ ................................ ......... 197 Essential Tremor ................................ ................................ ................................ ................................ .............. 203 2 Dementia – Neurocognitive disorders ................................ ................................ ................................ ............ 203 Seizure Disorders ................................ ................................ ................................ ................................ ............. 206 Syncope ................................ ................................ ................................ ................................ ............................ 211 Cerebral vascular accident ................................ ................................ ................................ .............................. 213 UROLOGY/RENAL – 8% ................................ ................................ ................................ ............... 222 Glomerular Disease ................................ ................................ ................................ ................................ ......... 222 Hydronephrosis ................................ ................................ ................................ ................................ ............... 230 Acute Renal Injury ................................ ................................ ................................ ................................ ........... 233 Renal Vascular disease – Renal Artery stenosis ................................ ................................ ............................. 238 Metabolic acidosis ................................ ................................ ................................ ................................ ........... 240 Prostatitis ................................ ................................ ................................ ................................ ......................... 242 CRITICAL CARE – 7% ................................ ................................ ................................ ................... 250 Acute Abdomen ................................ ................................ ................................ ................................ ............... 251 Acute GI bleed ................................ ................................ ................................ ................................ ................. 253 Acute Respiratory Distress ................................ ................................ ................................ .............................. 255 Diabetic Ketoacidosis ................................ ................................ ................................ ................................ ...... 256 Hypertensive Crisis ................................ ................................ ................................ ................................ .......... 258 Pericardial Effusion ................................ ................................ ................................ ................................ .......... 259 Shock ................................ ................................ ................................ ................................ ................................ 262 Status Epilepticus ................................ ................................ ................................ ................................ ............ 265 HEMATOLOGY – 5% ................................ ................................ ................................ ................... 268 Anemia of Chronic Disease ................................ ................................ ................................ .............................. 268 Thromb otic thrombocytopenic Purpura ................................ ................................ ................................ ......... 274 Von Willebrand Factor Deficiency ................................ ................................ ................................ .................. 277 Multiple Myeloma ................................ ................................ ................................ ................................ ........... 279 Leukemias ................................ ................................ ................................ ................................ ........................ 280 Lymphomas ................................ ................................ ................................ ................................ ..................... 282 INFECTIOUS – 5% ................................ ................................ ................................ ....................... 285 Tetanus ................................ ................................ ................................ ................................ ............................ 285 Diphtheria ................................ ................................ ................................ ................................ ........................ 286 Gonococcal Infections ................................ ................................ ................................ ................................ ..... 287 Rocky Mountain Spotted Fever ................................ ................................ ................................ ...................... 288 Cryptococcus ................................ ................................ ................................ ................................ .................... 291 Giardiasis and parasitic infections ................................ ................................ ................................ .................. 294 Syphilis ................................ ................................ ................................ ................................ ............................. 296 Epstein -Barr infection – Mononucleosis ................................ ................................ ................................ ......... 299 Herpes Simplex ................................ ................................ ................................ ................................ ................ 300 Salmonellosis ................................ ................................ ................................ ................................ ................... 306 3 CARDIOVASCULAR – 20% CAD Etiology: • Atherosclerosis is the MC cause • Other causes: coronary artery vasospasm, aortic stenosis, pulmonary hypertension, hypertrophic cardiomyopathy Risk Factors: • DM (worst) • cigarettes – most important modifiable • hyperlipidemia, hypertension, males, family history, obesity • age: women> 55, men > 45 • Metabolic Syndrome Pathophysiology : • Inadequate tissue perfusion and ischemia due to imbalance between coronary blood supply and demand • Formation of an atherosclerotic plaques o Fatty streak formation ▪ Lipid deposition in the white blood cells ▪ The first step in the development of atherosclerotic plaques o Formation of an early plaque ▪ LDL enters the endothelium in the fatty streak and is then oxidized attracting macrophages. These ingest LDL becoming foam cells who attract more macrophages o Formation of a fibrous plaque ▪ Proliferating smooth muscle cells and connective tissue becomes incorporated into a mature plaque. This cap is what causes the narrowing of the lumen • Myocardial ischemia o The narrowing from above causes reduced cardiac blood flow, especially in conditions where there is increased demand Clinical Manifestations : • Chest pain – MC sx • SOB • Dizziness, palpitations • Restlessness • Signs o Mitral regurg murmur that radiates to axilla o Signs of CHF • Signs of vascular disease: o Bruits o ischemic ulcers o diminished pulses Diagnosis : • EKG: 4 o Shows ST elevation or depression depending on severity o Resting EKG is normal in 50% of pts • Stress testing: o Most useful non -invasive screening tool o Stress EKG: ▪ Most widely used ▪ Bruce protocol: Incremental increases in workload with monitoring of heart rate, blood pressure and EKG changes ▪ Involves recording of the 12 lead EKG before, during and after exercise ▪ Will have increased increments of external workload until there is chest discomfort, severe SOB, dizziness, severe fatigue, ST depression of >0.2mV, fall in systolic BP >10 mmHg or development of ventri cular tachyarrhythmia ▪ Ischemic related ST changes are defined at a flat or down sloping depression >0.1 mV below baseline and lasting longer than 0.08s • Up sloping NOT considered characteristic of ischemia ▪ Positive test: ST depressions, hypotension/hypert ension, arrhythmias, symptoms o Myocardial perfusion imaging stress ▪ Exercise of pharmacologic ▪ Use thallium -201 or 99m -technetium sestamibi ▪ Indicated when a patient has baseline abnormalities on EKG o Stress Echo: ▪ Assesses LV function, valvular disease ▪ Can locate ischemia, wall motion abnormalities and visualize heart structures ▪ Dobutamine if pharmacological o Pharmacological ▪ Done in patients unable to exercise ▪ Vasodilators: adenosine of dipyridamole ▪ Can’t do this in pts w/ bronchospastic dise ases or with 2nd and 3rd degree heart block • Coronary angiography: o will provide definitive diagnosis, gold standard o Outlines the lumina of the coronary arteries o Indications ▪ Pts w/ chronic stable angina pectoris who are severely symptomatic despite medic al therapy and are being considered for revascularization ▪ Patients with troublesome sx that present diagnostic difficulties in whom there is need to confirm or rule out diagnosis ▪ Patients with known angina who survived cardiac arrest ▪ Pts w/ angina or ev idence of ischemia or noninvasive testing w/ clinical or laboratory evidence ▪ Patients judged to be high risk • Chest Xray: • Can show consequences of IHD – Cardiac enlargement, ventricular aneurysm, signs of heart failure Management : 5 • Lifestyle: o Exercise o Diet low in fat and cholesterol o Weight reduction o Smoking Cessation o Aggressive control of diabetes, HTN and hyperlipidemia • Beta blockers for management o Prolong life in pts with CAD • Revascularization o Percutaneous transluminal coronary angioplas ty – PTCA also known as ▪ Indicated if 1 -2 vessels are involved, but NOT left coronary artery and if ventricular function is normal ▪ Restenosis occurs in 30%, so adding stents help o Coronary artery bypass graft – CABG ▪ Indicated if left coronary artery is involved, more than 3 vessels or ejection fraction less than 40% Angina Prinzmetal Etiology: • Triggers: hyperventilation, cocaine or tobacco use, provocative agents like acetylcholine, ergonovine, histamine, serotonin Pathophysiology : • Focal spams of epicardial Coronary artery without obstruction with resultant transmural ischemia and abnormalities in LV function • Can lead to acute MI, ventricular tachycardia or fibrillation and sudden cardiac death Clinical Manifestations : • Non exertional chest pain, occurs at rest • Normal exercise tolerance o Pain is cyclical – mostly occurs in morning hours with no correlation to cardiac workload Diagnosis : • EKG: o ST segment or T wave abnormalities that are transient • Cardiac enzymes: o Norm al troponins o Normal CK -MB • Labs: o Check Mg o CBC o CMP o lipids • Stress testing with myocardial perfusion image or coronary angiography Management : • Sublingual, topical or IV nitrates 6 • Antiplatelet, thrombolytics, statins, BB • CCB – DOC for management – Diltiazem or Verapamil • Nitrates PRN Cocaine -Induced Pathophysiology : • Coronary artery vasospasm due to cocaine’s activation of the sympathetic nervous system and alpha 1 receptors Diagnosis : • EKG: • Transient ST elevations Management : • ASA, Nitroglycerin, Heparin, Anxiolytics • CCB and Nitrates – DOC • AVOID BB – can cause unopposed alpha vasoconstriction ACS Pearls: • Stable – predictable, relieved by rest and/or nitro • Unstable – no evidence on EKG or no evidence of myocyte necrosis • NSTEMI – no evidence on EKG, but evidence of myocyte necrosis • STEMI – evidence on EKG and evidence of myocyte necrosis CAD ASX SA UA NSTEMI STEMI PAIN • w/ exertion Worsening At rest At rest RELIEVED • Rest, NTG Rest None None TROPONINS • • • Elevated Elevated ST ELEVATION • • • • Yes PATHOPHYS Stenosis Thrombosis Thrombosis % OCCLUDED <70% >70% <100% 100% Etiology: • Atherosclerosis – MCC • Coronary artery vasospasm (Prinzmetal, cocaine -induced) Risk Factors: • Diabetes is the #1 RF Pathophysiology: • Symptoms of acute myocardial ischemia secondary to acute plaque rupture and varying degrees of coronary artery thrombosis • Plaque rupture leads to acute coronary artery thrombosis w/ platelet adhesion/activation/aggregation along with fibrin formation Clinical Manifestations: • Anginal Pain 7 o Retrosternal pressure that is not relieved with rest and nitroglycerin o Can radiate to arms, neck, back, shoulders, epigastrium, lower jaw o Non -positional, pleuritic chest pain o Levine’s sign – clenched fist on chest o Highest frequency in the morning o If this occurs at rest, usually indicated at least a 90% occlusion of artery • Sympathetic Stimulation o Anxiety, diaphoresis o Tachycardia o Palpitations o Nausea and vomiting o Dizziness • Physical Examination o Usually is nor mal o S4 heart sound – common in inferior infarcts o bradycardia – common in inferior wall infarcts • Can be silent in 25% o Occurs more often in women, elderly, diabetics and obese pts Approach to the patient: Diagnosis: • 12-Lead EKG: o Order ASAP o ST elevations > 1mm in more than 2 contiguous leads w/ reciprocal changes in the opposite leads o New LBBB → STEMI (until proven otherwise) ISCHEMIA LOCATION LEADS TO SHOW CHANGES ARTERY AFFECTED Inferior II, III, AVF Right Coronary Artery Posterior V1 and V2 (ST depressions) RCA and circumflex Anteroseptal V1 and V2 Proximal LAD Anterior V1-V4 Left Anterior Descending Lateral I, AVL, V5, V6 Circumflex 8 • Cardiac Enzymes: ENZYME DETECTABLE PEAK BACK TO BASELINE TROPONIN 3-12 hours 24-48 hours 5-14 days CK 3-12 24 hours 48-72 hours MYOGLOBIN 1-2 hours 8-10 hours 1-2 days Management: • All patients should be given Nitro with chest pain o It is CI in right sided (inferior leads) MI o Right side is preload dependent and nitro decreases preload • Beta blocker should be given ASAP o IV BB are given immediately and increase myocardial oxygen supply -demand relationship, decreases pain, reduces infa rct size and dec chance of arrhythmia formation • Aspirin o High dose given ASAP • Oxygen o Give as little as possible o If pt is stable on room air, no oxygen o Can make worse if the patient is receiving too much oxygen • Discharge: o Beta blocker o ACEi o DAPT: Asp irin + clopidogrel o Statin Complications: • Dressler syndrome: o Post MI syndrome – pericarditis o Occurs 1 -2 weeks post MI o Sx: fever, malaise o Pericarditis and pleuritis o CBC: leukocytosis o Tx: aspirin and ibuprofen • Ventricular dysfunction o The left ventricle undergoes a series of changes in the shape, size, thickness o Leads to more marked hemodynamic impairment o Tx: ACEi and vasodilators • Hypovolemia o Can contribute to hypotension and vascular collapse • Cardiogenic shock o Usually in pts w/ multivessel disease • Arrhythmias 9 o Due to ANS imbalance, electrolyte disturbances, ischemia, slowed conduction in zones of ischemic myocardium Stable Angina Etiology: • Triggers: mental or physical stress, exposure to cold Pathophysiology : • Stable angina is due to transient myocardial ischemia – occurs when coronary stenosis and myocardial oxygen supply are fixed and ischemia is participated by an increase in myocardial oxygen demand • Fixed atherosclerotic lesions narrowing major coronary art eries leading to decreased O2 supply and inadequate perfusion o When plaque is exposed to blood, platelets are activated and aggregate and the coagulation cascade is activated leading to deposition of fibrin strands. o These fibrin strands trap red blood cel ls and lead to decreased coronary flow • Normally, the endothelium controls vascular tone, maintains antithrombotic surfaces and controls inflammatory cell adhesion and diapedesis. • Risk factors above, affect the endothelium and make it less likely to do it s job. • It can lead to inappropriate constriction, luminal thrombus formation and abnormal interactions between blood cells • Symptoms start to occur when the stenosis reduces the diameter of an epicardial artery by 50% • When diameter is reduced by 70%, that ’s when flow at rest is reduced. Clinical Manifestations : • Chest pain or substernal pressure that lasts less than 10 -15 minutes • Heaviness, pressure, squeezing and tightness • Increased with exercise or exertion d/t increased demand w/ decreased supply • Symptoms are reproducible and predictable • Symptoms subside within minutes with rest or administration with nitro • Levine sign: clenched fist over sternum and clenches teeth when describing chest pain Diagnosis : • EKG: o Will be normal at rest, may have Q -waves if prior MI o ST depressions o LVH – signs of this indicate the increased risk of adverse outcomes of IHD
