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16775M passes out while mowing lawn: aortic stenosisNBS: echocardiogram (dx) Sx: SEM radiating to carotids Where is it heard best? RUSB/2nd intercostal spacePathophys: "calcification of valve"*Vs. "myxomatous degeneration" (MVP) vs. "cystic medial degeneration/cystic medial necrosis" (aortic dissection)*Prior to 70Y, d/t bicuspid aortic valve?ASHOCMAgeOlder Younger Heard best?RUSBLLSBMurmurSEM, radiates to carotidsSEMPulsePulsus parves et tardus ("late") d/t trouble getting blood out of ventricle (PMI…carotid)Pulses bisferiens d/t mitral valve moving towards LVOT mid-systole ("bifid carotid pulse") = 1. small 2. big carotid pulse Increase preload (squat, standing --> supine): more blood in LVLouder murmurSofter murmur (Anterior mitral leaflet occludes LVOT)Increase afterloadSofter murmur (less gradient for flow across valve)Softer murmurTxSurgically replace valveImplant defibrillator, beta blocker (more time in diastole = LV fills) Diastolic murmur heard best at apex: mitral stenosisBiggest RF: Rheumatic fever MCC complication: Afib d/t LA contracting against increased resistance --> dilation --> disruption of electrical conductivity+ compression of esophagus (dysphagia)Holosystolic murmur @ apex, radiating to axilla: mitral regurgitation Mid-systolic murmur @ apex, w/ click: mitral valve prolapseRF: ADPKD, Marfans, Ehlers-Danlos ?MRMVPIncrease preloadLouder murmurUnprolapse the valve by filling LV --> decrease regurg --> softer murmurIncrease afterloadLouder murmur (more blood to regurgitate)Softer ?Diastolic blowing murmur heard at RUSB: Aortic regurgitation RF: Takayasu, tertiary syphilis (@vasa vasorum of aortic arch), connective tissue disorder, retrograde aortic dissectionSx: wide pulse pressure (also seen in PDA)c/b: chronic volume overload of LV --> eccentric hypertrophy (sarcomeres in series) --> dilation of LV --> systolic dysfunction --> HFrEFVs. AS --> pressure overload --> concentric hypertrophy (sarcomeres in parallel) --> decreased luminal size of LV --> diastolic dysfunction Severe sudden onset chest pain with radiation to back: Aortic dissection Sx: differences in blood pressure between arms, mediastinal widening, unilateral pleural effusion + chest pain, elevated BPDx: Stable: CTA (c/I renal insufficiency)Unstable: TTETxPropranolol Avoid increased heart rate (place more shear stress on aortic valve) i.e. don't use hydralazine d/t ae: reflex tachycardia s/p baroreceptor activation by vasodilation : Stanford Type A: involves ascending aorta --> surgery Stanford Type B: does *not* involve ascending aorta --> medical therapy RF: HTNIVDU, fevers, 10lb weight loss, LLSB murmur: tricuspid valve endocarditis NBS: blood culture Dx: echocardiogram Tx: IV abx for 6wksEtiology: Staph aureus (MCC IVDU endocarditis) into blood stream, veins drain to R side of heart (tricuspid valve)Vs. recent dental procedure: Strep viridans --> subacute endocarditisIncreased risk with valvular issuesPpx: oral amoxicillin Vs. culture-negative: Coxiella BurnettiVs. + hemolytic anemia, malar rash on face: SLE Libman-Sacks endocarditisVs. Strep bovis: colon cancer! --> colonoscopyVs. 70d s/p recent valve replacement: Staph epidermidis (makes biofilm)Vs. recent immigration, URT w/o treatment: GAS Rheumatic fever70Y, heavy smoker, severe pain when walking to YMCA: PADNBS: ABI <0.9Vs. ABI > 1.1: Monckeberg arteriosclerosis 2/2 T2DM (calcified blood vessels)NBS: *toe* brachial index Tx: supervised walking program, cilostazol (PDE inhibitor leading to increased cAMP, smooth muscle relaxation), arteriography --> bypass@Femoral artery occlusion: pain @ thighPopliteal artery occlusion: pain @ legLeriche syndrome d/t occlusion of internal+external iliac branches of aorta + impotence, buttock pain #ripRF: smokingLong-term smoker, past 30min severe back/abdominal pain, pulsatile abdominal mass, hypotensive: ruptured AAARF: smokingDx: bedside ultrasound or CTAPpx: 65-75M w/ history of smoking or FMHx AAA? One time screening abd ultrasound>5.5 cm, growing >0.5 cm/6mo or >1cm/yr, symptomatic --> surgeryComplications of surgery:AKI d/t transient hypoperfusion of kidneysAAA @ Infrarenal aorta near renal arteryAnterior spinal artery syndrome d/t infarction of Artery of Adamkiewitz Sx: paraplegic/quadriplegic; all of spinal cord knocked out except dorsal columns (vibration/fine touch)Endo-leak = did not properly exclude aneurysm --> contrast going past contours of aneurysm stent Aortoenteric fistula Sx: dropping Hgb s/p weeks or months, heme-occult positive stools Bed-bound hospitalized patient, severe unilateral leg pain/tenderness: DVTRF: Virchow's triad = stasis, hypercoagulability, endothelial dysfunction NBS and Dx: duplex scan of LETx: heparin or IVC filter (prevent PE)Chest pain, ST elevations on EKG, radiation to jaw: STEMIACS?Unstable anginaNSTEMISTEMIChest pain+++Troponin?++ST elevation??+Unstable anginaNBS: Coronary angiography! (not exercise stress test) d/t high probabilityVs. Stable angina: NBS = stress test Echo stress test if known cardio anomalyExercise stress test preferred vs pharmacological stress test (adenosine/dipyrimadole/dobutamine for obese)*adenosine c/I in reactive airway disease*dobutamine c/I in arrythmias NSTEMISTEMIComplicationsMCC death s/p 48h: VfibDiffuse STE, chest pain, worsened with inspiration: pericarditis (post-myocardial vs Dressler's)Tx: NSAID (c/I renal failure), steroid, colchicine (c/I renal failure)Short PR segment, wide QRS, palpitations: WPWPathophys: bundle of Kent that allows direct communication atria --> ventricles Tx: procainamide Severe leg pain worse at end of day, painless ulcer above medial malleolus: chronic venous insufficiencyDx: duplex of LEPathophys: "incompetence of venous valves"Sx: painless ulcer, stasis dermatitis (d/t blood pooling)Tx: leg compression (Unna boots), leg elevation Wide-complex regular tachyarrythmia: Vtach Pulse? Yes: Hemodynamically stable? Amiodarone Hemodynamically unstable? Synchronized cardioversion No: ACLS -- defibrillation ................
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