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Internal Medicine

QuestionAnswer
What is the general definition of pulmonary hypertension? Presence of abnormally high pulmonary vascular pressure
What are the diagnostic criteria of Pulmonary hypertension? 1) Mean Pulmonary Arterial Pressure of greater than 25 mmHg at rest 2) Normal pulmonary arterial wedge pressure of 15 mmHg or less 3) Pulmonary vascular resistance of greater than 3 Wood units
What are the causes of PAH (Pulmonary Arterial Hypertension)? 1) Idiopathic 2) Hereditary 3) Drug/toxin induced 4) Association with: a) Connective tissue disease b) HIV c) Portal HT d) Congenital heart disease e) Schistosomiasis
What are the causes of Pulmonary hypertension due to left heart disease? 1) Left ventricular systolic dysfunction 2) Left ventricular diastolic dysfunction 3) Valvular disease 4) Left heart outflow/inflow obstruction and congenital cardiomyopathies
What are the causes of Pulmonary hypertension due to lung diseases? 1) COPD 2) ILD 3) Mixed restrictive and obstructive pattern 4) Sleep-disordered breathing 5) Alveolar hyperventilation disorders 6) High altitudes 7) Developmental lung diseases
What are the causes of Pulmonary hypertension with multifactorial mechanisms? 1) Hematological disorders 2) Metabolic disorders 3) Systemic disorders
What are the main groups of Pulmonary hypertension? Group 1 – Pulmonary arterial hypertension (PAH) Group 2 – PH due to left heart disease Group 3 – PH due to chronic lung disease and/or hypoxemia Group 4 – Chronic thromboembolic pulmonary hypertension (CTEPH)
What is the pathogenesis of Group 1 Pulmonary hypertension? 1) Pulmonary edema, alveolar hemorrhage, lymphatic dilatation, lymph node enlargement, and inflammatory infiltrates 2) Impaired production of NO and prostacyclin and increased thromboxane A2 and endothelin 1 3) Increased PVR and Right heart failure
What is the pathogenesis of persistent pulmonary hypertension in newborns? 1) Changes in vaso-reactivity and wall structure 2) Decreases in pulmonary vascular density with reduced alveolarisation.
What is the pathogenesis of Group 4 Pulmonary hypertension? Thrombi tightly attached to the medial layer in the elastic PA, replace the normal intima--> occlusion of the lumen or stenosis, webs and bands --> Collateral vessels from the systemic circulation can grow to re-perfuse areas distal to obstructions
What are the symptoms of Pulmonary hypertension? 1) Dyspnea (95%) 2) Weakness/Fatigue 3) Substernal chest pain on exertion, radiating to the left shoulder or axilla, and relieved by rest 4) Syncope 5) Peripheral edema and ascites 6) Hemoptysis
What are the physical signs of Pulmonary hypertension? 1) Cold extremities 2) Diminished peripheal pulse 3) Low BP 4) Prominent jugular venous a wave 5) Rt ventricular lift 6) Cyanosis 7) Split second heart sound with loud P2 8) Systolic ejection click 9) Graham Steel and tricuspid regurg murmur
What is class 1 of Pulmonary Hypertension? Pulmonary hypertension without limitation of physical activity or without symptoms at physical activity
What is class 2 of Pulmonary Hypertension? Pulmonary Hypertension causing slight limitation of physical activity, no symptoms at rest, and symptoms at movement.
What is class 3 of Pulmonary Hypertension? Pulmonary HT causing marked limitation of movement. Comfortable at rest
What is class 4 of Pulmonary Hypertension? Pulmonary HT causing inability to carry out physical activity without symptoms. Signs of HF. Dyspnea and fatigue at rest.
What CXR findings can be found in Pulmonary Hypertension? 1) Decreased peripheral lung vascularity 2) Hilar pulmonary artery prominence 3) Right ventricular enlargement
What are the ECG findings in Pulmonary Hypertension? Right atrial enlargement-->right ventricular hypertrophy and strain --> Right axis deviation
What equation is used to determine the likelihood of pulmonary HT? Right ventricular systolic pressure = [(TR jet)2 × 4] + estimated central venous pressure
How is the presence and severity of Pulmonary hypertension determined? Right heart catheterization
What is the supportive treatment of Pulmonary hypertension? Supervised aerobic and respiratory training Avoiding activities that cause symptoms Avoiding high altitudes Avoid pregnancy and OCPs
What is the pharmacological supportive treatment of Pulmonary hypertension? 1) Anticoagulants: Warfarin and Factor 10a Inhibitors 2) Oxygen therapy 3) Diuretics 4) Calcium channel antagonists
What is the targeted treatment of Pulmonary hypertension? 1) Prostacyclin analogs (Epoprostenol and Iloprost) 2) Phosphodiesterse 5a inhibitors (Sildenafil and Tadalafil) 3) Endothelin receptor antagonists (Bosentan and Ambrisentan)
What is the surgical treatment of Pulmonary hypertension? 1) Balloon-atrial septostomy creating a left-to-right intacardiac shunt 2) Pulmonary Thromboendarterectomy 3) Lung transplantation
What is the definition of pneumonia? An inflammatory process resulting from infection of the lung parenchyma by pathogenic microorganisms and usually associated with radiological evidence on CXR
What are the types of pneumonia? CAP HAP VAP
What is the pathogenesis of pneumonia? 1) Aspiration of oropharyngeal or nasopharyngeal secretions 2) This interaction is enhanced by cigarette smoke, infection with respiratory viruses, and particulate air pollutants.
What mechanisms do the airways possess to prevent adherence and colonization of bacteria? 1) Epithelial cells synthesize and secrete peptides (defensins and cathelicidins) 2) Pulmonary surfactant proteins A and C can inhibit bacterial binding to host cells and also promote phagocytosis 3) The presence of complement and immunoglobulins(IgA)
What are the risk factors for pneumonia? Age , smoking , alcohol and comorbidity (resp. and non resp), Geographic factors, seasonal timing, travel history, and occupational exposure
What are the clinical manifestations of pneumonia? 1) Fever 2) Cough 3) Sputum production 4) Dyspnea 5) Pleuritic pain 6) Hemoptysis
What are the physical findings in pneumonia? 1) Consolidation 2) Increased fremitus on affected side 3) Dullness 4) Bronchial breath sounds 5) Bronchophony 6) Crackles
What investigations are required to diagnose pneumonia? 1) CXR 2) CT 3) Labs: CBC, serum glucose, electrolytes, pulse oximetry or ABG ,CRP, PCT 4) Microbiological: sputum culture (40%), blood culture(20%). 5) Invasive: pleural tap, Bronchoscopy
What are the main serology markers which could be found in pneumonia? 1) S. pneumonia urinary antigen 2) Legionella urinary antigen
What is the sensitivity and specificity of the S. pneumonia urinary antigen? Sensitivity is 50% to 80% Specificity is 90%
What is the sensitivity and specificity of the Legionella urinary antigen? Sensitivity is 60% to 80% Specificity is greater than 95%
What tests are used to asses the severity of pneumonia? 1) CURB-65 2) PSI
What is CURB-65? Confusion Urea>7mMol/L RR>30 breaths/min SBP <90 or DBP <60 Age greater than 65
How is the severity of pneumonia indicated on CURB-65? 0-1 is non-severe 2 is intermediate 3-5 is severe
How is pneumonia treated? 1) Empirical therapy 2) Narrow spectum antibiotic
If an ECG shows a HR of 35 BPM and regular sinus rhythm, what does this indicate? Sinus Bradycardia
What is the definition of sinus bradycardia? Sinus rhythm with a resting heart rate of less than 60 BPM
How is sinus bradycardia diagnosed? Commonly, an incidental finding in young adults
What is the most common physiological cause of sinus bradycardia? Being an athlete
What are the pathological causes of sinus bradycardia? Inferior wall MI, Toxin exposure, electrolyte disorders, infection, sleep apnea, drugs,hypoglycemia, hypothyroidism, and increased intracranial pressure
Which drugs can cause sinus bradycardia? Digoxin, Beta blockers, CCBs, methyldopa, class I antiarrhythmic agents and amiodarone
What are some possible clinical manifestations of sinus bradycardia? Syncope, dizziness, light headedness, chest pain, and SOB
What are some pertinent findings in the history of a patient with sinus bradycardia? MI, CHF, drug history, toxic exposure, and other previous injury
What are the physical findings in sinus bradycardia? Slow HR with auscultation or palpation of peripheral pulses May reveal decreased consciousness, cyanosis, peripheral edema, and pulmonary vascular congestion
Which toxins can cause sinus bradycardia? Lithium, paclitaxel, toluene, dimethyl sulfoxide (DMSO), topical ophthalmic acetylcholine, fentanyl, alfentanil, sufentanil, reserpine, and clonidine
What are the intrinsic causes of sinus node dysfunction? Idiopathic degenerative diseases, ischemia, infiltration, inflammation, MSS disorders, SLE, scleroderma, and after ASD repair
What lab tests may be important in patients with bradyarrhythmias? Electrolytes,Glucose, Calcium,Magnesium, Thyroid function tests,and Toxicologic screen
How can the diagnosis of bradyarrythmia be confirmed? 12-lead ECG
What is the treatment of symptomatic bradyarrythmia? Treat underlying cause Permanent pacemaker
What is the pathology of Sick Sinus Syndrome? Dysfunction in the ability of the sinus node to generate or transmit an action potential to the atria
What disorders are associated with Sick Sinus Syndrome? Cerebral hypoperfusion, sinus bradycardia, sinus arrest, sinoatrial block, carotid hypersensitivity, or alternating episodes of bradycardia and tachycardia
What type of patients get Sick Sinus Syndrome? Elderly patients with concomitant cardiovascular disease
What is the usual treatment for Sick Sinus Syndrome? Permanent Pacemaker
What is the typical ECG finding in Type 2 SA block? Progressive prolongation of the PR interval
What are the causes of inflammatory heart disease? Viral,idiopathic, giant cell, and Eosinophilic myocarditis Sarcoidosis Lyme, HIV, and Chaga's disease Peripartum
What are the causes of extramyocardial cardiomyopathy? HT, CAD, valvular heart disease, and congenital cardiac anomalies
What are the inherited causes of secondary cardiomyopathy? NM disorders, x-linked, mitochondrial, familial dilated cardiomyopathy, and storage diseases
What are the types of cardiomyopathy? Dilated, restrictive, and hypertrophic
What are the symptoms of dilated cardiomyopathy? Left-sided CHF, fatigue, weakness, and emboli
What are the physical findings of dilated cardiomyopathy? Moderate to severe cardiomegaly S3 and S4 Mitral valve regurgitation
What are the chest X-ray findings in dilated cardiomyopathy? Moderate to marked left ventricular enlargement Pulmonary HT
What are the ECG findings in dilated cardiomyopathy? Sinus tachycardia Arrythmia ST segment and T wave abnormalities IV conduction defects
What are the echo findings in dilated cardiomyopathy? Left ventricular dilation and dysfunction Abnormal diastolic mitral valve
What are the symptoms of restrictive cardiomyopathy? Dyspnea and fatigue Right sided CHF Signs of storage diseases
What are the physical findings in restrictive cardiomyopathy? Mild to moderate cardiomegaly S3 or S4 AV valve regurgitation Kussmaul's respiration
What are the chest X-ray findings in restrictive cardiomyopathy? Mild cardiac enlargement Pulmonary HT
What are the ECG findings in restrictive cardiomyopathy? Low voltage Atrioventricular conduction defects
What are the echo findings in restrictive cardiomyopathy? Increased left ventricular wall thickness and mass Small or normal sized left ventricular cavity Normal systolic function Pericardial effusion
What are the symptoms of hypertrophic cardiomyopathy? Dynspnea, angina pectoris, fatigue, syncope, and palpitations
What are the classical physical findings in hypertrophic cardiomyopathy? Apical systolic thrill and heave Brisk carotid upstroke Common S4 Systolic murmur that increases with Valsalva maneuver
What are the chest X-ray findings in hypertrophic cardiomyopathy? Mild cardiac enlargement Left atrial enlargement
What are the ECG findings in hypertrophic cardiomyopathy? LV hypertrophy ST segment and T wave abnormalities Abnormal Q waves Atrial and ventricular arrythmias
What are the echo findings in hypertrophic cardiomyopathy? Asymmetrical septal hypertrophy Narrow left ventricular outflow tract Systolic anterior motion of the mitral valve Small or normal sized left ventricle
Causes of DCM: Idiopathic Post-partum Post-chemotherapy (doxorubicin) Acquired immodeficiency syndrome Infiltrative diseases (hemochromatosis) Metabolic (DM,Thyrotoxicosis) Tachycardia-induced Alcohol-induced
How is DCM caused by hemochromatosis reversed? By weekly phlebotomy
What is the irreversible infiltrative disease which causes DCM? Amyloidosis
What are the prognostic factors of DCM? NYHA, groups 2-4 LBBB Hyponatremia Elevated NE and ANP Nonsustained VT Syncope LVEDP >18-20 CI <2.5 l/min/m2
What is the treatment of DCM? Therapeutic modalities are geared towards treatment of HF / arrhythmias -->Beta adrenergic blockers, Anticoagulants (Afib, CVA, cardiac thrombus),Antiarrhythmics, and Dual chamber / bi-ventricular pacing Heart surgery / transplantation
What are the characteristics of the athletic heart? Septum<1.5cm EDD>4.5cm LA<4cm Always concentric and regresses after 3 months of stopping
What are the subtypes of HCM? Subaortic Midventricular Apical Diffuse
What is the inheritance of HCM? Familial HCM is inherited in autosomal dominant fashion (at least 50%) and sporadic
How does HCM manifest clinically? Asymptomatic Angina Syncope Dysnpea Sudden death
What is the pathogenesis of HCM? Dilated atria Normal-sized ventricles Variable decrease in systolic dysfunction Progressively worsening diastolic dysfunction
Procedure of choice for diagnosis of RCM? Echocardiography
What is the most common cause of RCM and how is it diagnosed? Amyloidosis Granular sparkling texture noted in 47% Increased thickness of papillary muscles, interatrial septum, valve leaflets, and left-ventricular wall thickness Valvular regurgitation Thrombi in the atrial appendages
Created by: Ulaisl