click below
click below
Normal Size Small Size show me how
Internal Medicine
Question | Answer |
---|---|
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 |