Kaplan Step 3 Cardiology 1.
Case 1 – 1 – Severe Severe pains in my chest a.
68M, dull, substernal CP
b.
Dx: ECG, CK-MB or troponin, troponin, CXR, pulseox i.
DDx: atrial fibrillation
c.
Dx: ECG, echo, TFT, TFT, cardiac enzymes, ABG ABG
d.
Tx: Slow rhythm by beta blocker, CCB, or digoxin (none of them convert to sinus rhythm), admit with continuous cardiac monitoring
st
STEMI – STEMI – give give ASA 1 , PCI (within 90min) or
i.
Start warfarin (INR 2-3)
TPA (indicated < 12hrs from pain onset best
ii.
Start ASA if no risk factors and lone afib
< 30min), and metoprolol ii.
b.
e. st
Unstable angina – angina – give give ASA 1 ,
VTach: tachycardia +/- hypotension. hypotension. Confirm with ECG.
c.
If low EF, give ACEI. If LDL > 100, give statins
i.
Unstable – Unstable – synchronized synchronized cardioverison
d.
CCB – CCB – if if cocaine, Printzmetal angina or severe asthma
ii.
Stable – Stable – amiodarone, amiodarone, lidocaine, or
– cannot – cannot tolerate beta blockers e.
Further dx: dx: repeat CK-MB
f.
Tx: ASA (clopidogrel if contraindicated), morphine, SL
procainamide f.
or IV NTG, admit to ICU i.
PCI within 90min of door to OR
ii.
Beta blockers (metoprolol or atenolol) and statins TPA followed by heparin within 12hrs of CP
iv.
O2 and intra-aortic balloon pump (IABP) – (IABP) –
v.
NSTEMI – NSTEMI – no no on TPA but yes on heparin and
b. c.
Pericarditis – Pericarditis – diffuse diffuse ST elevation, PR depression
3.
c.
Tx: before ECG, give IV atropine, IVF and consider
Then get ABG
e.
Tx: defib at 360 multiple times, IV access, intubate, epi Q5min or vasopressin, defib again then amiodarone or lidocaine, consider bicarb, defib
6.
Case 6 – 6 – my my chest hurts when I walk upstairs a.
62M with HTN comes to ED with CP when walking up the stairs = stable angina
dopamine then pacemaker
b.
Dx: ECG
Case 3 – 3 – funny funny sensation in his chest
c.
Tx: continue his usual usual meds – meds – atenolol atenolol and NTG
a. b.
All cardioversions are synchronized except for
i.
Start ASA
ventricular fibrillation
ii.
Outpatient cardiac catheterization
iii.
Statins if LDL > 100
Shock if unstable (SBP < 90, CP, SOB, confusion). Meds if stable – stable – amiodarone amiodarone (thyroid probs, lung
7.
fibrosis, blue skin, corneal deposits), lidocaine,
Case 7 – 7 – my my chest and stomach hurt while I was eating a.
procainamide
56M with HTN and DM, CP when eating = unstable angina
c.
Dx: BMP, ABG
b.
PE – PE – do do focal now, complete later
d.
Tx: DC cardioversion or amiodarone/lidocaine
c.
DDx: unstable angina, MI, dissecting dissecting aortic aneurysm,
e.
Management of VT i.
ii.
pericarditis, PUD
Pulse and stable condition 1.
IV access, O2; amiodarone (when
d.
Dx: ECG, CXR, CKMB CKMB or troponin
e.
Tx: unstable angina with ST depression – depression – give give beta
EF < 40%), lidocaine or
blockers, NTG, heparin, GPIIb/IIIa inhibitor when pain
procainamide
persists or angioplasty is planned
Unstable 1.
8. Synchronized at 100, 200, 360,
Case 8 – 8 – hyperlipidemia hyperlipidemia management a.
360 then amiodarone followed by f.
unsynchronized cardioversion a.
65M fluttering/palpitations, HTN, P 140, CV exam shows irregularly irregular rhythm
Dipyridamole thallium test and dobutamine echo – echo – stress test when pt can’t exercise. Is
Management of pulseless VT: manage as VF i.e.
Case 4 – 4 – Weird Weird feeling in my chest
58M w/ DM (LDL goal < 100) i.
lidocaine or procainamide
4.
Dx: ECG, order continuous cardiac monitoring If asytole, give epi and atropine
block); block); whereas there is tachycardia with RV infarct, Dx: ECG
DDx: VF, VT, MI, asystole, PE, pulseless pulseless electrical
d.
bradycardia (+ canon a waves = complete heart
b.
65M s/p anterior wall MI brought to ED d/t
i.
68M with inferior wall MI and hypotension and
tamponae, valve rupture and septal rupture
Stable – Stable – vagal vagal maneuvers, adenosine then
activity (correct underlying cause)
Case 2 – 2 – a pt’s BP has dropped dramatically a.
ii.
palpitations. He is unresponsive and loses his pulse
abcximab 2.
Unstable – Unstable – synchronized synchronized cardioversion
Case 5 – 5 – I’m having palpitations a.
for pts with ruptured valve/inotropic agents
g.
i.
BB, CCB or digoxin 5.
iii.
SVT: regular tachycardia w/o P waves, fibrillary wave or flutter waves
it reversible? Then fixable b.
DM and CAD then goal LDL < 70
c.
Arcus senilis – senilis – lipid lipid in the eye
d.
Dx: total cholesterol, LDL, TG, TG, HDL
e.
Tx: diet change & statin (lowers mortality most) if
a.
CAD and LDL > 100 9.
mild bibasilar rales, loud S1 – mitral stenosis, as it
Case 9 – I can’t breath a.
Must order with SOB pts = O2, pulseox, ABG and CXR
b.
68F with JVD, b/l rales to the apices, tachycardia 3/6 systolic murmur at the apex and S3 gallop, b/l LE
worsens it opens closer to S2 b.
d. e.
Biphasic P wave in ECG: LA hypertrophy
Heart failure leads to dilation which leads to
d.
Further Dx: echo, L heart catheterization
regurgitation
e.
Tx: salt restriction, diuretics, balloon valvuloplasty
Dx: ECG (look for ischemia or arrhythmia) , CXR, ABG,
(used on pregnant women first and transferred to
echo
general public) or commissurotomy if symptoms
Tx: sit pt upright, diuretics to decrease preload, O2,
persist with medical therapy (valve replacement if
digoxin after stabilization i. ii.
that fails) 14. Case 14 – I have cramping pain in my R calf while walking
Systolic dysfunction: ACEI, BB,
a.
71M long h/o heart disease CAD = PAD, smoker
spironolactone
b.
PE: no popliteal/pedal pulses, hair loss, smooth skin
Diastolic dysfunction: diuretics, BB;
c.
DDx: leg claudication
dobutamine if refractory
d.
Dx: ABI (< 0.9. Normal > 1), angiogram (most
10. Case 10 – my breath is short and my vision is blurry. I can’t think straight
accurate – to determine location) e.
Tx: stop smoking, ASA/clopidogrel, graded exercise
47M hypertensive crisis (BP 230/150) – high BP and
program, cilostazol (antiplatelet, antispasmodic),
acute end organ damage (confusion, blurry vision,
statins if LDL > 100, angioplasty
SOB, and CP) b.
Dx: CXR, ECG, O2, pulseox i.
nitrates, morphine, add BB/spironolactone and
a.
DDx: mitral stenosis, LA myxoma, ASD (fixed split of S2), TB, Chagas, Wegeners
c.
edema – signs of CHF and pulmonary edema c.
36F from Ecuador (think rheumatic fever 1st), JVD,
Eye exam shows AV nicking and retinal hemorrhages
15. Case 15 – My left lower leg i s painful and I have a swollen ankle a.
= hypertensive hemorrhages c.
Dx: BUN/Cr, ECG, CBC, CT head, CXR
d.
Tx: reduction of BP by 1/3 (but not below a diastolic of 95mmHg) by giving IV labetolol, nitroprusside,
breast cancer. i.
Tamoxifen: prevents osteoporosis, but causes clots and endometrial cancer
b.
NTG others – enalaprilat, esmolol, hydralazine, diazoxide, and trimethaphan, nicardipine
50F 3day h/o of L calf pain. She’s on tamoxifen for
PE: pitting edema of L ankle, pain in the calf on dorsiflexion of L foot (Homan’s sign)
c.
11. Case 11 – my legs are swollen
DDx: DVT, calf injury, Baker cyst, cellulitis, intramuscular hemorrhage
a.
58M to ER of swelling of legs then SOB
d.
Dx: duplex US
b.
PE: 2/6 systolic murmur at the apex going to the
e.
Tx: outpatient therapy enoxaparin or heparin for 5-
axilla – mitral regurgitation + rales = dilated cardiomyopathy (decr EF)
7days and warfarin for 3-6mos 16. Case 16 – I can’t breathe so well
c.
Dx: CXR, ECG
a.
56M in MVA with chest wall trauma
d.
Tx: discontinue alcohol, ACEI, BB, diuretics, digoxin,
b.
Dyspnea: O2, pulseox, CXR, ABG (COPD)
long-term anticoagulation if evidence of thrombosis,
c.
PE: JVD noted, hypotension, tachycardia
spironolactone
d.
Dx: pneumothorax, tamponade (pulsus paradoxus)
e.
Dx: CXR, ECG (electrical alternans), ABG
f.
Further Dx: echo (diastolic RA and RV collapse first
12. Case 12 – I fainted in ballet class a.
Syncope – sudden (cardiac, neuro) or gradual
on tamponade)
(glucose, O2, anemia, toxins) i.
Sudden: regain sudden (cardiac) or gradual (neuro)
b.
17F with recurrent syncope, S4 gallop and 2/6 systolic murmur
c.
DDx: vasovagal syncope, AS, HOCM
d.
Dx: ECG, cardiac enzymes,
e.
Further Dx: echo, cardiac monitoring
f.
Tx: BB (verapamil if it fails), avoid extreme exertion i.
Alcohol infusion into the myometrium (myomectomy if that fails)
ii.
Implantable defib for episodic syncope
13. Case 13 – I have a hard time breathing
g.
Tx: IVF, pericardiocentesis with a needle, possible placement of a pericardial window, surgical consultation, transfer to ICU
