UWorld Step 2 CK Notes - 2015

CARDIOLOGY Qid 3635 Recent Immigrant from China  Endemic Areas (Africa, India & China) CC:  Fatigue and Dyspnea on Exertion = decrease Cardiac Output  Abdominal distention for the Past 2 months = Hepatosplenomegaly SHx: Farmer his entire life VS: wnl PE: (Signs of Venous Overload)  Pedal Edema  Increase abdominal girth with free fluid = Ascities  Elevated JVP without Inspiratory decline = KUSSMAUL SIGN Chest Ausculation = decrease heart sounds & Accentuated sound directly after the S2 in Early Diastole = “KNOCK” OF S3 GALLOP CXR = ring of calcification around the heart  Pericardial Fibrosis JVP Tracing: Prominent X & Y DESCENTS Q: Most likely cause of symptoms? TB *** Dx: Constrictive Pericarditis In US, MCC of Constrictive Pericarditis include:  Idiopathic or Viral Pericarditis (>40%)  Radiation Therapy (~30%)  Cardiac Surgery (~10%)  Connective Tissue Disorders Tachypnea & Dyspnea occurs when  CO becomes compromised Qid: 4682 Renal Artery Stenosis vs. Abdominal Aortic Anerysm  Differenial in BP b/w the Px’s Arm – secondary to Subclavian Atherosclerotic dz o Aortic Dissection = Greater RIGHT ARM BP + SMOKING HX  SYSTOLIC BRUIT o RAS = Greater LEFT ARM BP  SYSTOLIC-DIASTOLIC BRUIT QID: 3768 Adenosine  inhibits L-type Ca channels, decreasing conduction velocity in the AV node

Qid: 4592 Normal Juguglar Venous Pressure ( <3 cm above the Sternal Angle) = suggest NL Central Venous Pressure = makes Right & Left HF Less Likely. Peripheral Edema due to Venous Insufficiency:  Leg discomfort, Pain or Swelling o Worsens: Prolonged Standing o Improves: After Walking or Limb Elevation  Depending on the severity. o Venous Dilation (Telangiectasia, Varicose Veins) o Pitting Edema o Skin discoloration o Dermatitis/Eczema o Lipodermatosclerosis o Skin Ulceration – Px Medial Ankle Ulcer  Initial Tx of Chronic Venous Dz: o Frequent Leg Elevation o Exercise o Compression Stocking  Px NOT responding to Initial Conservative measurement require  VENOUS DUPLEX ULTRASOUND to Identify Venous Reflux or Insufficiency  Px w/ Persistent symptoms & Documented Reflux should be referred for  ENDOVENOUS ABLATION Qid: 2153 Aortic Stenosis:  Exertional Symptoms  Chest Pain, Dyspnea, Dizziness, & Syncope  Delayed & Diminished Carotid Pulse (PULSUS PARVUS ET TARDUS)  Single and Soft S2, audible S4  Harsh Ejection (Crescendo-Decrescendo) Systolic Murmur in Second Right Intercostal Space with Radiation to Carotids Echocardiogram  should be obtained in ALL Px with SYNCOPE due to suspected structural Heart Dz. Qid: 4705 Large VSD  Failure to Thrive, Easy Fatigability & Heart Failure.  Pansystolic Murmur Loudest at Lt Lower Sternal Border (LLSB)

o DDx: Tetralogy of Fallot from Pulmonic Stenosis  Harsh, Systolic Ejection Murmur over Lt Upper Sternal Border (LUSB)  Diastolic Rumble at the Apex  due to increased flow across the Mitral Valve  Small VSD  Asymptomatic  Large VSD  Quieter due to LESS TURBULENCE through a Large Orifice. o Significant Left to Right Shunting Dx: Echocardiogram  Evaluate the location & size of the defect. DDx: Eisenmenger X  Cyanosis & Dyspnea secondary to Right to Left Shunting Qid: 8927 Peripheral Artery Dz (PAD):  Claudication ex: Cramping Pain in Rt thigh after walking 2 blocks (Limp)  Claudication or Pain in Leg Muscle brought on by a predicable amount of walking (or other form of exercise) and relieved by rest.  Intermittent Claudication + Diminished Pulses + (<1) Ankle Brachial Index  Intermittent Claudication = Strong Predictor of Future Risk of Cardiovascular Morbidity & Mortality o 20% 5 year risk of Nonfatal Myocardial Infarction & Stroke o 15% to 30% 5 year risk of death due to Cardiovascular causes Qid: 3881 Syncopal Episode:  Most probable explanation of Episode is:  ARRHYTHMIA: o Sudden Onset of Syncope without warning sings o Presence of Structural Heart Dz (Post-infarction Scar & Probable Mitral Regurgitation = mild holosystolic Apical Murmur) o Frequent Ectopic Beats o Thiazide diuretic = Electrolyte disturbance predisposing to Ventricular Arrhythmia  VASOVAGAL SYNCOPE: o Common Fainting Spell o Precipitated by Emotional Reaction o Preceded by: Presyncopal Dizziness, Weakness & Nausea

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AUTONOMIC DYSFUNCTION OR DRUG-INDUCED POSTURAL HYPOTENSION: o Orthostatic in Nature o Occurs on Standing when blood is redistributed SEIZURE: o Hx of Seizure

Premature Ventricular Complexes (PVCs):  Wide QRS (>120 msec)  Bizarre morphology  Compensatory pause  MC in Px with Cardiac Pathology  following MI  Multiple PVCs may indicate a worse prognosis  Tx with antiarrhythmic medications has actually been shown to worse survival  OBSERVATION** o No Tx indicated if Px is Asymptomatic o Beta-blockers are DOC for Symptomatic Px.