OSCE - Cardio

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OSCE - Cardio
2011-01-10 17:07:33
osce cardio

from osce and clinical skills handbook
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  1. identify as many causes of 2' HTN as you can
    • renal (renal parenchymal dz - glomerulonephritis, polycistic dz, diabetic nephropathy)
    • endocrine (hypo or hyperthyroid, pheo, cushing's, conn's, hyperparathyroid, hypercalcemia)
    • neurologic (tumour, SC trauma, sleep apnea, porphyria)
    • toxic (EtOH, coke, Pb poisoning, OCP, HRT, NSAIDs, corticosteroids...)
    • other (aortic coarctation, pregnancy, carcinoid syndrome, pain, anxiety, hypoglycemia, EtOH or drug withdrawal)
  2. list routine investigations for a pt newly dx w HTN
    • urinalysis
    • CBC
    • lytes
    • BUN/Cr
    • fasting glucose and lipids
    • EKG
  3. list conservative mg't for HTN
    • reduce BMI to between 18-25
    • limit EtOH
    • exercise 3-4 x/wk
    • restrict salt
    • stop smoking
    • stress management
  4. define accelerated HTN
    • asymptomatic
    • systolic BP >200 +/- diastolic BP > 120

    needs immediate tx to prevent potential complications of a malignant HTN crisis
  5. define malignant HTN
    • symptomatic accelerated HTN
    • papilledema, bulging discs, retinal hemorrhages
    • mental status changes
    • elevated Cr
  6. complications of malignant hypertensive emergency include
    • confusion
    • seizures
    • h/a
    • visual changes
    • cerebral thrombosis
    • intracerebral or subarachnoid hemorrhage
    • unstable angina
    • acute pulmonary edema
    • dissecting aortic aneurysm
    • sever pre-eclampsia and eclampsi
    • acute renal failure
    • pheo
  7. Which investigations should you order to investigate heart palpitations
    • lytes (Na, K, Mg)
    • CBC
    • BUN, Cr
    • LDH, CK
    • TSH, T4
    • cardiac enzymes
    • ECG, Echo, CXR
  8. list important management issues concerning a fib
    • rate control - managed with beta blockers, CaCBs or digoxin
    • Anticoagulation
    • Rhythm conversion
    • determine etiology
  9. DDx for bradyarrhythmias
    • sinus brady
    • sick sinus syndrome
    • junctional rhythm
    • ventricular escape rhythm
  10. DDx or conduction delay
    • 1', 2' or 3' AV nodal block
    • fascicular block
    • bundle branch block
  11. DDx for irregular tachy
    • a fib
    • a flutter w variable block
    • atrial or ventricular premature beats
    • ventricular fibrillation
  12. DDx for regular tachy (narrow complex)
    • SVT
    • a flutter
    • WPW syndrome
    • AV node re-entry
  13. DDx for regular tachy (wide complex)
    • SVT w aberrance or BBB
    • ventricular tachy
    • torsades de pointes
  14. when is a rhythm unstable?
    unstable arrhythmia = pt has hypotension, dyspnea, chest pain, presyncope or syncope

    definitively treat with direct current cardioversion
  15. Define syncope
    the sudden transient loss of consciousness w loss of postural tone
  16. define palpitations
    sensations of an unduly rapid or irregular heartbeat
  17. S&S if part of LAD was occluded
    i.e. left sided heart failure
    • dyspnea
    • orthopnea
    • basal crackles in the lungs
    • cough
    • hemoptysis
    • fatigue
    • syncope
    • systemic hypotension
    • cool extremities
    • peripheral cyanosis
    • enlarged apical impulse
  18. S&S if part of RCA was occluded
    i.e. right sided heart failure
    • peripheral edema
    • hepatic tenderness
    • hepatomegaly
    • pulsatile liver
    • elevated JVP
    • positive hepatojugular reflux
  19. DDx for chest pain
    • CV - CAD, angina, MI, aortic aneurysm/dissection
    • Resp - pnuemo, pleurisy, PE, pneumonia
    • GI - esophagitis, hiatus hernia, peptic ulcer, pancreatitis, cholecystitis
    • MSK - costochondrodynia, muscle spasm, chest wall pain NYD
    • Other - anxiety, shingles
  20. 6 steps of tx for pts with acute CAD
    • ABCs
    • telemetry
    • EKG
    • cardiac enzymes
    • IV access
    • drug tx (o2, ASA, nitro, BBlocker)
    • reassess pt
  21. define pulsus paradoxus
    inspiratory fall in systemic BP > 10 mmHg
  22. explain the pathogenesis of pulsus paradoxus
    • high negative intrapleural pressure draws blood back into vena cava
    • increases venous return to RA and RV --> increased filling of right heart
    • interventricular septum bulges into the LV outflow tract
    • SV decreases
    • BP decreases
  23. under what conditions would you see pulsus paradoxus
    • CVS: cardiac tamponade, pericardial effusions, constrictive pericarditis
    • Resp: asthma, emphysema, increased effort in ventilation
  24. define JVP
    • pressure of the internal jugular system
    • direct assessment of the pressure in the right atrium of the heart
  25. how do we differentiate JVP from carotid waveforms
    JVP - not palpable, multiple waveforms, soft quality, compressible, height changes w inspiration, sitting up and valsalva manoevre
  26. why do we prefer to read right sided pulsations rather than left sided JVP
    left sided may be falsely elevated b/c of kinknig of the innominate vein
  27. what features of JVP need to be described to the examiner
    • height
    • character of waveform
    • results of abdominojugular reflux
  28. what is a normal range for JVP
    4-5 cm above sternal angle
  29. when is the abdominojugular reflux considered abnormal
    when there is a sustained rise in JVP > 4cm after applying abdominal pressure for a min 15-30 sec
  30. what is Kussmaul's sign and why does it occur
    • paradoxical increase in JVP on inspiration
    • heart is unable to accomodate the increase in the venous return that accompanies the inspiratory fall in intrathoracic pressure
  31. in which conditions would you expect to see Kussmaul's
    • severe right sided heart failure
    • constrictive pericarditis
    • restrictive cardiomyopathy