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Ambulatory Medicine Presentation

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by

Radi Zinoviev

on 18 April 2014

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Transcript of Ambulatory Medicine Presentation

Treatment
Physical Exam Imaging
Blood pressure in right arm 90/50
Blood pressure in left arm 150/80

Muffled heart sounds
Pulsus paradoxus
JVD
Case #2
66 yr old man presents with lightheadedness and chest pain
Per wife: confused, with short term memory loss
Patient noted chest pain radiating to jaw

PMH: Long standing history of hypertension
SoHx: Remote hx of tobacco use
Purulent
Pericardiocentesis
Systemic antibiotics (Vanc + Ceft)
NSAID
PPI (NSAID prophylaxis)
Complications
Pathophysiology
Radi Zinoviev
42yo lady presents to clinic with substernal chest pain



Constitutional: well-developed and well-nourished.
HEENT: normocephalic, atraumatic; oropharynx is clear and moist.
Cardiovascular:
substernal rub
Pulmonary: Effort normal and breath sounds normal. No W/R.
Pain with inspiration
Abdominal: Soft, non-tender, non-distended. No rebound/guarding
Musculoskeletal: No edema and no tenderness.
Neurological:A&Ox3, normal muscle tone.
Skin: Skin is warm and dry. She is not diaphoretic.
Psychiatric: She has a normal mood and affect.

HR 98, BP 131/82, RR 20, T98.2F
EKG
Cardiac - Acute Fibrinous Pericarditis post MI
Aortic aneurism
Rheumatic fever
Drugs - ex. hydralazine
Infection - Coxsackie B
Acute Renal Failure - uremia
Collagen vascular disease

Radiation
Injury - surgery
Neoplasm
Dressler's Syndrome
Complications
Pericardial effusion
rapid effusion -> pericardiocentesis
Cardiac Tamponade
Beck's Triad: JVD, distant heart sounds, hypotension
pulsus paradoxus
Chronic Obstructive Pericarditis
Physical Exam
High Risk
1. Cardiac Tamponade
2. Aortic Valve Insufficiency

Medium Risk
3. Rupture

Low Risk
4. Myocardial Infarction
5. Arm / Brain Ischemia
Treatment
42yo lady presents to clinic with substernal chest pain

What are you most concerned about?
"Can't miss" ddx for chest pain

Pain radiates to back between scapulae
Pain improves when leaning forward, worse when lying back
Pain is pleuritic
Has felt febrile for a few days
Daughter was sick with URI two weeks ago and passed it on to patient
Big 5 Killers
ACS: STEMI, NSTEMI, UA
Aortic Dissection
Pulmonary Embolus
Esophageal Rupture
Pneumothorax
Other Urgent Diagnoses
CHF
PNA
Pericardial Effusion
What do you want to know?
Labs:
Troponin T - normal
ESR/CRP - mildly elevated
CBC - WBC 8000
Imaging:
CXR - normal
Echo - no pericardial effusion
Pericarditis
Non-purulent
Colchicine
NSAID
PPI
Corticosteroids if severe
Intimal tear in the aortic wall leads to separation of the layers
Risk due to malperfusion of vital organs
Risk Factors
… Increased age
… Hypertension
… Bicuspid aortic valve
… Coarctation of the aorta
Turner Syndrome
… Connective tissue disorders
… Ehlers-Darlos Syndrome
… Marfans Syndrome
Pre-Existing aortic aneurysm
Sex
Twice as common in men
Pregnancy
Drug use
Heart surgery
Vascular inflammatory conditions
Type A - hospital mortality 10-35%
Strict blood pressure control
Beta blocker, vasodilators
Pain control
Supplemental oxygen
Fluid resuscitation
No anticoagulants
Surgery
Complications highest within 2y
CT scan in 3mo and every 6-12mo after
Strict blood pressure control
1/3 of patients may require
surgery for AA

EKG
Cardiac Enzymes
CXR
CT scan
Type B - 30 day mortality 10%
Strict blood pressure control
Pain control
Observation
(Surgery for rupture, hemorrhage, aneurism formation or organ malperfusion)
Case 1
What test would you like to send for?
Case 2
Sudden severe chest pain or tearing upper back pain radiating to the back or neck
Loss of consciousness
Shortness of breath
Stroke-like symptoms
Diaphoresis
Pulse deficits/ cool extremities
Shock/Hypotension
Symptoms
Followup
Full transcript