Int Med Osce Cards

Myocardial ischemia - Unstable Angina (neg enzymes), NSTEMI (+ enzymes), STEMI (+ enzymes)

1 mm or 1 box elevation above baseline in 2 contiguous leads OR 2 mm/2 box in 2 precordial leads

Don't forget you need enzymes too!

CHARACTERIZE THE PAIN: radiation, exertion vs rest, relation to food, diaphoresis, N/V, Nitro?, reproducibility

SOB, palpitations, etc...

Ask FH (early MIs, strokes, ...)
Ask SH (smoking, lifesytle, drugs, ...)

- Admit to hospital on tele
- EKG
- Cardiac enzymes q6
- CXR
- CBC, CMP
- Pulse Ox
- Fingerstick glucose
- Chest CT
- MONA BASH (morphine, oxygen, nitro, ASA, B-blocker, ACEI, Statin, Heparin)
- Start Plavix
- Consult cardiology for potential PCI
- Start thrombolytics if in po-dunk, NE
- TTE
- Angiography

*MI/ACS, *Dissecting aorta, *PE, *PNA, *Tamponade, *AS, * Acute Pulmonary edema, *Endocarditis, Zoster, GERD, Tietze's, Esophageal spasm, PTX

A pericardial effusion that impairs filling of the heart

OLD CARTS

Recent MI, chest pain, SOB, trauma, hx of pericarditis,

JVP, Narrow pulse pressure, hypotension, tachy, distant heart sounds, pulsus paradoxus

Electrical Alternans

MI, Cardiogenic shock, Constrictive pericarditis, PE, AS, Dissection, Acute Pulm edema

- Admit to hospital
- EKG
- CXR
- Enzymes
- CBC, CMP
- Pulse Ox
- Fingerstick glucose
- TTE
- IV Fluids
- Cardiac Cath
- Consult cards for potential cardiocentesis
- Consult surgery
- Pericardiocentesis?
- MONA BASH?

Blood getting b/w the layers of the aorta causing obstruction of the aorta and vessels arising from it

Chest pain radiating to back or scapula, diaphoresis, not relieved by nitro, syncope?, Hx of HTN, Hx of Marfans, hx of trauma

Diff in pulses b/w upper extremities, aortic regurgitation murmur, check carotid pulses, neurologic symptoms (hemiplegia, hemianesthesia)

- CXR (mediastinal widening)
- EKG
- Chest CT
- Cardiac enzymes
- CMP, CBC
- Fingerstick glucose
- Pulse Ox
- MRI
- TEE
- Angiography
- B-blocker and Nitroprusside (think dec afterload)
- Consult cardiology
- Consult surgery

D-dimer, PT/PTT/INR

Infection of the endocardium

Recent illness (esp strep throat), Fever, change in mental status, recent dental procedure, any heart valves, IV drug use, myalgia, arthralgia, night sweats

Fever, new murmur, hematuria, roth spots in eye, janeways lesions, oslers nodes, arthritis, splinter hemorrhages

- EKG
- CXR
- Chest CT
- CBC, CMP
- Blood & Urine cultures
- PT/PTT/INR
- Fingerstick glucose
- TEE or TTE
- ESR, CRP
- IV antibiotics (Acute = Naf, Gent, Vanc, Subacute = vanco, gent, rifampin)
- Fluids

Ummmmm

SOB, Acute, tachypnea, chest pain, recent hospitalization, recent travel, recent surgery, swelling in leg, redness of leg, smoking, oral contraceptives, history of cancer, history of leg pain, IV drug use, FH of coag disorders

- EKG - sinus tach
- CXR
- Cardiac Enzymes
- D-dimer
- Chest CT w/ contrast
- If poor renal fxn, do V/Q scan
- U/S LE
- CBC, CMP, PT/PTT/INR
- ABG
- Angiography
- Start O2
- Heparin drip w/ coumadin bridge
- Lyse is hemodynamically unstable
- Filter placement is cannot anti-coag
- Consult pulm/vasc/cards

Obstruction of the aortic outflow tract

Bicuspid aortic valve, syncope, chest pain, fatigue, smoking history, cyanosis, PND, dizziness, DOE

Aortic stenosis (right second sternal border radiating to the carotids), can get mitral regurg, pulsus parvus et tardus (palpate carotids), feel for PMI, feel for thrill, S4

MI, PE, Acute pulm edema, dissection, carotid stenosis, arrhythmia, hypotension, hypoglycemia, HCM, rheumatic fever

- TTE
- Afterload reduction (treat as CHF - ACEI, statin, hydralazine, B-blocker,...)
- Consult surgery
- CXR
- EKG
- CBC, CMP, PT/PTT/INR
- Fingerstick glucose
- Chest CT
- Cardiac Cath

ummmm...

Acute onset SOB, cough w/ frothy pink sputum, orthopnea, PND, cardiac Hx, hemoptysis

PE, MI, AS, Dissection, Asthma, PTX, PNA, COPD exacerbation, ARDS

JVD, Dullness to percussion, crackles, ronchi, egophany, tactile vocal fremitus, heart murmur, S3 S4

- Admit
- EKG
- Chest XR
- Chest CT
- Basic labs
- Cardiac enzymes
- Blood cultures/Sputum culture
- LMNOP (lasix, morphine, nitro, oxygen, positioning)

SBP > 220, DBP > 110 w/ evidence of end organ damage (renal, eyes, etc...)

Drug use, neuro deficits, chest pain, dyspnea, HA, vision changes, hematuria, SOB, altered mental status, change in urination

*Ask about heart, kidney, eyes, and brain

Papilledema, high BP, murmurs/bruits, focal neuro deficit, flame hemorrhage, JVD, crackles

- EKG
- CXR
- Basic labs
- Cardiac enzymes
- Head CT
- TTE
- IV nitro drip OR IV labetalol (dec. BP 10% in 1st hour, dec to normal in 24-48 hrs)
- If vol. overload give Lasix
- O2

Look at EKG

Cardiac arrest, syncope, confusion, pulseless, mental status change, chest pain, palpitations, recent MI

- EKG
- CXR
- Cardiac Enzymes
- Basic labs
- O2
- If pulseless, cardiovert
If sustained (> 30 sec) = DC cardiovert and IV amio followed by pacemaker
If non-sustained = consider pacer and get EP studies

Unresponsive, may be seizing, no heart sounds, no pulse, no BP, cannot get history -- they are basically almost dead!

- Admit to ICU on tele
- Get EKG, look at EKG
- Start CPR
- Shock 200 J
- Shock 200-300 J
- Reanalyze
- Shock 360 J
- If still in Vfib, intubate
- Give epi IV and q3-5 min after
- Shock again at 360 J
- Refractory = IV amio and shock
- CPR (repeat above 2 in cycle)
- Start IV drip of last anti-arrhythmic given

Dyspnea, cough, wheezing, chest tightness, palpitation, insomnia, use of inhaler, triggers (food, etc...), steroids, ever been intubated, smoking, recent illness, meds

COPD exacerbation, asthma, PTX, PNA, PE, MI, Dissection, Acute pulm edema, Endocarditis

*Likely more chronic (days)

Wheezing, tachypnic, tachycardic, mental status changes, cyanosis, unable to speak full sentences

- Admit
- EKG
- CXR (clear)
- Normal labs
- ABG
- Blood cultures
- PFTs
- O2, Methylprednisolone, Duonebs, prophylactic ABx
- Outpt: inhaled steroid, salmeterol, albuterol, epi pen