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CPD: Chest Pain


CAD = Coronary Artery Dz
--RISK: obesity, dyslipidemia, HTN, insulin resis, prothrombic, inflam, smoking, hyperhyomocysteinemia, elevated CRP, menopause, inactivity
--S/Sx: mb ASx for decades-->ischemia, angina, TIA, IC, unstable angina, stroke, sudden death
--Dx: stress ECG, lipid profile, history, imaging incl: CT, US, cardiac catheter

ANGINA
--DDX: cervicothracic spine abn, nonspecific chest wall pn, GI dz pulm dz, pericarditis, psych, costochondral separation, costochondritis, dyspnea, aortic dissection, MVP, radiculopathy
--ETIO: CAD
--Risk: same as CAD, Hx in same sex close family, HTN, lipidemia, hard drinking water!!, "toxicity", diabetes, stress, menopause
--S/Sx: pressure/constriction, discomfort, chest, jaw, neck, L shoulder, arm, subscap
--S/Sx: incr HR, BP, diffuse apical pulse, mb S4 sound dt decr LV compliance
--Pathophysio: ischemia of heart muscle
--occurs at night, at risk-->unstable-->poss MI
--Dx: stress testing gives more false negatives in females
--types: variant/Prinzmetal's dt spasm, @ rest, ST elev not depress, same time ea day
--types: microvascular, "syndrome x", usu not seen on angiogram, typical sx
--types: silent ischemia: ASx CAD, most in diabetics, screen DM pts for CAD!!!
--PE: peripheral pulses, xanthomas, pt tenderness?->not CAD
--PE: EKG norm btw attacks
--EKG: during episodes see Q wave (small OK, big->prob) and T wave inversion, poss ST depression, small R wave

CHF
--PE: vitals, heart/lung auscultation, peripheral edema, JVD, abdominal exam (ascites, hepatomegaly)
--Dx: first test to order to aid in diagnosis: CXR
--Dx: second: BNP and echocardiogram

LCHF
--LCHF: decr CO-->incr pulm venous pressure-->pulm edema-->SOB, RCHF, renal insuff, liver dz
--volume overload dt PV, renal failure-->HTN and CHF
--S/Sx: tachycardia, DOE, fatigueOE, cold intol, proxysmal noct dypsnea & cough
--S/Sx: displaced apical impulse, S3 and S4 sounds
--S/Sx: R sided pleural effusions common with basilar rales
--S/Sx: central or peripheral cyanosis, restless, anxious
--ETIO: CAD, ischemia, MI, HTN, AS, cardiomyopathy, PDA, VSD
--ETIO: mitral or aortic regurg, arrhythmia
--COMPLIC: acute pulm edema, pallor, extreme dyspnea, cyanosis, tachypnea

A FIB

--S/Sx: irreg irreg rapid pulse, fatigue, weak, chest pain
--ECG: irreg intervals btw R waves, indiscernable P waves
--Tx: 1) control/reduce rate, 2) convert to normal rhythm, 3) prevent thrombus formation

V FIB
--S/Sx: flip-flop/flutter in chest

VPB = Ventricular Premature Beat
--ECG: QRS complexes regular in groups, then early beat, wide QRS, inverted T, then back to normal QRS
-->increasing early beats to lower ratio of normal beats is worse-->V tach-->V Fib

MITRAL REGURGE
--most likely systolic murmur at PMI
--loud systolic murmur in 5th interspace @ L midclavicular line (PMI)
--more with age

MVP
--antibiotic prophylaxis for dental work is no longer recommended

IE = Infx Endocarditis
--S/Sx: fever, pale, sweaty, chest pain, SOB, dark vertical discolorations on fingernails
--S/Sx: new murmur, loud, systolic, throughout precordium
--RISKS: IV drug use
--Dx: blood culture for infecting organism and echocardiogram looking for vegetations

PERICARDITIS
--S/Sx: SOB, chest pain, allev: bend forward
--Dx: ECG: ST elevation (same as MI but with no pathologic Q waves)

AAA
--S/Sx: deep boring pain in abdomen, radiates to back
--Dx: US of abdomen
--RISK: smoking, HTN, angina

Unilateral peripheral edema
--DDX: DVT, cellulitis, lymphatic obstruction, chronic venous insufficiency, varicose veins

LYMPHEDEMA
--S/Sx: ache, heavy, fully swell, worse in heat, oft unilateral
--Stages: pitting edema-->non-pitting/chronic inflam w/ early fibrosis-->irreversible edema with skin changes (hyperkeratosis, hyperpigmentation, verrucae, fungus)
--primary uncommon but more in females, mb present from birth
--secondary usdt surgery, trauma, radiation, tumors, infx.
--mbdt chronic venous insuff
--COMPLIC: lymphangina

IDIOPATHIC TELANGIECTASIAS
-- = spider veins, don't confuse with varicose
--clinically insignificant (??!?)

VARICOSE VEINS
--S/Sx: ache, fatigue, heat, better w/ elev, itching, intermittent claudication
--PE: with pt standing, check for diabetic neuropathy, ulcertaions, investigate for hip, knee, lumbar issues, arthritis, check arterial sufficiency
--COMPLIC: edema, eczema, pigment, ulceration
--Tx: compression, wound care, surgery, exercise, elev, herbs for venous health

CHRONIC VENOUS INSUFFICIENCY and postphlebitic syndrome
--posphlebitic syn = venous damage after DVT, mb w/o signs
--ETIO: DVT, valve insuff, decr heart contract, venous HTN
--RISK: trauma, obesity, old age
--COMPLIC: edema, inflam, hypoxia
--S/Sx: mb Asx but always causes signs; edema, ache, cramp, tired, paresthesia in legs
--S/Sx: worse stand/walk, better: rest/elev
--PROG: no change-->varicose veins-->stasis dermatitis-->mb ulceration

DVT
--RISK: over 60, smoking, heart failure, hypercoag, immobilized, catheter, limb trauma, obesity, malig, nephotic syn, OCP/HRT, preg, prior DVT, sickle cell, recent surgery
S/Sx: mb ASx or pain over area with deep ache, edema, ertyema, bluish vein disoloration
--PE: mb pain w/ deep palp, check calf circuference, over 3cm diff-->suspect DVT
--PE: mb + Homan's sign or palpable vein in popliteal fossa or femoral triangle
--DDX: venous insuff, superficial phlebitis, lymphatic obstruct, cellulitis, ruptured Baker's cyst, muscle/tendon tears
--Dx: ultrasound with doppler flow, mb test for D-dimer (elevated with DVT)
--Tx: test fibrinogen and bleeding times to monitor naturopathic Tx
--Tx: prevent PE first, control Sx second (PE = pulm embolism), anti-coag, analgesic, elev legs, IVC filters if no anti-cog, activity OK, naturopathic: anti-PLT, anti-inflam, fibrinolytic

RAYNAUD'S SYNDROME
--S/Sx: intermittent/reversible pallor/cyanosis of digits
--S/Sx: attacks last minutes-hours, usu no necrosis, triggered by cold, emotion
--S/Sx: mb pain, paresthesia
--complic: ischemia, necrosis usu only in 2ndary
--PREV: more in women, 3-5%!
--Tx: stop smoking!!!, biofeedback/releaxation, conventional: praosin, Ca++ channel blockers
--Tx: consider arginine, magnesium as vasodilators, gingko biloba, capsaicin, alt hyrdro
--ASSOC w/ migraine, variant angina, pulm HTN (common pathway??)
--Primary: (>80%) under 40 onset, mild bilat attacks, normal ESR, Al testing, nail fold capillaroscopy normal
--Secondary: over 30 onset, severe, painful, mb unilat, ischemia, nail fold shows enlarged/tortuous capillaries, abn ESR and Al blood tests
--ETIO: CT dz, endocrine, hematologic, vascular, neruologic, drug use, neoplasm, infx, trauma

BUERGER'S DZ aka Thromboangiitis obliterans
--PVD aggravated by tobacco, segmental inflam in small/med aa
--acute-->mb occlusive thrombi
--only in heavy smokers

PAD or PVD, Peripheral Arterial/Vascular Dz
--atherosclerosis resulting in lower limb ischemia
--12% of people in US, more men
--LOC: usu in calf but also feet, thighs, hips, buttocks
--RISK: same as atheroclerosis: obesity, dyslipidemia, HTN, insulin resistance, prothrombic states, pro-inflam, smoking, hyperhomocysteinemia, elevated CRP, menopause, inactvity, etc
--Sx: pain on exertion, releived by rest (intermittent claudication)
--Sx: later, pain may develop at rest, numb/tingle, unrelenting pain, worse on elevation
--Dx: doppler ultrasound, may also check blood for pro-clot/atherosclerotic chemistry
--Tx: aggressive risk modification, exercise, keeps legs low, avoid vasoconstriction
--Tx: best hygiene for extremities, thin blood, vasodilate, antiinflam
--Tx: (conventional) anti-PLT, pentoxifylline, cilostazol, PTA, bypass

PERIPHERAL ARTERIAL ANEURYSM
--70% popliteal, 20% iliofemoral, oft w/ AAA
--INCIDENCE: 20:1 in men, mean age 65
--ETIO: atherosclerosis, popliteal a entrapment, septic emboli
--S/Sx: usu ASx. If dt thromboemboli or rupture expect cyanotic pulseless extremities.
--Dx: US, then MRA or CT
--PROG: low risk of rupture, surgery if artery is twice normal size or in the arm

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