Step 2 Review: Cardiology and Pulmonology

Initial approach to chest pain involves an EKG to look for ST elevation or a new left bundle branch block, which indicates STEMI. ST elevation in leads II, III, and aVF suggests an inferior infarct related to the right coronary artery. Treatment involves restoring blood flow via cath lab or, if that's not accessible within 6 hours, thrombolytics are indicated (but not with contraindications such as hemorrhagic stroke).

Right ventricular infarction presents with hypotension, tachycardia, JVD, and clear lungs. Treatment differs from typical MI; avoid nitrates (decrease preload) and administer fluids to increase preload.

If the EKG is negative for ST elevation, check cardiac enzymes (troponin). Serial testing is needed every 6-8 hours to detect troponin trends. Myoglobin is the first marker to rise and fall. Treatment of NSTEMI involves MONA B (morphine, oxygen, nitrates, aspirin, beta-blocker) and scheduling coronary angiography. Interventions include stents or CABG.

For negative cardiac enzymes but continued chest pain, it implies unstable angina. Schedule an exercise EKG. Stop beta-blockers and calcium channel blockers beforehand. Alternatives include stress echo if EKG interpretation is limited or chemical stress test for patients unable to exercise. Positive tests necessitate coronary angiography.

Post-MI complications include arrhythmia (v-fib is the most concerning), papillary muscle rupture causing mitral regurgitation (5-7 days post-MI), ventricular free wall rupture presenting with hypotension, and septal rupture indicated by increased oxygen concentration in the right ventricle. Dressler syndrome (autoimmune pericarditis) occurs weeks later and responds to aspirin or NSAIDs.

Pericarditis presents with diffuse ST elevation and chest pain worse with inspiration and improves with leaning forward. Treat with NSAIDs. Costochondritis is reproducible with palpation, myocarditis follows a viral infection, and Prinzmetal angina (vasospasm) is worse at rest with ST elevation, treat with calcium channel blockers and nitrates.

EKG review includes Wenckebach (Mobitz type I), third-degree heart block (Cannon A waves), multifocal atrial tachycardia (MAT - varying P waves), ventricular tachycardia (wide QRS), WPW (delta wave, short PR interval - avoid AV nodal blocking agents!), atrial flutter(sawtooth pattern), and Torsades de pointes (prolonged QT).

SVT treatment begins with vagal maneuvers (carotid massage) followed by adenosine. Hyperkalemia displays peaked T waves and wide QRS; treatment involves calcium gluconate, insulin with glucose, and kayexalate.

Electrical alternans (varying QRS amplitude) indicates cardiac tamponade (pulsus paradoxus, hypotension, distant heart sounds, JVD). Atrial fibrillation (irregularly irregular, no P waves) is treated with rate control (beta-blockers or digoxin).

Discusses various murmurs, including aortic stenosis (crescendo-decrescendo systolic, radiates to carotids, replaced valve for treatment), HOCM (increases with Valsalva), mitral valve prolapse (late systolic with a click, increases with Valsalva), mitral regurgitation (holosystolic that radiates to axilla), VSD, PDA, ASD. Also covers diastolic murmurs: mitral stenosis, aortic regurgitation.

Reviews cardiac vs. pulmonary etiologies of dyspnea. Emphasizes the use of heparin when suspecting a PE. A young patient with shortness of breath and recent flu= mylocarditis. Stresses the importance of pulmonary capillary wedge pressure on right heart cath for differentiating CHF from pulmonary hypertension.

CHF is divided in systolic and diastolic. Reversible causes: alcoholic dilated cardiomyopathy and hemochromatosis restrictive cardiomyopathy. Highlights medications that improves survival: ACE inhibitors, beta blockers and spironolactone. Digoxin for symptom management.

Interprets various chest x-ray findings: lobar consolidation (pneumonia), hyperlucent lungs (COPD), cardiomegaly with Kerley B lines (CHF), cavity with air-fluid level (lung abscess), upper lobe consolidation and hilar adenopathy (TB), and thickened paratracheal stripe with splayed carina (mitral stenosis and cancer).

Emphasizes the distinction between transudative and exudative pleural effusions and the Lights criteria to differentiate. Heparing immediately when suspecting PE. Discusses Wells score.

ARDS is also reviewed, focusing on the bilateral that fluffy infiltrates on CXR and sepsis is the big cause. Lists the diagnostic criteria include Ratio of pao2 over fio2<200. Treatment is PEEP.

Explains how to read pulmonary function tests; obstructive vs. restrictive based on ratio fev1 to FBC. Bronchodilator response is present If fev1 improves greater than 12 percent.

Highlights that acute exacerbation its diagnosed via a change in Sputum. Oxygen is crucial if pulse ox is less than 88. The best prognosticator the for COPD it's fev1.

Outlines asthma classification and treatment steps based on symptom frequency and severity. Silicosis, asbestosis and Sarcoid. Includes some quick differentials based on key words.

Distinguishes benign vs. malignant nodules, and lists symptoms that equal cancer. Highlights each cancer type along with Paraneoplastic syndromes.

Review of Crohn's and Ulcerative Colitis (UC): involvement, characteristics, medication and risks. Also discusses: Toxic megacolon, erythema nodosum ( sarcoid patients) and pyoderma gangrenosum (the use of antibiotics).

Reviews key LFT patterns and associated conditions - AST > ALT (alcoholic hepatitis), ALT > AST (viral), Elevated D-Bili (obstruction), other lab correlations.

Different bugs per age along with side effects from taking rifampin.

Key lab values: Urine chloride, the use of EKG, renal biopsy findings.