Cardio
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  • Heart sounds
    • Splits
      • Split S1
        • RBBB: V1 looks like M, V6 looks like W, split S1, tx w pacemaker.
      • Wide S2
        • Pulmonic stenosis: exertional dyspnea, systolic ejection murmur, wide S2 splitting, dx with echo, tx with valvuloplasty.
        • RBBB: V1 looks like M, V6 looks like W, split S1, tx w pacemaker.
      • Fixed wide S2
        • ASD: fixed S2 splitting, right heart enlargement, dx w echo.
      • Paradoxical S2 (expiration split)
        • Aortic stenosis: angina, exertional syncope, systolic ejection murmur, weak delayed carotid pulse, LV hypertrophy (S4 gallop), dx w echo, tx w valve replacement.
        • LBBB: V1 looks like W, V6 looks like M, tx w pacemaker, cardiac resync.
    • Systolic murmurs
      • Hypertrophic cardiomyopathy: exertional dyspnea, angina, syncope, FHx, cardiomegaly with thick walls dx w echo.
      • Aortic stenosis: angina, exertional syncope, systolic ejection murmur, weak delayed carotid pulse, LV hypertrophy (S4 gallop), dx w echo, tx w valve replacement.
      • Pulmonic stenosis: exertional dyspnea, systolic ejection murmur, wide S2 splitting, dx with echo, tx with valvuloplasty.
      • Mitral regurgitation: Left failure (SOB, pulm edema), holosystolic murmur, dx by echocardiogram w doppler.
      • Mitral prolapse: mid systolic click-mur, hx of Marfan or Ehlers-Danlos, dx with echo.
      • Tricuspid regurgitation: right failure (JVD, edema, hepatomegaly), hx of rheumatic fever, holosystolic murmur, large v waves, pulsatile liver, dx w echo.
      • VSD: holosystolic murmur, cardiomegaly, dx w doppler echo.
    • Diastolic murmurs
      • Aortic regurgitation: exertional dyspnea, diastolic blowing (decr) murmur, wide pulse pressure, pulm edema (if acute), LA/LV dilitation (if chronic), dx w echo.
      • Pulmonic regurgitation: hx of pulmonary hypertention, diastolic blowing (decr) murmur, dx w echo.
      • Mitral stenosis: Dyspnea, hx of rheumatic fever, diastolic rumble (snap-dec-cres), dx with echocardiogram.
      • Tricuspid stenosis: abdominal distension, hepatomegaly, hx of rheumatic fever, diastolic snap-dec-cres murmur that increases w insp, large a wave (neck flutter).
    • Continuous murmurs
      • PDA: continuous, machine-like murmur, cardiomegaly (LA↑, LV↑), increased pulm vasc markings, dx w doppler echo.
    • Gallops (low freq extra diastolic heart sounds)
      • S3 (rapid ventricular filling tenses chordae tendoneae)
        • CHF: exertional dyspnea, JVD, peripheral edema, elevated BNP, can be chronic or acute decompensated.
        • Volume overload
        • Normal in kids
      • S4 (vigorous atrial contraction against stiff ventricle)
        • MI: substernal chest discomfort at this moment, EKG ST elevation or depression, wide & deep Q waves, LBBB, tx w aspirin, nitro, β-blk, anticoag, PCI asap.
        • Aortic stenosis: angina, exertional syncope, systolic ejection murmur, weak delayed carotid pulse, LV hypertrophy (S4 gallop), dx w echo, tx w valve replacement.
        • Hypertrophic cardiomyopathy: exertional dyspnea, angina, syncope, FHx, cardiomegaly with thick walls dx w echo.
        • Ventricular hypertrophy
    • Other
      • Acute rheumatic fever: 2-4 weeks after strep throat, arthritis, carditis (aortic, mitral regurg), chorea, rash, nodules (skin).
  • EKG
    • Rate and rhythm (Arrhythmias): normally 60-100 bpm and regular
      • Premature beats
        • Atrial premature beat: palpitations, caused by caffeine, EtOH, stress, EKG shows premature beat with abnormal P wave.
        • Ventricular premature beat: premature beat that has a wide QRS, if symptomatic then tx w β-blk, ICD.
      • Bradycardia: < 60 bpm
        • Sinus bradycardia: HR < 60 bpm, tx atropine (anticholinergic) and isoproterenol (beta agonist) if symptomatic.
        • Sick sinus syndrome: Periods of inappropriate bradycardia because of SA node dysfunction, hx of old age, causes brady-tachy syndrome if combined with afib.
        • 1st-degree AV block: prolonged PR interval, regular, no dropped beats.
        • 2nd-degree AV block: dropped QRS with (Mobitz I) or without (Mobitz II) gradual PR lengthening.
          • Mobitz I block: dropped QRS after gradual lengthening of PR: P-QRS, P--QRS, P---QRS, P----, P-QRS.
          • Mobitz II block: dropped QRS without gradual PR lengthening, can progress to 3rd deg blk, tx w pacemaker.
        • 3rd-degree AV block: slow, regular QRS independent of P waves (AV dissociation), tx w pacemaker.
        • Junctional escape rhythm: escape rhythm (40-60 bpm) from AV node or proximal His, no P wave, normal QRS wave.
        • Ventricular escape rhythm: escape rhythm (30-40 bpm) from ventricle, no P wave, wide QRS.
      • Tachycardia: > 100 bpm
        • Supraventricular tachycardia (SVT): narrow QRS
          • Regular
            • Sinus tachycardia: HR > 100 bpm, normal EKG, due to increased sympathetic tone, decreased vagal tone.
            • Focal atrial tachycardia: Sinus tachycardia with strange P waves.
          • Regular P-P interval, irregular QRS
            • Atrial flutter: saw-tooth appearance on EKG, tx w cardioconversion.
            • AVNRT: Atrial premature beat causes re-entry tachycardia: regular rate, narrow QRS, P wave buried inside QRS (may be seen as an R'), tx w IV adenosine.
            • AVRT (pre-excitation): AV bypass tract results in vent preexcitation: short PR, delta wave, wide QRS, causes re-entry tachy, tx w procainamide.
          • Irregular
            • Atrial fibrillation: tachy, irregularly irregular rhythm, noisy baseline with no discernible P waves, tx w anticoags, β-blk.
            • Multifocal atrial tachycardia: irregular, tachy, with multiple P morphologies, hx of pulm dz, tx w verapamil.
        • Ventricular tachycardia: wide QRS
          • Torsades de pointes: lightheaded, syncope, EKG looks like a standing wave in physics, caused by electrolyte disturbances, tx w IV Mg.
          • Ventricular fibrillation: chaotic baseline, no QRS, tx by defibrillation.
    • Axis
      • Left deviation
        • LAFB: Left axis deviation.
        • LV hypertrophy
      • Right deviation
        • LPFB: right axis deviation.
        • RV hypertrophy or strain (PE)
    • Intervals
      • PR: 3-5 small boxes
        • 1st-degree AV block: prolonged PR interval, regular, no dropped beats.
        • AVRT (pre-excitation): AV bypass tract results in vent preexcitation: short PR, delta wave, wide QRS, causes re-entry tachy, tx w procainamide.
      • QRS: < 2.5 small boxes
        • Ventricular premature beat: premature beat that has a wide QRS, if symptomatic then tx w β-blk, ICD.
        • Hyperkalemia: too much K (K > 5) causing neuro: muscle (weak/paralyze), cardio (slow, irregular, blocks), EKG shows T↑, QT↓, wide QRS if severe, tx w Ca.
      • QT
        • Hypercalcemia: renal (polyuria, stones), GI (nausea, constipation), cardio (short QT, valve calcification), MSK (weakness).
        • Hypocalcemia: muscle cramp/spasm, numbness and tingling (mouth, hands, feet), bp cuff causes hand spasms, prolonged QT.
        • Hypokalemia (U-wave): not enough extracellular K (<3.5) for repolarization, so neuro symptoms (muscle weakness, cardio arrhythmias), EKG shows U waves after T.
        • Hypomagnesemia: increased QT
    • Waves
      • P
        • RA enlargement: lead II (big hump, small hump), V1 (big hump, small dip)
        • LA enlargement: lead II (small hump, big hump), V1 (small hump, big dip)
      • QRS
        • RBBB: V1 looks like M, V6 looks like W, split S1, tx w pacemaker.
        • LBBB: V1 looks like W, V6 looks like M, tx w pacemaker, cardiac resync.
        • MI: substernal chest discomfort at this moment, EKG ST elevation or depression, wide & deep Q waves, LBBB, tx w aspirin, nitro, β-blk, anticoag, PCI asap.
        • RV hypertrophy: lead V1 spikes upward (R > S)
        • LV hypertrophy: V1 dip + V6 spike > 35mm. Or, aVL > 11mm. Or, I > 15mm
      • T and ST
        • MI: substernal chest discomfort at this moment, EKG ST elevation or depression, wide & deep Q waves, LBBB, tx w aspirin, nitro, β-blk, anticoag, PCI asap.
        • Acute pericarditis: fever, pleuritic chest pain worse lying down, friction rub, diffuse ST elevation in most leads, inflammation markers.
        • Hyperkalemia: too much K (K > 5) causing neuro: muscle (weak/paralyze), cardio (slow, irregular, blocks), EKG shows T↑, QT↓, wide QRS if severe, tx w Ca.
        • Hypokalemia (U-wave): not enough extracellular K (<3.5) for repolarization, so neuro symptoms (muscle weakness, cardio arrhythmias), EKG shows U waves after T.
  • Chest pain
    • Skin (shingles), Breast, MSK (hurts w motion or palpation)
    • Cardio
      • Stable angina: Substernal chest pain brought on by exertion, alleviated by rest or nitro.
      • Unstable angina: Substernal chest pain at rest or with minimal exertion, normal troponin.
      • Variant angina: spontaneous angina w ST elevations due to vasospasms, revert to normal afterwards, tx w vasodilators (Ca ch blk, nitrates).
      • MI: substernal chest discomfort at this moment, EKG ST elevation or depression, wide & deep Q waves, LBBB, tx w aspirin, nitro, β-blk, anticoag, PCI asap.
      • Acute pericarditis: fever, pleuritic chest pain worse lying down, friction rub, diffuse ST elevation in most leads, inflammation markers.
      • Cardiac tamponade: chest discomfort, dyspnea, tachy, JVD, pulsus paradoxus, EKG shows electrical alternans, CXR shows cardiomegaly, echo shows effusion, tx with drainage.
      • Aortic dissection: splitting of aortic wall (severe tearing pain) can rupture (effusions), occlude (ischemia), cause bp difference btwn arms, dx with echo (intimal flap).
    • Pulm
      • Pulmonary embolism: there's a clot (pleuritic pain) - you can't get oxygen (O2↓) no matter how hard you breath (tachypnea, SOB), dx by CT (contrast enhanced).
      • Pneumothorax: acute SOB, pleuritic chest pain, hypoxia, dx by CXR: visceral pleural line (upright, lateral decub), deep sulcus sign (supine), tx with chest tube, needle aspiration.
      • Pneumococcal pneumonia: fever, cough, chest pain, rusty sputum, increased white count, lung opacities, dx with sputum gram stain, urine antigen, blood culture, tx with azithromycin (normal) or levofloxacin (sick).
      • TB: chest pain, cough, nightsweats, hemoptysis, foreign/abroad/prison hx, apical lung opacities with cavitation.
    • GI
      • GERD: heartburn after meals and at night, relieved by antacid, dx w endoscopy, tx w PPI.
      • PUD: epigastric pain, indigestion, gets better w antacids, dx w endoscopy, tx w PPI.
      • Esophageal spasm: Substernal chest pain worsened by swallowing, dysphagia, dx w manometry, tx w Ca ch blk.
    • Neoplasms
      • Lymphoma (node++): cancer in lymph nodes (painless node++) that is either low grade (SLL, follicular), or high grade/B symptoms (burkitt, LBL, diffuse large, hodgkin).
      • Thymoma: Chest pain, myesthenia gravis (fatigue, weak, droopy), CXR shows thymus tumor.
  • Hypertension
    • Essential hypertension: hypertension without any secondary causes (normal serum K, urinalysis), FHx, tx w diuretic, β-blk, Ca ch blk, ACE inh.
    • CKD: Diabetes and hypertension causes progressive renal failure: GFR↓, metabolic acidosis, nephrotic (proteinuria, lipiduria), bone resorption (PTH↑, PO4↑, VitD↓), anemia, tx with ACE inh, dialysis, transplant if GFR < 20.
    • Aldosteronism: refractory hypertension, hypokalemia, metabolic alkalosis, aldo↓ even w salt loading, tx w eplerenone.
    • Renovascular hypertension: hypertension, abdominal bruits, hypokalemia, dx w angiogram showing renal artery stenosis.
    • Pheochromocytoma: episodic headache, sweating, tachycardia; hypertension, dx w 24 hr urine catecholamine collection, tx w surgery, alpha-blk.
    • Cushing's syndrome: moon face, hirsuitism, buffalo hump, wt gain, striae, hypertension, hyperglycemia, dx w late night saliva & urine cortisol lvls, ddx w ACTH & dexamethasone test.
    • Coarctation of the aorta: hypertension, bp differential (arms > legs), CXR shows aorta indentation, tx w surgery, valvuloplasty or stenting.
  • Cyanosis
    • Tetralogy of Fallot: episodes of cyanosis, mechanism = pulm stenosis + RV hypertrophy + VSD + overriding aorta, dx w echo.
    • TGA: neonatal cyanosis, RV hypertrophy, dx w echo, manage by keeping ductus open (prostaglandin, cath), tx w sugery to switch the vessels.
    • Eisenmenger's syndrome: hypoxia, cyanosis, hx of ASD, VSD, PDA, pulm artery dilitation w peripheral tapering.
  • Cardiomyopathies
    • Dilated cardiomyopathy: CHF with large but thin heart, hx of viral myocarditis, EtOH,, pregnancy, FHx.
    • Hypertrophic cardiomyopathy: exertional dyspnea, angina, syncope, FHx, cardiomegaly with thick walls dx w echo.
    • Restrictive cardiomyopathy: CHF symptoms, hx of amyloidosis, sarcoidosis, hemochromatosis, biopsy shows infiltration by amyloid, hemochromatosis.
  • Pericardial disease
    • Acute pericarditis: fever, pleuritic chest pain worse lying down, friction rub, diffuse ST elevation in most leads, inflammation markers.
    • Pericardial effusion: hx of pericarditis, CXR shows cardiomegaly, electrical alternans, dx w echo, can progress to tamponade.
    • Cardiac tamponade: chest discomfort, dyspnea, tachy, JVD, pulsus paradoxus, EKG shows electrical alternans, CXR shows cardiomegaly, echo shows effusion, tx with drainage.
    • Constrictive pericarditis: right heart failure (JVP↑, edema), inspirational JVD, pericardial knock, dx w imaging (thick pericardium) and cathetor (ventricular interdependence).
  • CHF: exertional dyspnea, JVD, peripheral edema, elevated BNP, can be chronic or acute decompensated.