Printzmetal's Angina Variant angina, coronary artery spasm Occurs at rest Many not have  CAD Percent of AMIs with normal EKG 4% Predictors of AMI Depression of areas oppositve peredict larger MI with inc mortality T-wave inversion within 4 hours is good prognostic sign dewinters T waves ST depression into rocket T-waves Acute LAD occlusion Elevation in aVR Acute LMCA occlusion Post MI papillary muscle rupture causes what murmur Acute mitral Regurgitation Acute onset CHF HD support, IABP, Surgery (OR) How does paget's dz effect the heart High outpt failure due to multiple AV malformations How does beriberi effect the heart High outpt failure due to B1 thiamine deficiency leads to dec SVR, edema, high output failure Osler nodes Tender nodules on the tips of the fingers and toes, IE,Osler=Ow Janeway lesions Non-tender hemorrhagic plaques on the palms and soles Roth spots retinal hemorrhages with central clearing triple coverage for prosthetic valve endocarditis vanc gent add rifampin (more gram + coverage Jones Criteria CASES Carditis Arthritis Syndenhams chorea Erythema marginatum subcutaneous nodules Minor:  Prev hs, arthralgia, ESR, prolonged PR interval, fever AS vs AR murmur AS : Systolic radiating into neck AR : Diastolic decrescendo at left lower sternal border, water hammer, duroziez's, Austin-flint, quinckes Most common cause mitral stenosis RHD Diastolic murmur + pulmonary edma in pregnancy = Mitral Stenosis Low apex diastolic murmur to axilla, loud S1 MS vs MR murmur MS - Diastolic rumble at apex MR - loud holosystolic murmur MR - may have no murmur if ruptured chordae tendineae Murmur Hypertrophic Cardiomyopathy Harsh, mid-systolic LLSB Louder with dec preload (standing, valsalva, hypovolemia) Dec with increased afterload (squat, trendenlenberg) Common viral cause of myocarditis Coxsackie B Sinus tach out of proportion to fever Young person with acute CHF = myocarditis 10 bpm per degree temp 100.5 at 150 is out of proportion Catecholamine crisis Pheo MAOI Cocaine Treatment? Alpha plus bb Do not use bb alone - unopposed alpha Labetalol plus Phentolamine (alpha blocker) Pathognomonic for MS Bilateral internuclear ophthalmoplegia (eyes can't look at nose) Myasthenia Gravis caused by? Auto-antibody against acetycholine receptors 25% tumor of thymus Hallmark:  Muscle weakness, fatiguability, dipolopia, ptosis Tx: Physostigmine - inhibits acetocholinesterase Lambert-Eaton Syndrome Similar to myasthenia gravis Autoimmune effects calcium channels Decreased DTRs Proximal thighs and hips, improves with use Associated with Cancer MS with Cancer Botulism Blocks acethycholine RELEASE at neuromusc jct Diplopia, ptosis, DESCENDING flaccid paralysis Anticholinergic symtpoms, dry, ileus, dilated eyes Floopy baby Tx Antitoxiin, PCN Tick Paralyisis Similar go Guillain-Barre Reapid ascending paralysis but NO PARESTHESIAS Tx, find tick and remove West Nile Virus Dead crows, birds Meningitis, Encephalitis Anterior Horn Cells, pure motor flaccid paralysis Sensation INTACT Send CSF for IGM antibodies to WNV ALS Amyotrophic Lateral Sclerosis Upper AND lower motor neurons Upper: Spasticity, no sendor deficits Lower: ant horn cells, atrophy, fasiculations Death slowly by respiratory failure Weakness, difficulty eating and swallowing Blood pressure goal hemorrhagic stroke 160/90 Cerebral - Cortical stroke syndrome Contralateal motor and sensory deficits, contralateral cranial nerve palsies,  all on oppositie side Brainstem stroke syndrome Cranial nerves uncrossed, corticospinal tract crossed Ipsilateral facial weakness Contralateral extremity weakness Face Same, Extremities opp = Brainstem Pontine stroke syndrome coma, miosis, altered breahing Cerebellar stroke syndrome Nystagmus, dizziness, N?V, ataxia Anterior Cerebral artery (2%) Contralateral legs and sensory Gait disturbance Middle Cerebral Artery (90%) Contralateral arms and face and sensory Aphasia or hemi-neglect Homonymous hemianopsia (blindness in the same field of vision each eye Eyes look toward side of stroke Seizure vs Stroke Which ways do the eye look Eyes look toward the Stroke Eyes look away from the Seizure (scary) Left MCA stroke Right hemiparesis Right homonymous hemianopsia (looks left) Aphasia Right MCA stroke Left hemiparesis Left homonymous hemianopsia (looks right) Left hemineglect Posteriror Cerebreal Stroke Supplies occipital cortex Homonymous hemianopsia (contralateral) Visual agnosia (can't recognize objects) Cortical blindness (after CPR) Minimal motor involvement. Just eye things think Posterior Cerebral Vertebrobasilar Supplies brainstem, cerebellum, visual cortex Vertigo, nystagmus Diplopia Dyarthira, dysphagia Quadriplegia coma, syncope Wallenberg's Syndrome Vertebral artery thrombosis Ataxia, vertigo, nystagmus, N/V Dec pain and temp ipsilatel face, contra body Ipsilateal Horners (ptosis, miosis, anhidrosis) VERTEBRAL ARTERY THROMBOSIS Locked in Syndrome Basilar artery at PONS Also seen with pontine hemorrhage and central pontine myelinolysis Awake and alert No motor except vertical eye movements Cerebellar Infarct Sudden inability to walk or stand (drop attack) Headache, dizzy, nystagums, ataxia, N/V Can present only N/V Early Sx consult Rapid deterioration with hemorrhage Lacunar Syndromes (Clear mental status) Pure sensory - Thalamus Nerve effected Mid shaft humerus Radia Shoulder dislocation Axiallary Post elbow dislocation Ant elbow Posterior elbow - Median Neve Ant elbow - Ulnar nerve Pediatric Fluid Calcuations This method is sometimes shortened to the 4-2-1 method of 4 ml/kg/hr for the first 10 kg, 2 ml/kg/hr for the next 10 kg, and 1 ml/kg/hr for each additional kilogram. (100 ml/kg/day x 10 kg) + (50 ml/kg/day x 3kg) = 1150 ml/kg/day/24hr = 47.9ml/hr Brown Sequard Ipsilateral loss of motor, proprioception and vibrationContralateral pain and temperature Central Cord Loss of motor and sensory Upper > Lower Anterior Cord Complete loss of motor, pain and temp below lesion but retains proprioception and vibratory Ohio mississipi river valley, bird, bad fungal Histoplasmosis Southwest, arthritis, erythema nodosum fungal Coccidioidomycosis Southeast, budding yeast, bone lesions Blastomycosis PCP CD4 <200 Bat wing interstitial pattern Bactrim and steroids if Pa02 < 70 Cryptococcus meningitis CSF india ink encapsulated yeast Niseria Meningitis csf Gram neg diplococcic S. pneumonia csf gram positive cocci in pairs