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