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Treatment of HTN with other Comorbidities

Lipid Lowering Agents
Drug Name Statin Drugs “-statins” Niacin Effects Decrease LDL (best) MOA HMG-coA reductase inhibitor; inhibit precursor: mevalonate Inhibit lipolysis; reduce VLDL secretion Prevent intestinal reabsorption of bile acids Side Effects Hepatotoxicity Rhabdomyolosis Hyperglycemia Hyperuricemia Flushing  TX: Aspirin Taste bad GI discomfort Decrease A,D,E,K absorption Cholesterol Gallstones Increase LFT

Decrease LDL, but raises HDL

Bile Acid resins “cholestryamine: bind Cdificle, colestipol, colesevelam” Cholesterol absorption blockers “Ezetimibe” Fibrates “Gemfibrozil, Clofibrate, Fenofibrate” Omega 3-Fatty Acids

Decrease LDL

Decrease LDL

Decrease TAGs (best)

Prevents cholesterol reabsorption at small intestine brush border Upregulate LPL  TAG clearance Reduce arrhythmia

Myositis, hepatotoxicity, cholesterol gallstones Fishy Taste

Decrease TAG

calcification of valve. decrease with squatting Mitral Stenosis    OS: it’s sticky. heard in the 2nd-3rd right interspace Notes    Pulsus parvus et tardus Can hear in carotids.Heart Murmurs Type of Murmur Aortic Stenosis Characteristics Crescendo-decrescendo following ejection click. & syncope Causes: bicuspid valve. papillary muscle rupture Click: chordia tendinae tensing Increase with valsalva.MS & secondary  AS. sphyllis. in the 2nd-3rd interspace Pansystolic (holosystolic) heart along the left lower border sternal border. chronic RF Pulmonary Regurgitation Tricuspid Stenosis Mitral Regurgitation Early diastolic decrescendo. AR Right-sided heart sounds increase with inspiration & Left-sided heart sounds increase with expiration Left Lateral Decubidus Position: MR. LV dilation. Left-sided S3/S4 sounds . endocarditis. heard in left side of sternum Late diastolic decrescendo murmur heard on left side of sternum Pansystolic (holosystolic) heard at the apex. Low diastolic (bounding pulse) Causes: Aortic root dilation (Sphyllis & Marfans) and RF    Rheumatic Fever: primary  MR. RF. radiates to right lower sterna border Rumbling late diastolic murmur with opening snap Pansystolic (holosystolic) best heard at the 4th-6th left intercostals space Continuous machine murmur High-pitched diastolic murmur with widened pulse pressure   Best at Left Lateral Decubidus Position Hand grip and squatting increase Causes: ischemic heart. weak pulses. leaflets have to snap open Expiration with increase Causes: RF Tricuspid Regurgitation /VSD PDA Aortic Regurgitation     Throughout S1 & S2 (Loudest at S2) Causes: congenital rubella & prematurity Normal systolic. unilateral valve. MS. radiates to axilla    MVP Pulmonary Stenosis Tricuspid Regurgitation /VSD Late systolic murmur with midsystolic click Crescendo-decrescendo systolic murmur.

MI Diagnosis Transmural Infact     Increase necrosis Affects entire wall ST elevation on ECG Q Waves     Subendocardial Infarct Due to ischemic necrosis of < 50% of ventricle wall Subendocardium especially vulnerable to ischemia Due to fewer collaterals. higher pressure ST depression on ECG .

personality changes) Truncal Ataxia. dysarthria Contralateral hemiballismus Anterograde amnesia: can’t make new memories Eyes look away from side of lesion Eyes look toward lesion Paralysis of upward gaze (Parinaud Syndrome) Notes Frontal Lobe Right Parietal Lobe (non-dominant) Ex. finger agnosia. acalculia. disinhibited behavior Disinhibition. Korsakoff: memory loss. reemergence of primitive reflexes (more motor cortex) Spatial Neglect Syndrome: agnosia of the contralateral side of the world Agraphia. hypersexuality. ataxia. confabulation. left and right disorientation Reduced levels of arousal and wakefulness Tremor at rest.Brain Lesions Area of Lesion Amygdala (bilateral) Consequence Kluver-Bucy Syndome: hyperorality. poor judgement. limb ataxia Damage: Ipsilateral deficiets. ophthalmoplegia. fall towards side of lesion (cerebellum  SCP  contra cortex  corticospinal ducussation  ipsilateral effects) Wernicke-Korsakoff Syndrome (Wernicke: confusion. athetosis “Parkinson Effects: Hypokinesis” Inention tremor. Women puts make up on one side of face Left Parietal Lobe (dominant) Gerstmann Syndrome Reticular activating System (RAS) Midbrain Basal Ganglia Cerebellar Hemisphere Cerebellar are LATERAL: affect LATERAL limbs Mammillary Bodies (bilateral) Associated with Thiamine Deficiency (Vitamin B1) Cerebellar Vermis Subthalmic Nucleus Hippocampus PPRF Frontal eye fields (pre-motor cortex) Superior colliculi Vermis is CENTRALLY located: affects CENTRAL body . chorea. deficits in concentration.

Superior Colliculus STT Central Canal Medial Lemniscus Medial Geniculate Body Substania Nigra Corticospinal CorticoBulbar Red Nucleus Cn 6 Inferior Cerebellar Peduncle Vestibular Nucleus MLF Medial Lemniscus Lateral Spinothalmic Tract Spinal Trigeminal nucleus and tract CN 7 Corticospinal Tract Inferior Cerebral Peduncle Vestibular Nuclei Nucleus of Solitary Tract CN 12 Dorsal Motor Tract Spinal Trigeminal tract and nucleus Lateral Spinothalamic tract Inferior Olivary Nucleus Medullary Pyramid Medial Lemniscus .

pain modulation and SLEEP Motor (basal ganglia). amygdala. OCD Parkinson’s Disease Mesocortical and Mesolimbic Pedunculopontine Nucleus Ach Associated with Alzheimer’s. hypothalamus Integration of sensory and Emotion** Pulvinar contains medial and lateral geniculate bodies Connected to Basal Ganglia******* Connected to basal ganglia and Cerebellum*** Trigeminal Sensory Receives STT & DCML Contributes to ARAS A thin layer surrounding thalamus and functions to inhibit the thalamic nuclei Lateral Dorsal. Lateral posterior. REM sleep Excess Mania Deficiency depression Pathway Medial Forebrain Bundle Raphe Serotonin Aggression & mania Depression & Insomnia Substantia Nigra & Venral Tegmentum Dopamine Schizophrenia. Tourettes Syndrome. REWARD. Anterior Cerebral Supplies anterior 1/3 via Medial Striate Branches Middle Cerebral supplies middle 1/3 via Lateral Striate Branches (M1 branches) Posterior Cerebral supplies posterior 1/3 via Thalamogeniculate Arteries . endocrine (aka prolactin inhibiting factor) LEARNING. learning difficulties Thalmus Nuclei Nuclei Anterior Thalamic Nuclei Mediodorsal Location Anterior Thalamus Medial Thalamus Function Recieves mamillothalamic tract & relays to cingulated gyrus Connects to prefrontal cortex. 3. Pulvinar Ventral Anterior Nucleus** Ventral Lateral Nucleus Ventral Posterior Medial (VPM) Ventral Posterior Lateral (VPL) Intralaminar & Centromedian Nuclei Reticular Nucleus Lateral Thalamus Ventral Thalamus Ventral Thalamus Ventral Thalamus Ventral Thalamus Internal Medullary Lamina Surrounds thalamus Thalamic Blood Supply: 1.Neurotransmitters Nuclei Locus Coeruleus Neurotransmitter NE Effects Arousal and Reward (enhances awareness of incoming stimuli) Enhance mood. 2. short-term memory. satiety.

2. A crossed system (extremely important in memory) Stria Terminalis: Amygdala to hypothalamus (important for physiological responses to fear) Hypothalamospinal Tract: descending sympathetic fibers a.Hypothalmus Nucleus Preoptic Suprachiasmatic Supraoptic Anterior Paraventricular Dorsomedial Ventral Medial Arcuate Posterior Mammillary Bodies Lateral Function Regulates Gonadotrophic Hormones Control of circadian rhythms (sleep/wake) -“you need sleep to be supracharasmatic” ADH secretion -lesion = central diabetes insipidus -Stimulation = SIADH Dissipation of heat and parasympathetics -lesion = hyperthermia Oxytocin secretion Stimulation = obesity and savage behavior Satiety Center Lesion = obesity and savage behavior Prolactin inhibiting factor -lesion = hyperprolactinemia Conservation of heat. 6. Mammilothalamic Tract: mammillary bodies to ANTERIOR NUCLEUS of thalamus (then to cingulated gyrus) Mammillotegmental Tract: mammillary bodies to reticular formation Medial Forebrain Bundle: hypothalamus to cortex Fornix: hippocampus to mammillary bodies a. anorexia Connections to Hypothalamus 1. loss of ciliospinal reflex) . anhydrosis. 4. miosis. sympathetic -lesion = poikliothermia Receive info from Fornix Outputs to Anterior Nucleus of Thalamus Important for Weirnke-Korsakoff Hunger Center (inhibited by leptin) -stimulation = eating Lesion = starvation. Lesion = Horner’s (partial ptosis. 5. 3.

Occlusion = Contralateral CST & DCML***. Paramedian Pontine Branches i. Travels along longitudinal fissure to supply medial parts of frontal and parietal lobes.CNS Blood Supply  Spinal Cord o Anterior Spinal Artery  Derived from vertebral arteries  Supplies ventral grey. PPRF. hypothalamospinal tract. Occlusion = contralateral LOWER LIMB motor and sensory loss e. … iii. medial temporal lobes (hippocampus) ii. aphasia (Broca’s. Supplies superior cerebellum & cerebellar nuclei. Nucleus Ambiguous. Supplies some of optic tract***. cingulate gyrus and part of basal ganglia ii. and lateral surfaces of hemispheres*** ii. ipsi lateral eye abduction paralysis e. Anterior Choroidal i. Enlargement may compress trigeminal = trigeminal neuralgia d. vestibular/cochlear nuclei. and some of posterior internal capsule*** c. STT contralateral g. or hemineglect Vertebral System a. Horners. supplies Posterior Columns  Loss = isolated DCML below lesion (touch. Supplies posterior inferior cerebellar suface.e. Travels w/optic nerve. contral body pain/temp. amygdale. Supplies insula. supplies corpus callosum. MLF. Medial portions of upper and lower pons ii. Posterior Inferior Cerebellar Artery (branches from vertebrals) i. ventral & lateral white funiculi  Occlusion = Anterior Cord Syndrome (bilateral STT. Basically the reticular formation of pons f. CST. Opthalamic i. Posterior Communicating i. supplies retina and eye b. possible ispi face pain and temp. c. Links the anterior and posterior brain circulations d. there are two of them)  Derived from vertebral arteries. facial nucleus (sometimes). Middle Cerebral i. proprioception. Occlusion = ipsi face paralysis (LMN)***. Anterior Cerebral i. some cerebral peduncles. Anterior inferior cerebellum and caudal dosolateral pons ii. Caudal Dorsolateral pons has: middle cerebellar peduncle. ataxia. Lenticulostriate branches supply part of internal capsule iii. STT. ipsi horners…. Posterior lateral medulla has: STT. Short Circumferential i. Supplies occipital cortex. some hippocampus. CN 7 fibers. medial lemniscus iii. Ischemia symptoms depend on branch (M1-4). Occlusion = visual defects  1. iii. transcortical). Posterior Cerebral Artery i. hypothalamospinal tract. vibration) o Artery of Adamkiewicz  From an intercostals T9-12 and supplies most of lower 2/3 of cord  Occlusion can result in Anterior Cord Syndrome Brain Internal Carotid Arteries a. & minor motor tracts below occlusion is lost) o Posterior Spinal Arteries (i. Wernike’s. ataxia. Supplies CST. Abducens nucleus. Occlusion = contra loss of pain/temp on body. vestibular cochlear nuclei…. 2. posterior lateral medulla ii. caudal midbrain and rostal pons ii. Long Circumferential i. possibilities include: contral lateral face/upper body paresis and parathesia (internal capsule). vertigo. Anterior Inferior Cerebellar Artery i. conduction. inferior cerbellar peduncle. . Superior Cerbellar Artery i. Ventral Lateral Pons = hypthalamospinal. dysphagia***… b.

Mossy Fibers: All inputs (spinocerebellar tracts. motor planning. Reticular Formation Red Nucleus Ventral Lateral Thalamus Balance. timing. equilibrium Muscle Tone. pons. force of movement . to which they excite General Flow of information through cerebellum: Inputs (mossy climby)  cerebellar cortex  purkinge fiber  deep nuclei of cerebellum  output fibers & Lobe Phylogeny Functional Input Flocculonodular Archicerebellum Vestibulocerebellum Vestibular Nuclei Deep Nuclear Output Fastigial Nucleus Effector Function Anterior Paleocerebellum Spinocerebellum Spinocerebellar Tracts Cortex via pontine nuclei from corticopontine tract Posterior Neocerebellum Cerebrocerebellum Globose & Emboliform Nuclei Dentate Nucleus Vestibular Nuclei. 2. Posture. Axial Muslces Coordination. cortex…these synapse on Granule cells) Climbing Fibers: input from inferior olive (synapse on purkinje cells).Cerebellum Fibers entering Cerebellum 1. gait. anti-gravity. speed.

Neck Anatomy Posterior Triangle: Brachial Plexus. Brachialis. Coracobrachialis Muscle AX (Axillary Nerve): Deltoid and Teres Minor Muscle R (Radial Nerve): Extensors. Hypothenar Muscles . External Jugular. and Omihyoid muscle             LTN (Long Thoraic Nerve): Serratous Anterior Muscle SS (Suprascapular Nerve): Infraspinatus & Supraspinatus Muscle LP (Lateral Pectoral Nerve): Pectoralis major muscle Upper SS (Upper Subscapular Nerve): Subscapularis Muscle TD (Thoraic Dorsal Nerve): Lattisimus Dorsi Muscle LSS (Lower Subscapular Nerve): Teres major Muscle MC (Musculocutaneous Nerve): Biceps. Triceps Muscle M (Median Nerve): Pronators. Subclavian Artery/Vein. Thenar Muscles U (Ulnar Nerve): interosseous.