Professional Documents
Culture Documents
• Work up-
– Exercise EKG: avoid b-blockers and CCB before.
– Can’t do EKG stress test if old LBBB or baseline ST elevation
or on Digoxin. Do Exercise Echo instead.
– If pt can’t exercise- do chemical stress test w/ dobutamine
or adenosine.
– MUGA is nuclear medicine test that shows perfusion of
areas of the heart. Avoid caffeine or theophyline before
– Positive if chest pain is reproduced, ST depression, or
hypotension on to coronary angiography
Post-MI complications
• MC cause of death? Arrhythmias. V-fib
• New systolic murmur 5-7 Papillary muscle rupture
days s/p? (regurg mumur)
Cannon-a waves on
physical exam.
“regular P-P interval
and regular R-R
interval”
3rd Degree Heart Block
-not a p before every QRS spaced regularly
http://www.ispub.com/ispub/ijpn/volume_4_number_1_43/an_unusual_cause_of_seizures_in_a_10_year_old/seizures-fig1.jpg
Ventricular tachycardia --> Tx: (if unstable, defib), (if stable, tx with lidocaine or amiodarone)
-delta wave --> WPW (Wolff Parkinson White) -- tx: procainamide, DO NOT GIVE b-blockers, digoxin, CCB (verapimil or
www.emedu.org/ecg/images/wpw_3a.jpg diltazem) --> anything that slows down AV node
Atrial flutter (2:1 between vent:atr). Unstable - cardiovert, medically stable - give b-blockers and digoxin (like Afib)
“Regular rhythm with a ventricular rate of 125-150 bpm and atrial rate
of 250-300 bpm” Torsades de pointes -- look for low K or low Mg, TCA overdose (look for electrolyte abn)
www.emedu.org/ecg/images/k_5.jpg
Renal failure patient/crush injury/burn victim w/ “peaked T-waves, widened QRS, short QT
and prolonged PR.” Hyperkalemia --> peaked T-waves
“Alternate beat variation in direction, amplitude and duration of the QRS complex” in a
patient w/ pulsus paradoxus, hypotension, distant heart sounds, JVD
(AFIB - neither rate/rhythm that much better -- rhythm NOT more
can't see p-waves = undulating baseline effective so we do RATE CONTROL). Tx with beta-blockers or
AFIB -- too much synthroid, palpitations and SOB in elderly, digoxin
CHF with valve disease, hypothyroidism “Undulating baseline, no p-
waves appreciated, irregular R-R
interval” in a hyperthyroid pt, old
www.ambulancetechnicianstudy.co.uk/images/SVT.gif
pt w/ SOB/dizziness/palpitations
w/ CHF or valve dz
>Valsalva decreases preload --> less blood going thru stenotic Ao valve
>Squatting increases preload
>Handgrip increases afterload
Murmur Buzzwords
parvus et tardus
• SEM louder w/ valsalva, softer HOCM
young pt in for sports physical - louder with valsalva
w/ squatting or handgrip.
• Late systolic murmur w/ click Mitral Valve Prolapse
"click" - younger patient
palpitations and syncope
louder w/ valsalva and
handgrip, softer w/ squatting
• Holosystolic murmur radiates Mitral Regurgitation
not an ejection mumur, it's holosystolic
to axilla w/ LAE
More Murmurs
“Thickened peritracheal
stripe and splayed
carina bifurcation”
www.meddean.luc.edu -L. atrial enlargement (bad mitral
http://en.wikipedia.org/wiki/ stenosis) and mediastinal mass/
“Cavity containing an air- cancer
ARDS
• Pathophys: inflammation impaired www.ispub.com/.../ards3_thumbnail.gif
• Diagnosis:
1.) PaO2/FiO2 < 200 (<300 means acute lung injury)
2.) Bilateral alveolar infiltrates on CXR
3.) PCWP is <18 (means pulmonary edema is non
cardiogenic) (R/O cardiac causes - not problem with forward blood flow)
PFTs
Obstructive Restrictive
Examples Asthma Interstitial lung dz (sarcoid,
COPD silicosis, asbestosis.
Emphysema Structural- super obese,
MG/ALS, phrenic nerve
paralysis, scoliosis
FVC ↓ <80% predicted ↓ <80% predicted
FEV1 ↓ <80% predicted ↓ <80% predicted
FEV1/FVC **** ↓ <80% predicted Normal
TLC ↑ >120% predicted ↓ <80% predicted
RV ↑ >120% predicted ↓ <80% predicted
Improves >12% with Asthma does Nope
bronchodilator COPD and Emphysema
Bronchodilator response - improvement of FEV1 with 12% don’t.
DLCO reduced Reduced in Emphysema Reduced in ILD due to
(diffusion) 2/2 alveolar destruction. fibrosis thickening distance
COPD Acute exacerbation
• Criteria for diagnosis? Productive cough >3mo for >2 consecutive yrs Narrow TI, can cause
LABA LAAC
•
arrhthmias
Treatment? 1st line = ipratropium, tiotropium. 2nd Beta agonists. 3rd Theophylline
• Indications to start O2? PaO2 <55 or SpO2<88%. If cor pulmonale, <59
• Criteria for exacerbation? Change in sputum, increasing dyspnea
(amount, colour)
• Shown to improve 1.) Quitting smoking (can decr rate of FEV1 decline
mortality? 2.) Continuous O2 therapy >18hrs/day
• Why is our goal for SpO2 COPDers are chronic CO2 retainers. Hypoxia is
94-95% instead of 100%? the only drive for respiration.
• Important vaccinations? Pneumococcus w/ a 5yr booster and yearly
influenza vaccine
Your COPD patient comes with a 6
week history of this…
acute-onset clubbing
>>lung cancer
-get CXR
http://cancergrace.org/lung/files/2009/02/nail-clubbing.jpg
• If pt has sxs twice a week and PFTs are normal? Albuterol only
• If pt has sxs 4x a week, night cough 2x a month and
PFTs are normal? Albuterol + inhaled CS moderate --> mod-intermittent AND mod-
consistent
steroids. Watch peak flow rates and blood gas. PCO2 are getting tired -->
need to intubate
(non-caseiting granuloma)
So you found a pulmonary nodule…
• 1st step = look for an old CXR to compare!
• Characteristics of benign nodules:
– Popcorn calcification = hamartoma (most common)
– Concentric calcification = old granuloma
– Pt < 40, <3cm, well circumscribed
• Tx w/ CXR or CT scans q2mo to look for growth
• Characteristics of malignant nodules: http://emedicine.medscape.com/
article/356271-media
http://emedicine.medscape.com/ar
ticle/358433-media
A patient presents with weight loss, cough,
dyspnea, hemoptysis, repeated pnia or lung
LUNG CANCER
collapse.
• MC cancer in non-smokers? Adenocarcinoma. Occurs in scars of old pnia
• Location and mets? Peripheral cancer. Mets to liver, bone, brain and adrenals
• Characteristics of effusion? Exudative with high hyaluronidase (GIVES a characteristic
pleural effusion)
commons.wikimedia.org
medinfo.ufl.edu/~bms5191/gi/images/cd1a.jpg
Pyoderma gangrenosum
(no abx, no I and D, tx the disease)
http://www.ajronline.org/cgi/con
tent-nw/full/188/6/1604/FIG20
studenthealth.co.uk
*Chemoprophylaxis (INH for 9mo) for kiddos <4 exposed to known TB.
• Drug Side Effects:
– Rifampin- body fluids turn orange/red, induces CYP450
– INH- peripheral neuropathy and sideroblastic anemia (prevent
by giving B6. Hepatitis w/ mild bump in LFTs
– Pyrazinamide- Benign hyperuricemia not enough to cause gout
– Ethambutol- optic neuritis, other color vision abnormalities.
Endocarditis
Acute endocarditis- acute - staph
• most common bug? Staph aureus seeds native valves from bacteremia
Subacute Native valve endocarditis-
• Most common valve? Mitral Valve (MVP is MC predisposition)
• Most common bug? Viridens group strep (subacute - on native valve)
• Post-exposure prophylaxis-
– If stuck w/ known HIV pt AZT, lamivudine and
nelfinavir for 4wks
HIV+ patient with DOE, dry cough, fever,
chest pain
Pneumocystis -- fluffy bilateral infiltrates
• Prophylaxis? Start
st
when CD4 is <200. Can d/c is >200 for >6mo
nd
1 - Trim-sulfa 2 - Dapsone
3rd- Atovaquone 4th- Aerosolized pentamidine
(causes pancreatitis!)
HIV+ patient with diarrhea
CD4 count
• CMV- (<50)
– Dx w/ colonoscopy/biopsy. Diarrhea can be bloody
– Tx w/ gancicylovir (neutropenia) or foscarnet (renal
tox)
• MAC- (<50) diagnosis of exclusion, no stool, ova parasites
ethylene glycol
hypersegmented neutrophil
acanthocyte
nl methylmelonic acid.
schistocytes
www.nejm.org/.../2005/20050804/images/s4.jpg
OA. RA.
www.yorkshirekneeclinic.co.uk/images/D3.jpg
www.hopkins-arthritis.org/.../radiology2.jpg
• Symmetric, bilateral
arthritis, malar rash,
Psoriatic oral ulcers,
Arthritis. SLE.
proteinuria,
thrombocytopenia.
www.learningradiology.com/.../cow60.jpg Arthritis is not
erosive or have
DIP joint involvement, rash w/ silvery scale on lasting sequellae.
elbows and knees, pitting nails and swollen fingers.
A patient comes in w/ acute swollen
painful joint…
• 1st best test? Tap it!
• WBCs >50K Septic arthritis
• 30 yr old who “travels a lot Gonococcal. Cx may be negative. Look
for work” also for tenosynovitis and arm pustules. Tx w/ ceftriaxone.
• 70 yr old nun Staph aureus. Tx w/ nafcillin or vanco.
• WBCs 5-50K Inflammatory. If no crystals, think RA, ank spon, SLE, Reiter’s
• Needle shaped, negatively Gout. Monosodium Urate.
birefringent crystals.
• Acute TX? Indomethacin + colchicine (steroids if kidneys suck).
• Chronic TX? Probenecid if undersecreter. Allopurinol if overproduc.
• Rhomboid shaped, positively Pseudogout. Calcium pyrophosphate.
birefringent crystals.
• WBCs 200-5K OA, hypertrophic osteoarthropathy, trauma
• WBCs <200 Normal.
Antibodies to Know!
• If negative, rules out SLE? ANA – peripheral/rim staining.
• Most sensitive for SLE? Anti-dsDNA or Anti-Smith
• Drug induced lupus? Anti-histone
(hydralazine).
• Sjogren’s Syndrome? Anti-Ro (SSA) or Anti-La (SSB)
• CREST Syndrome? Anti-centromere
• Systemic Sclerosis? Anti-Scl-70, Anti-topoisomerase
• Mixed connective tissue Anti-RNP
disease?
• 2 tests for RA? RF (against Fc of IgG)
Anti-CCP (cyclic citrullinated peptide)
Skin signs of systemic diseases:
http://www.clevelandclinicmeded.com/medicalpubs/
img.medscape.com/pi/emed/ckb/dermatology/1048
http://www.clevelandclinicmeded.com/medicalpubs/
http://www.clevelandclinicmeded.com/medicalpubs/
Dermatitis Herpetiformis
http://www.clevelandclinicmeded.com/medicalpubs/
http://dermnetnz.org/systemic/necrolytic-erythema.html
http://www.clevelandclinicmeded.com/medicalpubs/
Necrolytic migratory
Porphyria Cutanea Tarda Erythema Nodosum erythema
http://bestpractice.bmj.com/best-practice/images/bp/376-
2_default.jpg
http://www.clevelandclinicmeded.com/medicalpubs/
http://www.clevelandclinicmeded.com/medicalpubs/
Pemphigus Vulgaris Behcet’s Syndrome
Bullous Pemphigoid
Other Skin Randoms
http://dermnetnz.org/systemic/acrodermatitis-enteropathica.html
Acrodermatitis http://www.dermnetnz.org/systemic/pellagra.html
img.medscape.com/.../276262-279734-252.jpg
library.med.utah.edu
keratoacanthoma. 276624-media
www.ncbi.nlm.nih.gov/bookshelf/picrender.fcgi...
If Lymphadenopathy
Stage 0 or 1 need no tx- 12 yrs
img.medscape.com/.../197800-199425-29.jpg
till death
If Splenomegaly
Tx w/ imantinib (Gleevec), inhibits Stage 2 tx w/ fludrabine
tyrosine kinase. 2nd line is bone
If Anemia
marrow transplant.
Cx = blast crisis. If Thrombocytopenia
Stage 3 or 4 tx w/ steroids
• Enlarged, painless, rubbery Think Lymphoma
lymph nodes
• Drenching night sweats, “B-symptoms” = poor prognosis along w/
fevers & 10% weight loss. >40, ↑ESR and LDH, large mediastinal LND
• Best initial test? Excisional lymph node biopsy
• Next best test? Staging Chest/Abdominal CT or MRI. If still unsure,
staging laparotomy is done. Bone marrow bx (esp for NHL