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AMA surg journal
cardiac exam
	note demeanor and mood of patient
	completely examine all systems

cardiac auscultation
	recognition of pitch important
	concentrate on segments of the heart sound

	S1 mitral and triscuspid
		normally split
		loud in mitral stenosis

	S2 aortic pulmonic
		fixed split S2 indicative of increased right ventricular flow
			i.e. left to right shunt with increased flow
	
	S3 pericardial knock occurring in early diastole
		may indicate left ventricular dysfunction

	S4 may indicate right ventricular dysfunction

	Clicks are always systolic have brief duration and are high pitched
		congenital and aortic valve stenosis
		mitral and tricuspid valve stenosis
		pulmonary hypertension

	murmurs may be systolic diastolic or continuous
		systolic		
			ejection
				diamond shaped
				aortic stenosis r 2nd ics, apex, rad both carotid
				pulmonic stenosis l 2nd ics, little radiation
				IHSS increased with Valsalva, left sternal border
			holosystolic
				regurgitant or shunt
					mitral regurg apex rad axilla
					tricuspid regurg left sternal border and over liver
				VSD left sternal border
					dims with increase pulmonary hypertension

		diastolic
		       stenosis	
			mitral stenosis low pitched early diastolic apical
			tricuspid stenosislow pitched quiet left sternal border 4th and 5th ICS
		       regurgitant
			aortic regurg blowing high pitched lower left sternal edge to apex
				Austin Flint murmur (mid diastolic rumble with aortic regurg)
			pulmonic regurg left ICS
				Graham Steele murmur due to valve stretch in pulmonary htn
		
		continuous
			pda 2nd left ICS medial clavicle
			arteriovenous fistula over lesion
			coarctation of aorta or p.a.
			various fistulas and aortopulmonary window

	pericardial friction rub

	cerebral ischemia or infarction
		The sudden onset of focal sensory loss, weakness, or speech disorder 
		particularly in older people with 
			hypertension
			diabetes
			hypercholesterolemia
			heart disease
			history of cigarette smoking.

Cerebellar hemorrhage
	commonly begins with an occipital headache followed by 
	nausea, vomiting, lightheadedness or vertigo, and ataxia of gait

Chlamydia-
	This is a rare, yet possible, cause of meningoencephalitis. 

					
			
		

hypertension
	urgencies - may be reversed in several hours
 
	emergencies- in one hour

	post op hypertensive urgency has been defined as >190/100

	children and pregnant females more apt to develop htn encephalopathy with hypertension

	check BP in all limbs, think aortic aneurysm, mi, cva, check retina

	nicardipine is a titratable intravenous calcium channel blocker approved for tx of htn emergencies

	Labetalol is a combined blocker of the alpha and beta adrenergic receptors given intravenously
		drug is that it is also effective as an oral antihypertensive agent 
		initial intravenous bolus of 0.25 mg/Kg, followed by larger boluses (0.5 mg/Kg) 
		every 15 minutes until the BP is controlled or a total dose 3.25 mg/Kg has been given. 

	Esmolol a beta-adrenergic blocking agent that has an extremely brief elimination half-life (<10 minutes). 
		available for intravenous use both as a bolus and as an infusion. 
		It is of particular value for some dysrhythmias and  used in  hypertensive crises.
		dosage is 0.5-1 mg/Kg followed by an infusion at 50-200 mcg/Kg/min.

	Clonidine (0.1 mg PO q 20 min.) has been used for the treatment of hypertensive crises
		in hypertensive urgencies
		This medication has been widely studied. 
			In a random, double blind study, comparing the effects of oral nifedipine 
			versus oral clonidine in 51 patients, clonidine was found to produce 
			a more gradual decrease in BP than nifedipine
		 Sedation was observed in those patients taking clonidine. 
		 choice for those patients in whom BP control within a few hours is desired.
		 have iv fluids ready just in case.

	captopril 

 

leptospirosis
	Leptospirosis
		caused by a family of spirochetes with numerous serogroups and serotypes
		clinically distinct syndromes: anicteric leptospirosis and icteric leptospirosis. 

	anicteric leptospirosis
		meningitis
		septicemic phase characterized by abrupt onset with fever, malaise, headache, myalgia, and 						

nonpurulent conjunctivitis hepatosplenomegaly, lymphadenopathy, rashes. 
		This septicemic phase usually lasts three to seven days followed by
		
		immune phase, characterized by a lower temperature and the development of meningeal signs. 		

Renal disease
			proteinuria
			pyuria
			microscopical hematuria
			mild-to-moderate azotemia
			severe renal dysfunction is rare.
	
	Icteric leptospirosis 
		hyperbilirubinemia, hepatic dysfunction, renal failure, 
		pulmonary infiltrates, and cardiac dysfunction. 
		fatal myocarditis has been found.  


	

nutrition
	
	major nutritional diseases
		marasmus - deficiency of all nutrients
		kwashiorkor - deficiency primarily of protein
		xerophthalmia - deficiency of retinol ( Vitamin A )
			drying (xerosis) of conjunctiva
			keratomalacia
			night blindness in early vitamin A deficiency
			leading cause of blindness in young in developing countries
			seen in marasmus and kwashiorkor
		rickets - vitamin D (ergocalciferol, cholecalciferol) deficiency and dependency
			restlessness, and developmental delay
			bone growth defect, bowing, osteomalacia in adults 

	vitamin A toxicity
		headache
		nausea
		diplopia

	cns manifestations
		pellagra - niacin (nicotinic acid) deficiency
			may complicate INH therapy
			use of corn protein (maize)
			scarlet stomatitis, glossitis, dermatitis, diarrhea, cns aberrations

		beriberi - thiamine (B1) deficiency
			thiamine pyrophosphate alpha keto acid decarboxylation (CHO metabolism)
			polished rice (devoid of the husks)
			fatigue, irritability, sleep disturbances
			memory disorder
			precordial pain
		        dry beriberi 	peripheral neuropathy
		        cerebral beriberi	Wernicke-Korsakoff syndrome (acute hemorrhagic polioencephalitis)
		        wet beribery 	tachycardia leading to cardiogenic shock
		        infantile beriberi 	aphonia, cardiac failure, breastfed infants of thiamine deficient mothers
  
		pyridoxine deficiency or excess
		vitamine b 12 deficiency
		taste and smell-zinc deficiency

	lips gums teeth tongue and buccal mucosa
		B complex deficiency
		scurvy

	bones and joints
		rickets - see above
		scurvy - vitamin c deficiency (collagen formation)
			gingivitis, teeth loosening, poor wound healing
			conjunctival hemorrhage,  ecchymoses, petechiae,  
			lassitude, weakness, irritability, weight loss.
			ddx adult - arthritis, gingivitis, hemorrhagic diseases
		osteomalacia- vitamin D deficiency, rickets		
		osteoporosis- calcium deficiency

drug-nutrition interactions
	tyramine-a component of cheese and potent vasoconstictor which may cause
	hypertensive crisis in those on monoamine oxidase inhibitors.

			
pulsus paradoxus is a fall in systolic bp greater than 10 with inspiration
	obstructive pulmonary disease
	constrictive pericarditis
	cardiac tamponade
	restrictive cardiomyopathy

poisoning

	always suspect ingestion in children with unusual presentations
		arrhythmia
		altered mental status
	elderly-drug mistakes
	hospitalized-drug errors
	occupational or environmental exposures
	
	for altered mental status, or respiratory depression
		naloxone
		glucose
		thiamine
	ipecac 15 mg/kg up to 15 to 30 mls note contraindications


	antidotes (rough overview)
		naloxone for opioid overdose
		atropine for organophosphate toxicity
		methylene blue for methemoglobinemia
		acetylcysteine for acetaminophen poisoning
		digibind dig FAB for digitalis glycoside ingestions

	presentations
		CNS stimulation
			sedate with 	diazepam or barbiturate
			seisures		diazepam 5-10 mgs adult (slow push)
						0.1-0.2 mg per kg for child  (slow push) 
					 phenobarbital 100 - 200mgs im or iv for adults
						4-7 mg/kg for children
					phenytoin
		CNS depression
			intubation, narcan
		
		cerebral edema, in sedative, CO lead and other CNS depressants
			20%mannitol 5 to 10 mls per kilogram
			dexamethasone 1mg per meter squared BSA iv drip
						
		renal failure-dialysis
		
                  	hepatic failure

	eliminators
		urine alkalinization in salicylate poisoning
			sodium bicarbonate 2 to 3 m3qs per kg
		hemodialysis, peritoneal dialysis, hemoperfusion, lipid dialysis
			not effective in digitalis glycosides, or tricyclic antidepressants (large vol of dist)
		chelating agents in metal poisoning
	
	toxidromes
		anticholinergic
			dry, hot and red
			fixed dilated pupils
			mad
			
			
			
			
		anticholinesterase inhibition
			wet
			fasciculations
			constricted pupils
			

		cholinergic
			wet
			fasciculations
			constricted pupils
			
		extrapyramidal
			opisthotonous, torticollis, oculogyric crisis

		hemoglobinopathies
			headache, coma, cherry red skin, cyanosis, chocolate blood

		metal fume fever
			dry headache fatique nausea, respiratory distress

		narcotic	
			pupils pinpoint, lethargy coma

		sympathomimetic
			excitation, seizures,tachycardia			
		sympathomimetic
		withdrawal

	anticholinergic atropine aminita antihistamines
	anticholinesterase inhibition, organophosphates
	cholinergic betel nut pilocarpine

	alcohol poisoning
		ethanol
			 fluids with glucose, consider hypoglycemic course, dialysis for levels over 300
		isoproanol (rubbing alc) fluids and glucose watch electrolytes, support

		methanol  	antifreeze, solvents, varnish 
			ethanol and glucose, bicarb, consider acidotic course

	amphetamines heart block psychosis
	
	antihistamines arrhythmias

	arsenic antimony chelate with penicillamine throat constriction burning
	
	atopine is a belladonna alkaloid
	
	belladonna, scopolamine, atropine, physostigmine (if severe) hot and dry dilated pupils

	benzene V FIB

	benzodiazepines, flumazenil

	bismuth dimercaprol

	beta blockers pacing glucagon 3-5 mgs iv in adults

	calcium channel blockers calcium chloride, atropine

polyarthritis
	Serologic studies should be obtained
		antinuclear and antistreptococcal antibodies 
		antibodies to Borrelia burgdorferi in the case Lyme disease is endemic

rheumatic fever

	carditis, chorea, migratory polyarthritis, erythema marginatum, subcutaneous nodules
	significant familial susceptibility	
	age 4 to 18 for first attack
	a history also is a risk factor for recurrence, especially if not treated (50%) in strep A disease
	may cause heart failure