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
