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CARDIOLOGY
AV Block
Type Signs & Symptoms/Info/Wok!p "#n#gement $%G
ist 'egee -Asymptomatic
-EKG showing lengthened PR interval
-Determine site of block using EKG
findings atropine e!ercise or vagal
maneuvers
-"reat reversible
causes such as
ischemia increased
vagal tone or meds
-Pacemaker usually not
recommended
Secon'
'egee
Wencke(#c)
*"o(it+ type
I,
-"ypically asymptomatic
-EKG shows progressive PR prolongation
for several beats prior to nonconducted P
wave
-#eats classically occur in ratios of $%& '%$
or (%'
-)an be a result of inferior *+
-"reat reversible
causes such as
ischemia increased
vagal tone or meds
-Pacemaker if there is
symptomatic
bradycardia
"o(it+ type II -*ay be asymptomatic or have signs of
hypoperfusion or ,
-PR interval remains unchanged prior to anonconducted P wave
-"reat reversible
causes such as
ischemia increasedvagal tone or meds
-*ost patients will
re.uire a pacemaker
T)i' 'egee -*ay have di//iness presyncope syncope
v-tach v-fib worsening , or angina
-P waves don0t correlate to 1R2-Escape rhythm takes over for 1R2
34unctional or ventricular5
Ventic!l# T#c)yc#'i#
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Tos#'es 'e pointes is a
polymorphic form of 6"
Ventic!l# fl!tte is a rapid 3&'7-
&875 unstable form of 6" that can
deteriorate to 6
C#!ses
-Electrolyte imbalances
-Acid9base abnormalities-,ypo!emia
-*+
-Drugs
Signs & Symptoms
-)an remain alert and stable with
short runs
-Prolonged runshypotension
myocardial ischemia syncope
chest pain dyspnea
-2udden cardiac death
"#n#gement
-"orsades% remove offending med use
anti-arrhythmics
-"reat if : $7 s with antiarrhythmics
3amiodarone lidocaine procainamide5
-)ardioversion if pt remains unstable
Ventic!l# i(ill#tionC#!ses
-;nderlying ischemia or
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Signs & symptoms
-2udden onset chest pain
nausea vomiting diaphoresis
2=#
-@aw neck scapular throat or
arm pain
-D=E
-)hest pain : $7 min not
responsive to G
-,ypovolemia-," or hypotension
-"achy or bradycardia
-2$ or 2'
-2igns of ),
-2ystolic murmurs
-riction rub if day & or later
-)hange from stable angina to
A)2 B angina at rest new onset
angina that markedly limits
activity more fre.uent angina
long duration angina or angina
occurring with less e!ertion than
previous
-Remember that women theelderly and diabetics may have
atypical presentations
Wok!p
-=btain C& lead within C7 min of arrival
and repeat every C7 minutes if initial EKG
is not diagnostic 3CstEKG is negative '7
of the time5
- ?7 or resp
distress5
-Aspirin G
-*orphine for continued chest pain
despite G
-"reat , if present with G furosemide
-Give L-blocker if , is not present in
order to reduce myocardial o!ygen
demand-#egin 87 mg atorvastatin for pts not
already on
-Echo to determine cardiac function
A''ition#l ST$"I Te#tment
-Antiplatelet and anticoagulant therapy
for all patients 3in addition to aspirin5
-Emergent stent if > $ hours from
symptom onset
-Alternative is lytic therapy if not
contraindicated symptoms > C& hours
and P)+ unavailable within ?7-C&7
minutes
-)A#G rarely performed during acute *+
A''ition#l .ST$"I Te#tment
-Antiplatelet therapy for all patients 3in
addition to aspirinF clopidogrel
ticagrelor etcI5
-Anticoagulant therapy for all patients
3heparin5
-+nvasive intervention based on presence
of high risk factors 3recurrent angina at
rest elevated troponin 2" depression
high risk stress test result E > '7
hemodynamic instability sustained 6"
recent P)+ prior )A#G "+*+ score5-Glycoprotein ++A9+++# inhibitor in
addition to all other meds for a subset of
select pts who will undergo early P)+
Te#tment of Coc#ineRel#te' ACS
-#en/os every C( minutes PR
-D=0" give L-blockers
0ostACS Te#tment
-)ontinue drugs used during hospitali/ation% L-blocker statin A2A 2 C 3salt
conserving indicating a
functioning kidney with
normal physiologic response
to volume depletion5
6ariable usually normal i f
in4ury is acute and there is still
tubular functioning
: C if oliguric > C -6ariable
Urine #smolalit : (77 > '77 &(7-$77 6ariable 6ariable
Urinar Se!iment -#enign or hyaline cast s -;sually normal
-*ay see R#)s O#)s or
crystals
-*uddy br
own casts renal tubular casts
-Ohite cells white cell casts
S eosinophils
-Red cells dysmorphic red
cells and red cell casts
1et)itis Diffeenti#l-Oith dischargethink gonorrhea or chlamydia first others includeMycoplasma, &reaplasma, 'richomonas
-Reactive arthritis with associated urethritis
-;rethral carcinoma
-*en% balanitis
-Oomen% candidiasis cystitis
O2#i#n CystsDiffeenti#l;ruptured ectopic mittelschmer/ ovarian torsion degenerating leiomyoma P+D acute endometritis
!nction#l Cysts *0)ysiologic O2#i#n Cysts, .on!nction#l Cysts-)aused by e!aggerations of normal
menstrual cycle rather than true
neoplasms
-+ncreased risk with smoking
Types
-ollicular cyst% continued growth of
follicle despite failed ovulation
-)orpus luteum cyst% failure of
involution with enlargement after
ovulation and continued progesterone
secretion
-"heca lutein cyst% a result of abnormalpregnancy uncommon
Signs & Symptoms
-)an be asymptomatic
-Pelvic pain and
dyspareunia if large
-ollicular% pelvic pain if
rupture
-)orpus luteum% adne!al
enlargement one-sided
pain missed menses
-"orsioned or ruptured
cyst will cause acute
abdominal pain rebound
tenderness
Wok!p
-*ust be differentiated from malignancy 3benign B mobile cystic
unilateral smooth > C7 cm minimal septations5F get pelvic ;2
"#n#gement
-Oill usually regress spontaneously
-"reatment only if recurrent or symptomatic 3=)Ps etc5
-Ruptured cyst% e!pectant management if uncomplicated 3no
hypotension tachycardia fever leukocytosis signs of acute abdomen
or ;2 suspicious for malignancy5 surgical management if
complicated
0ognosis-Risk of torsion if large or penduculated
-ot associated with
ovulation
Types
-Dermoid cysts 3teratomas5%
contains developmentally
mature skin and sometimes
hair bone nails teeth
other tissue
-Endometrioma 3chocolate
cyst5% related to
endometriosis
-2erous or mucinouscystadenomas
Signs & Symptoms
-)an be
asymptomatic
-Adne!al tenderness
"#n#gement
-2urgical e!cision
Ce2icitis
$tiologies
-+nfectious% chlamydia gonorrhea ,26 ,P6 trichomoniasis
Mycoplasma genitalium )*6 #6
-oninfectious% cervical cap pessary or diaphragm use
chemical or late! allergy cervical trauma
Signs & symptoms
-Postcoital spotting
-+ntermenstrual spotting
-Dyspareunia
-;nusual vaginal discharge
-+f chroniccervical stenosis leukorrhea granular redness
erythema vulvar irritation
-2alpingitis
-Edematous or friable cervi!
Wok!p
-2"+ testing
-Oet prep
-Pap M pelvic
Te#tment
-)hlamydiasingle a/ithromycin dose or do!ycycline
-Gonorrheaceftria!one +* or single cefi!ime oral dose
-,26acyclovir
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-"richomoniasissingle metronida/ole
0el2ic Infl#mm#toy Dise#se
-+nflammation of the uterus fallopian
tubes and9or ovaries and possibly
surrounding pelvic organs
-;sually polymicrobial with 2"+s
endogenous organisms
Risk #ctos
-*ultiple se! partners
-Douching
-2moking
Signs & Symptoms
-Pelvic or abdominal pain
-Painful defecation
-Abnormal vaginal bleeding
-Dyspareunia
-;terine adne!al or cervical motion
tenderness
-R;1 pain 3from perihepatitis5
-2igns of 2"+ infection
Wok!p
-"esting for G)
hlamydia ,+6 hep #
syphilis
-)ervical cultures
-h)G
-Pelvic ;2 if concern for
abscess
-)#)
-;A
"#n#gement
-+f no other cause of pelvic or abdominal pain can be found in a se!ually active
woman at risk for 2"+s always treat for P+D
-#egin antibiotic before cultures come back
-Admit for inpatient management if there is pregnancy nonresponse to oral
antibiotics inability to take P= severe illness or tubo-ovarian abscess
-=utpatient treatment of mild-mod P+D% ceftria!one +* do!ycycline
-+npatient treatment of severe or complicated P+D% +6 cefo!itin P=
do!ycycline
-"reat partners
0ognosis
-Risk for infertility increases with each episode
O2#i#n Tosion
-A gynecologic emergency caused by ovarian
ischemia as a result of complete or partial
rotation of the ovary on its ligamentous
supports
-allopian tube may also be torsioned
Risk #ctos
-=varian mass
-=vulation induction for infertility
Signs & Symptoms
-Acute pelvic pain 3although rarely can be
chronic pelvic pain5
-9v
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-#uilding collapse
-"rapped in machinery
-atural disasters
-*6)s
-Prolonged duration of wearing antishock garment
-+nability to move away from hard surface 3)6A )=
hypoglycemia fall etc5
paresthesias paralysis
"#n#gement
-A#)s
-)ardiac monitoring
-luid resuscitation
-Pain management
-*annitol% a non-osmotic diuretic to help wash myoglobin
out of renal tubules to protect kidneys
-)ompartment syndrome% fasciotomy hyperbaric o!ygen
0ognosis
-Degree of physiologic dysfunction is not related to time
elapsed before e!trication
#ct!es
0e'i#tic #ct!es Types of #ct!es Gene#l Infom#tion
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-#owing and greenstick f! are uni.ue to kids due to
their skeletal immaturity
-Growth plate f! are classified by 2alter-,arris
-*ost f! only re.uire closed reduction
-Kids heal faster due to more active periosteum and
higher cartilage
#ct!es Associ#te' 8it) C)il' A(!se
-*etaphyseal corner f!% child abuse until proven
otherwise
-Posterior rib f!% child abuse until proven otherwise-Any fracture in a child under C
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Ankle #ct!e -+nvolves lateral medial or posterior
malleolus
-*=+% eversion or lateral rotation on the
talus
-"enderness in these areas suggests fracture vs strain
or sprain 3=ttawa ankle rules5
-=ttawa ankle rules help determine
need for !-ray
-2tandard AP and lateral views on
!-ray 3plus AP view with C(Z
internal rotation if suspecting ankle
fracture5
-Elevation and ice
-2hort leg cast
oot #ct!e -+nvolves talus calcaneus metatarsals or
phalanges
%nee #ct!es
#ct!e Type Infom#tion Signs & Symptoms Wok!p "#n#gement & 0ognosis
0#tell# #ct!e -*=+% direct blow -Knee pain difficulty walking
-2welling and bruising
-Aspiration will show hemarthrosis
with fat globules
-Point tenderness
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-*ortality &7-$( in the first year
-*a4ority will re.uire corrective surgery
#ct!e
Type
Infom#tion Signs & Symptoms Wok!p "#n#gement & 0ognosis
$6t#c#ps!l
#
-Does not affect blood supply to
femoral head B complications of
nonunion are rare
-2table vs unstable 3detached fragment
of lesser trochanter5
-,9o fall or trauma
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the body
-!me#l
S)#ft
-"ypically from trauma in the elderly -E!tensive bruising of upper arm
-Orist drop from radial nerve damage
-Orist splinting and casting over site of
break
S!p#con'yl#
#ct!e
-Pediatric fracture
-;sually involves distal humerus
-
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Colles
#ct!e of
Dist#l R#'i!s
-*=+% ==2,posterior
displacement of wrist 3Tdinner fork
deformityU5
-)asting alone if nondisplaced
-)losed reduction followed by casting if
slightly displaced
-=R+ M short arm cast if displaced
Smit)
#ct!e of
Dist#l R#'i!s
-*=+% opposite )olles B fall on back
of hand
-=R+ M short arm cast
C)#!ffe!
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Bo6et)
"et#c#p#l
-*=+% blow of closed fist againstanother ob4ect
-2plinting vs percutaneous pinning
Common #ct!es of t)e SpineSpon'ylolysis -2tress f! of pars
interarticularis usually
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Diffeenti#l
-*uscle strain
-=steoarthritis
-,erniated disc
-2pinal stenosis
-2ciatica
-2acroillitis
-Rheumatoid
arthritis
-*etastatic cancer
-)ompressionfracture
-=steomyelitis or
epidural abscess
-)auda e.uina
tumor
-+schial bursitis
-Piriformis
syndrome
-ibromyalgia
-Aortic aneurysm
-Duodenal ulcer
-Kidney stones
-Pyelonephritis-Pancreatitis
-Prostatitis
-,ip osteoarthritis
Re' l#gs fo Seio!s
$tiology
-"rauma
-;ne!plained weight loss
-Age : (7 or h9o
osteoporosis or prolonged
corticosteroids
-;ne!plained fever
-,istory of urinary or other
infections
-+mmunosuppression or D*-,9o cancer
-+6 drug use
-Age : J7
-ocal neuro deficits or
progressive or disabling
symptoms
-Duration : H weeks
-Prior surgery
-ighttime pain
-#ladder dysfunction
-2addle pattern anesthesia
0)ysic#l $6#m-+nspect gait and spinal
motion
-2pinal palpation
-2traight leg raise test
-Peripheral pulses
-ocused neuro e!am
-"esting of
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Stoke-An acute neurological deficit of vascular etiology with symptoms lasting : &' hours-*ore prevalent in the Tstroke beltU in 2E ;2
Diffeenti#l; transverse myelitis #ell0s palsy Gullain-#arre myasthenia gravis "+A
Types of Stoke
-emo)#gic Isc)emicAccounts for C(-&7 of strokes
0#enc)ym#l IC-
-#leeding within the brain itself-Primary if due to spontaneousrupture of small vessels damaged
by chronic ," or amyloidangiopathy
-2econdary if due to traumavascular abnormalities tumorsimpaired coagulation or vasculitis
-Presentation will be severe ,"bad ,A n9v focal neuro deficits
-+f in thalamus or basal ganglia
contralateral motor and sensorydeficit aphasia language or spatial neglect depressed
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-An acute focal neurologic deficit as a result of
ischemia that resolves within &' hours
-)an be caused by brain spinal cord or retinal
ischemia
Diffeenti#l
-2ei/ure
-*igraine with aura
-2yncope
-,ypoglycemia
-Encephalopathy-*ultiple sclerosis
Wok!p
-)#) #*P to r9o metabolic causes
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-Represents an infection of the arachnoid mater and )2 Signs & Symptoms
-#acterial% fever nuchal rigidity A*2 severe ,A
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-Represents an infection
of the brain itself
-*ay be primary or
postinfectious
Diffeenti#l
-*eningitis
-*eningoencephalitis
-2troke
Agents
-,26
-Rabies virus
-O6
Signs & Symptoms
-ever
-,eadache
-
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$pi'!#l -em#tom#-Due to tearing of middle meningeal
artery
-Rarely seen in kids > & and in the
elderly as the dura is firmly attached in
these ages
Signs & Symptoms
-,A vomiting confusion9lethargy
aphasia sei/ures hemiparesis
-;nconsciousness abnormal pupil
reactions to light or abnormal posturing
due to compression of ) by hematoma
-;sually coe!ists with a skull fracture
Wok!p
-oncontrast head )" shows hematoma that
does not cross suture lines brain parenchyma
may be compressed to the midline
"#n#gement
-;sually re.uires craniotomy with evacuation of bleed
St#t!s $pileptic!s
-2ingle unremitting sei/ure with duration : (-C7 minutes or fre.uent sei/ures w9o interictal
return to baseline clinical state
C#!ses
-oncompliance with antiepileptic drug regimen
-Drug or Et=, withdrawal
-Acute brain in4ury or infection
-*etabolic disturbances
Wok!p
-2imultaneous assessment M treatment
-)areful neuro e!am for any focal deficits
-EEG
"#n#gement-
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-ormal physical activity does not aggravate
Oith tension and migraine headaches watch for signs of hemicrania continua 3daily unilateral headache with miosis ptosis eyelid edema lacrimation nasal congestion rhinorrhea5 which can
transform from migraine or tension headaches and is prompted by medication overuseF responds only to indomethacin
"ig#ine -e#'#c)e
-,ighest prevalence in &(-'( year olds with decreased
incidence during childbearing years-*ay have genetic component incurring
hypercoagulability
-,igh incidence of comorbid depression
-Precipitators% stress hormones hunger sleep
deprivation odors smoke alcohol meds high
tyramine foods
-,igh incidence of P= with migraines with aura
Signs & symptoms
-*ay have prodrome of sensitivity to touch or
0)#m#cologic T)e#py
A(oti2e .onopioi's% 2A+Ds acetaminophen rectal indomethacin +* ketorolac E!cedrin migraine
Tipt#ns;constrict intracranial bood vessels interrupt pain transmission centrally
-ever use during an aura due to risk of stroke
-2umatriptan /olmitriptan 3wafer avail5 etcI
-AEs% parestesias di//iness flushing somnolence rebound ,A with overuse
$gots% direct smooth muscle vasoconstrictors non-selective (-,"C-R agonists
-Ergotamine
-Dihidyroergotamine% available as in4ection nasal rectal 2