Robert M. Gullberg M. D. / FACP Internal Medicine Bulletpoints Handbook

Intended For: Healthcare Practitioners and Students at all Levels
1. Auflage 2015
ISBN: 978-1-4835-4811-1
Verlag: BookBaby
Format: EPUB
Kopierschutz: Adobe DRM (»Systemvoraussetzungen)

E-Book, Englisch, 150 Seiten

Dr. Robert Gullberg is Board Certified in Internal Medicine and has three decades of clinical experience. He knows how to communicate the intricacies of Internal Medicine to medical students, PA students, and nursing students of all levels. He utilizes bullet points, which are handy for quick reference and memorization, and he has handpicked the most common topics you need to know. 'Internal Medicine Bulletpoints Handbook' is essential to building a sturdy foundational knowledge of Internal Medicine.

Autoren/Hrsg.

Robert M. Gullberg M. D., Facp

FACP,

Leseproben

Cardiology Cardiac auscultation- Sytoloic Heart Failure- most common cause is CAD and aging, alcohol, aortic stenosis, noncompliance with meds. Rx- ACE inhibitors, carvedilol/metoprolol (tartrate-immediate release, succinate is long-acting release), and diuretics are DOC. AICD (Automatic implantable Cardioverter Defibrillator) in patients with NY Class 2-3, EF 35% or less. It is the leading cause of hospitalization in patients older than 65 years in US. Diet- 2 gram Na restriction, 50 ounce/day fluid restriction is key for compliance. New York Heart Association (NYHA) is a functional classification system. Class I-mild, no limitation of activity. No SOB with ordinary activity. Class II- mild, slight limitation of activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitations, or SOB Class III- moderate, marked limitation of activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitations, and SOB Class IV- severe, unable to carry out any physical activity without discomfort. Symptoms are at rest also. Discomfort increased with activity. Aortic Stenosis- up to 25% adults develop it. Common symptoms- syncope, CP or CHF (AS triad) Can be silent. The heart murmer- 2nd right intercostal space, radiates to carotids. Watch for LVH, and angina pectoris flare ups. Valve area normally 1.5-2.0 square cms. < 0.8 square cms is considered severe AS. Pathology in most patients is bifid valve (with stenosis; not regurgitation) or aortic sclerosis (calcified). Treatment is AV replacement or balloon valvuloplasty No need for prophylaxis since AHA guidelines changed in 2007. Watch for aortic dilatiation in bifid valve patients. Atrial fibrillation- 6 seconds= 30 boxes; x 10= rate= 185 Atrial fib is the most common cardiac arrhythmia. Quality of life tends to be poorer without control. (lose atrial kick) 8% in people over 80 years old have it. Causes- HTN, heart disease (CAD or valvular), chronic lung disease, hyperthyroidism, alcohol abuse are the most common. Treatment- 1) anticoagulation with either warfarin, Pradaxa (dabigatran), a direct thrombin inhibitor, Xarelto, Eloquis, Lixiana. Adjust dose with CrCl. 2) Rate control-metoprolol, diltiazem. Infrequently digoxin. 3) Rhythm control-chemically with amiodarone (Pacerone)/ or dronedarone (Multaq), dofetilide (Tikosyn), or Direct Current Conversion. Ablation is used for cases that aren’t controlled. Atrial flutter 4:1 Third degree heart block- Patients present with significant bradycardia and sometimes hypotension. Causes are cardiac ischemia; especially inferior wall MI, Lyme’s, idiopathic Treatment is a dual chamber pacemaker. Atropine may be given if hypotensive, but usually has no effect. Acute Myocardial Infarction- location of STEMI- II, III, AVF- inferior (especially smokers)= right coronary artery disease. Anterior septal- V1-V2, anterior-lateral- I, AVL, V3-V6.-LAD/circumflex artery disease. (widow maker’s disease) Markers include CPK-MB fraction and troponin levels. Immediate treatments include oxygen and nitroglycerin. Most cases are treated with thrombolysis (Plavix-clopidogrel or Effient-prasugrel or Brilinta -ticagrelor, heparin or LMWH, and aspirin), and PCI (percutaneous coronary intervention)- bare-metal stents or drug-eluding stents are primarliy used. Other meds used are the glycoprotein IIb/IIIa inhibitors-block platelet and thrombin interaction (abciximab-Reopro or eptifibatide-Integrilin), and now bivalirudin (Angiomax), a direct thrombin inhibitor, similar to hirudin, the chemical in leech saliva. All risk factors must be neutralized for future prevention. (smoking, high cholesterol, obesity, diabetes, HTN are the common ones). Five types of MI: Type 1- spontaneous MI secondary to plaque rupture Type 2- MI secondary to increased oxygen demand Type 3- acute MI associated with sudden death Type 4- MI associated with percutaneous angioplasty or stents Type 5- MI associated with CABG. Scoring of MI for mortality in first 14 days- TIMI (Thrombosis in MI) - Mnemonic = AMERICA (7 Points)- Age>65, Markers- increased, EKG- ST segment changes. Risk factors- 3 or more risk factors- age, family history, diabetes, high cholesterol, HTN, smoking, obesity, sedentary lifestyle, metabolic syndrome. Ischemia- 2 or more anginal events in last 24 hours. CAD- prior 50% coronary stenosis. Aspirin use in last week. Point Score- 0-1- 4.7%, 2- 8.3%, 3- 13.2%, 4- 19.9%, 5-26.2%, 6-7- 40.9%. Cardiac Biomarkers- Troponin- the most sensitive/specific test for myocardial injury. Better than CPK-MB. Peaks at 12 hours. Released in 2-4 hrs after infarct and stays up for 7 days. Can be elevated in infarct, PE, CHF, and myocarditis. Other markers are LDH1, AST, myoglobin, BNP, IMA (Ischemia modified Protein), and GPBB (glycogen phosphorylase B) Supraventricular Tachycardia- Common SVT rate of 150 SVT is generally not life threatening, but it does cause symptoms of SOB or lightheadedness. At least 5 types; including multifocal atrial tachycardia seen in in severe COPD patients, atrial flutter, and JET (Junctional Ectopic Tachy) Physical maneuvers that stimulate vagus nerve/AV block don’t always work. Adenosine 6 mg IV is an ultra short acting AV node blocker. If it works, then suppress future SVT with diltiazem, verapamil, or metoprolol. Radioablation surgery has revolutionized treatment for recalcitrant SVT. Signal average EKGs (SAEKGs) can be helpful to stratisfy risk of death from ventricular arrhythmias. (PVCs and VTach) Hypertension-75 million US adults suffer from hypertension. (26% adults worldwide). 95% is idiopathic (primary; or essential). Secondary causes are renal artery stenosis (RAS), cortisol excess (Cushing’s disease), obesity, hyperthyroidism, pheochromocytoma, and aortic coarctation. Consequences of HTN include stroke, CAD, PVD, CHF, diastolic dysfunction, aortic aneurysm, dementia, and CKD. Treatment- diuretics (thiazides,loop-a)furosemide b) ethacrynic acid-no sulfa, K-sparing- a) amiloride b) triamterene c) spironolactone d) eplerenone- like spironolactone but less gynecomastia, helps in CHF pts.) ACE inhibitors- less helpful in Black patients, and good in CHF after MI, or reduce proteinuria in DM, ARBs- similar to ACE, but less cough, beta-blockers- a)labetalol b) carvedilol c) nebivolol, calcium-entry blockers- vasodilation and decrease TPR, direct vasodilators- a) hydralazine b) minoxidil, alpha-blockers-peripheral- a) doxazosin,b) terazosin and central- clonidine, renin inhibitors (Aliskiren). For Blacks, use diuretics and Calcium channel blockers first. In hospital Rx- IV hydralazine, labetolol, or IV vasotec. DASH (Dietary Approaches to Stop Hypertension)-diet. Low fat, low sugar, +grains, + veges, low salt. Peripheral Vascular Disease- 20% of patients may be asymptomatic. 15-20% of adults have PAD , especially over 70 years of age. Claudication is pain, weakness, numbness or cramping, primarily in legs. Also, decreased hair growth and nail growth. Risk factors- smoking, DM, HTN, dyslipidemia,obesity, +family hx, high CRP Diagnosis- Ankle Brachial Pressue Index (ABPI)- <9-PAD, <8-mod PAD, <5-severe PAD. CT angiography is definitive. Treatment- quit smoking, manage DM, control HTN, treat high cholesterol. Aspirin, clopidogrel, and statins all are helpful. Cilostazol (Pletal) or Trental (pentoxifylline) alleviate symptoms. Angioplasty, stents, and fem-pop bypass surgery are reserved for more difficult cases. Stress Testing-Bruce protocol is the standard method. 2 or 3 minute stages for speed and elevation of treadmill. Hold beta-blockers, Calcium blockers, nitrates. Watch for functional aerobic impairment. Goal is > 6 mets of work. Goal is achieving 85% of predicted HR. Sestamibi is standard nuclear isotope tracer for walking stress tests. Monitor for EKG changes and arrythmia. Dobutamine is a beta-agonist used for a “chemical” stress test. Adenosine (hold caffeine) or Lexiscan (regadenoson)-vasodilators, are also used for “chemical” stress test. Watch for low BP, heart block, flushing, SOB, GI affects. Adenosine is contraindicated in asthma/COPD. When to use stress-echo? To check heart and valvular function during stress. Acute pericarditis- A 30 year old electrician comes into the ER in August with severe anterior chest pain that worsens with cough and sitting up. He has felt like he had the flu for 10 days. It is described as a sharp pain associated with SOB. A pericardial rub was heard with the patient sitting forward. EKG shows: Diffuse ST seg elevation with PR interval downsloping Causes: neoplastic (35%), autoimmune-lupus (24%), viral (21%)- enteroviral, influenza, cmv, herpes simplex, bacterial (6%), uremia (6%), TB (5%), idiopathic (4%), Dressler’s (3%). Complications: cardiac tamponade, constrictive pericarditis. Treatment: NSAIDS for 3 months. May add colchicine to NSAIDS. Prednisone is reserved for refractory cases. May need pericardiocentesis or pericardial window if larger effusion. Diastolic Dysfunction (DD)- Normal E...