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Dilated Cardiomyopathy

MCC: Idiopathic

Secondary MCC: Due to CAD leading to ischemic cardiomyopathy

Unexplained new onset HF should be evaluated with stress testing or angiography

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Atrial Dysrhythmias

Atrial Fibrillation/Flutter

Unstable: Synchronized Cardioversion

Stable: BBlockers, CCB, Digoxin to get rate <100. then anticoagulate

CHADS 1- Aspirin, CHADS >/= 2, Warfarin, Dabigatran, Rivaroxaban

CHADSVAS: CHF, HTN, >75yo (2), DM, Stroke (2), PAD, 65-74yo, female

Multifocal Atrial Tachycardia

Seen with COPD. 3 different P wave morphologies. “Polymorphic P waves”

Treat COPD, Treat like Afib, but NO BB

Caused due to low O2, so correct O2 FIRST (also caused by electrolytes)

Give O2 first, then Diltiazem

Supraventricular Tachycardia (SVT)

rate: 160-180, no P waves, no fibrillatory waves, narrow QRS

Unstable: synchronized cardioversion

Stable: #1-Vagal/Valsalva/Ice –> IV Adenosine –> BB, CCB, digoxin

Best long term–> Radiofrequency catheter ablation

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STEMI on EKG

New ST elevation at the J point in 2 anatomically contiguous leads:

>1mm in all leads EXCEPT V2, V3

>2mm in V2, V3

New LBBB in setting of ACS

*J point is where QRS meets ST

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Mamalian bite

Humans, cats, dogs

Prophylaxis with Amoxicillin-clavulanate

Cat scratch disease is different: Bartonella henselae (G- Bacilli)

Papule at site, Regional adenopathy, +/- fever

Azithromycin may speed resolution, Usually self limiting

*Lymph nodes may become suppurative

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Meningitis workup

Obtain Lumbar Puncture

**If altered mental status, or focal neurological defect--> Head CT FIRST

Bacterial: LP: Elevated protein, Elevated Cell count, Decreased glucose

Gram stain only 50% sensitive

Obtain Blood cultures before abx

Start empiric abx: Ceftriaxone, Vancomycin, + Dexamethasone (+ampicillin for Listeria is >50yo or immunocompromised)

Other causes:

Viral

Cryptococcus (HIV)

Lyme (IV ceftriaxone or penicillin)

TB (very slow, 9months RIE therapy)

RMSF (centripidal spreading rash, doxycycline)

Listeria (immunocompromised, ampicillin)

Neisseria (Petechial rash- prophylaxis to exposure)

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Rash

Parvovirus B19

Lacy/reticular, slapped cheek

Syphillis

Involves palms and soles, desquamating

Lupus

Malar 

Coxsackie Virus A

Grey-yellow vesicles, erythematous papules on the palms and soles. Oral ulcers

Dermatomyositis 

Heliotropic (purple around eyelids)

Kawasaki

Rash with conjunctivitis, thrombocytosis, lymphadenopathy

Lyme

Target 

RMSF 

Peripheral rash spreads central. Maculopapular then petechial

Juvenile rheumatoid arthritis

Salmon, high ferritin, fever, splenomegaly

Celiac disease

Dermatitis herpetiformis

Septic arthritis

Rash, polyarthritis, tenosynovitis

PCP Pneumonia

Rash (add clindamycin, primaquine)

Acute interstitial nephritis 

rash

Measles

Red and dark red maculopapular

Rubella

red

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Atopic Dermatitis

Eczema

Increased IgE, triad of asthma, allergic rhinitis, atopic dermatitis

Pruritic, lichenified plques, often on flexor surfaces

First line: Moisturizers

Second line: Topical steroids (Triamcinolone). Flares only.

Can use Topical Tacrolimus in sensitive areas instead of steroids

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Measles

Measles (Rubeola)

Conjunctivitis, cough, coryza, koplik

Koplik spots (white lesions, buccal mucosa, vagina)

Dark red/brown macopapular rash-> centrifugal spread

Spares palms/soles

Treatment:

Supportive, Vitamin A

Prevention:

Live attenuated measles vaccine: 12months, 5 years

Exposure:

>1yo: Vaccine only if within 72hrs

Pregnant or immunocomprimised: Ig only

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Hypertensive Urgency

IV Nitroprusside

or

IV Labetolol

or

IV Nicardipine

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ACS Mortality Benefit

Aspirin

Beta blockers

Thrombolytics

Angioplasty (best)

Statins

Clopidogrel, prasugrel, ticagrelor

*ACEi or ARB if low EF

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Unstable angina

Difference between USA and NSTEMI is lack of cardiac enzymes.

Both have no ST elevation or pathologic Q waves

Treatment: 

Aspirin

Beta blockers

Nitrates (no mortality benefit)

Clopidogrel

LMW Heparin

G IIb/IIIa inhibitors (abciximab)  lower mortality especially if going to PCI 

Oxygen (only helps if hypoxic)

Morphine (no mortality benefit)

90% improve with above regimen 1-2 days.

PCI early or late controversial

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Stable angina

Diagnosis:

Resting EKG (if abnormal treat as unstable angina)

Stress test (exercise or pharmacologic)

Positive test--> Cardiac cath

Treatment:

Aspirin

Beta blocker

Nitrates (do not lower mortality)

Lifestyle mods (statin if LDL>100, 70 if DM), diet, exercise

CCB second line

ACE/ARBs for low EF (Lower mortality in systolic dysfunction)

Angioplasty has not been shown to decrease mortality in stable angina more than medical therapy alone

Mild disease: Normal EF- ASA, Nitrates, BB, ......possible CCB

Moderate disease: Normal EF- ASA, Nitrates, BB, .....possible PCI

Severe disease: Decreased EF- ASA, Nitrates, BB, PCI

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Murmurs

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Desensitization

Desensitize penicillin allergy in Neurosyphillis (tertiary syphillis or pregnancy)

Desensitize allergies that cannot be avoided

**MUST STOP BETA BLOCKERS BEFORE DESENSITIZATION**

If patient goes into anaphylaxis and is on BB, will need epi, but BB will block epinephrine

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Sickle Cell Infection

Acute Chest Syndrome: Ceftriaxone + Azithromycin

Osteomyelitis: Ceftriaxone + Clindamycin

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Primary Biliary Cirrhosis

Autoimmune, middle aged women

Fatigue

Inflammatory arthritis

Pruritus 

Hyperpigmented skin

Xanthelesmata

↑Alk Phos AST, ALT, Bili can be normal Best test: Anti-Mitochondrial Antibodies

Complication: Bone loss, osteopenia, osteoporosis

Treatment: Ursodeoxycholic acid decreases symptoms, transplant time.

Definitive is liver transplant. Can still recur after transplant.

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Rhabdomyolysis

Toxic effect of myoglobin on kidney tubule

ELEVATED: K, CPK, Urine myoglobin

DECREASED: Ca, HCO3

Treatment:

IVF hydration

Mannitol

Sodium Bicarbonate: Alkalization of urine

Insulin if high K, Calcium gluc if peaked T waves

GET EKG!