Part 15 Flashcards
AV nodal re-entry tachycardia treatment (3)
- mammalian diving reflex, vagal maneuvers of carotid, valsalva
- adenosine 6mg rapid IV bolus (stops heart with a chemically short half life drug to allow for full refractory period to return)
- Electrophysiologist (EP) lab referral***
Mammalian diving reflex
When water fills the nostrils, the autonomic nervous system redirects blood flow thru peripheral vasoconstriction from the limbs and viscera to the heart and brain to conserve oxygen, causes slowing of the heart rate
AV reentrant tachycardia (AVRT) nick name
Wolf parkinson white syndrome
Atrial flutter
Involves circus movement (conduction around same loop in atrium) generally 250-350 bpm, saw tooth pattern, often with picket fence P waves seen in leads 2, 3, and AVF
atrial flutter treatment (4)
- Digoxin
- B blockers or Ca2+ blockers
- pacemaker
- ablation
Atrial fibrillation
Occurs when atrial rate is 350-700 bpm, ventricular rate may be normal or rapid, involves a complete lack of P waves, irregularly irregular rhythm, at risk for stroke and hypotension
Common causes of atrial fib (4)
- thyroid abnormalities
- alcohol
- COPD
- underlying heart disease
Afib treatment (3)
- rate control (B blockers, Ca2+ channel blockers, digoxin
- anticoagulation before and after cardioversion
- rhythm control
Defibrillation will not work on a heart that has reached what stage of arrest?
Asystole
Ventricular arrhythmias occur from the…
….AV node down
ventricular tachycardia
3 or more successive PVC’s, nonsustained is less than 30 sec and sustained is more, rate >100bpm usually regular rhythm, may or may not see P waves
Torsades de pointes
Form of polymorphic ventricular tachycardia assoc with prolonged QT interval >500ms, changes in amplitude and morehphology of QRS around isoelectric line, causes of prolonged QT interval can be congenital or acquired
Ventricular fib requires…
…electric shock
Brugada syndrome
Congenital channelopathy caused by mutation of cardiac Na+, K+ or Ca2+ , ST segment elevation in one of the right precordial leads (V1-V3) at baseline or after use of Na+ blockers, 3 subtypes
Commotio cordis
Ventricular fib caused by blunt, non-penetrating blow to chest during vulnerable portion of ventricular repolarization, more common in children and adolescents, more common with moderate to high velocity strike usually projectile right during a T wave
Ventricular flutter
Ventricular tachyarrhythmia 250-350 bpm, rapidly deteriorates into ventricular fib
Ischemia will manifest on an EKG as…
…ST depression
ST elevation indicates…
Acute injury within past 24-48 hrs
T wave inversion or ST elevation or depression across all leads is pathonomonic of what condition?
Pericarditis
Punumbra
Direct death of tissue from blocked artery that is not perfused, surrounded by ischemic and injured tissue in a circular area around the source
Lesions that occlude LAD represent ___% of MI’s, RCA represents ___%, and circumflex represents ___%
50, 30, 20
Inferior wall MI is represented in leads…
II, III, and AVF
Lateral wall MI is represented in leads…
I, AVL, V5, V6
Septal/anterior wall MI is represented in leads…
Septum: V1,2,
Anterior: V3,4
Posterior wall MI findings on EKG
ST DEPRESSION in V1 ,2, 3,
Early treatment of MI (3)
Coronary angioplasty with balloon angiogram Stent placement (bare metal or drug eluding) -Coronary artery bypass graft either by harvesting saphenous vein, radial artery, or left internal thoracic artery
Lateral wall MI occludes what artery?
Circumflex
Posterior and inferior MI occludes what artery?
Posterior descending artery
S1 heart sound occurs during what phase of the heart cycle? What about S2?
- At the end of diastole/start of systole
- At the end of systole/start of diastole
Pulse pressure definition
Difference between systolic and diastolic blood pressure
End systolic volume
Volume of blood remaining in LV following cardiac contraction and ejection of blood
Ejection fraction and avg value
Stroke volue/end diastolic volume, should be about 55%
Aortic area Pulmonic area Erb's point Tricuspid area Mitral area Locations
- 2nd intercostal space right sternal border
- 2nd intercostal space, left sternal border
- third intercostal space, left sternal border
- 4th intercostal space, left sternal border
- 5th intercostal space, mid clavicular line
S3 gallop
Early diastolic sound following S2 with new blood entering a dilated ventricle, may be normal in children or indicative of CHF, CAD, or aortic/mitral insufficiency
S4 gallop
Late diastolic sound right before S1 due to ejection of blood from atria during atrial contraction hitting a stiff noncompliant wall, long standing hypertension causing LV hypertrophy is key, may be normal but almost always pathologic
Cardiac friction rub
Creaking, grating, or scratching sound heard with pericardial inflammation, classically has 2 systolic and one diastolic component, heard best at the left sternal border (increased when leaning forward) when patient is not breathing
Erythema nodosum
An idiopathic inflammatory disease affecting primarily the skin in the front of the legs below the knees causing very painful macules
Wegener’s granulomatosis
Autoimmune inflammatory disease of the blood vessels that has a distinct saddle nose appearance
Xanthelasma (hyperlipoproteinemia)
Sharp demarcated deposits of cholesterol underneath the skin, usually near the eyelids, usually not painful or problematic
Kawasaki’s disease
Inflammation of blood vessels often seen in children less than 5 years old, presents with a week of high fever, bilateral conjunctivitis, strawberry tongue, cervical lymphadenopathy and plaque-like rash on trunk and proximal extremities.
Acanthosis nigricans
Characterized by dark discoloration of body folds and creases seen in obese or diabetic patients
Cowden’s disease
Sees development of multiple noncancerous growths called hamartomas that are associated with development of breast and thyroid cancer
Peutz Jegher’s syndrome
Genetic disorder causing benign hyperpigmented macules on lips and mucosa
Infective endocarditis
From infection of the endocardium, can see janeway lesions (spots on palms and soles), oslers nodes (painful red lesions on hands and feet), and splinter hemorrhages (tiny blood spots under nails)
Steven johnson syndrome
An emergency reaction to medication or disease that causes red/purple purpura rash to spread systemically
Neurofibromatosis
A genetic condition that causes tumors to form on nervous tissue, skin can see pigmentation and freckling
Pityriasis rosacea
hAn unknown triggered rash that begins as a large oval patch herald patch before a fawn colored generalized rash appears, spontaneously resolves in 6 weeks, common and harmless
Schleroderma
Hardening and tightening of skin often seen in women 30-50, co-occurs with raynauds often
Cautions against iodinated contrast (3)
- Iodine allergy
- Shellfish allergy
- Renal insufficiency (relative contraindication depending on severity)
Gadolinium
Used in MRI and MRA but highly contraindicated in renal failure because it cannot dialysize out and thus ends up depositing into soft tissue resulting in possible nephrogenic systemic fibrosis (stiffening of all tissue similar to scleroderma but caused by gadolinium)
CT is better for ___ visualization, MRI is better for ___ or ___, MRA is best for ___
Bone, soft tissue, nerve, vascular
Generalized pruritis all over can be a sign requiring further evaluation as it may be due to…
….lymphoma
FEES
Fiberoptic endoscopic evaluation of swallowing, passing a scope thru the nose and down into the back of the throat then having a patient eat and drink, a non radiation alternative to X ray to visualize food bits left in piriform sinus (posteriolateral on either side of laryngeal opening)
Sialogram of parotid
Dilation and cannulation of parotid with plastic tube followed by injection of dye to assess for sialolith or other blockage, not often used opposed to sialendoscopy (can visualize and treat in one go) or the CT
PET scan
Positon emission tomography, use of X ray or CT following injection of radionucleotide product most often using fluorodeoxyglucose (FDG) (radiotagged sugar that measures high metabolic activity)
Radioactive Iodine uptake scan
Discontinued practice compared to ultrasound when formerly used to assess thyroid but often still used in whole body radioactive iodine uptake scan in order to see post thyroidectomy/thyroid cancer to assess treatment
Iodine doesn’t just isolate to the thyroid but also the…
…salivary glands (if using radioactive iodine uptake scan must keep fluids to push it and avoid xerostomia as an unpleasant side effect)
Hereditary hemorrhagic telangectasias (HHT)/osler-weber-rendu disease
AV vascular malformations that can occur anywhere in mucosal surfaces of the body and result in large bleed putting at risk often requiring intervention
Videostroboscopy
Visual assessment of various vocal cord conditions and abnormalities thru mouth or nose, gold-standard in laryngological diagnostic care
Parts of the jaw (parasymphyseal/mental, body, angle, ramus, condyle, and coronoid process)
- Parasymphyseal/mental is near the chin
- the body is the horizontal portion protruding back
- angle is the shift to the vertical
- ramus is the vertical portion before the condyle (posterior) and coronoid processes (anterior)
Mandible condylar fracture common causes, diagnostic study, and treatment
- Often seen with falling and hitting chin on ground or being uppercut
- evident on CT
- not typically treated with intervention but only soft diet (retain bite strength)
Mandible ramus fracture
Sees condyle displacement within the joint and often occurs with counter fracture on opposite side, have a weak bite, treated with surgical intervention
Lefort I-III scale
-Scale to measure midface fractures described as either complete or one sided (hemi lefort)
I is a palate fracture and can move palate with thumb manipulation
II also includes the nose
III includes the zygomata (craniofacial dysjunction, the face completely removed from the cranium)
Zenker diverticulum
An outpouching just below or around the cricopharyngeus where the internal lining of esophagus pouches outward, often diagnosed when swallowed items sit for a period of time and then are coughed back up days later, surgically repairable
Steeple sign
A sign on x ray of narrowing of trachea indicative of croup (laryngotracheobronchitis)
Thumb print sign
A sign of epiglotitis seen on a lateral x ray of the head
Hot potato voice
A characteristic sign of epiglotitis or peritonsillar abscess seen in someone with a thick and muffled voice
Invasive fungal sinusitis vs allergic fungal sinusitis (mycetoma)
Invasive is an emergency as it eats into bone requiring surgical intervention most often seen in immunocompromised while allergic fungal sinusitis is relatively harmless and can be removed easily
Concha bullosa
An enlarged middle turbinate seen in approx half the population that can be resected if causes issue such as congestion or runny nose
Patients with nasal polyps (mucus retention cysts) present completely…
…asymptomatic
Thyroglossal duct cyst origin and sign
Because the thyroid begins growth at the base of the tongue before moving forward and down, congenital malformation of the thyroid gland resulting in cyst in duct located anterior midline neck can result in elevation visually upon sticking tongue out
Why is it important to remove part of the hyoid bone when treating a thyroglossal duct cyst via surgical removal?
Part of the duct travels thru the hyoid bone in order to prevent remnants of the cyst from remaining (sistrunk procedure)
What layer of epidermis contains melanocytes?
Stratum basale
What type of sudoriferous glands produce watery sweat?
Eccrine glands
Keratinocytes definition
Skin cells, the most common cell type in the epidermis composing the superficial layer of skin
Langerhan’s cells definition
Specialized epidermal cells that function immunologically
Merkel’s cells definition
Specialized epidermal cells that function to provide somatosensory function (light touch and discrimation)
5 layers of epidermis from base up
- stratum basale (germinativum)
- stratum spinosum
- stratum granulosum
- stratum lucidum
- stratum corneum
Stratum granulosum
3rd deepest layer of epidermis composed of cells that flatten and form granules in the cytopalsm creating a water proof barrier of the skin
2 layers of the dermis and their characteristics
1) Papillary dermis - thin layers of collagen popping into the epidermis
2) Reticular dermis - deep, dense, irregular collagen
Sebaceous glands
Glands associated with hair follicles that secrete oil onto hair surface
Eccrine (merocrine) sweat glands, what stimulation are they from sympathetic NS?
Produce watery sweat not associated with hair follicles all around the body stimulated by heat and cholinergic SANS stimulation
Apocrine sweat glands, what stimulation are they from sympathetic NS?
Thick milky sweat glands that leads to extensive odor and is concentrated in axilla, perianal and genital regiions, associated with hair follicles and activated by adrenergic SANS from stress or sex stimulation
Dermis and blood shunting
When body is hot, vasodilation occurs shunting blood to the skin surface to lose heat to surrounding area, and inverse in the cold
Meissner’s and Vater pacini corpuscles
Specialized nervee cells that transmit sensations of touch and pressure via mechanoreceptors found in the dermis
Terminal hairs
Thick pigmented hair that is androgen sensitive!!!!
Vellus hairs
Short, fine, nonpigmented hair that covers much of the body and is not androgen dependant
Lanugo hairs
Fine hair found on the fetus and some anorexics normally shed and replaced with vellus hair within months
Anagen, catagen, and telogen phases of hair
growth, transition, cessation and shedding phases respectively
Lunula
Crecent shaped dome at base of nail
Nail bed
Flesh beneath nail, contains blood vessels, nerves, and melanocytes (can still get melanoma!)
Nail plate
Actual fingernail, made of transulcentt keratin
Eponychium
Cuticle, skin of the finger and the fusing of that with the nail to provide a wataerproof barrier at the base of the nail
Paronychium
Lateral nail folds, skin that lies over the nail plate on its sides
HPV subtypes associated with malignancy (6)
6, 11, 16, 18, 31, 35
Verruca vulgaris
Common wart, usually asymptomatic but painful at times and appears as a hyperkaratotic papule with rough irregular surface and often seen on hands and knees but can occur anywhere, often resoves without intervention
Filform (digitate) warts
Long slender growths with stalk like appearance that manifest on areas of thin skin (such as face) and commonly bleed, often need treatment
Concerns of pregnancy and genital warts
-Neonates may acquire infection when passing thru infected birth canal so depending on number of lesions may advise C section to avoid transmission to neonate
2 biggest treatments for genital warts
-surgical excision (lowest recurrence rate) -cryotherapy (safe even during pregnancy)
Molluscum contagiosum
Caused by a DNA poxvirus strictly in humans, has distinct appearance of single or multiple umbilicated (caseous plug, distinct clinical diagnosis) papular lesions round, dome shaped and waxy
Most effective treatment for molluscum contagiosum
Curettage, most of the time spontaneously resolves tho
Herpetic whitlow Herpes gladiatorum
-HSV of finger following inoculation from self or other -Face, arms, neck, and trunk infection from contact sport players
HSV gold standard diagnositc test
Isolation of virus by culture
Tzank smear
A quick rapid means of testing HSV but does not distinguish between 1 and 2
Characteristic rash of varicella zoster virus
“Dewdrop on roses” maculopapular lesions
Eczema of children and adolescents often occurs in these locations
-lichen plaques of flexural distribution, palamar aspect of wrists, neck
First, second, and third line treatment for atopic dermatitis
Topical corticosteroids, systemic corticosteroids (prednisone), topical calcineurin inhibitors (cyclosporine)
Contact dermatitis treatments (3)
-topical steroids -oral antihistamines -systemic corticosteroid s reserved for severe cases
Nummular eczema and what should be ruled out prior to diagnosing
Chronic inflammatory skin disease characterized by pruritic coin shaped lesions often on the extremities (and never on the head) sometimes with central clearing
Tinea corporis
Seborrheic dermatitis
Dandruff, relapsing skin disorder with erythematous, scaley patches located in areas with high density of sebacious glands such as lateral nasiolabial folds, eyebrows, or scalp
Perioral dermatitis
Presents with small inflammatory papules around the mouth that spares the vermillion border of the lip, differentiated from acniform by lack of comedomes, self limiting, seen pirmarilyin women btwn 16-45
Lichen planus, whats the buzz word with it?
Rare Immune mediated mechanism that causes development between 30’s-60’s of papulosquamous eruption with violaceous (buzz word) papules on skin
Wickham’s striae
Reticulated and lacey marks located on lichen planus eruption
Tullio phenomenon
Physical manifestation of dizziness following exposure to loud sounds, typically an issue of the semicircular canals requiring CT
Kiesselbach plexus
Located in the anterior nasal septum, this highly vascular arterial area is formed from terminal branches anastamosing of the internal and external carotids and is the most common cause of anterior epistaxis (this is why you hold the lower part of the nose during a nosebleed and not up at the bridge)
Dental occlusion measurement
Either normal occlusion, overbite (class II), underbite (class III), open bite (cannot bring teeth together no matter what, can make it impossible to eat things like yummy carrots :’((((( )
Weber and rinne hearing tests
Weber test that doesn’t lateralize is normal.
Weber test that lateralizes to one side has either conductive loss of the same ear or sensorineural loss of the opposite ear, rinne test with air conduction greater than bone is normal or confirmatory of contralateral sensorineural loss, and bone conduction greater than air conduction is confirmatory of conductive loss
Torus palentine
A form of exostosis (which can be seen in the ear), hard lumps on the roof of mouth that if present for long time then not problematic as it is just overgrowth of the palate bone
Ranula
Cyst or obstruction of submandibular or sublingual duct that will enlarge upon eating and occasionally pop with clear salty drainage, benign and may require surgical incision
Nasal septal perforation complications (4)
Saddle nose malformation, whistling noise when breathing, epistaxis, and foul smell
Mastoiditis
Resultant from ottitis media that is left untreated or in countries that do not have good infrastructure, sees ears sticking out away from head at a downward angle with soft red tissue, requires tubal drainage immediately to prevent development of meningitis or epidural abscess
Otitis media with effusion will have a distinct __ color defining the diagnosis on physical exam, hemotympanum will have a distinct __ color
Amber yellow, purple
Cholesteatoma
Collection of epithelialized skin debris in the middle ear that will erode the ossicles over time that will locally grow and destroy hearing, eventually causing facial paralysis but requires surgical intervention
Removal of bugs from the ears should be done with….
….oil or lidocaine, NOT water as that will cause swelling
Components of outer, middle, and inner ear
Outer: auricle and external auditory canal
Middle: tympanic membrane, ossicles, middle ear space
Inner: cochlea, semicircular canals, vestibulocochlear nerve
Microtia, Anotia
Congenital malformation of pinna, complete absence of pinna
Most common malignant tumor of the external auditory canal
Squamous cell carcinoma
Exostosis
Multiple benign bony growths of the external auditory canal arising from compact bone commonly in individuals exposed to repeated cold water (surfer’s ear) can be removed surgically if too large
Treacher collin’s syndrome (TCS), Robin sequence, Crouzon syndrome
- TCS is a genetic disorder characterized by deformities of eyes, ears, mouth, cheekbones, and chin that may result in complications
- Pierre Robin sequence is a condition where an infant has a smaller than normal jaw with the tongue often falling back into the throat creating difficulty breathing often alongside cleft palate that can be treated surgically
- Crouzon syndrome is a genetic disorder characterized by the premature fusion of certain skull bones (craniosynostosis). This early fusion prevents the skull from growing normally and affects the shape of the head and face sometimes needing surgery to treat
- All often see microtia, anotia, atresia, or congenital malformation of the ossicular chain
Viral cochleitis symptoms (3) and treatment (1)
Sudden hearing loss, vertigo, facial paralysis, or pain, treated with oral steroids
Meniere disease
Episodic vertigo and hearing loss that lasts for hours, fullness, and tinnitus, hearing loss is usually low frequency but can progress and is usually unilateral
Acoustic neuroma
Most common benign tumor that originates from the vestibular portion of the 8th cranial nerve presenting with unilateral or asymmetrical hearing loss, tinnitus, dizziness, headaches, and disequilibrium
