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Pulsus Paradoxus

Cardiac tamponade sign where you have an accentuation/exaggeration of the normal drop in BP during inspiration to >10 mm Hg bc less blood to heart and less filling from inspiration and also tamponade pushing in on atria/ventricles


Pulse Deficit

Atrial Fibrillation
count heart beats and peripheral pulse rate doesn't match bc not every heart beat generates a strong peripheral beat bc not long enough time for diastolic filling in Afib


Pulsus Parvus et Tardus

Slow and Late Pulse associated with Aortic Stenosis bc harder to get aortic pressures up


Pulsus bisference

HOCM and AR !!! Double beating arterial pulse bc squeeze a lot out initially and rapid rise in aortic pressure but then blood quickly bounces back and re-raises pressure again a little - returning waves from periphery


In Dilated Cardiomyopathy, how can you tell difference between Cardiogenic etiology and Volume overload etiology?

Poor pump = low EF

Volume overload = good EF


What EKG leads do you check to see if sinus rhythm?

P axis on Limb Lead I and avF p waves need to be upright from SA node


How do you count HR in EKG?

take 300 and divide by number of big boxes

normal is 3 (100 bpm) to 5 (60 bpm)


How would you see an LAD infarct on EKG?

Precordial leads V1-V5 and shows anterior wall infarct


How would you see a RCA infarct on EKG?

Leads 2, 3, avF and means Inferior wall infarct


How would you see a Left Circumflex infarct on EKG?

Leads I, avL and V6 and shows lateral wall infarct


What is a normal PR interval?

3-5 small blockes = 120-200 msec


What is First degree AV block?

PR interval longer than 5 blocks >.2 sec and slow conduction


What are the 2 types of Second degree AV block and how can you distinguish them?

Mobitz 1 - Weinkeback = PR widens prior to dropping a QRS

Mobitz 2 - PR unchanging and suddenly missing QRS ( worse)


What is 3rd degree AV block?

complete heart block where P wave completely divorced from QRS


Symptoms/Exam findings for Mitral Stenosis

cause? treatment

Caused from Rhuematic Heart Disease and see Fish mouth fused commissures and hockey stick appearance to valves on Echo

Symptoms arise from increased pressure gradient from LA and LV - like CHF and increased Atrial pressure is the cause! Can get RHF and pulmonary edema

Signs are mitral facies, Loud P2 as mitral slams shut, RV heave from dilatoin, Large A wave in JVP

Auscultation - opening snap!!! Diastolic low pitched rumble murmur with presystolic accentuation and Loud S1 when it shuts

Radiology LAE - see double density, upliting L main bronchus, and enlarged posterior area on lateral

Tx - control HR - allow more diastolic filling, Diureses (less volume) manage Atrial Fibrillation


Symptoms, cause, clinical findings treatment etc for Mitral Regurgitation

Cause - valve pathology (ex papillary rupture or myxomatous) or LV dilation

Acute - BAD - rupture, endocarditis, trauma and no time to dilate so pulmonary edema!

Patho- LA dilation, reduced outflow, LV dilation (both get big) leading to LHF and see good EF

Auscultation -
1) Holosystolic murmur high intensity
2) S3 "Slushing In" extra volume reverberating
3) Hyperdynamic apex with thrill to back and axilla

Tx- AFterload reduction!!!


Mitral Prolapse

usually asymptomatic but can see palpitations, chest pain, fatigue syncope - REgurgitation!

posterior valve leaflestts enalred, change collagen, myomatous material, Marfans

Mid to late systolic click and late systolic murmur and changes with manuver


Aortic Stenosis

Bicuspid, Senile, Rheumatic

thicker hypertrophic ventricle with increased pressure - like systemic HTN = Concentric LV hypertrophy = CHF and Angina

CHF bc high diastolic pressure

Get HF, Syncope and angina!!!! (cant increase CO with exercise - syncope on exertion) can get arrhythmias

1) Crescendo-decrescendo systolic flow murmur
2) Ejection Click - bicuspid valve after S1 opening of aortic
3) Pulsus Parvus et Tardus harder to raise aortic pressure
4) S4 gallop = "A stiff wall" bc atrial kick onto stiff wall

Bicuspid valve - accellerated degeneration process and likely to see aoric dilation, aneurism and disssection


Aortic Regurgitation

Valve leaky from congenital, rhumatic, endoc OR Root dilation from dissection or syphilis or marphans

Chronic AR - Wide Pulse Pressure!!!!! eccentric LVH changes in caivty side and wall stress -- results in CHF and angina

1) wide PP - head bob, uvula etc
2) cardiomegaly
3) early diastolic high pitched blowing decrescendo murmur
3) Pulsus Bisferience (like HOCM) 2 beats in periphery

Acute - emergency and massive pulmonary edema, no wide PP - same volume overload but no dilation

Treatment - Diuretics - decrase diastolic in ventricle to stop flooding lungs and AFterload decreasing to encourage forward flow


AS vs AR

AS - pressure overload and systolic problem - LV hypertrophy

AR - volume overload and diastolic problem - LV dilation


Drugs to use for HTN in pregnancy

MethylDopa!!!! (central A2 agonist that doesnt change CO to placenta)

Hydralazine - for preecclampsia

Only 1 beta blocker - lobatolol?


when do you hear S3?

vibration of a distended ventrile during filling "from volume overload in CHF or MR"


whats the first step and subsequent steps in atheroma formation?

LDL OXIDATION!!! then endothelial dysfunction then monocyte activation and VCAM1 to recruit them to eat the LDL and create foam cells that then cause SM proliferation and creation of plaqe


What drugs cause INCREASED mortality after MI?

Class Ic propafenone and flecanide - only used for VTACh or SVT



positive inotrope that has high toxicity but when used at lower levels increases parasympathatic responses and slows HR but can lead to AV block if already have bradycardia


How do Fibrates work? what are tey?


act tio DECREASE TG by increasing LPL through PPAR


What do you do to treat salycylate OD?

Urine Trap with Bicarbonate!


How do you treat Iron overload?



what is reverse use dependence?

K+ channel blockers (Class 3) bind better and Prolong QT more in bradycardia and slower rhythms so pace people to keep HR up


how do you treat torsade?