Internal Medicine 1,Conrad Fischer

Internal Medicine 1,Conrad Fischer - USMLE Step 2 —...

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Unformatted text preview: USMLE Step 2 — Lesson 1: Cardiology: Myocardial Infarction Internal Medicine Highlights Conrad Fischer, MD Maimonides Medical Center Residency Director Cardiology Myocardial Infarction Differential of Chest Pain A 52-year-old man comes to the ER with 1 hour of severe chest pain on exertion. He is nauseated and diaphoretic with slight shortness of breath. The pain does not change with respiration or bodily position. Exam shows normal vitals, clear lungs, no murmurs, and no tenderness. Changes With Respiration • Pneumonia • Pneumothorax • Pulmonary embolus • Pleuritis • Pericarditis All can give fever - so can MI. Changes With Position • Pericarditis only • when lying back causes more pain Changes With Palpitation • Costochondritis only EKG shows 2 mm of ST segment elevation in V2-V4 Anything 1 mm in 2 electrically connected leads is sufficient for diagnosing acute MI • II, III F: Inferior wall • : Anterior Wall • I,L, : Lateral wall What would you do next? Cardiac Enzymes Do not answer enzyme testing next: • Takes too long to obtain results • Treatment should be initiated first • Won't be positive yet • Won’t change what to do, regardless of results (positive or negative) at this time Cardiac Enzymes Begins to Elevate Lasts CPK-MB 4-6 hr 2 days Troponin 4-6 hr 1-2 wk Myoglobin 1-4 hr s LDH 12-24 hr s LDH currently is not useful. Never answer it. Best Answers: Which has the best sensitivity, but poor specificity? • Myoglobin Which has the best specificity? • Troponin CPK-MB is sensitive and specific, but not as sensitive as myoglobin or as specific as troponin. Treatment of Acute MI in ALL Patients Decrease Mortality Time Dependant Aspirin YES (25%) YES Nitrates ?? ? Morphine (Analgesics) ?? ? Thrombolytic YES (25%) YES β- Blockers YES (10-20%) NO Special Circumstances • Angioplasty o Patients with major bleeding or risk of bleeding o Patients who can’t receive thrombolytics for any reason o Patients failing thrombolytics and progressing to hemodynamic instability o Equal in efficacy to thrombolytics Special Circumstances • ACE Inhibitor o Patients with decreased left ventricle function or CHF • Lidocaine o Never as prophylaxis o All patients who develop major vertricular arrhythmias (ventricular tachycardia or fibrillation) Pacemakers • Anything slow or that could become slow • Third-degree AV block • Mobitz II second degree block • Left bundle branch block USMLE Step 2 — Lesson 2: Cardiology: Congestive Heart Failure Cardiology Congestive Heart Failure Congestive Heart Failure/Pulmonary Edema A 67-year-old woman comes to the ER with 1-2 hours of severe shortness of breath. She has a history of two MIs in the past. She comes with a pizza in one hand and a bag of Doritos in the other, and she is chewing a sausage. Her respiration rate is 34; BP, 130/82; and PUD, 18. Jugulovenous distention is present. Chest: rales to apices....
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This note was uploaded on 04/09/2008 for the course COM 101 taught by Professor Miss during the Spring '08 term at Nova Southeastern University.

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Internal Medicine 1,Conrad Fischer - USMLE Step 2 —...

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