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Last Minute Internal Medicine: A Concise Review for the by Rebecca Miksad, Patricia DeLaMora, George Meyer

By Rebecca Miksad, Patricia DeLaMora, George Meyer

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Retrograde conduction is often present when block is in the His-Purkinje system but is virtually never present when block is in the AV node. (From ME Josephson, Clinical Cardiac Electrophysiology: Techniques and Interpretations, 3d ed. ) Table 1-20 Toxicity of Frequently Used Antiarrythmic Agents PROARRHYTHMIC TOXICITY DRUG NONARRHYTHMIC TOXICITY Digoxin Anorexia, nausea, vomiting, visual changes Quinidineb Anorexia, nausea, vomiting, diarrhea, cinchonism, tinnitus, hearing and visual changes, thrombocytopenia, hemolytic anemia, rash, potentiation of digoxin levels Lupus erythematosus-like syndrome, anorexia, nausea Anticholinergic actions: dry mouth, urinary retention, visual disturbances (avoid in narrow-angle glaucoma) constipation, congestive heart failure Dizziness, confusion, delirium, seizures, coma; side effects potentiated by liver and heart failure Ataxia, tremor, gait disturbances, rash, vomiting Dizziness, nausea Taste disturbance, bronchospasm Procainamideb Disopyramideb Lidocaine Mexiletine Flecainide Propafenonec TDPa A FLUTTER 1:1 VT/VF BRADYCARDIA Atrial tachycardia, VT, AV nodal block, accelerated junctional rhythms, atrial and ventricular prema ture depolarizations; acceleration of ventricular rate during atrial fibrillation or flutter in the presence of preexcitation 2% ++ ++ + 2% + ++ + 2% + ++ + – – – +b – – – – +++ +++ ++ ++ ++ ++ Rare Rare Table 1-20 Toxicity of Frequently Used Antiarrythmic Agents (continued) PROARRHYTHMIC TOXICITY DRUG Amiodarone Sotalol NONARRHYTHMIC TOXICITY TDPA A FLUTTER 1:1 VT/VF BRADYCARDIA Pulmonary infiltrates and fibrosis, hepatitis, hypo- and hyperthyroidism, photosensitivity, peripheral neuropathy, tremor Bronchospasm Rare +++ +++ +++ +++ + + +++ a TDP (torsades de pointes) occurs most often in the setting of slow heart rates, QT prolongation, and hypokalemia or hypomagnesemia and at the time of conversion from atrial fibrillation to sinus rhythm.

Figure 5-2. Page 76. ) Note: Flow-volume loops measure the volume dynamics of the respiratory cycle and its shape can aid in diagnosis. For example, obstructive lung disease has a characteristic downward scooping on the expiratory flow-volume curve. 48 Chapter 2 ◆ Pulmonology Table 2-3 Obstructive vs. Restrictive Lung Disease OBSTRUCTIVE RESTRICTIVE Tidal Volume ↓ ↓ Residual Volume ↑ ↓ Total Lung Capacity ↔↑ ↔↓ Functional Residual Capacity ↑ ↓ Vital Capacity ↔↓ ↓ FEV1 ↓ ↔↓ FEV1/FVC Ratio ↓ ↔↑ Forced Vital Capacity ↓ ↔↓ FEF 25–75 ↓ ↔↓ Table 2-4 Summary of Obstructive and Restrictive Lung Disease CATEGORY DESCRIPTION Obstructive Lung Disease • Obstruction of small airways resulting in increased resistance to airflow • FEV1/FVC ratio less than 70% on spirometry Restrictive Lung Disease • Decreased lung volumes due to parenchymal, pleural, or chest wall disease CAUSES • • • • • • • • • • • • • • • Asthma Bronchiolitis Pneumonia (viral, mycoplasma) Cystic fibrosis Emphysema Foreign body Tumors COPD ARDS Pneumonia (lobar, bacterial) Pulmonary fibrosis ILD Scoliosis Pleural effusion Pulmonary edema FEV1 = Forced expiratory volume in 1 second; FVC = Forced vital capacity; COPD = chronic obstructive lung disease; ARDS = acute respiratory distress syndrome; ILD = interstitial lung disease; FEF = Forced expiratory flow.

A. AV nodel reentry. Upright P waves are visible at the end of the QRS complex. B. AV reentry using a concealed bypass tract. Inverted retrograde P waves are superimposed on the T waves C. Automatic atrial tachycardia. Inverted P waves follow the T waves and precede the QRS complex. (Reproduced, with permission, from Kasper DL, Braunwald, E, Fauci, AS, Hauser SL, Longo DL, Jameson, JL, & Isselbacher KJ, Eds. Harrison’s Principles of Internal Medicine, 16th Edition. Figure 214-7, page 1349. ) Figure 1-5 Multifocal atrial tachycardia.

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