Treatment of HTN with other Comorbidities

Lipid Lowering Agents

Drug Name Statin Drugs -statins Niacin Effects Decrease LDL (best) MOA HMG-coA reductase inhibitor; inhibit precursor: mevalonate Inhibit lipolysis; reduce VLDL secretion Prevent intestinal reabsorption of bile acids Side Effects Hepatotoxicity Rhabdomyolosis Hyperglycemia Hyperuricemia Flushing TX: Aspirin Taste bad GI discomfort Decrease A,D,E,K absorption Cholesterol Gallstones Increase LFT

Decrease LDL, but raises HDL

Bile Acid resins cholestryamine: bind Cdificle, colestipol, colesevelam Cholesterol absorption blockers Ezetimibe Fibrates Gemfibrozil, Clofibrate, Fenofibrate Omega 3-Fatty Acids

Decrease LDL

Decrease LDL

Decrease TAGs (best)

Prevents cholesterol reabsorption at small intestine brush border Upregulate LPL TAG clearance Reduce arrhythmia

Myositis, hepatotoxicity, cholesterol gallstones Fishy Taste

Decrease TAG

Heart Murmurs

Type of Murmur Aortic Stenosis

Characteristics Crescendo-decrescendo following ejection click, heard in the 2nd-3rd right interspace

Notes

Pulsus parvus et tardus Can hear in carotids, weak pulses, & syncope Causes: bicuspid valve, unilateral valve, calcification of valve, sphyllis, chronic RF

Pulmonary Regurgitation Tricuspid Stenosis Mitral Regurgitation

Early diastolic decrescendo, heard in left side of sternum Late diastolic decrescendo murmur heard on left side of sternum Pansystolic (holosystolic) heard at the apex, radiates to axilla

MVP Pulmonary Stenosis Tricuspid Regurgitation /VSD

Late systolic murmur with midsystolic click Crescendo-decrescendo systolic murmur, in the 2nd-3rd interspace Pansystolic (holosystolic) heart along the left lower border sternal border, radiates to right lower sterna border Rumbling late diastolic murmur with opening snap Pansystolic (holosystolic) best heard at the 4th-6th left intercostals space Continuous machine murmur High-pitched diastolic murmur with widened pulse pressure

Best at Left Lateral Decubidus Position Hand grip and squatting increase Causes: ischemic heart, LV dilation, endocarditis, RF, papillary muscle rupture Click: chordia tendinae tensing Increase with valsalva, decrease with squatting

Mitral Stenosis

OS: its sticky, leaflets have to snap open Expiration with increase Causes: RF

Tricuspid Regurgitation /VSD PDA Aortic Regurgitation

Throughout S1 & S2 (Loudest at S2) Causes: congenital rubella & prematurity Normal systolic, Low diastolic (bounding pulse) Causes: Aortic root dilation (Sphyllis & Marfans) and RF

Rheumatic Fever: primary MR,MS & secondary AS, AR Right-sided heart sounds increase with inspiration & Left-sided heart sounds increase with expiration Left Lateral Decubidus Position: MR, MS, Left-sided S3/S4 sounds

MI Diagnosis

Transmural Infact
Increase necrosis Affects entire wall ST elevation on ECG Q Waves

Subendocardial Infarct
Due to ischemic necrosis of < 50% of ventricle wall Subendocardium especially vulnerable to ischemia Due to fewer collaterals, higher pressure ST depression on ECG

Brain Lesions
Area of Lesion
Amygdala (bilateral)

Consequence
Kluver-Bucy Syndome: hyperorality, hypersexuality, disinhibited behavior Disinhibition, deficits in concentration, poor judgement, reemergence of primitive reflexes (more motor cortex) Spatial Neglect Syndrome: agnosia of the contralateral side of the world Agraphia, acalculia, finger agnosia, left and right disorientation Reduced levels of arousal and wakefulness Tremor at rest, chorea, athetosis Parkinson Effects: Hypokinesis Inention tremor, limb ataxia Damage: Ipsilateral deficiets, fall towards side of lesion (cerebellum SCP contra cortex corticospinal ducussation ipsilateral effects) Wernicke-Korsakoff Syndrome (Wernicke: confusion, ophthalmoplegia, ataxia; Korsakoff: memory loss, confabulation, personality changes) Truncal Ataxia, dysarthria Contralateral hemiballismus Anterograde amnesia: cant make new memories Eyes look away from side of lesion Eyes look toward lesion Paralysis of upward gaze (Parinaud Syndrome)

Notes

Frontal Lobe

Right Parietal Lobe (non-dominant)

Ex. Women puts make up on one side of face

Left Parietal Lobe (dominant) Gerstmann Syndrome Reticular activating System (RAS) Midbrain Basal Ganglia Cerebellar Hemisphere

Cerebellar are LATERAL: affect LATERAL limbs

Mammillary Bodies (bilateral)

Associated with Thiamine Deficiency (Vitamin B1)

Cerebellar Vermis Subthalmic Nucleus Hippocampus PPRF Frontal eye fields (pre-motor cortex) Superior colliculi

Vermis is CENTRALLY located: affects CENTRAL body

Superior Colliculus

STT Central Canal Medial Lemniscus Medial Geniculate Body

Substania Nigra

Corticospinal CorticoBulbar

Red Nucleus

Cn 6
Inferior Cerebellar Peduncle Vestibular Nucleus

MLF

Medial Lemniscus

Lateral Spinothalmic Tract

Spinal Trigeminal nucleus and tract CN 7

Corticospinal Tract Inferior Cerebral Peduncle Vestibular Nuclei

Nucleus of Solitary Tract CN 12 Dorsal Motor Tract Spinal Trigeminal tract and nucleus

Lateral Spinothalamic tract Inferior Olivary Nucleus

Medullary Pyramid Medial Lemniscus

Neurotransmitters
Nuclei Locus Coeruleus Neurotransmitter NE Effects Arousal and Reward (enhances awareness of incoming stimuli) Enhance mood, satiety, pain modulation and SLEEP Motor (basal ganglia), REWARD, endocrine (aka prolactin inhibiting factor) LEARNING, short-term memory, REM sleep Excess Mania Deficiency depression Pathway Medial Forebrain Bundle

Raphe

Serotonin

Aggression & mania

Depression & Insomnia

Substantia Nigra & Venral Tegmentum

Dopamine

Schizophrenia, Tourettes Syndrome, OCD

Parkinsons Disease

Mesocortical and Mesolimbic

Pedunculopontine Nucleus

Ach

Associated with Alzheimers, learning difficulties

Thalmus Nuclei
Nuclei Anterior Thalamic Nuclei Mediodorsal Location Anterior Thalamus Medial Thalamus Function Recieves mamillothalamic tract & relays to cingulated gyrus Connects to prefrontal cortex, amygdala, hypothalamus Integration of sensory and Emotion** Pulvinar contains medial and lateral geniculate bodies Connected to Basal Ganglia******* Connected to basal ganglia and Cerebellum*** Trigeminal Sensory Receives STT & DCML Contributes to ARAS A thin layer surrounding thalamus and functions to inhibit the thalamic nuclei

Lateral Dorsal, Lateral posterior, Pulvinar Ventral Anterior Nucleus** Ventral Lateral Nucleus Ventral Posterior Medial (VPM) Ventral Posterior Lateral (VPL) Intralaminar & Centromedian Nuclei Reticular Nucleus

Lateral Thalamus Ventral Thalamus Ventral Thalamus Ventral Thalamus Ventral Thalamus Internal Medullary Lamina Surrounds thalamus

Thalamic Blood Supply: 1. 2. 3. Anterior Cerebral Supplies anterior 1/3 via Medial Striate Branches Middle Cerebral supplies middle 1/3 via Lateral Striate Branches (M1 branches) Posterior Cerebral supplies posterior 1/3 via Thalamogeniculate Arteries

Hypothalmus

Nucleus Preoptic Suprachiasmatic Supraoptic

Anterior Paraventricular Dorsomedial Ventral Medial Arcuate Posterior Mammillary Bodies

Lateral

Function Regulates Gonadotrophic Hormones Control of circadian rhythms (sleep/wake) -you need sleep to be supracharasmatic ADH secretion -lesion = central diabetes insipidus -Stimulation = SIADH Dissipation of heat and parasympathetics -lesion = hyperthermia Oxytocin secretion Stimulation = obesity and savage behavior Satiety Center Lesion = obesity and savage behavior Prolactin inhibiting factor -lesion = hyperprolactinemia Conservation of heat, sympathetic -lesion = poikliothermia Receive info from Fornix Outputs to Anterior Nucleus of Thalamus Important for Weirnke-Korsakoff Hunger Center (inhibited by leptin) -stimulation = eating Lesion = starvation, anorexia

Connections to Hypothalamus 1. 2. 3. 4. 5. 6. Mammilothalamic Tract: mammillary bodies to ANTERIOR NUCLEUS of thalamus (then to cingulated gyrus) Mammillotegmental Tract: mammillary bodies to reticular formation Medial Forebrain Bundle: hypothalamus to cortex Fornix: hippocampus to mammillary bodies a. A crossed system (extremely important in memory) Stria Terminalis: Amygdala to hypothalamus (important for physiological responses to fear) Hypothalamospinal Tract: descending sympathetic fibers a. Lesion = Horners (partial ptosis, miosis, anhydrosis, loss of ciliospinal reflex)

CNS Blood Supply Spinal Cord o Anterior Spinal Artery Derived from vertebral arteries Supplies ventral grey, ventral & lateral white funiculi Occlusion = Anterior Cord Syndrome (bilateral STT, CST, & minor motor tracts below occlusion is lost) o Posterior Spinal Arteries (i.e. there are two of them) Derived from vertebral arteries, supplies Posterior Columns Loss = isolated DCML below lesion (touch, proprioception, vibration) o Artery of Adamkiewicz From an intercostals T9-12 and supplies most of lower 2/3 of cord Occlusion can result in Anterior Cord Syndrome Brain Internal Carotid Arteries a. Opthalamic i. Travels w/optic nerve, supplies retina and eye b. Anterior Choroidal i. Supplies some of optic tract***, some cerebral peduncles, some hippocampus, amygdale, and some of posterior internal capsule*** c. Posterior Communicating i. Links the anterior and posterior brain circulations d. Anterior Cerebral i. Travels along longitudinal fissure to supply medial parts of frontal and parietal lobes, supplies corpus callosum, cingulate gyrus and part of basal ganglia ii. Occlusion = contralateral LOWER LIMB motor and sensory loss e. Middle Cerebral i. Supplies insula, and lateral surfaces of hemispheres*** ii. Lenticulostriate branches supply part of internal capsule iii. Ischemia symptoms depend on branch (M1-4), possibilities include: contral lateral face/upper body paresis and parathesia (internal capsule), aphasia (Brocas, Wernikes, conduction, transcortical), or hemineglect Vertebral System a. Posterior Inferior Cerebellar Artery (branches from vertebrals) i. Supplies posterior inferior cerebellar suface, posterior lateral medulla ii. Posterior lateral medulla has: STT, Nucleus Ambiguous, inferior cerbellar peduncle, hypothalamospinal tract, MLF, vestibular cochlear nuclei. iii. Occlusion = contra loss of pain/temp on body, possible ispi face pain and temp, ataxia, Horners, dysphagia*** b. Anterior Inferior Cerebellar Artery i. Anterior inferior cerebellum and caudal dosolateral pons ii. Caudal Dorsolateral pons has: middle cerebellar peduncle, STT, hypothalamospinal tract, vestibular/cochlear nuclei, CN 7 fibers, iii. Occlusion = ipsi face paralysis (LMN)***, contral body pain/temp, ataxia, vertigo, ipsi horners. c. Superior Cerbellar Artery i. Supplies superior cerebellum & cerebellar nuclei, caudal midbrain and rostal pons ii. Enlargement may compress trigeminal = trigeminal neuralgia d. Paramedian Pontine Branches i. Medial portions of upper and lower pons ii. Supplies CST, facial nucleus (sometimes), Abducens nucleus, PPRF, medial lemniscus iii. Occlusion = Contralateral CST & DCML***, ipsi lateral eye abduction paralysis e. Long Circumferential i. Basically the reticular formation of pons f. Short Circumferential i. Ventral Lateral Pons = hypthalamospinal, STT contralateral g. Posterior Cerebral Artery i. Supplies occipital cortex, medial temporal lobes (hippocampus) ii. Occlusion = visual defects

1.

2.

Cerebellum
Fibers entering Cerebellum 1. 2. Mossy Fibers: All inputs (spinocerebellar tracts, pons, cortexthese synapse on Granule cells) Climbing Fibers: input from inferior olive (synapse on purkinje cells), to which they excite

General Flow of information through cerebellum: Inputs (mossy climby) cerebellar cortex purkinge fiber deep nuclei of cerebellum output fibers

&

Lobe

Phylogeny

Functional

Input

Flocculonodular

Archicerebellum

Vestibulocerebellum

Vestibular Nuclei

Deep Nuclear Output Fastigial Nucleus

Effector

Function

Anterior

Paleocerebellum

Spinocerebellum

Spinocerebellar Tracts Cortex via pontine nuclei from corticopontine tract

Posterior

Neocerebellum

Cerebrocerebellum

Globose & Emboliform Nuclei Dentate Nucleus

Vestibular Nuclei, Reticular Formation Red Nucleus Ventral Lateral Thalamus

Balance, gait, anti-gravity, equilibrium Muscle Tone, Posture, Axial Muslces Coordination, motor planning, speed, timing, force of movement

Neck Anatomy

Posterior Triangle: Brachial Plexus, External Jugular, Subclavian Artery/Vein, and Omihyoid muscle

LTN (Long Thoraic Nerve): Serratous Anterior Muscle SS (Suprascapular Nerve): Infraspinatus & Supraspinatus Muscle LP (Lateral Pectoral Nerve): Pectoralis major muscle Upper SS (Upper Subscapular Nerve): Subscapularis Muscle TD (Thoraic Dorsal Nerve): Lattisimus Dorsi Muscle LSS (Lower Subscapular Nerve): Teres major Muscle MC (Musculocutaneous Nerve): Biceps, Brachialis, Coracobrachialis Muscle AX (Axillary Nerve): Deltoid and Teres Minor Muscle R (Radial Nerve): Extensors, Triceps Muscle M (Median Nerve): Pronators, Thenar Muscles U (Ulnar Nerve): interosseous, Hypothenar Muscles