Reviews Before becoming PGY: management of heart failure

Reviews Before becoming PGY: management of heart failure

Reference: 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure

1. 懷疑是HF- 問病史：CAD、HTN、藥物- 問症狀- PE：四肢溫度、水腫、頸靜脈壓、心臟聽扣觸、呼吸音- EKG- 抽血：NT-proBNP(切125 pg/ml)、 BNP(切35 pg/ml)- 心臟超音波

2. 預防心衰竭- 生活型態：運動、控制血壓(SPRINT STUDY- SBP 120mmHg)、戒菸、少量飲酒即可甚至戒酒- 藥物：ACEI等高血壓藥物、empaglifozin for DM病人
- 追蹤：NT-proBNP等

3. 有症狀的HFrEF- ACEI、beta-blocker(Carvedilol, Bisoprolol, Metoprolol)- Diuretics 症狀治療
- 如果EF<=35則考慮

• 心跳快於70bpm: Ivabradine

• QRS>=130 msec: 評估是否需要CRT，如果有症狀VT/VF也考慮ICD

• 考慮ARNI (angiotensin receptor-neprilysin inhibitor)= LCZ696= Entresto
• 若以上都無法控制，考慮digoxin、fixed-dose isosorbide dinitrate/hydralazine (HISDN)、left ventricular assist device(LVAD)、心臟移植

- 避免：CCB，若一定需要用請考慮amlodipine, felodipine

4. HFpEF的治療方針

- ACEI, ARB, beta-blockers and MRAs: 還沒有明顯/一致的證據證實能緩解症狀

- 偏向症狀治療，如給予利尿劑

Reviews Before becoming PGY: Pediatrics (下篇)

Reviews Before becoming PGY: Pediatrics (下篇)

References:
=UpToDate
=Medscape
=OSCE 臨床技能測驗完全攻略

=北榮兒科臨床手冊(104/08修訂版)
 

1. 抽搐
-問診重點

• 發作前：是否哭泣用力？藥物？創傷？近期生病？站立過久？感覺前兆？頭痛頭暈想吐
• 發作時：單側/雙側？局部/全身？有規律？時間多久？眼口睜開？對聲音/疼痛有反應？
• 發作後：是否混亂無法聽指示？是否有持續的神經學症狀？
• 其他：心理狀態、家族史、發展史等

- 抽搐常見原因(依常見度遞減)

• 熱痙攣、癲癇
• 電解質不平衡、中樞神經感染
• 腦瘤、蜘蛛膜下腔出血

- 抽搐鑑別診斷工具

• 必做ABG
• CBC, Na, Ca, Glu, NH3
• CSF
• cultures
• 遺傳診斷、藥物調查(urine)
• EEG對探討病因沒有太大的幫助；影像(brain sono/CT/MRI)有助於局部抽搐的診斷

2. Febrile convulsion
- 定義：

• 6個月~5歲
• 燒到38度(發燒後第一天就抽筋)
• 排除CNS infection和metabolic abnormalities
• 之前不能有過non-febrile convulsion

- 分simple & complex：simple的是全身性<15 mins且一天只有一次，但1/3還會復發
- risk factors 包括家族史、孕中暴露到尼古丁、iron deficiency、atopic diseases
- 治療：BZD等藥物(risk > benefit)

3. 發燒+紅疹
-  原因/特色：

• adenovirus：咽部肺部、角膜結膜發炎、出血性膀胱炎
• Kawasaki：口手足、草莓舌 
• enterovirus：口手足、心肌炎、咽峽炎、腦膜炎、肢體麻痺
• measles：鼻炎、咳嗽、結膜炎，退掉後有色素沉澱/脫皮，嚴重者支氣管炎/肺炎/全腦炎
• scarlet fever(Streptococccus)
• Roseola  Infantum(HSV-6,7)：blanching、Nagayama spot(懸雍垂附近)，退掉後沒有色素沉澱/脫皮
• drug allergy
• UTI

4. Asthma in children
- Differential of chronic cough


Algorithm for evaluation of chronic cough in children
retrieved from UpToDate

 

Reviews Before becoming PGY: Pediatrics (中篇)

Reviews Before becoming PGY: Pediatrics (中篇)- 新生兒黃疸

References:
=UpToDate
=OSCE 臨床技能測驗完全攻略

=北榮兒科臨床手冊(104/08修訂版)
=Jackie Lou C. Acha "hyperbilirubinemia" retrieved from SlideShare

1. Neonatal jaundice

- 生理性黃疸的五個原因：血紅球較多/turnover rate較高、血紅素較脆弱、肝臟無法有效conjugate bilirubin、腸道菌無法有效將bilirubin轉化出urobilinogen/stercobilin甚至藉beta-glucuronidase反轉回unconjugated form
- 生理性黃疸的特色：

• 多落在Bhutani nomogram的40 percentile以下(low risk)
• 時間上出生後1~2週內消失/ 不會在剛出生24hrs之內出現
• 足月/早產兒都會有，但早產兒較慢達peak(一週)、peak較高(15 mg/dl)、機率較大(80%)
• 不需治療

- 病理性黃疸的原因：溶血、非溶血(血腫/polycythemia/腸肝循環↑/UGT1A1 defect/hypothyroidism/bilirubin排泄障礙)
-病理性黃疸的特色：

• 太早--->出生後24hrs內
• 太高--->bilirubin >95 percentile
• 太高--->direct bilirubin >1mg/dl (total<5), or >20%(total>5)
• 太快--->0.2mg/dl per hour, 5mg/dl per day
• 太久--->持續兩週(足月)/三週(早產)
• 須注意潛在疾病，高於25mg/dl 會有神經傷害 (甚至更低就會!)

- 病理性黃疸的急慢性變化

• 急性：ABE- 高頻哭聲、嗜睡、肌肉低張力--> 發燒、肌肉高張力--> 呼吸中止、難以餵食、角弓反張、癲癇、昏迷、虛弱顫抖哭
• 慢性：kernicterus-  基底核、腦幹受損，產生不自主運動、聽覺異常、向上注視異常、琺瑯質不全

- 病理性黃疸的治療：照光、blood exchange、補albumin、IVIG、ursodeoxycholic acid、metalloporphyrin?

- Breast feeding jaundice and breast milk jaundice

from SlideShare

breast feeding jaundice--> encourage intake
breast milk jaundice--> stop breast feeding for 2~3 days

# http://www.pathophys.org/neonatal-hyperbilirubinemia/neonataljaundice-approach/

Reviews Before becoming PGY: Pediatrics (上篇)

Reviews Before becoming PGY: Pediatrics (上篇)

References:
=UpToDate
=OSCE 臨床技能測驗完全攻略
=北榮兒科臨床手冊(104/08修訂版)
=衛福部疾管署官網

1.  Failure to thrive
- 在兒童(<2 歲)稱為生長遲滯
- 操作型定義是生長速度遲緩，且體重低於<2%生長曲線
- 必須排除基因問題、IUGR、早熟、constitutional growth delay(骨齡成熟較慢)
- 源於營養不足(包括攝取/消化/代謝/吸收降低、排除/需求增加)
- 在調查原因的過程中，可以先試著調整食物配方

2. Developmental delay/milestones
- 包括動作(粗/細)、認知、語言、行為、社會/情緒/心理層面
- 須排除視力、聽力問題- 發展里程碑：

• 五個月-->雙手可抓東西/放入嘴巴
• 六個月-->對人哭笑反應/手上東西可換手拿
• 十個月-->可不用協助而坐/可用指尖拿東西/發出無意義聲音
• 一歲-->可扶著東西走路/理解簡單指示
• 十八個月大-->疊三四個積木/不用協助而走路
• 兩歲-->可組成句子

3. Acute abdominal pain
- 先了解是持續性或陣發性
- 按年齡鑑別診斷

• 0~2歲：腸套疊/扭結、腸胃炎、闌尾炎、腹股溝疝氣、幽門狹窄等
• 3~6歲：額外考慮便秘、呼吸泌尿感染、腫瘤、創傷、膽道囊腫
• 更大的兒童：額外考慮潰瘍、AIR、婦科問題　

- 按機制思考鑑別診斷

• 臟器發炎(往往伴隨發燒)
• 消化道阻塞(間歇性絞痛/含膽汁嘔吐)
• 血管性(缺血壞死/腫瘤囊腫/過敏性紫斑症)
• 創傷等其他因素

4. 腸病毒
- 有很多subtypes，包括polio,  Coxsackie A(口手足), Coxsackie B(肋膜痛/心肌炎)等
- 糞口/飛沫傳染，感染後兩周內最容易傳染，經上呼吸道1~3 wks/糞便3~8 wks
- 表現有皮膚疹、腦膜炎、腦炎、眼部感染(結膜炎)、肋膜痛、心肌炎/心包膜炎、肺炎/支氣管炎等
- 腸病毒重症前兆(通常在發病後第三天，不會超過一個禮拜)，持續有

• 嗜睡、意識改變、活力不佳、無力
• 肌躍型抽搐(類似驚嚇，睡覺時較頻繁)
• 肢體麻痺
• 頸部僵硬、發燒
• 嘔吐
• 呼吸急促
• 心跳加快或心律不整

甚至有交感神經興奮的症狀
- 腸病毒重症住院indications

• <3 歲
• 發燒超過3天
• 3大警訊(嗜睡、肌躍型抽搐、嘔吐)
• 血糖>150mg/dl
• WBC>17500 cumm

- 若懷疑影響中樞神經，可給予

• IVIG
• Fluid challenge
• CSF檢驗
• EKG monitor

- 分四期：手口足病/疱疹性咽峽炎期--> 中樞神經發炎期(反而要限水，避免心臟負荷)-->自主神經失調期-->心臟衰竭期(考慮ECMO)

 

Reviews Before becoming PGY: acute coronary syndrome

Reviews Before becoming PGY: acute coronary syndrome

Reference: ACLS training center website; 麻州總醫院內科學手冊第六版
 
1. Algorithm from ACLS training center
https://www.acls.net/images/algo-acs.pdf
 
2. 症狀與鑑別診斷

• Prinzmetal's
• UA, NSTEMI, STEMI, +/- Heart failure?, right side or left side?
• Aortic dissection

3. 確定時間點
Q: 離症狀開始已經有多久？
A: STEMI一定是以reperfusion為目標，12hrs 以內做reperfusion比較有效，超過則跑UA/NSTEMI的流程。
 
Q: 處置需要多快？
A: door to needle 30 mins, door to balloon 90 mins
4. ACS初步處置(<10 mins)與實驗室檢查
- initial medications: pain control, oxygen, cath team activation, aspirin(160~325mg)
- 確定沒有contraindications(右心梗塞、主動脈狹窄、低血壓、使用PDE5 inhibitor) 再用NTG
- EKG:一般AMI應該大家都會看，[特殊]如果有舊的LBBB，判讀時看STD in V1-V3, STE>=5mm(QRS反向)或STE>=1mm(QRS同向)
- cardiac enzymes: prefer using troponin> CKMB> CK
- CXR(<30 mins)


from AHA 2007

5. PCI前其他處置？
- beta blocker: for HTN，一旦有HF症狀、低血壓、2度以上AVB等就不能用，goal of HR=50~60 bpm
 - other antiplatelet, anticoagulant: Ticagrelor, Prasugrel> Clopidogrel; Enoxaparin
- statin: atorvastatin 80mg QD
 
- ACEI/ARB: 尤其是有共病(CKD, HTN, DM)、HF(EF<40%)
- diuretics: LV failure
- inotropes for vital signs stability: dopamine, dobutamine, milrinone
 
6. 其他相似病症初步處置
- Prinzmetal's: high dose CCB + standing nitrite ; 避免aspirin, non-selective beta blocker
 
7. UA/NSTEMI，或STEMI從症狀開始已超過12小時

- 區分risk groups(如TIMI score)，high risk　 三分以上(含)-->dual antiplalet
                                                                             + UFH or Enoxaparin or Bivalirudin
                                                                             +/- GPI (除了已經用Bivalirudin)
                                                                            -->24hrs內做 early PCI
                                                                            (early vs. late, 可看GRACE score決定)

                                                         low risk     三分以下--> dual antiplalet
                                                                             + UFH or Enoxaparin or Fondaparinux
                                                                            --> stress test(treadmill<-11視為high risk)
　
TIMI for UA/NSTEMI: https://www.mdcalc.com/timi-risk-score-stemi


 

Grace score: https://www.mdcalc.com/grace-acs-risk-mortality-calculator

 





 8. Complications and prognosis
- RV infartion: AVB

- papillary muscle rupture, VSD,  free wall rupture, arrhythmia(Afib, VT/VF), LV thrombus, ventricular aneurysm/pseudoaneurysm, pericarditis, Dressler's syndrome 

- STEMI prognosis: TIMI score, 30 days mortality

https://www.mdcalc.com/timi-risk-score-stemi

9. 長期用藥/處置

- low dose aspirin(80 mg QD)

- Ticagrelor or Prasugrel 至少一年
- statin: atorvastatin 80 mg QD + ezetimibe?
- beta blocker

- EF差、有共病可考慮ACEI, aldosterone inhibitor

- 舌下NTG 備用
- ICD if EF<40%, VT/VF for 2 days (post MI)

 

Reviews Before becoming PGY: lipid-lowering agents

Reviews Before becoming PGY: lipid-lowering agents 參考: -台大環境與職業醫學部網站  "如何看懂健檢報告系列之(2)---高血脂(診斷) " by 謝怡君醫師/郭育良教授 -麻州總醫院內科手冊6th edition - Case Files: Internal Medicine - NEJS weblink   Q: Dyslipidemia怎麼定義？ A: 三酸甘油脂、低密度脂蛋白膽固醇及 apo B高於國人平均值的90%，而高密度脂蛋白膽固醇及 apo A-1小於國人平均值的10%        針對沒有underlying的人可以用下面的方式大概評估 LDL-  切130以上, 計算的方法是total-HDL-(TG/5) HDL- 切40以下 Total cholesterol- 切200以上 TG-   切200以上 Q: Metabolic syndrome定義？ A: 以下條件需三項成立──腰圍男生超過90cm、女生超過80cm、TG大於等於150、HDL<40(男)/50(女)、血壓大於等於130/85 mmHg、禁食血糖大於等於100 mg/dl 。   Q: 測量血脂需要注意？ A: 須禁食12小時- LDL, TG      不需禁食- HDL, total cholesterol     ACS發作後可能會維持 MAX 6禮拜的高血脂   Q: 實際對心血管疾病影響最大的是？ A:  LDL，TG>500~1000 mg/dl要降低則是為了降低pancreatitis的可能性   Q: 考慮使用藥物的指標？ A: 已經有心血管問題、40-75歲有DM、LDL>190、40-75歲10年心血管疾病risk>7.5%(Framingham score:  https://www.mdcalc.com/framingham-coronary-heart-disease-risk-score)   Q: 藥物選用？ A:  降LDL- statin類(HMG-CoA inhibitor)、resins(bile acid sequestrants)、ezetimibe、PCSK9i      升HDL- niacin      降TG- fibric acid、niacin(B3)、omega-3   Q: Statin類選用？追蹤？劑量調整？ A: 最能降低LDL的是Rosuvastatin(Crestor)、Atorvastatin(Lipitor)     用藥後6wks可追蹤用藥情形，定期注意CK、 liver enzyme，之後半年一年追蹤     若想double劑量，大約可降6%血脂 Q: 希望血脂降多低？ A: LDL每下降39mg/dl，心血管發生率降22%！至於要降多低，可跳去看NEJS～ (http://jerryljw.blogspot.tw/2017/05/2017aace-aace-2017-guidelines-of.html) Q: 血脂高的鑑別診斷？ A: 首先要排除secondary的原因如hypothyroidism、DM、obstructive liver disease、chronic renal failure、nephrotic syndrome、drugs(estrogen、progestin、anabolic steroids、corticosteroids、protease inhibitor)、alcohol等，若有家族病史或premature ACS(男55女65歲)，可以推測為familial hyperlipidemia   Q: 一般人檢測血脂需要多頻繁？ A: 男35女45歲以上，每五年檢查一次

Reviews Before becoming PGY- pulmonary function test

Pulmonary function test

Reference:  "Overview of pulmonary function testing in adults"(2016) Meredith C McCormack, MD, MHS, retrieved from UpToDate

 

Q:  PFT主要的內容？

A:  spirometry(before and 10 to 15 minutes after a bronchodilator, Albuterol 90 to 100 mcg  #4 IH?), lung volume examination

      DLCO, maximal respiratory pressures, flow-volume loops,

      submaximal exercise testing, and bronchoprovocation challenge

 

Q: PFT注意事項？

A: 若平常都用inhalor BID，則PFT四小時前開始不可用SABA、十二小時前開始不可用LABA、二十四小時前開始不可用LAMA。

Q: Spirometry 是測什麼？
A: (白話)測量深吸氣後大力、完整吐氣時，每個時間點的呼氣量。

↑ from wikipedia



Q: FVC減少、呼吸道阻塞時怎麼測？

A: 可以改測SVC(Slow exhalation)，但是如果是restrictive  lung則兩者的結果一樣爛。

 

Q: Spirometry的判讀流程？
A: 先看 FEV1/FVC, 再看DLCO。結果大致分三大種：較確定obstructive type的COPD、變異性較大的asthma、restrictive type的ILD/neuromuscular problem。 



↑from UpToDate



Q: Flow-volume loop的鑑別診斷用途？
A: 當聽到stridor的時候使用，能幫助辨別airway obstruction的部位。

from UpToDate

Q: Maximal respiratory pressures是什麼？
A: 經過有阻力的吹口大力吸氣 / 噘嘴吐力的最大壓力值。
 

* PFT tutorial website: https://depts.washington.edu/uwmedres/Library/eLearning/Pulmonary/

 Here are some notes from the website listed above:
 
- For obstructive pattern, the severity depends on...

	FEV1 > 80% predicted: mild obstruction
	50% < FEV1 < 80% predicted: moderate obstruction
	30% < FEV1 < 50% predicted: severe obstruction
	FEV1 < 30% predicted: very severe obstruction - For decrease DLCO, the severity depends on...      65% predicted < DLCO <80% predicted: Mild      50% < DLCO < 65% predicted: Moderate      DLCO < 50% predicted: Severe

- For reduced DLCO, the meaning is...

1. obstructive--> emphysematous, reduced surface area for gas exchange.
2. normal spirometry and lung volumes-->anemia, pulmonary hypertension, heart problem
3. restrictive -->idiopathic pulmonary fibrosis
4. Not equalled to hypoxemia!

Mind: diffuse alveolar hemorrhage的病人DLCO可能不降反升！
 
- For restrictive pattern, the severity depends on...

     65% < TLC < 80% predicted: mild restriction
     50% < TLC < 65% predicted: moderate restriction
     TLC < 50% predicted: severe restriction
 
- Characteristics of  idiopathic pulmonary fibrosis
    septal thickening
    traction bronchiectasis
    more prominent in the periphery of the lungs (sub-pleural regions)

 

- For mixed obstructive+ restrictive pattern, the severity depends on...
   
     FEV₁ > 80% predicted: mild
     50% < FEV₁ < 80% predicted: moderate
     30% < FEV₁ < 50% predicted: severe
     FEV₁ < 30% predicted: very severe  
 
 

實戰課題Medical Internship Topic 7: CXR案例判讀

* All pictures from https://radiopaedia.org, just for learning purpose

1. Atelectesia
- Displacement of fissure
- Bronchovascular crowding 
- Increase opacity
https://openi.nlm.nih.gov/detailedresult.php?img=PMC2823759_1752-1947-4-17-1&req=4

* Juxtaphrenic peak sign(peaked or tented appearance of a hemidiaphragm which can occur in the setting of lobar collapse): mostly upper lobe atelectasia


* Reverse S sign=Golden S sign: upper lobe atelectasia


* Luftsichel sign: LUL lung collapse

 
* Flat waist sign: LLL lung collapse
http://posterng.netkey.at/esr/viewing/index.php?module=viewing_poster&task=viewsection&pi=28734&ti=86331&searchkey= 

* Paraesophageal line deviation, azygoesophagus recess
 
2. Hilar obstruction: DDx
- Sputum
- Tumor
- TB
- LN
 
 3 Lung lobules
http://slideplayer.com/slide/9428451/29/images/2/Lung+Unit+Acinus+:+That+
part+of+the+lung+supplied+by+a+terminal+bronchiolus.+This+includes+
respiratory+bronchioli,+alveolar+ducts,+and..jpg
 
4. Descriping lung lesions:
- Fluffy margin
- Early coalescence
- Alveologram
- Rapid timing(?)
 
5. Cryptococcus pneumonia
- Lower lungs, nodules, air bronchogram


 
6. Slow in progress nodules
- BAC( a kind of adenocarcinoma)
- Lymphoma
- Autoimmune related, inflammation
 
7. Describing lung nodules
- 2S: size, shape
- 3C: calcification, cavitation, contrast
- DOA: doubling time, density, other, area, age
- scalloped(lobulated), corona radiata, rabbit ears, rat tail sign, pleural tag sign, eccentric cavitation, thick wall(>16mm? ex: SCC with cavitation)
 
8. DDx of lung nodules/masses
- H: hema(spread by blood)
- I: infection
- I: inhalation
- N: neoplasm
 
9. Fungus ball: aspergiilus

 
10. Bronchogenic cyst: homogenous, smooth

 
11. Calcifications:
good signs- popcron(harmatoma), diffuse, laminated, central nidus
bad signs- eccentric, strippled
Ring- teratoma, thymogenic cyst
 
12. Congenital pulmonary airway malformations (multicystic, bronchial proliferation)

13. Lung sequestration
- Often triangular


14. Varicella pneumonia
- Fast
- Skin rashes, vesicles
- Calcification(+)
DDx: miliary TB


15. GGO
- Viral
- Clamydia
- Legionella
- Cryptococcus
- PJP

16. Proteinosis, PJP in AIDS
- Long term
- Crazy paving
- Reticular
DDx: PAS(+), milky BAL  in proteinosis

17. LAM(lymphangioleiomyomatosis)
- Penumothorax
- Chylothorax
- Young people

18. Thymoma
- Anterior mediastinum
- Calcification(-)

19. EMH (extramedullary hematopoiesis)
- Bilateral
- Paraspinal rib widening


20. Hilum overlay


21. Asbestosis (associated with mesothelioma)


22. Diaphragm hernia
Morgagni hernia: right, anterior
Bochdalek hernia: left, posterior
 

實戰課題Medical internship topic 6: Hyponatremia

Hyponatremia

1.      Def: <135mmol/L

2.      First DDx: rule out pseudo-hyponatremia

• Hypertonic: hyperglycemia?

Na在hyperglycemia時會降低，correct Na=Na + 1.4×(sugar－100)

• Isotonic : hyperlipidemia, hyperproteinemia?
• Another consideration: sample mixed with IV injection fluids?

3.      Hypotonic :

• Too much water? (beware of fluid retention)à do not give N/S, but restrict Na+ and water intake
• Not enough solutes? (beware of poor intake)à may give N/S

4.      Symptoms:

nausea and vomiting, headache, confusion, loss of energy and fatigue,

restlessness and irritability, muscle weakness, spasms or cramps, seizures, coma

5. Na supplement if needed

•  Rate of infusion is important
•  應補鈉總量（mmol）=[135-病人血Na+(mmol/L)]×體重(kg)×0.6~0.5
•  補鈉的速度不能超過4~6 mEq/L/hour，24 hrs內不能超過9 Eq/L

6. Monitoring

•   Urine output
•   Na recheck Q4H

神經內科Neurology note 1: stroke

Stroke

1. Categories

- ischemic: 4/5

• atherosclerosis of large vessels, RFs: HTN, DM, hyperlipidemia
• lacunar stroke at small vessels(<1.5 cm on CT), RFs: HTN, DM
• cardiogenic embolism(multiple, unusual, distal sites, RFs: valvular diseases, MI, arrhythmia, rheumatic, op hx 

- hemorrhagic: 1/5

2. Stenosis level

- severe stenosis: >70%

3. Stroke symptoms

- FAST: facial asymmetry, arm drop, slurred speech, time on onset

- motor: treat this part first!

- sensory

- consciousness, cognition etc.

* unspecific symmetric symptom: less likely due to stroke

4. NE:

pupil reflex: CN2 light sensation-->CN3 miosis

diplopia/nystygmus: CN3, CN4, CN6

http://emedicine.medscape.com/article/1214490-differential

temporalis m. strength: CN5

facial asymmetry and wrinkles on forehead: CN7

- central: wrinkle loss

- peripheral

uvula deviation: to the "good" side, CN9

tongue deviation: to the "bad" side, CN12

SCM power: CN11 (little value for localization of lesion)

Barbinski sign: null-->also abnormal!

http://epomedicine.com/clinical-medicine/pathological-reflexes-variations-of-babinski/

tendon reflex: hyper-->seek upper lesion
muscle power: check reaction to pain if patient's unconscious
gait/FNF/HKS/: cerebellar signs
speech:  eight types of aphasia

• can repeat: transcortical(sensory/motor/mixed)/anomic
• cannot repeat: Broca/Wernicke/conductive/global

5. Localization of lesion

http://www.slideshare.net/kurian3/localization-of-stroke-cvs-stroke-for-post-graduates

ICA territory: transient monocular blindness
ACA territory: leg > arm
MCA territory: face & arm > leg, aphasia(dominant side), apraxia&neglect (non-dominant side)
PCA territory: alexia w/o agraphia, macula sparing homonymous hemianopia
Vertebral/PICA
Basilar territory: pupil, longtract sign, CNS, cerebellar, lock-in
Cerebellar
Lacunar

6. Stroke management

- check cause of stroke( young stroke? underlying? )

- keep SBP<200 (or 220/120)in acute phase(14 days or less), SBP 140/90 afterwards

- hydration for 3~5 days
- Atorvastatin 80 mg if LDL >100, goal: LDL <70

- aspirin if no contraindications (GI discomfort-> shift to clopidogrel)

- consider NOAC (dabigatran, rivaroxaban, apixaban, edoxaban) or warfarin for AF patients according to histories and clinical symptoms

- rehabilitation, beware of choking

- tPA o.9mg/kg (max: 90mg) w/in 4.5 hrs if no contraindications(check NIHSS, stroke hx, BP, glucose, bleeding tendency etc.)
- Thrombectomy w/in 6 hrs
- CEA/ stenting if severe stenosis

7. TIA and subsequent stroke risk in one week: ABCD2 score, high risk:4↑
A: age(65↑)
B: BP (140/90↑)
C: clinical (weak  --> 2 points/ speech-->1 point)
D: duration (60 --> 2 points or 10~59 mins-->1 point)
D: DM

8. NIHSS/mRS evaluation
http://www.mdcalc.com/nih-stroke-scale-score-nihss/
http://www.mdcalc.com/modified-rankin-scale-neurologic-disability/

9. PFO and stroke: if 4mm↑, shunting at rest, aneurysm, septal mobility

# Good reference for interns in Taiwan: 
http://intm.vghtc.gov.tw/imd/ch/%E7%A5%9E%E7%B6%93%E5%85%A7%E7%A7%91%E5%B7%A5%E4%BD%9C%E6%89%8B%E5%86%8A.pdf