A. Kulak. Samford University.
There may be wheeze and cough pro- r low-dose spironolactone generic losartan 50 mg with amex diabete quebec congres 2014, which improves progno- ductive of frothy pink sputum buy generic losartan 25 mg diabetes insipidus expected lab values. On auscultation crepitations may be itoring of renal function and potassium levels buy 50mg losartan overnight delivery diabetes symptoms vision problems. In acute pul- can aggravate myocardial ischaemia and cause further monary oedema there may be ‘bat wing’ or ground reductionincardiac output cheap 25mg losartan amex diabet-x antifungal. Aminophylline infusion can be considered if there is r Cardiac inotropes are usually necessary to maintain bronchoconstriction purchase 25mg losartan amex diabetes mellitus type 2 wikipedia free encyclopedia. If patient is hypertensive hydralazine or diazoxide (ar- r Any cardiac arrhythmia should be corrected and terial dilators) can be used to reduce cardiac afterload angioplasty considered in patients with cardiogenic and hence increase stroke volume. Any underlying problem such as arrhythmia should r Intra-aortic balloon pumping may be instituted but it be corrected. Severe circulatory failure resulting from a low cardiac output usually characterised by severe hypotension. Aetiology This is an extreme type of acute cardiac failure the most common cause of which is myocardial infarction. Pathophysiology Cardiogenic shock is severe heart failure despite an ad- equate or elevated central venous pressure, distinguish- Incidence ing it from hypovolaemic or septic shock. Hypotension Commonest cause of pulmonary hypertensive heart dis- may result in a reduction in coronary blood ﬂow, which ease. Chapter 2: Disorders of pericardium, myocardium and endocardium 65 Sex r Atrial ﬁbrillation is a common complication and M > F should be treated appropriately. This is related to the underlying lung pathology and ex- tent of respiratory failure. Acute pericarditis Deﬁnition Pathophysiology Acute pericarditis is an acute inﬂammation of the peri- Hypoxia is a potent cause of pulmonary arterial vaso- cardial sac. With Aetiology time there is compromise of right ventricular function Multiple aetiologies but common causes are as follows: r Myocardial infarction: 20% of patients develop acute and development of right ventricular failure, often with tricuspid regurgitation. Dressler’s syndrome is an immune- Pulmonary hypertension, right ventricular failure and mediated pericarditis occurring between 1 month and the chest disease together produce the clinical picture. Pathophysiology During acute pericarditis the pericardium is inﬂamed Management and covered in ﬁbrin causing a loss of smoothness and r Heart failure should be treated and the underlying an audible friction rub on auscultation. Sharp substernal pain with radiation to the neck and r Long-termoxygentherapyhasbeenshowntoimprove shouldersandsometimestheback. Characteristicallythe prognosis in hypoxic chronic obstructive airways dis- pain is relieved by sitting forward and made worse by ly- ease but must be maintained for >18 hours per day. A pericardial 66 Chapter 2: Cardiovascular system friction rub is pathognomonic but may be transient, best Aetiology heard at the left sternal edge accentuated by leaning for- Haemopericardium, tuberculous pericarditis and acute ward and held expiration. Complications Pericarditis is often complicated by pericardial effusion Pathophysiology and occasionally tamponade. Where there is an associ- Chronicinﬂammation,orhealingafteracutepericarditis atedmyocarditis,featuresofheartfailuremaybepresent. This surrounds and constricts the ventricles Macroscopy/microscopy such that the heart cannot ﬁll properly, hence causing a An acute inﬂammatory reaction with both pericardial reductionincardiac output. Auscultation reveals soft S1 and S2 echocardiogram, viral titres and blood cultures. Investigations r Chest X-ray is frequently normal but may show a rel- Management atively small heart. There may be a shell of calciﬁed Analgesia and anti-inﬂammatory treatment with aspirin pericardium particularly on the lateral ﬁlm. However, it may be normal even in the pres- Most cases of acute pericarditis, particularly of viral ori- ence of the disease. Constrictive pericarditis Deﬁnition Management Acondition in which reduced elasticity of the peri- Medical intervention is of little value except for digoxin cardium results in poor cardiac output.
Inelderlypatientssurgicalremovalmay up with regular echocardiography is therefore indicated not be necessary cheap losartan 25mg visa diabetes type 2 disability. Patients may complain of breathlessness purchase 50 mg losartan otc diabetic diet oranges, dif- ﬁculty in ‘catching their breath’ losartan 50 mg online diabetes treatments wiki, a feeling of suffocation order 50 mg losartan mastercard blood glucose blood test, Cough and sputum or tightness in the chest buy losartan 25mg line diabetes pancreas. Dyspnoea should be graded by the exertional capability of the patient and the impact Acough is one of the most common presentations of on their lifestyle. In general dyspnoea arises from either the respira- The most common patterns are shown in Table 3. It is usu- thopnoea and paroxysmal nocturnal dyspnoea suggests ally streaky, rusty coloured and mixed with sputum. It a cardiovascular cause, patients with lung disease may should be distinguished from haematemesis (vomiting experience orthopnoea due to abdominal contents re- of blood) which may appear bright red or like coffee stricting the movement of the diaphragm. For diagnosis, respiratory dyspnoea is best considered 1 The most common cause is acute infection, particu- according to the speed of onset and further differenti- larly with underlying chronic obstructive airways dis- ated by a detailed history and clinical examination (see ease. Wheeze and stridor 3 Pulmonary oedema in cardiac failure causes pink, frothy sputum and pulmonary infarction such as pul- Wheeze and stridor are respiratory sounds caused by air- monary embolism may cause haemoptysis. Massive haemoptysis may be caused by bronchiectasis, Awheeze is described according to where it is best bronchial carcinoma or tuberculosis. Recent Smoker, weight Haemoptysis Carcinoma until proved (weeks) loss, occasionally otherwise (often dull chest pain associated pneumonia) speciﬁc size of airway – usually one bronchus) or poly- creased airway pressure opens the valve, so expiratory phonic (widespread airway limitation). Othercauses inhalation, acute epiglottitis (drooling, unwell), ana- include chronic obstructive airways disease and acute phylaxis, inhaled foreign body. It occurs airway (larynx, pharynx or trachea), extrinsic com- because in inspiration, a valve-like effect worsens ob- pression (lymph nodes, retrosternal thyroid), bilateral struction in the major airways. Pulmonary oedema Cardiac history, intermittent (exertional, orthopnoea, paroxysmal nocturnal dyspnoea) or acute – basal crackles, frothy sputum, cardiac chest pain Extrinsic allergic alveolitis Recurrent, occupational exposure Days/weeks Pleural effusions Dull to percussion, reduced breath sounds Carcinoma of the bronchus/ Obstruction causes collapse and consolidation of lung. Months/years Chronic bronchitis/emphysema Smoking history, cough & sputum Idiopathic pulmonary ﬁbrosis Clubbing and cyanosis, ﬁne crackles Occupational ﬁbrotic lung disease Occupational history 92 Chapter 3: Respiratory system Respiratory chest pain with abdominal pain, e. Chest pain can arise from the cardiovascular system, the respiratory system, the oesophagus or the musculoskele- talsystem. Respiratorychestpainisusuallyverydifferent Signs fromischaemicchestpain,asitischaracteristicallysharp, and worse on inspiration. Clubbing On enquiring about chest pain ask about the site, nature (sharp, burning, tearing), radiation, precipitat- Clubbing is an increased amount of soft tissue in the ing/relieving factors (deep inspiration, coughing, move- terminal phalanx of the ﬁngers and toes, concentrated ment) and any associated symptoms such as dyspnoea. It is caused by inﬂamed pleural pathological mechanism of clubbing is unknown, and surfaces rubbing on one another. Pleurisy may also be caused by connective tissue diseases such as rheumatoid Normal breath sounds are caused by the turbulent ﬂow arthritis. They are Chest wall pain may be easily confused with pleuritic transmitted to the chest wall through the lungs (see pain, as it is often sharp, but it can be reproduced by Table 3. Other Bronchiectasis causes include thoracic herpes zoster – a persistent pain, Lung abscess which may be burning and last several days before the Chronic empyema Pulmonary ﬁbrosis rash appears. Idiopathic pulmonary ﬁbrosis Retrosternal pain may be due to tracheitis or medi- Cystic ﬁbrosis astinal disease (lymphoma, mediastinitis) but is more Asbestosis commonly cardiac. Cardiovascular Cyanotic congenital heart disease Infective endocarditis Gastrointestinal Cirrhosis, especially primary biliary Non-respiratory chest pain cirrhosis Central chest pain, particularly if radiating to the neck Inﬂammatory bowel disease Coeliac disease or arms, is more likely to be cardiac. Pericarditis causes Idiopathic Familial usually before puberty a sharp retrosternal/precordial pain which may mimic Idiopathic pleuritic pain as it may be exacerbated by deep inspira- Rare Thyroid acropachy tion, but is classically relieved by leaning forwards. Pain Pregnancy at the shoulder tip is often referred pain from the di- Unilateral clubbing Bronchial arteriovenous aneurysm aphragm, and may reﬂect an abdominal cause such as Axillary artery aneurysm cholecystitis. Equally, respiratory disease may manifest Chapter 3: Respiratory procedures 93 Table3. Inspiration is However, theseconditionsmayoccurwithoutwheeze, slightly louder and longer than despite severe obstruction.
Paraplegia Affecting both lower limbs buy 25mg losartan visa managing diabetes at everyday health, and usually caused by a thoracic or lumbar spinal cord lesion e losartan 50mg low cost blood glucose levels normal range. Bilateral hemisphere (anterior cerebral artery) lesions can cause this but are rare purchase losartan 25mg with visa diabetic diet menu foods. Monoplegia Contralateral hemisphere lesion in the motor cortex causing weakness of one limb 25mg losartan sale metabolic disease pediatrics, usually the arm order 25mg losartan mastercard diabetes insipidus zucker. Test the abil- r Bradykinesia (slowness in movements) is noticeable ity of the patient to sit on the edge of the bed with their when doing alternate hand tapping movements, or arms crossed. Micro- r Gait:Wide-basedgait,withatendencytodrifttowards graphia (small, spidery handwriting). Even a mild cerebellar problem makes tiation of movement is impaired (hesitancy) with the this very difﬁcult. A festinating gait is Causes include the following: r when the patient looks as though they are shufﬂing in Multiple sclerosis r order to keep up with their centre of gravity, and then Trauma r has difﬁculty in stopping and turning round. The three groups of tremor are distinguished by obser- r Metabolic: Alcohol (acute, reversible or chronic de- vation (see Table 7. If unilateral, the leg is swung out to the side to move it forwards (circumduction). If bilateral, the Extrapyramidal signs (Parkinsonism) pelvis has to alternately tilt and the gait often becomes r Appearance: Expressionless face. Thepatientcanstandontip-toe,butoften Resting tremor which is slow and classically pill- not on their heels. Even if mildly affected the patient is unable to strating whether seizure activity is suppressed by walk heel-toe in a straight line. In or encephalitis, as well as occurring in focal status Parkinson’s disease, this pattern tends to be asym- epilepticus. They are useful in the di- agnosis of muscle disease, diseases of the neuromuscular Electroencephalography junction, peripheral neuropathies and anterior horn cell disease. It is obtained by placing electrodes on the scalp, using a jelly to reduce electrical Electromyography resistance. A recording of at least half an hour is usually Aneedleelectrodeisplacedintomusclesandinsertional, needed, to maximise the chances of picking up tran- resting and voluntary electrical activity is studied, using sient abnormalities. Its main use is for the classiﬁcation of epilepsy, but is r Peripheral neuropathies and anterior horn cell disease it may also be useful in the diagnosis of other brain dis- lead to a reduced number of motor units, which ﬁre orders such as encephalitis. Surface electrodes or occasionally needles are used both r Suspected spinal cord compression. The knees are drawn up as far as possible and uation of brachial and lumbosacral plexus and nerve the neck ﬂexed, to open up the spinous processes of the roots. The lumbar puncture needle is inserted in the midline Lumbar puncture with its stylet in place aiming slightly towards the um- bilicus. If the needle encounters ﬁrm resistance, it Indications should be withdrawn and another approach tried. When any of the following are suspected: Sometimes the patient will feel a pain radiating into r Infection (meningitis, encephalitis, fungal infections the leg or back – this is due to the needle touching a or neurosyphilis). A simultaneous blood diagnosis of idiopathic (benign) intracranial hyperten- sample for glucose should be sent. Chapter 7: Cerebrovascular disease 295 Bleeding, infection, arachnoiditis, exacerbation of spinal various processing which may be performed on the data.
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