Professional Documents
Culture Documents
Priscilla's Guide To Medicine
Priscilla's Guide To Medicine
Table of Contents
SHORT CASES IN MEDICINE ............................................................................................................................................................ 5
MEDICINE = CARDIO SHORTS................................................................................................................................................................................ 5
MEDICINE = RESPI SHORTS ................................................................................................................................................................................... 9
MEDICINE = RENAL SHORTS ...............................................................................................................................................................................14
MEDICINE = ENDOCRINE SHORTS ......................................................................................................................................................................15
MEDICINE = HANDS SHORTS...............................................................................................................................................................................16
ENDOCRINE ........................................................................................................................................................................................ 17
MEDICINE (THYROID) = PHYSICAL EXAMINATION.........................................................................................................................................17
MEDICINE (THYROID) = INTRODUCTION .........................................................................................................................................................20
MEDICINE (THYROID) = THYROID LUMPS .......................................................................................................................................................23
MEDICINE (THYROID) = MANAGEMENT OF HYPERTHYROIDISM .................................................................................................................23
SURGERY (THYROID) = HYPERTHYROIDISM ....................................................................................................................................................26
MEDICINE (THYROID) = HYPOTHYROIDISM ....................................................................................................................................................30
SURGICAL (THYROID) = THYROID CARCINOMA ..............................................................................................................................................33
SURGICAL (THYROID) = THYROIDECTOMY ......................................................................................................................................................36
RHEUMATOLOGY ............................................................................................................................................................................. 38
MEDICINE (RHEUMATOLOGY) = RHEUMATOID ARTHRITIS SONG ...............................................................................................................38
MEDICINE (RHEUMATOLOGY) = GENERAL POINTS ABOUT ARTHRITIS .......................................................................................................39
MEDICINE (RHEUMATOLOGY) = SYSTEMIC LUPUS ERYTHEMATOSUS (SLE).............................................................................................40
MEDICINE (RHEUMATOLOGY) = GALS SCREEN ..............................................................................................................................................46
MEDICINE (RHEUMATOLOGY) = RHEUMATOID ARTHRITIS ..........................................................................................................................48
MEDICINE (RHEUMATOLOGY) = EXAMINATION OF RHEUMATOID HANDS .................................................................................................56
MEDICINE (RHEUMATOLOGY) = CASE STUDY .................................................................................................................................................59
MEDICINE (RHEUMATOLOGY) = CLERKING OF RHEUMATOID ARTHRITIS .................................................................................................62
MEDICINE (RHEUMATOLOGY) = SCLERODERMA LONG CASE .......................................................................................................................63
MEDICINE (RHEUMATOLOGY) = GOUT .............................................................................................................................................................66
MEDICINE (RHEUMATOLOGY) = GOUT HISTORY TAKING .............................................................................................................................68
MEDICINE (RHEUMATOLOGY) = CHRONIC TOPHACEOUS GOUT (SHORT CASE) .........................................................................................71
DIABETES ............................................................................................................................................................................................ 72
MEDICINE (DIABETES) = HISTORY TAKING .....................................................................................................................................................72
MEDICINE (DIABETES) = DIETARY ADVICE .....................................................................................................................................................74
MEDICINE (DIABETES) = COUNSELING A NEWLY DIAGNOSED DIABETIC ....................................................................................................75
MEDICINE (DIABETES) = DIABETES MANIFESTATIONS ................................................................................................................................76
MEDICINE (DIABETES) = DIABETES MELLITUS ..............................................................................................................................................77
MEDICINE (DIABETES) = HYPOGLYCEMIA .......................................................................................................................................................79
MEDICINE (DIABETES) = DIAGNOSIS OF DM ..................................................................................................................................................81
RENAL MEDICINE ............................................................................................................................................................................. 83
MEDICINE (RENAL) = NEPHROTIC SYNDROME HISTORY TAKING...............................................................................................................83
MEDICINE (RENAL) = NEPHROTIC SYNDROME ...............................................................................................................................................85
MEDICINE (RENAL) = SECONDARY HYPERTENSION ......................................................................................................................................89
MEDICINE (RENAL) = DIALYSIS MODALITIES ..................................................................................................................................................90
MEDICINE (RENAL) = RENAL TRANSPLANT (MAJOR RISKS) .......................................................................................................................92
MEDICINE (RENAL) = ADULT POLYCYSTIC KIDNEY DISEASE (APKD) ......................................................................................................92
sound was loud and there was an opening snap followed by a mid-diastolic murmur heard best over the
apex which was accentuated with the patient in the left lateral position. There was no PSM heard over the
tricuspid area or Graham-Steell murmur heard over the pulmonary area.
This was not associated with signs of right heart failure as the jugular venous pressure was not raised and
there was no peripheral oedema. Auscultation of the lung bases also did not reveal the presence of
inspiratory crepitations.
So in summary, Mdm XXX is an elderly chinese lady who has mitral stenosis. I say this because
(a) presence of atrial fibrillation
(b) tapping apex beat which is not displaced
(c) opening snap with a MDM heard best over the apex and accentuated by the patient lying in the left
lateral position
This is not complicated by pulmonary hypertension, congestive cardiac failure, infective endocarditis or
over-anticoagulation
# Request to examine = neurological system (pronator drift for hemiplegia)
peripheral pulses (occlusion by emboli)
Mitral regurgitation
Mdm XXX is an elderly chinese lady who appears to be alert, well, comfortable and orientated at rest. Her
vitals are as follows = HR 80/min, regular. There is no RR delay, RF delay or collapsing pulse. RR is 16/min, not
tachypneic or dyspnoeic. She does not appear to be in any respiratory distress and is pink on room air. On
general inspection, there are no signs of pallor, jaundice or cyanosis.
On examination of the peripheries, there are no stigmata of infective endocarditis such as clubbing, splinter
haemorrhages, Janeway lesions or Osler nodes.
On examination of the praecordium, there were no surgical scars or chest wall deformities. The apex beat
was displaced in the 6th intercostal space 1cm lateral to the mid-clavicular line and was heaving in nature.
There was no parasternal heave or thrills felt over the base of the heart. On auscultation, the first and
second heart sounds were heard. There was no 3rd heart sound. In addition, there was a grade 3/6 PSM
heard loudest over the apex with radiation to the axilla. There was no radiation to the carotids.
This was not associated with signs of right heart failure as the jugular venous pressure was not raised and
there was no peripheral oedema. Auscultation of the lung bases also did not reveal the presence of
inspiratory crepitations.
So in summary, Mdm XXX is an elderly chinese lady who has mitral regurgitation. I say this because
(a) displaced apex beat which is heaving in nature
(b) grade 3/6 PSM heard loudest over the apex with radiation to the axilla
This is not complicated by congestive cardiac failure or infective endocarditis
Aortic stenosis
Mdm XXX is an elderly chinese lady who appears to be alert, well, comfortable and orientated at rest. Her
vitals are as follows = HR 80/min, regular. There is no RR delay, RF delay or collapsing pulse. However, I note
that the pulse is of low-volume and slow-rising in nature. RR is 16/min, not tachypneic or dyspnoeic. She
does not appear to be in any respiratory distress and is pink on room air. On general inspection, there are
no signs of pallor, jaundice or cyanosis.
On examination of the peripheries, there are no stigmata of infective endocarditis such as clubbing, splinter
haemorrhages, Janeway lesions or Osler nodes.
On examination of the praecordium, there were no surgical scars or chest wall deformities. The apex beat is
not displaced and is thrusting in nature. There was no parasternal heave or thrills felt over the base of the
heart. On auscultation, the first and second heart sounds were heard. There was no 4 th heart sound. In
addition, there was a grade 3/6 ESM heard loudest over the aortic area with radiation to the carotids
which was accentuated by forced expiration.
This was not associated with signs of right heart failure as the jugular venous pressure was not raised and
there was no peripheral oedema. Auscultation of the lung bases also did not reveal the presence of
inspiratory crepitations.
So in summary, Mdm XXX is an elderly chinese lady who has aortic stenosis. I say this because
(a) low-volume slow-rising pulse (anacrotic pulse)
(b) apex beat is not displaced and is thrusting in nature
(c) grade 3/6 ESM heard loudest over the aortic area with radiation to the carotids and accentuated by
forced expiration
This is not complicated by congestive cardiac failure or infective endocarditis
# Request = BP (narrow pulse pressure)
Aortic regurgitation
Mdm XXX is an elderly chinese lady who appears to be alert, well, comfortable and orientated at rest. Her
vitals are as follows = HR 80/min, regular. There is a collapsing pulse noted but no RR delay or RF delay. RR is
16/min, not tachypneic or dyspnoeic. She does not appear to be in any respiratory distress and is pink on
room air. On general inspection, there are no signs of pallor, jaundice or cyanosis.
On examination of the peripheries, there are no stigmata of infective endocarditis such as clubbing, splinter
haemorrhages, Janeway lesions or Osler nodes.
On examination of the praecordium, there were no surgical scars or chest wall deformities. The apex beat is
displaced in the 6th intercostal 1cm lateral to the mid-clavicular line and is heaving in nature. There was no
parasternal heave or thrills felt over the base of the heart. On auscultation, the first and second heart
sounds were heard. There was no 3rd heart sound. In addition, there was a grade 2/6 EDM heard loudest
over the upper left sternal edge which was accentuated with forced expiration. There was no Austin-Flint
murmur detected.
This was not associated with signs of right heart failure as the jugular venous pressure was not raised and
there was no peripheral oedema. Auscultation of the lung bases also did not reveal the presence of
inspiratory crepitations.
So in summary, Mdm XXX is an elderly chinese lady who has aortic regurgitation. I say this because
(a) collapsing pulse
(b) displaced apex beat which is heaving in nature
(c) grade 2/6 EDM heard loudest over the upper left sternal edge and accentuated by forced expiration
This is not complicated by congestive cardiac failure or infective endocarditis
# Request = BP (wide pulse pressure; Hills sign)
other features of AR
Tricuspid regurgitation
Mr XXX is a young chinese gentleman who appears to be alert, well, comfortable and orientated at rest. His
vitals are as follows = HR 80/min, regular. There is no RR delay, RF delay or collapsing pulse. RR is 16/min, not
tachypneic or dyspnoeic. He does not appear to be in any respiratory distress and is pink on room air. On
general inspection, there are no signs of pallor or cyanosis. However, he appears to be jaundiced.
On examination of the peripheries, there are no stigmata of infective endocarditis such as clubbing, splinter
haemorrhages, Janeway lesions or Osler nodes. I did not note the presence of needle tracks in the cubital
fossae.
On examination of the praecordium, there are no surgical scars or chest wall deformities. The apex beat is
not displaced and is normal in nature. There was a parasternal heave detected but no thrills were felt over
the base of the heart. On auscultation, the first and second heart sounds were heard. There was no loud
P2. In addition, there was a grade 3/6 PSM heard loudest over the lower left sternal edge which was
accentuated with forced inspiration. I did not hear a MDM which might be suggestive of mitral stenosis.
This is associated with signs of right heart failure as the jugular venous pressure was raised till the level of the
mid-neck with giant v waves seen. There was also bilateral lower limb pitting oedema till the level of the
knees. However, auscultation of the lung bases also did not reveal the presence of inspiratory crepitations.
So in summary, Mr XXX is a young chinese gentleman who has tricuspid regurgitation. I say this because
(a) jaundiced
(b) parasternal heave but with no other signs of pulmonary hypertension
(c) grade 3/6 PSM heard loudest over the lower left sternal edge and accentuated by forced inspiration
(d) signs of right heart failure with raised JVP, giant v waves and lower limb pitting oedema
This is not complicated by left heart failure or infective endocarditis
# Request = abdomen (pulsatile liver, hepatomegaly, splenomegaly)
respiratory system (COPD, bronchiectasis, pulmonary fibrosis)
On examination of the chest, I did not note any surgical scars or chest wall deformities. The main physical
findings are that of a right-sided pleural effusion. I say this because there is decreased chest expansion over
the right lower third of the posterior chest associated with stony dull percussion, decreased breath sounds
as well as decreased vocal resonance. There was no cervical lymphadenopathy.
I looked for but did not find any underlying aetiology. In particular, there were no other abnormal chest
findings, hand deformities, characteristic malar rash or stigmata of chronic liver and renal disease. I would
have liked to examine the cardiovascular system in detail but I note that there is no lower limb oedema.
So in summary, Mr XXX is an elderly chinese gentleman who has a right-sided pleural effusion. I say this
because the right lower chest
(a) decreased chest expansion
(b) stony dull percussion note
(c) decreased air entry
(d) decreased vocal resonance
This is likely to be a small effusion as there is no mediastinal displacement. He is currently not in respiratory
distress
Pulmonary fibrosis
(after examination) I would like to complete my examination by requesting for the vitals and sputum mug
as well as to examine the patient for a raised JVP
Mdm XXX is a middle-aged chinese lady who appears to be alert at rest. Her vitals are as follows: HR
80/min, regular and not bounding. She appears to be in respiratory distress as evidenced by tachypnoea
with a RR of 24/min, on supplemental oxygen via nasal prongs at 2L/min, use of accessory muscles of
respiration as well as the presence of intercostal retractions. There is also evidence of central cyanosis.
However, there is no terminal asterixis. On general inspection, she does not appear to be cachexic. There
are no signs of pallor or jaundice.
On examination of the peripheries, I note the presence of digital clubbing. However, there are no tar stains,
wasting of the intrinsic hand muscles or tenderness and swelling over the wrist joints. There are also no signs
suggestive of Horners syndrome. The trachea and apex beat are not displaced.
On examination of the chest, there are no surgical scars or chest wall deformities. The main physical
findings are suggestive of bibasal pulmonary fibrosis. I say this because there is dullness to percussion over
the lung bases associated with decreased air-entry and fine end-inspiratory crepitations that do not clear
with coughing. Vocal resonance is normal. There is no cervical lymphadenopathy.
There is no evidence of pulmonary hypertension as there was no parsternal heave or palpable P2
detected. I would have liked to examine the patient for a raised JVP but I note that there is no lower limb
oedema.
So in summary, Mdm XXX is an elderly chinese lady who has bilateral lower lobe fibrosis. I say this because
of
(a) digital clubbing
(b) bibasal fine end-inspiratory crepitations which do not clear with coughing
She is currently in respiratory distress as evidenced by tachypnoea and central cyanosis. However, her
condition is not complicated by pulmonary hypertension or cor pulmonale.
My differentials are
(a) congestive cardiac failure with pulmonary oedema no clubbing, evidence of fluid overload,
crepitations clear with coughing
(b) bronchiectasis productive cough, coarse pan-inspiratory expiratory crepitations
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because there is decreased chest expansion, dullness to percussion, decreased air-entry associated with
coarse pan-inspiratory crepitations, bronchial breathing as well as increased vocal resonance. There is no
cervical lymphadenopathy.
So in summary, Mr XXX is an elderly chinese gentleman who has evidence suggestive of consolidation in
the lower 1/3 of the right posterior chest. I say this because
(a) decreased chest expansion
(b) dullness to percussion
(c) decreased air-entry, coarse pan-inspiratory crepitations, bronchial breathing
(d) increased vocal resonance
He is currently not in respiratory distress.
Collapse
(after examination) I would like to complete my examination by requesting for the vitals and sputum mug
Mr XXX is an elderly chinese gentleman who appears to be alert at rest. His vitals are as follows: HR 80/min,
regular and not bounding, RR 16/min not tachypneic or dyspnoeic. He does not appear to be in any
respiratory distress and is pink on room air. On general inspection, Mr XXX appears to be cachexic. There
are no signs of pallor, cyanosis or jaundice.
On examination of the peripheries, there is no sign of digital clubbing, tar stains, wasting of the intrinsic
hand muscles or tenderness and swelling over the wrist joints. There are also no signs suggestive of Horners
syndrome. There is tracheal deviation to the right with no mediastinal displacement.
On examination of the chest, there are no surgical scars or chest wall deformities. The main physical
findings are in the upper 1/3 of the right anterior chest suggestive of an upper lobe collapse. I say this
because of right tracheal deviation, flattening of the right chest wall, decreased chest expansion, dullness
to percussion, decreased air-entry as well as decreased vocal resonance. There is no cervical
lymphadenopathy.
So in summary, Mr XXX is an elderly chinese gentleman who has evidence suggestive of a right upper lobe
collapse. I say this because
(a) right tracheal deviation
(b) flattening of right chest wall
(c) decreased chest expansion
(d) dullness to percussion
(e) decreased air-entry and vocal resonance
He is currently not in respiratory distress.
# important to exclude malignancy
# Brocks syndrome = collapse due to compression of right middle lobe bronchus by enlarged lymph node
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Lung cancer
(after examination) I would like to complete my examination by requesting for the vitals and sputum mug
Mr XXX is an elderly chinese gentleman who appears to be alert at rest. His vitals are as follows: HR 80/min,
regular and not bounding, RR 16/min not tachypneic or dyspnoeic. He does not appear to be in any
respiratory distress and is pink on room air. On general inspection, I note that he is cachexic. There are/are
no signs of pallor or jaundice.
On examination of the peripheries, I note the presence of digital clubbing as well as hypertrophic
pulmonary osteoarthropathy. However, there are no tar stains, wasting of the intrinsic hand muscles or
features suggestive of Horners syndrome.
On examination of the chest, there are no surgical scars or chest wall deformities. The main physical
findings are that of a collapse-consolidation over the right upper 1/3 of the posterior chest as well as a
right-sided pleural effusion involving the lower 2/3 of the posterior chest. I say this because
(a) collapse-consolidation
- tracheal deviation to the right
- dull percussion note
- decreased air-entry with no adventitious sounds
- increased vocal resonance
(b) pleural effusion
- decreased chest expansion over the right lower chest
- stony dull percussion note
- decreased air-entry with no adventitious sounds
- decreased vocal resonance
- likely to be moderate in size as the apex beat is slightly displaced in the 6 th intercostal space 1cm lateral
to the mid-clavicular line
In addition, multiple small enlarged cervical lymph nodes were found bilaterally ranging from 1-2 cm in
length. They were non-tender, firm, matted and relatively immobile.
So in summary, Mr XXX has multiple chest findings including a right upper lobe collapse-consolidation as
well as a right-sided pleural effusion. He most likely has a right lung malignancy. This is supported by the
findings of cachexia, pallor, clubbing, HPOA as well as cervical lymphadenopathy.
I would like to examine the patient for hepatomegaly, focal neurological deficits and to percuss the
vertebral column for tenderness.
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Endocrine
Medicine (Thyroid) = Physical Examination
Start
1. Ask the patient to sit comfortably at the edge of the bed or on a chair.
2. Introduce yourself and explain purpose for examination.
Inspection
1. General appearance
restless, edgy, nervous
thin/large body habitus
2. Eyes
Thyroid stare
Exophthalmos (visible sclera below lower limbus)
Lid retraction (upper limbus visible due to sympathetic overstimulation of lipopolysaccharide)
Lid oedema (chemosis, conjunctivitis, exposure keratitis, tarsorraphy)
Strabismus
3. Neck
Goiter (diffuse/nodular)
Overlying skin changes (erythema, tethering of skin)
Dilated veins (suggests retrosternal extension with thoracic inlet obstruction)
Previous surgical scar along skin creases
4. Ask patient to drink a sip of water but only swallow at your command
If neck swelling rises (due to attachment to larynx) thyroid, thyroglossal cyst
If inferior border not visible retrosternal extension
5. Ask the patient to open mouth and protrude tongue thyroglossal cyst
Palpation
1. Ask the patient if there is pain subacute thyroiditis malignant infiltration, haemorrhage into cyst
2. Move behind the patient and look over his head for proptosis
3. Begin palpation from behind with pulps of fingers over the gland. Slightly flew patients neck to relax SCM
4. Feel the isthmus (overlies thyroid cartilage) and then the lobes
Size = WHO grading of goiter
Grade 0
Grade 1
Grade 2
Grade 3
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MR palsy
Lid retraction and Lid lag
Opthalmoplegia
Exophthalmos and Chemosis
Legs
1. Pretibial myxoedema
Elevated symmetrical skin lesions
Well-defined
Red but not inflamed
Swollen but not edematous
Skin is shiny and has peau d orange appearance
Request
1. Pembertons sign (thoracic inlet obstruction retrosternal extension)
Instructions = ask patient to lift arms over the head and wait for 1 minute
+ve sign = facial plethora, cyanosis, inspiratory stridor, non-pulsatile elevation of JVP (main
features), periorbital oedema, exophthalmos, conjunctival injection, retinal venous dilation, dilated
collateral vessels on the chest
2. Vitals = T: (subacute thyroiditis), BP (wide pulse pressure, collapsing pulse)
3. Chest = gynecomastia, CVS examination (signs of CCF)
4. Eye examination and referral
Visual field defect
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Embryology
1. Descends from foramen caecum (lies in the midline at the junction of the anterior 2/3 and posterior 1/3 of
the tongue) to normal position in the neck
2. Brings with it parathyroid glands on each side
3. Eventually rises at the level of the 2nd and 3rd tracheal rings
4. Failure to descend ectopic thyroid tissue
Physiology
Regulation of thyroid hormone release
1. Hypothalamus secretes TRH (thyrotropin-releasing hormone)
2. TRH stimulates the production of TSH (thyroid stimulating hormone) from the anterior pituitary gland
3. TSH acts on the thyroid gland to increase production and release of T3 and T4
4. T3 + T4 exerts negative feedback on TSH production by acting on the pituitary gland
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hypothalamus
TR
H
TSH
thyroid gland
T3 + T4
peripheral tissues
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Functions of T3 and T4
1. binds to nuclear thyroid hormone receptor hormone receptor complex binds to thyroid hormone
response elements in target genes regulate gene expression
2. metabolic effects =
up regulate carbohydrate and lipid catabolism
stimulate protein synthesis
increase basal metabolic rate therefore increase heat production
3. critical for development and function of
central nervous system
skeletal muscle (growth)
reproductive tissue
4. effects are potentiated by human growth hormone
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Organification
thioamides
iodides
thioamides
coupling
Endocytosis
release
iodides
lithium
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Anions
* No longer in use
Thioamides
* MOA = interferes with oxidation, Organification and coupling (inhibit thyroid peroxidase enzyme)
* 2 main types
(a) Propylthiouracil (PTU) (also inhibits peripheral conversion of T4 to T3)
- Strong binding to plasma proteins unlikely to cross placenta and enter breast-milk
- For use in pregnant and lactating mothers
(b) Carbimazole
- Partially metabolised in liver to active metabolite (methimazole longer t1/2)
- crosses placenta and secreted in breast-milk
- preferred over PTU due to more convenient dosing (OM vs TDS)
* Indications = definitive treatment for thyrotoxicosis (1-2yrs)
Pre-operative treatment (shrink gland before surgery)
Awaiting effects of RAI
* S/E = agranulocytosis (1st sign is sore throat; Mx = stop meds, admit immediately, take blood
C/s, IV broad-spectrum antibiotics, barrier nursing)
Hypersensitivity reactions (pruritic MP rash, fever)
Cholestatic hepatitis
Arthralgia
* Advantages = reversible hypothyroidism
Can be used in children
* Disadvantages = high relapse rate once drug is withdrawn (60-80%)
Side-effects
Slow onset (requires 3-4 weeks to deplete pre-formed thyroid stores)
Iodides
* MOA = interferes with Organification and release of thyroid hormones
* Indications = pre-operative treatment for surgery (given for 10 days prior)
Treatment of thyroid storm
Prophylaxis against endemic goiter
* S/E = hypersensitivity reaction
Iodism from chronic overuse (bleeding disorders, conjunctivitis, drug fever, inflamed
Salivary glands, metallic taste, oral ulcers, rash)
* Advantages = decreases size and vascularity of gland
* Disadvantages = increases thyroid iodine stores (delays effectiveness of thioamide and RAI
Therapy
Severe exacerbation of thyrotoxicosis on drug withdrawal
Radioactive iodine (RAI)
* MOA = RAI emits both and waves
waves penetrates 0.5mm of thyroid tissue and destroys follicular cells
No damage to surrounding tissue
Radioactivity disappears after 2 months (cytotoxic effects peak at 4 months)
* Advantages = convenient (single oral dose)
Inexpensive
Usually results in permanent cure
* Disadvantages = takes 2-3 weeks to take effect (need to give anti-thyroid drugs in the interim)
Cannot be used in children (risk of genetic damage cancer)
Hypothyroidism require life-long L-thyroxine
Exacerbates pre-existing thyroid eye disease
Radiation induced thyroid dysfunction (hyperthyroid in 5%, hypothyroid in
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30%)
* Indications
(a) Not fit for surgery
(b) failed pharmacological therapy
(c) Adverse effects from anti-thyroid drugs agranulocytosis, hepatotoxicity
(d) Relapse after previous surgery
* Contraindications
(a) Children
(b) Patients who are pregnant or intending to get pregnant within the next 6 months
(c) Lactating mothers
(d) Iodine allergy
(e) Severe thyroid eye disease
* Process = render patient euthyroid with anti-thyroid drugs
Stop medications 4 days prior to administration and restart 4 days later
* Advice to give
- Stay at home for 2-3 weeks
- avoid public places
- avoid pregnant women and children for 1/52
- Exacerbation of symptoms within first 2 weeks (esp if not euthyroid before treatment)
- Stress on importance of regular f/u and the need to report hyper/hypo-thyroid symptoms
- need for lifelong L-thyroxine
- avoid pregnancy for the next 6 months
- Condition may relapse
* Efficacy = 10-30% become hypothyroid in the 1st year
5% per year thereafter
Symptomatic control
* Sinus tachycardia = -blockers
* AF = digoxin, -blockers (rate control)
Warfarin (prevent embolic complications)
Protective eye measures
* General measures = hypromellose eye drops (day)
Lubricating eye ointment (night)
Tinted glasses (protection from sun, wind, and FB)
Stop smoking
* Specific measures
(a) Exposure keratitis, corneal ulceration lateral tarsorraphy
(b) Strabismus, diplopia prism glasses, surgery
(c) Papilloedema, loss of visual acuity, visual field defect
# Urgent Rx with PO prednisolone 60mg OM
# Orbital radiation
# Plasmapheresis
# Orbital decompression by surgical removal of floor and medial orbital wall (if no improvement within 7296 hours)
Surgery
* Advantages = usually results in permanent cure
* Disadvantages = will require life-long L-thyroxine
Risks of surgery (refer)
* Prognosis of the end of 1 year = 80% euthyroid, 15% hypothyroid, and 5% relapse
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Graves Disease ( GD )
* definition = diffuse enlargement of thyroid gland due to TSH receptor-stimulating auto antibodies which frequently
Results in Hyperthyroidism
* Commonest cause of thyrotoxicosis in Singapore (>90%)
* affects 1.28% of the population
* pathogenesis= stimulating auto-antibodies against TSH-receptor
* clinical features = diffuse and smooth goitre
Occurs in young females ( 20-40 years old )
Strongly associated with HLA-DR3 inheritance
Associated with AI disorders ( IDDM, pernicious anaemia, vitiligo, Addisons disease, myasthenia
Gravis)
* 5 indicators of toxicity
(a) Resting tachycardia
(b) Warm and sweaty palms
(c) Fine Tremors
(d) Hyper-reflexia
(e) Thyroid bruit
*features unique to GD : Graves opthalmoplegia, pretibial myxoedema, thyroid bruit
*Graves opthalmoplegia
- increased volume of retro-orbital connective tissues and extraocular muscles
- does not depend on thyroid status
- orbital fibroblasts aberrantly express TSH receptors differentiate into adipocytes secrete
Glycosaminoglycansfibrosis and swelling
-due to = marked infiltration of retro-orbital space by mononuclear cells
Inflammatory oedema and swelling of extra-ocular muscles
Accumulation of ECM components ( glycosaminoglycans, hyaluronic acid)
Increased adipocyte differentiation leading to fatty infiltration
-factors that increase risk = age, male gender, smoking , RAI ( steroids usually given to decrease risk)
* Little evidence to suggest increased frequency of thyroid cancer in GD
* Management = anti-thyroid drugs ( PTU, carbimazole)
-blockers ( block sympathetic effects on CVS )
RAI
Subtotal thyroidectomy
Protective eye measures
* Graves disease in pregnancy = TSH-receptor Ab crosses placenta fetal hyperthyroidism
Anti-thyroid agents crosses placenta fetal hypothyroidism
Multi-nodular Goitre
* epidemiology = commonest cause of goitre in the UK
Usually in older women ( 60 years old)
* pathogenesis = occurs spontaneously or in long standing simple goitre
-reflects impaired synthesis of thyroid hormones
-results from repeated stimulation and involution of thyroid follicles
- low levels of thyroid hormonescompensatory rise in serum TSH levelshypertrophy and hyperplasia of
Follicular cellsdiffuse goitreinvolution of follicular epithelium if dietary iodine increases or demand for
Thyroid hormone decreases
-endemic goitre= due to iodine deficiency
-physiological goitre= occurs in puberty and pregnancy due to increased demands
* Clinical features
(a) usually euthyroid
(b) Hyperthyroidism/Thyrotoxicosis
- hyperactive focal nodule within long-standing goitre (Plummer syndrome)toxic MNG
- Permanent with no spontaneous remission. Therefore, anti-thyroid drugs not appropriate long-term Rx.
(c) mass effects
(d) malignant change < 5%
* Management
(a) anti-thyroid drugs ( not useful as relapse occurs after withdrawal; autonomous nodule not responsive to
Medications)
(b) RAI = lower risk of hypothyroidism
(c) Subtotal thyroidectomy = for compressive symptoms
27
* Comparison with GD
Graves Disease
Younger patients
Diffuse goitre
Eye signs common
AF uncommon
Autoimmune disorders common
Toxic adenoma
* Epidemiology= usually in females > 40 yrs old
* Arises from follicular adenoma ( benign neoplasia derived from follicular epithelium)
- vast majority are non-functional
- small portion undergo toxic change to cause thyrotoxicosis
- rarely precursors of cancer
* Pathogenesis= activating somatic mutations in TSH receptor signalling pathway chronic cAMP pathway
Stimulation generates cells that acquire growth advantage
* Histopathology = discrete solitary mass, well circumscribed, encapsulated, no infiltrative margins, atrophy of
Remaining gland, cut surface brown and glistening ( due to colloid), uniform follicular growth,
No areas of necrosis or haemorrhage
* Clinical features = painless mass
Mild hyperthyroidism ( 50% have isolated elevation of T3 only)
* Management
(a) Anti-thyroid drugs ( not useful as relapse occurs after withdrawal)
(b) RAI = lower risk of hypothyroidism due to compensation of remaining thyroid gland
(c) surgery
Thyrotoxic Periodic Paralysis
* Epidemiology = usually in Asian males
Onset in 3rd- 4th decades
* associated with transient hypokalemia
-triggers = high carbohydrate intake ( insulin release intracellular shift of K + )
Exercise/trauma/infection/emotional stress ( adrenalin release)
- dextrose and agonists may exacerbate hypokalemia
* Clinical features
- episodic limb weakness lasting 7-72 hours
- no weakness in between attacks
* Investigations
(a) U/E/Cr
(b) ECG = ST depression, flattened T waves, prominent U waves
* Management
- control thyrotoxicosis
- replace K= propanolol, spironolactone , K+ supplements
Thyroid Storm
* acute life threatening hyper metabolic state induced by excessive release of thyroid hormones in individuals with
Thyrotoxicosis
(a) Surgical = inadequately prepared thyrotoxic patient undergoing thyroid surgery
Non-thyroidal surgery in patients with undiagnosed thyrotoxicosis
(b) Medical
-sepsis ( most common precipitating cause)
-RAI
-sudden withdrawal of anti-thyroid drugs
-administration of iodinated contrast medicum
-infarction ( AMI,CVA)
-trauma
* Clinical features
- hyperpyrexia, diaphoresis, palpitations, tachyarrythmias, hypertension with wide pulse pressure, CCF, tremors,
28
delirium, agitation, frank psychosis, seizures, nausea, vomiting, diarrhoea, abdominal pain, jaundice
-complications: high-output cardiac failurehypotensive shock. Dehydration. Multi-organ dysfunction syndrome
* Burch-Wartofsky score
-scoring system = >25 (thyrotoxicosis possible)
= >45 ( thyroid storm probable)
-based on = temperature
CNS effects
Hepatogastrointestinal dysfunction
Tachycardia
Congestive Cardiac Failure
AF
History suggestive of thyrotoxicosis
* Investigations = FBC, U/E/Cr, LFT, TFT, ECG, CXR, septic work-up
* Management
-admit patient in HD or ICU
-urgent referral to endocrinologist
(a) PO PTU/ carbimazole or lithium carbonate ( if allergic to the former) = rapidly lowers T3 levels
(b) IV sodium iodide = blocks further release
Must be given at least 1 hr after PTU (or else will exacerbate thyrotoxicosis)
(c)Tachycardia= IV propranolol
(d)AF = IV digoxin
Cardioversion if unstable
Anti-coagulate if unstable
(e) IV dexamethasone = protect against shock, block peripheral conversion of T4 to T3
(f) CCF = digoxin, diuretics
(g)supportive therapy = oxygen supplementation
Monitor vitals
IV hydration ( hyperpyrexia, diaphoresis, vomiting, diarrhoea)
Tepid sponging, ice packs, anti-pyretics (do not give aspirininhibits binding of thyroid
hormones to
Binding proteins)
Sedation if patient restless (chlorpromazine)
Treat precipitating cause (antibiotics)
* should respond to above therapy within 24-48 hours
Compressive effects of goitre
Venous drainage
* facial congestion
*cyanosis
*plethora
*dilated veins in face and neck
Oesophagus
*dysphagia
Trachea
*stridor=positional in nature (on neck extensionpush goitre into thoracic inlet)
*may cause trachomalaciapost operative complication
Recurrent laryngeal nerve
*direct invasions
*lymphadenopathy
*hoarseness of voice
Carotids
*arteries usually resistant to tumour invasion
*drop attacks(rare)
29
30
- coarse facial features (periorbital oedema, thick nose and lips, macroglossia)
- loss of outer 1/3 of eyebrows
- xanthelasma
- hoarse voice (sound like jabba the hutt)
* neck
- previous thyroidectomy scar
- goitre
* peripheries
- pulse -> bradycardia
- Tinels test -> carpal tunnel syndrome
- finger-nose test and dysdiadochokinesis -> cerebellar syndrome
- proximal myopathy
- ankle jerks -> delayed relaxation
- abdomen -> faecal masses
Investigations
Confirm diagnosis
* thyroid function test = low fT4, high TSH
* thyroid auto-Ab panel = TSH-receptor inhibitory Ab, anti-TG Ab, anti-TPO Ab, anti-microsomal Ab
* RAI = reduced radioisotope uptake
Complications
* FBC = anaemia secondary to menorrhagia
* fasting lipid panel = increased TC and TG
Associated AI disorders
* IDDM = fasting glucose, HbA1c
* pernicious anaemia = Hb, MCV, vitamin B12 levels, anti-IF Ab, anti-parietal cell Ab
* Addisons disease = U/E/Cr (hypo Na+ and hyper K+)
Evidence of decompensation
* serous effusions = pleural, pericardial, joint
* carpal tunnel syndrome
* cerebellar syndrome
* bradycardia/heart failure
* dyslipidaemia
* depression/psychosis
Hashimotos thyroiditis
* autoimmune inflammation of the thyroid gland usually in middle aged women (45-65 yrs old)
* a/w other AI disorders IDDM, Addisons disease, pernicious anaemia, SLE, MG, B-cell NHL
* clinical features = insidious onset of hypothyroidism a/w painless enlargement of thyroid gland
* Mx = L-thyroxine replacement
monitor for malignancy (lymphoma) -> do serial neck examinations
Post-partum thyroiditis
* autoimmune inflammation of the thyroid gland occurring 2-10 months post-partum
- associated with anti-thyroid peroxidise antibodies
- very similar to Hashimotos thyroiditis -> cannot be distinguished on pathology specimens
- current theory = underlying asymptomatic AI thyroiditis that flares post-partum due to fluctuations
of immune function
- clinical features = silent (no pain or swelling)
short period of hyperthyroid -> prolonged but self-limiting period of hypothyroid
Riedels thyroiditis
* extremely rare disease
* unknown aetiology (? Autoimmune)
* clinical features = slight enlargement of thyroid gland
woody hard and fixed mass (thyroid parenchyma replaced with fibrous tissue which
filtrates into surrounding neck structures)
31
32
33
2. Possibly of using radioactive iodine = cannot be used if only hemithyroidectomy done due to uptake in
normal thyroid lobe
3. Use of TG as surveillance method to detect recurrent or metastatic disease
Follicular Carcinoma
Makes up 10-20% of thyroid carcinomas
Occurs in young and middle aged adults (40-60 yrs old)
Linked to endemic goitres
Tendency to metastasize early by homogenous route (liver, bones, lungs). Worse prognosis!
Tx
o Total thyroidectomy
o L thyroxine replacement
o Radioactive iodine
Medullary Carcinoma
Makes up 5% of thyroid carcinomas
Occurs in young and middle aged adults (40-60 yrs old)
Arises from parafollicular c (neuroendocrine) cells -> secrete calcitonin
80% arises spontaneously (in the elderly) -> unifocal; worse prognosis
20% may be familial and linked to MEN 2 syndrome (screen family members) -> multifocal; better prognosis)
# MEN 2 syndrome = medullary thyroid cancer, pheochromocytoma, primary hyperparathyroidism due to RET
proto-oncogene mutation
100% penetrance for MTV; 90% penetrance for PCC, 50% for primary hyperparathyroidism
Metastasize by local extension, lymphatic and hematogenous routes
Pathology = amyloid trauma
Tx :
o Pheochromocytoma (urinary catecholamine) and parathyroid hormone (ipTH and Ca2+)
o Screen pre op
o Total thyroidectomy (resect pheochromocytoma first, remove all parafollicular cells -> junction of
middle and lower third of thyroid gland)
o Monitor calcitonin levels
Anaplastic Carcinoma
Least common of the thyroid carcinomas (<5%)
Occurs in the elderly (60-80 yrs old)
Aggressive tumour with local extension and distant metastasis via lymphatic and hematogenous routes
Very poor prognosis (average survival is 6-9 mths after diagnosis)
Must be differentiated from lymphoma (better outcome)
Tx:
o Debulking surgery
o Palliative radiotherapy and chemotherapy
Lymphoma
Require biopsy to make diagnosis
Tx : radiotherapy and chemotherapy
34
Clinical Features
History
Lump in neck
Mass pressure effects =
Physical examination
Lump in the neck = ill defined, solitary, hard, immobile, tender
o Usually spreads to the LNs in the tracheal-oesphageal groove (level 6)
o Can affect levels 2 (jugulo-digastric), 3 (mid-jugular), 4 (supraclavicular) as superior thyroid pedicle
drains in a cephalic direction
o Not commonly seen or palpable unless >1.5-2 cm in diameter
Palpable deep cervical lymph nodes (10% of cancers)
Palpable deep cervical lymph nodes (10% of cancers)
+ or signs of hyperthyroidism
Management
Total thyroidectomy -> remove both sides + paratracheal lymph nodes +- cervical lymph nodes
Recurrence and mortality increases by 2x if not done!
RAI ablate residual cells
Scan for metastasis in chest cavity and bone
Monitor TSH/TG regularly -> increases with recurrence (should not have any thyroid tissue left)
o No thyroglobulin
o TSH 0.1ng/ml
Monitor calcitonin levels if patient has medullary carcinoma
L-thyroxine replacement for life -> suppress TSH release (remove stimulus for remaining tirrue)
No remaining T3 + T4 synthesis
Lifelong follow up : Physical examination (cervical LAD, thyroid gland)
Thyroid Ultrasound
35
1. Lobectomy
2. Subtotal thyroidectomy (GD)
3. Total thyroidectomy (MNG, carcinoma)
# Normal thyroid lobe is the size of distal phalanx of the thumb (4g) -> leave the equivalent behind
Indications for thyroid surgery
C Cancer
C- Control
C Compression (dyspnoea, stridor, cough, hoarseness, dysphagia)
C Comesis
Pre-operative considerations
Operating Procedure
Specific
Early:
a) Haemorrhage
Can compress trachea very easily (limited space between strap muscles and trachea)
Clinical features = dyspnea, stridor, shock
Management = remove sutures immediately
b) Pneumothorax
c) Thyroid storm
d) Hypoparathyroidism
Inadvertent removal or injury to the parathyroid glands during surgery
Hypocalcemic tetany usually occurs POD 2-5
Clinical features =
a)
Circumoral parasthesiae
b)
Tingling of extremities
c)
Painful carpopedal spasms
d)
Laryngospasm
36
e)
Chvosteks sign (tapping of facial nerve in front of external auditory meatus will
cause hemifacial spasm
f) Trousseaus sign (carpopedal spasms induced by tourniquet around arm)
Management: slow infusion of 10ml of 10% calcium gluconate (extravasations can cause
necrosis) and oral calcium intake
e) Recurrent laryngeal nerve damage
Lies behind the thyroid gland in the groove between oesophageal and trachea
Close to the inferior thyroid artery
Damage to 1 nerve -> slight hoarseness (weak voice)
Damage to 2 nerves -> almost complete loss of voice + severe airway narrowing
f) External branch of the superior laryngeal nerve damage
Travels with the superior arterio-venous pedicle
Damage affects high frequency speech and voice projection
Late
a) Hypothyroidism -> L thyroxine for life if total thyroidectomy
b) Recurrent hypothyroidism
c) Keloid scarring
37
Rheumatology
Medicine (Rheumatology) = Rheumatoid Arthritis Song
Mdm XXX is a middle aged Chinese lady who is alert and comfortable at rest. On general inspection, I note
that she appears to be Cushingoid as evidenced by the characteristic rounded facies (facial plethora, acne,
and hirsutism). In addition, she also has a pair of rheumatoid hands.
Pathology
I say this because there is bilateral symmetrical deforming polyarthropathy involving the small joints of
the hand namely the MCPJ and PIPJ and sparing the DIPJ. I note bilateral Z-thumb deformities, swan neck
deformities affecting joints and Boutonniere deformity affecting joints. There is ulnar deviation of the
fingers, radial deviation at the wrists, ulnar subluxation at the MCPJ and dorsal subluxation of the DRUJ
(distal radial-ulnar joint). There are no rheumatoid nodules seen over the extensor surfaces or over the
olecranon process. I note muscle wasting of the intrinsic muscles. There are no nail changes or psoriatic
plaques seen.
Stage
The disease is likely to be in a quiescent stage and there is no overlying erythema, joint
swelling/tenderness of increased warmth.
Complication of the disease
Her disease is complicated by disabling arthritis as Mdm XXX is unable to make a fist and there is severe
limitation of movements at the wrist and shoulder joints. Therefore I do not note the presence of a trigger
finger, dropped fingers or carpal tunnel syndrome.
Function
Functionally, Mdm XXX is only able to hold a cup with both hands. She is unable to button her shirt, grasp
a pen and write.
Summary and Request
So in summary, Mdm XXX has features of rheumatoid arthritis complicated by disabling arthropathy. The
disease is likely to be in a quiescent stage and there are signs of steroid use.
Examine the other joints = elbow, shoulder, TMJ, neck, hip, knee, feet.
Extra articular features =
38
Warmth
Pain
Erythema
Swelling
Loss of function
Inflammatory
1 hr
Rest (unless in severe/ active cases)
Movement
Present
yes
Non-inflammatory
<30mins
Movement
Rest
Absent
mo
Key Words
Polyarthritis
Rheumatoid arthritis
Osteoarthritis
Connective tissue like SLE
Reactive arthritis
Gout/ pseudo gout
39
Pathogenesis
Autoimmune disorder with the fundamental defect of failure to maintain self tolerance
Type 3 hypersensitivity = immune complex formation with deposition in target organs
Involves a bewildering array of auto-antibodies
Antinuclear antibodies (ANA)
Directed against several nuclear antigens (DNA, histones, non-histone proteins)
Senstive = positive in 95% of patients with SLE
Not specific = also positive in Sjogrens, polymyositis/dermatomyositis, RA, autoimmune hepatitis
Anti-Sm Ab
Specific for SLE. Virtually diagnostic
Anti-phospholipid antibodies (lupus anticoagulant, anticardiolipin Ab)
Present in 40-50% of lupus patients
Phospholipids required for coagulation. Therefore, prolonged aPTT that fails to correct even after
addition of normal plasma
Prothrombotic state = venous thrombosis (DVT/PE)
Arterial thrombosis (AMI/CVA)
Recurrent spontaneous miscarriages
Livedo reticularis
Predisposing factors
Genetic/family history
Non genetic factors: Drug lupus = isoniazid, procainamide, hydralazine, chlorpromazine,
minocycline
Lung and skin involvement >renal and CNS involvement
Remits once drug is stopped
Anti-histone Ab are characteristic (anti-dsDNA is almost never detected)
Clinical features
Constitutional symptoms
LOW
LOA
Fatigue/malaise
Fever
40
Skin
Eyes
Mouth
Joints
CNS
CVS
Lungs
Renal
41
Hematological
Anaemia = hemolytic, chronic disease
Leucopenia (esp lymphopenia)
Thrombocytopenia
Anti phospholipid syndrome = venous and arterial thrombosis, recurrent spontaneous miscarriages
Generalized lympadenopathy +/- splenomegaly
Diagnostic criteria
At least 4 out of 11
1. Malar rash
2. discoid rash
3. Photosensitivity
4. Oral ulcers
5. Arthritis
6. Serositis
Pleuritis or pericarditis
7. Renal disorders
8. Neurological disorders
9. Hematological disorders
11. ANA
Major causes of death = renal failure, intercurrent infections and diffuse CNS involvement
42
Laboratory findings
1. FBC
2. ESR, CRP
ESR = raised
CRP = normal (consider infection if raised)
3. PT/PTT
4. U/E/Cr
Renal impairment
Proceed to do urine dipstick, UFEME, urine c/s , urine phase contrast, 24 hr CCT/UTP, urine PCR, renal
biopsy
5. Autoimmune markers
anti-dsDNA = high
serum complement = low C3 and C4
High C3 degradation product
ESR = high (do CRP to distinguish lupus flare from infection)
Management
General measures
Pharmacotherapy
No curative therapy
Different modalities
(a) Joint symptoms = NSAIDs
(b) Skin symptoms/joint symptoms not controlled by NSAIDs = hydroxychloroquine (annual eye check for
maculopathy)
(c) Renal involvement = steroid and pulsed IV cyclophosphamide
(d) Severe episodes = high dose prednisolone, cytotoxics (azathioprine, cyclophosphamide, methotrexate)
(e) Chronic disease = low dose prednisolone
Prognosis
43
(e) APLS
(f) High disease activity
prognosis = 90% 5 year survival
80% 10 year survival
Avoid during active disease (esp with sig organ impairment) due to high risk of spontaneous miscarriage
and exacerbation of SLE
Should wait until disease has been quiescent for at least six months before attempting pregnancy
Management of patients with active lupus = corticosteroids, NSAIDs and hydroxychloroquine
Cyclophosphamide and methotrexate are contraindicated
Azathioprine can be used cautiously
Patients with migraine headaches, Raynauds phenomenon, history of phlebitis or APL Ab should not be
treated with OCPs (increases risk of thrombosis)
History taking
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Malar rash
Discoid rash
Photosensitivity
Alopecia, dry eyes and mouth, oral ulcers
Gangrene of fingers, Raynauds phenomenon
Chest pain, dyspnoea
Joint pain
Seizures
Change in urinary frequency and volume, haematuria, frothy urine, loin pain
Anaemia = pallor, chest pain, palpitation, fatigue, giddiness, dyspnoea, jaundice
Leukopenia = susceptibility to infections
Thrombocytopenia = gum bleeding, easy bruising, menorrhagia
APLS = history of recurrent spontaneous abortion, DVT/PE, AMI, CVA
Hands
Arms
44
Face
Conjunctiva pallor
Mouth ulcers
Alopecia
Chest
Abdomen
Legs
Vasculitic rash
Lower limb pitting edema (due to lupus nephritis)
45
2. Spine
3. Arms
46
Fingers on thumb
Measurement of fine movements
Squeeze across MCP joints
Early arthritis = pain and tenderness on squeezing before other abnormalities seen
4. Legs
Inspection
Leg
Deformities
Knee
Bulk of quadriceps muscle
Loss of parapatellar fossae
Feet
Callus formation = abnormal weight bearing
Movement
Fully flex knee and hip joint
Place hand on knee joint to feel for crepitus
Internally and externally rotate hip joint
Squeeze across MTP joints
Early arthritis = pain and tenderness on squeezing before other abnormalities seen
47
History
Arthritis
- Classically, swollen, painful, stiff hands and feet worse in the morning
- Chronic inflammatory joint disease with relapsing and remitting course
- Insidious onset with joint pain and early morning stiffness
- Symmetrical polyarthropathy = PIPJ, MCPJ, wrist, MTPJ and knees (spares distal DIPJ)
- Joints progressively enlarge limited ROM and complete ankylosis (stiffness due to abnormal adhesion and rigidity of the bones of the joint)
Constitutional symptoms
- LoA, LoW, fatigue, fever, rash
- Anemia chest pain, SOB, giddiness, palpitations, fatigue
Extra-articular involvement
- Skin = Raynauds phenomenon, rash
- Head and Neck = red eyes, dry eyes and mouth (Sjgrens syndrome)
- Pulmonary and Cardiac = chest pain, SOB
- CNs = numbness, parasthesiae, weakness
Atypical presentations
- Palindromic = acute recurrent, relapsing, remittent arthritis usually affecting 1 large joint for a few hours, with symptom-free intervals of days
months between attacks. (Was I Saw! wrist, ankle, shoulder, IPJ)
- Persistent monoarthritis
- Systemic = pericarditis, pleurisy, LoW, constitutional symptoms
- Acute onset of widespread arthritis
48
Extra-articular involvement
1. Eyes
Sclera episcleritis, scleritis, scleromalacia, scleromalacia perforans
Conjunctiva pallor, keratoconjunctivitis sicca (Sjgrens syndrome)
Lens cataracts from steroid use
Extra-Ocular Muscles mononeuritis multiplex, myasthenia 2 penicillamine, EOM tendon synovitis
Fundi maculopathy from hydroxycholoroquine use
2. Head and Neck
Mouth ulcers from DMARD treatment, dry mouth and enlarged parotids (Sjgrens)
TMJ crepitus
Neck tenderness, muscle spasm, limited ROM (atlanto axial sublux, basilar invagination by dens
protrusion,
subcervical spine)
3. Respiratory system
Upper airway cricoarytenitis
Pleura pleural effusion, pleurisy
Bronchioles bronchiolitis obliterans and organizing pneumonia (BOOP)
Parenchyma lower lobe pulmonary fibrosis, penumonitis, rheumatoid nodules
Infiltration Caplans (rheumatoid nodules in periphery of lung fields a/w coal workers pneumoconiosis)
4. CVS
Pericarditis
Aortic/mitral regurgitation
5. Lympadenopathy
6. GIT
Splenomegaly (5%)
Feltys syndrome (1%) = RA w/splenomegaly and hypersplenism anemia, leukopenia, thrombocytopenia and leg ulcers (ameliorated by
splenectomy)
Methotrexate use hepatomegaly
7. Upper Limb
Vasculitis = nail-fold infarcts, splinter hemorrhage, telangiectasia, Raynauds phenomenon
Subcutaneous nodules (indicates seropositivity and more aggressive arthritis, found on flexor and myocardium)
Entrapment neuropathy
8. Lower Limb
Hip limited ROM
Knees quadriceps wasting, synovial effusion, flexion contracture, genu valgus deformity, Bakers cysts in popliteal fossae
Lower Leg leg ulcers, calf swelling (ruptured Bakers cyst), peripheral neuropathy, mononeuritis multiplex
Ankle limited ROM, nodules on Achilles tendon
Feet foot drop (peroneal nerve entrapment), MTPJ (swelling, subluxation)
Differentials
49
FBC
50
Diagnosis of RA made when 4 criteria are met (93% sensitivity and 90% specificity)
Morning stiffness
>1 hours
Arthritis of 3 joints
Arthritis is symmetrical
Rheumatoid nodules
Radiological changes
6 weeks
51
Complications
Complications of disease
Increased risk of IHD and lymphoma
Ruptured tendons
Joint destruction and resultant disability
Cervical myelopathy
Amyloidosis proteinuria, nephritic syndrome and renal failure
Side effects of therapy
Dyspepsia, BGIT, asthma (NSAIDs)
Renal impairment (NSAIDs, penicillamine)
Proteinuria (gold salts, penicillamine)
Anemia (NSAIDs)
Bone marrow depression (DMARDs)
5 causes of anemia in RA
1. Anemia of chronic disease
2. Iron deficiency anemia
BGIT due to NSAIDs use
3. Megaloblastic anemia
Increased cellular turnover (folate acid deficiency)
Methotrexate use
Pernicious anemia
4. Hypersplenism
2 to Feltys syndrome
5. Aplastic
BM suppression due to gold and penicillamine use
Assessment of disease severity
Symptoms
Duration of morning stiffness
Pain score
Severity of fatigue
P/E
Number of swollen joints
Number of tender joints
Degree of swelling tenderness
Extra-articular disease
Lab values
ESR and CRP = active disease, infection, Amyloidosis, Sjgrens disease
52
Anemia
Rh factor titres = correlates with likelihood that patient has extra-articular disease (not activity of arthritis)
Inflammatory joint fluid = high polymorph count, low complement, fibrin
Imaging
Progressive bony erosions on serial X-ray films
Low bone marrow density
Sjgrens syndrome
Connective tissue disorder a/w dry eyes(keratoconjunctivitis sicca) and dry mouth (xerostoma)
May be a/w autoimmune thyroid disease, MG or autoimmune liver disease
Ix = Schirmer filter paper test (crude measure of tear production; <5mm, N at least 15mm after 5 mins)
Tx = artificial tears, artificial saliva and NSAIDs
Principles of Management
Treatment modalities
Symptomatic relief
Paracetamol
Pain
NSAIDs
Pain
Give with PPI or H2-R blocker
- Aspirin, Ibuprofen
CI = BGIT, PUD, Asthma
S/E = BGIT, interstitial nephritis,
- COX 2 inhibitor(Arcoxia), if
bronchoconstriction
elderly
DMARDS (mono or combination therapy)
- Start if persistent synovitis > 6 weeks
- Slow onset of action (may take weeks to months)
Hydroxychloroquine
Mild disease
S/E = maculopathy, rash, N/V/D, ototoxicity,
aggravates psoriasis
Sulphaslazine
Moderate disease
Methotrexate
53
Lefluonomide
Inhibits activated T
cells
Corticosteroids
Indications
Azathioprine, Cyclosporin A,
cyclophosphamide
- vasculitis
- severe disease
- exacerbations not
responding to other
drugs
Severe disease with
failure of other
therapies
Anti-cytokine therapy
-suppress disease activity only during treatment relapse on discontinuation
Infliximab (against TNF)
Etanercept (against TNF receptor)
Surgery
Paramedical services
Others
54
*drugs causing cytopenias = warn patient to stop meds and consult doctor if sore throat develops.
Clinical course
Variable
- most have fluctuating disease with the greatest progression during the initial 4-5 years
Most develop deforming and destructive arthritis after 15-20 years
Life expectancy reduced by 3-7 years
Poor prognostic factors
1. Female
2. Older age of onset (>60 YO)
3. Systemic features: LoW, extra-articular manifestations
4. Vasculitis
5. Early bone erosions
6. Rheumatoid nodules
7. Persistent disease activity > 12 months
8. Insidious onset
9. HLA-DR 4 linkage
10. Rh factor > 1 in 512
55
56
57
58
Diagnosed in 7/2003
Manifestation: 45 years of bilateral symmetrical polyarthritis: Joint pain over bilateral wrist, MCPs,
PIPs with early morning stiffness > 1hour
-
Bilateral deformities of writs, MCPs, fingers, left elbow and right shoulder with ulnar deviation
Crepitus left knee with genus varus
Serology:
RF 98, ANA 1/320
DsDNA ve
Markers of activity
ESR baseline ~ 30 (highest 99, lowest 17), CRP normal,
Anti-HCV and HbsAg ve, albumin baseline 31, creatinin baseline 200
X- ray hands 12/2005: Ulnar deviation mainly in MCPs with carpal bone fusion and erosions
Treatment: No treatment btw 7/2003 till 10/2005 (burnt out RA) given glucosamine for OA knee
a) Prednisolone: 5mg om 10/2005: left knee effusion; max dose 10mg om. Current 7.5 mg om
b) Sulfasalazine: 500mg om till 11/2005: Pancytopenia (WBC 3.9 Hb 9.7 Plt 129)
Restarted 6/2/2007 at 500mg Om when left knee and ankle jts remained active in spite of IA TA.
Stopped since 20/2/07: AoCRF; also left knee inflammatory OA rather than RA flare
c) Hydroxychloroquine: 200mg om 12/2005 till 2/2006: blurred vision, feels unwell
d) IA triamcinalone 10/2005 and 12/2005 and 12/2006 left knee
Last admitted to RAI for left knee effusion 20/10/2007 23/10/2007 thought to be inflammatory OA
with a ddx of active RA: PNL 5mg om and 2.5mg on (7.5mg od) ; GWR imp was that of inflammatory
OA left knee, decision then to stop SSZ. Reduced PNL to 2.5mg bd Plans to refer ortho output.
Since discharge: Joints quiescent; remained on tailing dose of PNL until 30/10/07
TKR 18.10.07
Seen 30/10/07: Advised early RAI rv by Dr Sat (ortho)
Co Post TKR: 2 days after developed Left forefoot and ankle pain. Mid tarsal jts red, swollen, tender RA
flare. Increased PNL from 1mg bd to 2.5 mg bd with plans for DMARD if still active
3.11.07: With interval mild improvement of left foot pain and swelling. But reported right foot pain as
well. Ddx: ?Crystal arthropathy with worsening renal impairment (Cr 239-258) PNL increased
10mg/d x 1 week then 7.5mg/d; uric acid 573 -> 590 -> 632 umol/L
2) Hyperlipidemia
On simvastatin 10mg on
- Last lipid panel 8/07: Chol 5.0 LDL 3.0 HDL 1.4 TG 1.4
3) Type 2 DM
- On tolbutamide 250 mg tds
59
DRE: No malena/bld on PR
Jts: Left forefoot still swollen since 30/10/07
Left knee slight swelling, left ankle increased warmth
Other jts: Quiet
Labs:
FBC: WBC 6.2 Hb 6.3 PLT 232 Retics 4.8%
CRP 30.3 ESR 91
Renal Panel: Na 139 k 5.3 (Lysed) Cr 390 Urea 25.3
Alb 23 LFT normal
CKMB/CK/Trop 1 normal
Fe 22 Fe sat 67% H Ferritin 512 Transferrin 1.3 L
Vit B12 Folate normal
TFT normal
Random Cortisol Normal response 241
Ufeme
Urine c/s
Bld c/s
Issues:
CIC RU 300mls
IDC since 12/12/07
61
Duration of disease
First presentation: initial clinical picture
Joint pain and swelling: which joints involved
3.
-
4.
5.
-
Dry mouth
Cervical spondylosis: neck pain/stiffness, radicular pain and weakness
6.
-
Acute/sudden onset
Character of pain (increase with rest, decrease with movement)
Joint stabilization/replacement
ADL
Work
Social recreation
Housework
Home modifications
Dry eyes
62
History
Skin
Raynauds (90%)
Edema
Thickened stretched skin
Cutaneous ulcers
Pigmentation, depigmentation (vitiligo)
Dx criteria 1 major or 2 or more minor
Major: scleroderma affecting MCP and MTP
Minor: Sclerodactyly, digital tip pitting or loss of
subst of digital finger pads, bibasal pulmonary
fibrosis
Other organs
Polyarthralgia
Proximal myopathy
Fever
Dysphagia
Lungs
o SOB (due to anemia)
Cardiac
o Chest pain pericarditis
o RHF edema
GI
o Malabsorption
Renal
o Decrease urine CRF
o Frothy urine proteinuria
Initial presentation
Investigations done biopsy etc.
Treatment and Cx treatment
Cx disease
Physical Exam
General
Hands
Arms/Skin
Head
Cachexia
Bird like facies
Raynauds
Oatcinosis, ulcers
Telangiectasia
Arthropathy
Contractures
Thick tethered skin
Pigmentation
Vitiligo
Proximal myopathy
Alopecia
Eyes
Anemia (chronic dz, folate and B12 def, Fe def from chronic esophagitis,
microangiopathic hemolytic anemia)
Sjogrens
Mouth
63
Chest
Lungs
Other joints
Other
Investigations
To confirm diagnosis
To look for complications
Bloods
Urine
Radio
FBC
U/E/Cr
ANA
Anti-centromere Ab
Dipstick
Urinalysis
CXR
2D echo
Anaemia
Renal failure
Nearly always +ve
Proteinuria
Effusion, fibrosis, CA
RHF
Management
Supportive, symptomatic
Pt education
Scleroderma itself
Raynauds
Oesophageal symptoms
HTN
Cytotoxics
Early stages: cyclophosphamide, MTX
Late stage: penicillamine
Vasodilators CA++ blockers, aspirin
Antacids
PPIs
Antihypertensives
64
1. FACE
Avian-like facies with pinched nose
Skin = tight
Raynauds phenomenon
Dry eyes & mouth
Diagnosis
1.
2.
3.
4.
Systemic sclerosis
Limited cutaneous scleroderma (extremities + face)
Diffuse cutaneous scleroderma (extremities + face + trunk)
Overlap syndrome (PMS, DMS, SLE)
65
Natural History
3 classes of stages
trauma
66
Aetiology
Primary Hyperuricaemia (95%)
production of
excretion of uric
purine
acid
Idiopathic
Idiopathic
Genetic enzyme
defects
- Lesch-Nyhan
syndrome (Xlinked
recessive)
67
Joint deformities
Loss of function
68
Urate urolithiasis= loin to groin pain, renal colic, dysuria, haematuria, FUN, obstructive
symptoms, history of stones
Urate nephropathy= decreased urine output, history of renal impairment
Drug allergy
Social history
Family history
Differentials
-
Investigations
Bloods
69
Management
Acute management
1. Colchicine
- Most efficacious if given within first 24 hours
- MOA= inhibits urate phagocytosis by WBC
- Side effects= diarrhea, nausea, vomiting, bone marrow suppression, renal impairment
- Dosing regimen= 1 g stat, 0.5g 2 hourly until a maximum of 4g or pain subsides.
2. Analgesic
- NSAIDS: give indomethacin (DO NOT GIVE ASPIRIN)
- Corticosteroids (oral/ IM/ intra-articular)
3. Joint aspiration
4. Joint immobilization
- Jones bandage
5. Rest in bed or at least 1 day after pain subsides
Chronic management (aim= serum urate <5 mg/dL)
1. Lifestyle modifications ( refer dietician)
- Weight loss
- Low purine diet: avoid beans, meats, seafood, legumes
- Avoid alcohol
2. Review medications
- Cytotoxics
- Aspirin
- Diuretics (frusemide, thiazides)
3. Medications ( should be covered with NSAIDs or colchicines)
(a) Allopurinol
- Indications: frequent major attacks ( >5x/year)
Radiological evidence of bony erosions (end-stage disease)
Urate urolithiasis
- MOA= competitive xanthine oxidase inhibitor
- Side effects: rash (5-10% risk of SJS esp within the 1st month), bone marrow suppression,
renal impairment
- Never start within 1 month of acute flare (to be avoided during acute attacks because might
exacerbate the flare)
- Can be used in patients with abnormal renal function
(b) Uricosuric agents (probenecid, sulfinpyrazole)
- S/E = gastrointestinal irritation (nausea, vomiting)
Aplastic anaemia
Nephritic syndrome
- can only be used if renal function normal must encourage fluid intake (ensure urine
output > 2L/day)
(c) rasburicase
MOA = urate oxidase enzyme that promotes conversion of uric acid into allantoin (inactive
metabolite and 10x more water-soluble)
Does not occur in humans
Indications = prevention and treatment of tumor lysis syndrome in patients receiving
chemotherapy for leukemia and lymphoma
Very expensive!
4. Surgical intervention
- Indications = infection, deformity, pain, ulcerating tophi
70
(a) presence of gouty tophi = olecranon bursae, pinna of ear, prepatellar bursae, archilles tendon
(b) feet, ankle and knee for similar changes
(c) haematological malignancy = hepatosplenomegaly, generalized lymphadenopathy
(d) signs of alcoholism = duputyrens contracture, parotidomegaly
(e) vitals = temperature, HPT
(f) urine dipstick = glycosuria (DM)
Differentials
1. Tendon xanthomata
- yellow (not chalky)
- stuck to tendons (not joints)
- bursa not involved
- no active arthritis
2. Rheumatoid arthritis
71
Diabetes
Medicine (Diabetes) = History taking
Name/age/ethnicity/gender/occupation
Date of admission
Presenting complaint
-
Uncontrolled DM
Hypoglycemia
DKA/HHS
Unrelated problem
Initial diagnosis of DM
Age of diagnosis
Type 1/2 DM
Presenting complaint = polyuria, polydipsia, polyphagia, LOW, fatigue
Investigations = random BSL, 2 hr OGTT
Current management
Follow up with whom? How often? Compliance?
Lifestyle modification
(a) Diet = dietary restrictions, compliance, meals at home/outside, how many meals and snacks
(b) Exercise = frequency, intensity, type of exercise, compliance
- Medications
(a) OHGA = started immediately after diagnosis? Type and dosage, compliance, any recent changes
(b) Insulin = started when, indications for starting, type and dosage, injection site + rotation, who fills it,
who injects it (important if patient has retinopathy), compliance, recent changes
(c) Monitoring = home glucose monitoring + how often, whether it is recorded down, average reading,
do you know what to do when it is too high/low
3. Current control
- Recent HbA1C
- Symptoms of hyperglycemia
- Acute complications
(a) Hypoglycaemia = extreme hunger, giddiness, diaphoresis, tremors, palpitations, fits
(b) DKA/HHS = abdominal pain and vomiting, managed in GW/HD/ICU
4. Screening for complications
- Retinopathy = history of cataracts/eye problems/laser treatment, BOV, annual diabetic retinopathy
screening/ophthalmologist follow up
- Nephropathy = management of renal impairment, annual screening (24 hour UTP/CCT), frothy urine,
lower limb oedema, polyuria/oligouria
- Neuropathy = numbness/ parasthesiae, weakness, postural giddiness, nocturnal diarrhea, gastroparesis
(early satiety, nausea and vomiting), dysphagia, urinary retention i.e. overflow incontinence/UTI,
impotence
- IHD/AMI = history of IHD/AMI, chest pain, SOB, diaphoresis, nausea/vomiting, giddiness
- CVA = history of CVA
- PVD = history of abscess, ulcers, gangrene, amputations, cellulitis, poor wound healing, vascular
claudication, foot care education, annual foot screening at OPD
72
Drug history
-
Drug allergies
Current medications
Social history
-
Smoking
Alcohol
Family set up
Main caregiver
Type of housing
Lift landing
Finances
Functional status
Family history
73
74
Pathogenesis
-
Explain action of pancreas = secretes insulin that allows peripheral uptake of glucose
Insulin=Hormone
In a patient with DM: insufficient insulin or insulin resistance
Therefore increased glucose left in blood= DM
Chronic complications: Microvascular and macrovascular
i) Microvascular: retinopathy, nephropathy, neuropathy
ii) Macrovascular: IHD, CVD, PVD
DM doesnt kill but its complications do
Weight loss
-
Diet
-
Exercise
-
Medications
-
Ask patient what types of medications they are on and when they take it
Explore compliance
If on insulin, demonstrate technique, get them to show you
Others
-
75
Urogenital manifestations of DM
Kidneys :
Nephrotic syndrome
Renal failure
Glomerulosclerosis (Kimmelstein-Wilson lesion)
Chronic pyelonephritis
Emphysematous pyelonephritis
Renal papillary necrosis
Type 4 RTA
Contrast nephropathy
Genital
Vaginal candidiasis
Impotence
Retrograde ejaculation
2. Skin Manifestations of DM
a) Suggestive of DM
-
Acanthosis Nigricans
Vitiligo
Hyperpigmentation over neck, cheek, back of hands (Addisons Disease)
Thick greasy skin (Acromegaly)
Papery thin skin (Cushings)
Bronzed skin (Haemochromatosis)
b) Exclusive to DM
-
Granuloma annulare
Dermopathy
Necrobiosis Lipodica Diabeticorum
Scleroderma Diabeticorum (Thickening and hardening of skin)
c) Complications of Disease
-
d) Complications of treatment
-
Lipodystrophy
Jaundice (Tolbutamide)
76
Epidemiology
Prevalence (Singapore) = 8.2% (2004 NHS), 8th most common cause of death
- Prevalence increases sharply with age
18-29 years: 0.5%
40-49 years: 7.9%
60-69 years: 28.7%
- Gender: Males (8.9%) > Females (7.6%)
- Ethnicity: Indians (15.3%) > Malays (11.0%) > Chinese (7.1%)
A/w considerable mortality and morbidity from chronic complications
- 3-fold increase in mortality mostly due to cardiovascular disease
Classification
Primary Diabetes
- Type 1 DM (IDDM): absolute insulin deficiency resulting from destruction of beta cells
Type 1A: Immune mediated
Type 1B: Idiopathic, not a/w AI disorders, more common locally
Associated AI disorders: Graves Disease, Hashimotos thyroiditis, Addisons disease, myasthenia
gravis, celiac disease, vitiligo, pernicious anaemia
- Type 2 DM (NIDDM): disorder of insulin secretion and action (relative insulin deficiency)
May range from predominantly insulin resistance with relative insulin deficiency to
predominantly secretory defect with insulin resistance
Preceded by a period of abnormal glucose homeostasis (IFG/IGT)
Secondary Diabetes: Disease causing pancreatic islet cell damage
- Genetic defects: maturity onset diabetes of the young
- Genetic syndromes: DIDMOAD, Down, Turners, Klinefelter syndrome
- Exocrine pancreatic defects: Chronic pancreatitis, Ca pancreas, CF, haemochromatosis
- Endocrinopathies: Cushings syndrome, acromegaly, hyperthyroidism, PCOS, phaechromocytoma,
glucagonoma
- Drugs: glucocorticoids, thyroxine, diuretics, phenytoin, alpha-interferon
Gestational Diabetes )GDM): insulin resistance related to metabolic changes in pregnancy, increased
insulin requirements leading to impaired glucose tolerance
Pathogenesis
Type 1 DM
- Absolute insulin deficiency resulting from autoimmune destruction of islet beta cells
- Commonly develops in childhood, manifests at puberty and progresses with age. But can occur at any
age (even in 8th, 9th decade of life)
- AI markers: Islet cell Ab; glutamic acid decarboxylase Ab, insulin Ab,
Phases
(a) Prediabetes = autoAb as markers
(b) - honeymoon phase = spontaneous decrease in insulin requirement after starting treatment, may
last 3 to 6 months, exogenous insulin abates inflammatory process and allows remaining beta cells to
function
- Relapse phase = progressive increase in insulin requirements
- Permanent phase = complete destruction of beta cells
Type 2 DM
- Most common form of DM
77
Age of onset
Weight
Lab results
- Plasma insulin
-Plasma glucagon
-Anti-islet cell antibodies
Islet cell morphology
Complications
Type 1 DM
Absolute insulin deficiency
- Genetics:
HLA-genes
Twins = 30-70%
concordance
- AI destruction
- Viral infection?
Juvenile (<20 years)
Normal/LOW
Type 2 DM
1. Insulin resistance
- Genetics
no HLA-linkage
Twins = 60-80%
concordance
- Environment: obesity
2. Beta cell dysfunction
Adult-onset (>40 years)
Obese
Absent/Low
High (due to low/no
insulin)
Yes
Insulitis
Marked atrophy and
fibrosis
Diabetic ketoacidosis
Hypoglycaemia
High/Normal
Low
No
No insulitis
Focal atrophy and amyloid
deposition
Hyperglycaemic
Hyperosmolar State
78
- Sweating
- Trembling
- Tachycardia
- Pallor
- Hunger
- Anxiety
Behavioural disturbances
- Irritable
- Aggression
79
Non-specific
- Confused/AMS
- In coordination
- Seizures
- Focal neuro deficits
- Speech difficulty
Drowsy ( GCS)
- Nausea
- Headache
- Tiredness
80
No
Yes
Repeat
FPG
DM
FPG>7.0m
mol/L
No
Yes
FPG
<6.0mmol
/L
6.16.9mmol/
L
Normal FG
OGTT
>11.1
7.8-11.0
Impaired glucose tolerance
2hr post
challenge
glucose
<7.8
81
82
Renal Medicine
Medicine (Renal) = Nephrotic Syndrome History Taking
Name/Age/Race/Gender/Occupation
Past Medical History
Date of admission
Presenting Complaint
1.
2.
Associated with
Abdominal distension? Can clothes still fit?
Increase in weight?
SOB? Exertional dyspnoea/Orthopnea/Paroxysmal nocturnal dyspnoea?
Periorbital/Facial oedema? (esp so in the morning)
3. Aetiology
Renal
o Frothy urine, oliguria, concentrated urine (signs of proteinuria)
o Haematuria (Nephritic syndrome)
o Fever, URTI symptoms (trigger, post infectious glomerulonephritis)
o Diarrhoea (IgA nephropathy)
o History of Hepatitis B/C infection
o Recent drug intake
o Joint pain, rashes (autoimmune)
o Polyuria, polydipsia, polyphagia, LOW (DM)
CVS
o Chest pain, SOB, palpitations, giddiness/syncope, diaphoresis, nausea/vomiting
GIT
o LOA, LOW, lethargy, jaundice, pruritus, easy bruisability (chronic liver disease)
o Mucoid/bloody stools, alternating constipation and diarrhoea (inflammatory bowel disease)
4. Complications
Spontaneous bacterial peritonitis (fever, abdominal pain)
Hypovolemia (abdominal pain, vomiting, dizziness)
5. Management prior and during admission
6. Is this the first time that this happened? Describe prior episodes.
2. Management
83
3.
Followed up with whom? Frequency of follow up? Compliance to follow up? Investigations done at
every follow up? Annual investigations?
Medications?
o Steroids, cyclophosphamide, chlorambucil, levamisole, cyclosporine A
o Compliance with medications?
o Side effects: obesity, hypertension, cataracts, osteoporosis, increased susceptibility to infections,
cosmetic changes, gastritis, diabetes
Fluid and dietary restrictions
o Fluids: as desired
o Diet: no refined sugars, no fat (if patient is on steroids), less protein
Level of control
o Number of relapses? Number of hospitalisations?
o For each relapse Presentation? Triggers? Treatment?
o When was the last episode?
Monitoring
o How often?
o Records in nephrotic diary?
o Do you know what to do when proteinuria is found?
o Indications for admission?
Complications
Hypovolemia (abdominal pain, vomiting, giddiness)
Acute renal failure
Thromboembolism
o Was any blood clot found?
o Treatment with heparin/warfarin only if symptomatic or immobile
Increased susceptibility to infections
Spontaneous bacterial peritonitis
o History of abdominal pain of fever treatment?
o Pneumococcal vaccinations?
o Prophylactic antibiotics?
Hyperlipidemia
o On statins?
Drug History
1. Drug allergies
Social History
1.
2.
3.
4.
5.
Smoking
Alcohol drinking
Family set-up? Main caregiver?
Finances
Have to miss a lot of work?
Family History
84
3.
4.
Clinical entity
Characterized by classical triad
Proteinuria (> 3g/1.73m3/day)
Hypoalbuminemia (<30g/L)
Oedema
Usually associated with hyperlipidemia and lipiduria
Hypertension, haematuria and azotemia are rare (characteristic of nephritic syndrome)
Aetiology
1.
2.
Secondary glomerulonephritis
Vascular (Henoch-Schnlein Purpura)
Infective (hepatitis B/C, malaria, HIV, post streptococcal)
Drugs (captopril, TCM, NSAIDS, gold, penicillamine)
Autoimmune (SLE)
Metabolic (diabetes)
Infiltrative (Amyloidosis)
Neoplasia (multiple myeloma, lymphoma)
Causes
1.
2.
Children
Minimal change disease (80%)
Adults
Minimal change disease (30%)
Focal global sclerosis (21%)
Mesangial proliferative glomerulonephritis (25%)
Membranous glomerulonephritis (12%)
Focal segmental glomerulosclerosis
Pathogenesis
1. Derangement in glomerular capillary walls proteinuria hypoalbuminemia
2. Loss of oncotic pressure generalised oedema
3. Drop in plasma volume diminished glomerular filtration rate compensatory rise in aldosterone
promotes retention of salt and water by kidneys further aggravates oedema
Clinical signs
1.
2.
3.
4.
5.
6.
85
Complications
1. Hypovolemia
Presents with abdominal pain, vomiting and giddiness
Pathogenesis: third space loss results in insufficient blood volume in vessels to maintain adequate
blood pressure leads to peripheral vasoconstriction and urinary Na+ retention
Indicators: decreased urinary Na+, increased hematocrit/urea/creatinine
Management: IV 20% albumin
2.
3.
86
LOA
Investigations
Acute management
1.
2.
3.
4.
5.
6.
87
Chronic management
1.
2.
3.
4.
Immunosuppression
PO furosemide with Span K and low salt diet only if oedematous
Monitoring at home with albustick and educate patient on how to escalate therapy and when to admit
Prevention of infections
Pneumococcal vaccination
Prophylactic antibiotics
Prompt treatment of infections
NO LIVE ATTENUATED VACCINES (especially if on steroids)
Immunosuppresants
Immunosuppressive therapy is used for minimal change disease
1.
Corticosteroids
High dose prednisolone (1mg/kg/day)
80% remission rate achieved by 16 weeks
Regime
o High dose prednisolone continued for 1 week after remission is achieved
o Taper dose over 6 months, and subsequently discontinue
o Can give alternate day prednisolone during tapering to minimise side effects
Complications
o Cosmetic changes: moon-like facies, hirsutism, acne, central obesity, buffalo hump,
supraclavicular fat pads
o Metabolic: obesity, diabetes, hypertension
o Endocrine: menstrual irregularities, Addisonian crisis, osteoporosis
o Musculoskeletal: proximal myopathy, aseptic necrosis
o Posterior subcapsular cataracts
o Gastritis/Peptic ulcer disease (PUD)
o Increased catabolism: thin skin, easy bruising, abdominal striae
o Increased susceptibility to infections especially opportunistic ones
o Steroid psychosis
2. Alkylating agents
Cyclosporine A, cyclophosphamide
o Indicated in frequently relapsing, steroid dependant nephrotic syndrome (clinically significant
cataracts, difficult hypertension, diabetes, and disabling emotional disorders due to cosmetics
appearance)
3. Mycophenolate mofetil
4. Tacrolimus
88
89
Peritoneal Dialysis
Types
o Continuous ambulatory PD (CAPD)
o Automated PD (APD) fluid exchange performed by machine, usually 3 cycles per night
Process
o Hypertonic lactate + glucose solution placed into peritoneum via Tenchkoff catheter (inflow
10min; outflow 20min)
o Results in hyper filtration across peritoneal membrane
o Since lactate can diffuse into blood stream patients tested and classified into high and low
transporters of lactate
High transporters need to remove dialysis fluid after 3 hrs
Low transporters need to remove dialysis fluid after 4-5 hrs
o Lactate degradation products can cause sclerosis of peritoneal membrane compromises
hyper filtration and diffusion
Advantages
1. Simple, reliable and safe from a cardiovascular point of view (suitable for patients with low EF)
2. Convenient greater freedom of mobility
3. Pain free
4. Removes large volume of fluids
5. Greater freedom of diet and fluid intake
6. Preserves residual renal function as BP fluctuates less (BP fluctuations during HD causes
repeated renal micro infarcts)
Disadvantages
1. Patient motivation and treatment compliance required
2. Limited to patients <75kg
3. Body imagine problems catheter sticking out of abdomen
Ideal candidates
1. Elderly
2. Diabetics
a. IP insulin
b. Difficult venous access
c. Low EF
3. Stroke patients
a. Mobility problems
4. Paediatric patients
5. IHD patients
a. Low EF
b. Cannot tolerate BP variations
Contraindications
1. Polycystic kidneys = less intra-peritoneal volume available
90
Haemodialysis
Advantages
o No protein or potassium losses
o Removes large volumes of fluid
o Regular supervision and nursing intervention
o Patient free of burden of caring for self (esp for patients with poor motivation)
Disadvantages
o Bound to dialysis centre difficulties travelling abroad
o Heparin use increased risk of bleeding
o Increased CVS instability
o Requires vascular access difficult venous access. Blockade, infection, thrombosis.
AVF: longer lifespan (7-10 yrs). Fewer complications.
AVG: use of synthetic tubes or saphenous vein. Shorter lifespan (2yrs).
o B2-microglobin Amyloidosis: may cause CTS, arthralgia and bony changes. Better removed via
hemofiltration.
91
General risks
o Risk of GA (<1%)
o Risk of death (<1%)
o Pain
o Bleeding (<1%)
o Wound infection (<1%)
o Damage to surrounding structures
Specific risks
o Early
Renal vein thrombosis (<5%)
Ureter anastomotic leak (<5%)
Acute graft rejection
Blood-borne infections
o Late
Immunosuppresants
Risk of infection (esp 1st 6mths)
Risk of cancer
Specific side effects
Chronic graft rejection & graft failure
Require HD/PD again
Introduction
o Prevalence 1:1000
o Accounts for 6% of adult CRF
o Occurs at birth but manifests in later years (~40yo)
o AD inheritance with nearly 100% penetrance
PKD 1 located on chr 16 (85%)
Encodes for polycystin 1 protein cell-cell and cell-matrix interaction
PKD 2 located on chr 4 (15%)
Encodes for polycystin 2 protein Ca and Na membrane channel proteins
o Bilateral disease (unilateral cases likely multicystic renal dysplasia)
Differentials for bilateral renal cysts
Multiple simple cysts
Infantile polycystic kidney disease
Tuberous sclerosis (angiomyolipomas)
Von Hippel-Lindau syndrome
Renal manifestations
o Grossly enlarged kidneys (ballotable +/- palpable)
o Multiple expanding cysts with little intervening parenchyma
Filled with clear, turbid or hemorrhagic fluid
Present in both renal cortex and medulla
Eventually lose tubular connections and become isolated from glomeruli require
transepithelial transport of solutes and fluid for further expansion
o Decrease in renal concentrating ability polyuria
o Altered endocrine function
Increased rennin secretion (intrarenal ischaemia from distortion of renal architecture)
HTN
Increased erythropoietin secretion better maintained hct in ESRF
o Complications
UTI (commonest) pyelonephritis
Gross intermittent haematuria
Renal calculi (urinary stasis secondary distortion of collecting system by cysts)
Cyst rupture/infection
Hemorrhage into cyst
Hypertension
92
93
Definitions
-
Differential Diagnoses
-
Organisms
-
E. coli (>70%)
Enterococcus
Enterobacter
Proteus
Klebsiella
Pseudomonas
Symptoms
Acute appendicitis
Diverticulitis
Cholecystitis
Salpingitis
Perinephric abscess
Cystitis
Classification
Upper UTI
- Pyelonephritis
Uncomplicated
- Normal renal tract
- Normal renal function
- Normal host defenses
Risk Factors
-
Female
Sexual intercourse
Lower UTI
- Urethritis
- Cystitis
- Prostatitis
Complicated
- Male patients
- Abnormal urinary
tract
- Impaired renal
function
- Impaired host
defenses
- Virulent organisms
Acute Pyelonephritis
- Almost always a/w
lower UTI
(ascending)
- Haematogenous
route less common
Prostatitis
Frequency
Urgency
Nocturia
Dysuria
Haematuria
Suprapubic pain
Cloudy and foul
smelling urine
Obstructive
symptoms
Fever a/w chills and
rigors
Renal colic
Vomiting and
diarrhoea
Symptoms of lower
UTI
Acute renal failure
oliguria
Sepsis
Flu-like symptoms
Lower back ache
Enlarged & tender
prostate
Few urinary
symptoms
Signs
-
Fever
Signs of dehydration
Abdominal tenderness/guarding
Positive renal punch
Renal mass
94
Prostatitis
-
Complications
-
Perinephric abscess
Pyonephrosis
Necrotizing papillitis in pyelonephritis ARF
Urosepsis
Advice
Investigations
Urine
- Urine
dipstick
- UFEME
- Urine c/s
Bloods
- FBC
- ESR and
CRP
- U/E/Cr
- Blood c/s
Imaging
- KUB
- CT KUB
- Renal U/S
- IVU
- Flexible
cystoscopy
- MCU
- DMSA
- MAG-3
Radio-opaque stones
Highly suspicious of stones
Hydronephrosis
Physiological/anatomical upper
tract abnormalities
Radiolucent stones
Renal function
Lower urinary tract abnormalities
Prevention
Sterile Pyuria
a)
b)
c)
d)
e)
f)
g)
Renal TB
Inadequately treated UTI
Calculi
Prostatitis
Bladder tumour
Interstitial nephritis
Appendicitis
Reflux uropathy
Renal scarring and differential
renal function (recurring UTI)
Management
Lower UTI
Acute
pyelonephritis
Acute
95
Cx of hypovolemia:
Cerebral hypoxia
ARF
AMI
Hemorrhagic enteropathy
Liver failure (fatty change, haemorrhagic necrosis, impaired lactate metabolism)
2.
-
Cx of hypervolaemia
Pulmonary oedema
Pleural effusion
AMI/CCF
Hypertension
3. Physiology
Body
2/3 water
(60%)
2/3 intracellular
(40%)
1/3 extracellular
(20%)
1/3 solids
(40%)
96
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
BP normal, hypertensive
Capillary refill normal
Eyes normal
Mucous membranes normal
JVP normal, raised (>3cm)
Skin turgor normal, increased (taut, non-pliable)
Heart S3 best heard in left lateral position
Lungs bibasal inspiratory crepitations, wheeze
Liver enlarged, tender
Legs normal, oedema
Urine output normal
Lab results dilutional effects
6. Replacement fluids
a. Crystalloids normal saline (limited to extracellular space), Ringers lactate, Hartmanns
solution
b. Colloids albumin, gelafundin
i. Stays within intravascular space
ii. Indications: for volume expansion in acute blood loss, hypoalbuminaemic states eg.
cirrhosis (causes intravascular depletion and interstitial fluid excess)
c. Blood
7. Dextrose
a. Distributes within both intracellular and extra cellular spaces
b. Once dextrose is metabolised, infusion is essentially free water may cause cell lysis
c. D5 consists of 50g of dextrose dissolved in 1L of water, has an osmolality of 252mosm/L
d. Can be used when treating hypoglycaemia or when keeping IV access patent in patients with
intravascular volume excess (quickly leaves intravascular space)
e. Dextrose/saline maintenance IV fluid for patients who cannot accomplish normal oral intake
97
1. pH = 7.40 (7.35-7.40)
2. HCO3 = 24mmol/L (22-32)
3. PCO2 = 40mmHg (35-40)
(a) Simple
1. Metabolic acidosis (HAGMA, NAGMA)
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis
(b) Mixed acid/base
1. Respiratory/metabolic combinations
- But never respiratory acidosis with respiratory alkalosis
2. Complex acid/base
- Metabolic acidosis, metabolic alkalosis and respiratory acidosis
pH
pCO2
HCO3
Metabolic acidosis
decrease
decrease
decrease
Metabolic alkalosis
increase
increase
Increase
Respiratory acidosis
decrease
increase
Increase
Respiratory alkalosis
increase
decrease
decrease
pCO2 > 45
AG > 11
AG normal
98
HCO3 decrease
(a) Common (esp < 12 mmol/L) = metabolic acidosis
(b) Uncommon = respiratory alkalosis + metabolic compensation
pCO2 increase
(a) common = respiratory acidosis
(b) uncommon = metabolic alkalosis + respiratory compensation
Any compensation?
(a) In acute disorders, compensation may not have set in
Adequate compensation?
(a) Simple compensation
Primary
disorder
Metabolic
acidosis
Metabolic
alkalosis
Respiratory
acidosis
Initial
change
Decrease
HCO3
Increase
HCO3
Increase
pCO2
Compensatory
response
Decrease pCO2
Expected compensation
Increase pCO2
Increase HCO3
Respiratory
alkalosis
Decrease
pCO2
Decrease HCO3
Metabolic acidosis
Diabetic ketoacidosis
Starvation (esp paediatric patients with GE)
Alcohol-induced
2. Renal failure =
ARF,CRF
3. Lactic acidosis = Failure to excrete lactate (liver failure, biguanides)
Hypoxia
(Cardiac heart failure, AMI
Respiratory bilateral pneumothorax
Blood haemoglobinopathy
4. Poisoning (PEEMS)=
paraldehyde, ethanol, ethylene glycol, methanol, salicylates
(b) NAGMA (5%)
1. Diarrhea
2. Carbonic anhydrase inhibitor ingestion
3. Renal tubular acidosis
4. Ureteral diversion
99
Calculate osmolar gap = serum osmolality calculated osmolality (2Na + urea + glucose)
- Normal serum osmolality = 285-295 mOsm/kg
- Normal osmolar gap = 15 (10-20 mOsm/kg)
- Hyperosmolality but no osmolar gap = hypernatremia, hyperglycemia, uraemia
- Hyperosmolality with osmolar gap = small molecular weight molecules present in large
quantities that are not of the usual electrolytes
Complications
1. Circulatory collapse =
Decreased cardiac response to catecholamines
Depressed myocardial contractility
Venous constriction redistribution of blood into central circulation,
therefore heart failure
2. Circulatory insufficiency tissue hypoxia lactic acidosis
3. Increase in pulmonary vascular resistance
4. Hyperkalemia
Management
(a) Treat reversible causes
(b) IV 8.4% NaHCO3 infusion
- Indications = pH < 7.20 or HCO3 < 12mmol/L
- Usually correct only half the deficit
- Do not correct too quickly = Paradoxical intracellular acidosis
Hyperosmolar injury from NaHCO3
Secondary respiratory alkalosis
(c) Monitor ABG, serum K, serum Ca
(d) Severe acidosis = dialysis
Indications for dialysis
1. Hyperkalemia
2. Severe metabolic acidosis
3. Severe uraemia (encephalopathy and pericarditis)
4. Severe uncontrolled hypertension from severe fluid overload not responding to
diuretics
5. Severe pulmonary oedema
6. Poisoning (methanol, ethylene glycol, severe salicylates)
Metabolic alkalosis
100
Respiratory acidosis
Respiratory alkalosis
101
Respiratory Acidosis
1. CNS depression
2. Neuromuscular disorder
3. Thoracic cage limitation
1. Anxiety
2. Drugs
3. CNS stimulation
Respiratory Alkalosis
4. Liver disease
5. Pulmonary disease
6. Excessive mechanical
ventilation
102
103
o
o
Biochemical results
K+ , HCO3- , CL-
Normal anion gap
(Acidic urine)
Causes
Adrenal disorders (Addisons disease, CAH), R A renal
Hyporeninaemic hypoaldosteronism (interstitial nephritis) R A renal
Pseudohypoaldosteronism R A
Clinical features
Primary renal disease
Adrenal disease
Management
HCO3- supplements
K+ reduction (Eg. Furosemide, thiazides)
Flucortisone
Hyperchloraemic
Type 1
Type 2
Type 4
Yes
Yes
Yes
>5.5
<5.5
acidosis
Minimum Urine
pH
Plasma
becomes established)
Low-normal
Low-normal
High
Renal stones
Yes
No
No
Defect
Reduced H+ excretion
Impaired cation
in distal tubule
tubule
exchange in distal
potassium
tubule
104
Hyperkalaemia
1. Definition = K+ > 5.0 mmol/L (3.5 5.0)
2. Causes
Increased K+ Intake
Cellular death
Spurious
105
3.
4.
5.
Grading of severity
a. Mild = K+ <6.0 mmol/L
ECG can be normal or show tall tented T waves
b. Moderate = K+ = 6.0 -7.0mmol/L
ECG shows tall tented T waves
c. Severe = K+ >7.0mmol/L
Clinical presentation = parasthesia (tingling around lips/fingers)
muscular weakness (flaccid paralysis, loss of tendon jerks)
abdominal distension, paralytic ileus
cardiac arrythmias -> sudden death
ECG changes = tall tented T waves
increased PR interval
widening of QRS complex
ventricular tachycardia/fibrillation
Management
a. Resuscitate the patient = ABC
b. Create IV access
c. Place on continuous ECG monitoring
d. Treat reversible causes = hypovolemia, acidosis (do ABG)
e. 4-step management
i. Stabilize membrane potential = IV 10ml 10% calcium gluconate over 10 mins
Immediate onset and effects last for 1 hr
Cardio-protective function (does not reduce serum K+)
IV calcium to be used only =
ECG evidence of severe K+
o Severe hyper K+
o Significant neuromuscular weakness
Use with absolute caution in patients on digoxin -> severe digitalis toxicity
Ensure IV line is working -> extravasation of calcium into subcutaneous tissue can cause
necrosis
ii. Shift ECF K+ into ICF
1. IV bolus 40ml 50%D + 10units soluble insulin over 10min (6U to renal failure patients)
2. IV 0.5mg Salbutamol in 5%D over 10 min
neubulized salbutamol: N/S = 1:3 over 10mins
Risk of tachycardia
iii. Remove K+ from the body
1. Resonium A (15 30g PO; 30g rectal enema)
2. haemodialysis
iv. Prevent further K+ increase
1. Medications review and advice
2. Dietary review and advice
f. Treat concomitant metabolic acidosis with 8.4% NaHCO3
HO on call
a. Check with sample is not haemolysed
b. Ask for patients vitals and symptoms (i.e. chest pain, SOB, palpitations, parasthaesiae, weakness)
c. Past medical history = ESRF
d. Order ECG if K+>5.5 mmol/L and place on contunous ECG mentoring if K+>6.0 mmol/L
e. Orders
i. K+ > 5.0 mmol/L = PO Resonium 15g stat or 30g fleet enema
ii. K+ > 5.5 mmol/L = as above
IV 10ml 10% calcium gluconate over 10mins
IV 40ml D50% + IV 10U soluble insulin
iii. K+ > 6.0 mmol/L = as above
nebulised salbutamol:N/S = 1:3 over 10 mins
iv. If fluid overloaded as well = IV Frusemide
urgent dialysis (if recalcitrant to treatment)
f. Recheck if K+ 2 hrs later
106
Hypokalemia
1. Definition = K= < 3.5 mmol/L
Urgent treatment required if K+ <2.5 mmol/L
Hypokalemia exacerbates digoxin toxicity
Usually occurs with hypocalcaemia and hyomagnesaemia
2.
Causes
Reduced K+ intake
Intracellular shift of
K+
GIT losses
Renal losses
3.
Clinical presentations
Muscle weakness
Hypokalemic periodic paralysis (intermittent weakness lasting up to 72hrs)
Reduced intestinal motility -> paralytic ileus
Cardiac effects
o Ventricular arrythmias
o Asystole
o Potentiation of digitalis toxicity
ECG
o Flattened T waves
o Prominent U waves
o Prolonged PR interval
o Severe (ST depression, T wave inversion)
4. Management
Absolute indications for treatment
1. Digoxin therapy
2. DKA treatment
3. Respiratory muscle weakness
4. Severe hypokalaemia (<2.5mmol/L)
5.
HO on call
1. Check that sample not spurious, i.e. not taken distal to drip site
2. Check patients vitals, PMHx, current medications = stop diuretics, insulin and salbutomol
3. Order ECG if K+ < 3.0mmol/L and place on continuous ECG monitoring if K+ < 2.5 mmol/L
4. Orders
K+ < 3.5 mmol/L
o Oral Span K+ 0.6 1.2g OM
o Mist KCL 10ml TDS
107
K+ < 2.5 mmol/L or K+ < 3.0 mmol/L with digoxin/AMI/IHD = IV KCl replacement
o Check that patient is not oliguiric
o Calculate K+ deficit = 0.6 X BW X (4 - __)
o 1 cycle = 10mmol of 7.45% KCl solution in 100ml water given over 1 hr increases K+ by 0.1 unit
o IV K+ = maximum 20 mmol/hr, maximum 20 mmol/pint, never given as IV bolus
5. recheck K+ 2 hrs post-replacement
Spurious
Non-Spurious
Normal/High
True
hyponatraemia
Pseudohyponatraemia
*Causes = lipids,
proteins, glucose
*True Na+ =
>300mosm
<100mosm
Fluid overload
Hypovolaemi
a
Step 3: Urinary Na+
>20 mmol/L
Cardiac failure
Nephrotic syndrome
Liver cirrhosis
Protein-losing enteropathy
GIT
1. Vomiting
2. Diarrhea
3. Intestinal
fistula
1. Renal failure
Euvolaemia
Step 3: Urinary Na+
<20 mmol/L
>20 mmol/L
Non-endocrine
1. Drugs
2. 1 polydipsia
Endocrine
1. SIADH
2. Hypothyroidism
3. Addisons disease
<20 mmol/L
>20 mmol/L
Renal loss
Skin
1. Burns
2. Excessive
sweating
3. Exudative skin
disease
1. Excess
diuretics
2. Tubulopathy
108
3. Clinical Features
Defined as:
a) Absolute in serum osmolality
b) Rate of development of hyponatraemia
c) Volume status
Hypervolaemia = oedema
o associated features of CCF, liver disease, renal disease
Euvolaemia = drug history
o associated features of Addisons disease, hypothyroidism
Hypovolaemia = dehydration
Hyponatraemia = neurological, due to cerebral oedema (headache, lethargy, weakness, altered mental state,
restlessness, fits, coma)
4. Management
Usually replacement of Na+ if Na+ <125mmol/L
Hypovolaemia
o Cannot correct > 10mmol/day
Na+ deficit = (140 Na+) x 0.6 x body weight
o Usually, do not add in daily requirements of risk of over-correcting
o [Na+] in replacement fluids
0.9% N/S = 154 mmol/L
0.45% N/S = 77 mmol/L
0.23% N/S = 38.5 mmol/L
(3% N/S = 514 mmol/L)
o Example = 60kg male, [Na+] = 130 mmol/L
Na+ deficit = 10 x 0.6 x 60 = 360 mmol/L
Volume of 0.9% N/S = 360/154 = 2.34L over 24 hours
o Correct too quickly central pontine myelinosis
* If hyponatraemia develops slowly = brain adapted to ing serum osmolality, sudden rise will cause shrinking
of brain cells which is potentially fatal
o Correct too quickly APO
Euvolaemia
o Fluid restriction
o Investigations: CXR, TFT, random cortisol (8am), synacthen test
Hypervolaemia
o Fluid restriction
o Hypertonic saline with frusemide = limit treatment-induced CCF expansion
5. SIADH
No history of diuretic history
Absence of oedema/hypovolaemia
Aetiology
a) Malignancy
Small cell lung cancer
Pancreatic cancer
Duodenal cancer
b) CNS
Meningitis
CVA
Subarachnoid haemorrhage
Trauma
109
c) Chest
TB
Pneumonia
Abscess
Aspergillosis
d) Metabolic
Porphyria
e) Drugs
Narcotics
Chlorpropamide (OHGA)
Anti-depressants (amitriptyline)
Neuroleptics (haloperidol, fluphenazine, chlorpromazine)
Management
o Fluid restriction
o Treat underlying cause
o Chronic symptomatic SIADH = demecleocycline/lithium (induces nephrogenic diuresis)
In psychiatric patients = always think of drug-induced SIADH
Exclusion criteria
o Normal renal/fluid/adrenal/thyroid function
Inclusion criteria
o Plasma = Na+, osmolality
o Urine = Na+, osmolality
110
Hypernatraemia
Input Disorder
Drugs
1. Excess
saline
2.Drugs
with high
Na content
3. NaHCO3
after
cardiac
arrest
Pituitary DI
(desmopressin increases urine
Osm)
Hereditary
1. DIDMOAD Syndrome
Impaired ADH
regulation
Endocrine
1. Conns
2.Cushings
Output disorder
Acquired
1. Head Injury
2. Pituitary
surgery
3. CNS Infection
4. Idiopathic
Renal
1. Osmotic dieresis
-DKA
-Urea
-Mannitol
TPN
Extrarenal
1. Excess
sweating
2.Burns
Nephrogenic DI
(desmopressin does not increases
urine Osm)
Hereditary
Acquired
1. Hypokalaemia
2. Hypercalcaemia
3. Obstructive uropathy
4. Nephrotoxic drugs
111
3. Physiology
Increased serum osmolality cause a reflex increase in thirst and ADH secretion
-
hypernatraemia is rare unless thirst mechanism is abnormal or there is limited access to water
4. Clinical Features
Hypernatraemia: confusion, coma, seizures, weakness
Dehydration
Diabetes insipidus: polyuria, polydipsia, increased thirst
5. Management
Free H20 deficit = [ (serum Na 140) x 0.6 x BW] / 140
(Serum Na Fluid Na) / [(0.6 x BW) + 1] = 1 L of fluid will correct Na by ___ mmol/L
Fluids:
o D5% = 0 mmol/L Na+
o 0.9% N/S = 154 mmol/L
o 0.45% N/S = 77 mmol/L
o 0.23% N/S = 38.5 mmol/L
Total fluids = water deficit + maintenance
Correct the deficit over 24 h and the remainder over the next 1-2 days
Eg 60/C/Female
[Na] = 160mmol/L
BW = 60kg
Free H20 deficit = (160-140)/140 x 0.6 x 60 = 5.1L
If D5% given : (160 0)/ [ (0.6 x 60) +1 ] = 4.3 1 L of D5% will decrease Na by 4.3 mmol/L
If 0.9% N/S given : (160-154)/ [(0.6 x 60)+1] = 0.16 1L of 0.9% NS will decrease Na by 0.16 mmol/L
112
Gastrology
Medicine (GIT) = History Taking: GIT (General)
Name/age/race/gender/occupation
Date of admission
Presenting Complaint
1. GI symptoms
a. Nausea + vomiting
Describe vomitus = nature (liquid, digested/undigested food)
colour (yellow bilious liquid, coffee-ground, blood)
Projectile pyloric stenosis, raised ICP
Timing = >1h after meal (GOO, gastroparesis)
early morning (pregnancy, raised ICP)
b. LOA + LOW malignancy, depression
How much weight was lost?
Duration
c. Dysphagia
Onset
Frequency (intermittent suggests oesophageal spasm)
Solids or liquids?
Progressively getting worse (suggests ca, stricture, achalasia)
Painful on swallowing (odynophagia)
Able to initiate swallowing? (inability suggests neurological disease)
Regurgitation (fluid regurgitation highly suggests neurological disease)
d. Heartburn + acid regurgitations (symptoms of GERD)
Precipitants = foods
Aggravating factors = lying supine, bending, alcohol, change in posture
Relieving factors = antacids
e. Abdominal pain
Onset, frequency, duration
Sudden/gradual onset
What were you doing at onset?
Constant/intermittent
Site and radiation
Character (sharp, dull, crampy, colicky)
Severity
Precipitating factor(s) (food, lying down, alcohol)
Aggravating factor(s) (movement in peritonitis)
Relieving factor(s) (sitting up and leaning forwards, antacids/vomiting in GERD/PUD, defecation in
colonic disorders)
f. Constipation
Diarrhoea = frequency (usually > 3x/day)
consistency of stools (watery)
fever (infection)
mucous (IBD, IBS, solitary rectal ulcer, villous adenoma)
blood (colorectal ca, IBD)
travel and contact history)
g. GI bleeding haematemesis, malaena, haematochezia
113
Drug History
1. Any known drug allergies
2. Long-term medications
- Types and indications for use (esp. NSAIDs, aspirin, warfarin)
- Dose, frequency of dosing
- Compliance with use
- Side-effects
3. TCM use
Social History
1.
2.
3.
4.
5.
Smoking
Alcohol drinking
Family set-up (main caregiver, health of family members, finances)
Lift-landing
Functional status (ADL/iADL)
Family History
114
115
5. Lips
a. Capillary haemorrhages (hereditary haemorrhagic telangiectasia or Rendu-Osler-Weber syndrome)
b. Perioral freckle-like spots (Peutz-Jeghers syndrome)
c. Angular stomatitis (iron-deficiency anaemia; Plummer-Vinson syndrome)
Neck
1. Palpate left supraclavicular fossa for enlarge lymph node (Virchows node indicating advanced intraabdominal malignancy)
Chest
1. Check for gynaecomastia (palpate area around nipple) and spider naevi
Abdomen
1. Kneel down at the right side of the bed and position yourself so that you are at eye level with abdomen and
watch for asymmetrical movement
2. Ask patient to point to site of pain (if any)
3. Determine direction of flow in distended veins (empty a distended vein below the umbilicus by flattening it
out and occluding it at both ends, release lower finger, empty vein again, release upper finger; if the flow of
blood is downwards, the cause is portal hypertension; if the flow of blood is upwards, the cause is due to
obstruction of IVC)
4. Begin superficial (? Soft/ guarding/ tender) and deep (organs and masses) palpation. Use the pulps of
fingers (flex metacarpophalangeal joints and distal interphalangeal joints) and palpate systematicall (work
all the way up from one side to the other and always begin from the non-tender area). Look at face during
palpation for signs of pain
a. Guarding = may result from tenderness, anxiety, peritonitis
b. Rigidity (wash board rigidity) = peritonitis
c. Rebound tenderness = peritonitis
5. If there is a mass, describe it interms of : size, shape, surface, tender, mobility, consistency, pulsatile
a. Try to get below it (if it is a pelvic mass, cannot get below it)
b. Bimanually palpate if (if cannont, then mass is located more anterior)
6. Examine specific organs: liver, spleen, kidneys
Liver
1. Place lelft hand on right costal margin and right hand at a similar angle to the ribs
2. Start in the right iliac fossa
3. Palpate deeply during inspiration and move fingers upwards during expieration (will feel liver edge moving
towards fingers during inspiration)
a. Normal causes of palpable liver: ptosis 20 hyperinflation (asthma, emphysema),
supradiaphragmatic collection)
4. Percuss intercostals spaces downwards until dullness occurs upper limit of liver dullness
5. Lower limit is where you feel the liver edge/ percuss upwards until dullness occurs
6. Describe liver in terms of size, (hepatomegaly measure liver span and length below right costal margin),
surface (smooth.nodular), pulsatile, tender, consistency, edge
Gallbladder
1. If biliary obsturtion/ acute cholecystitis suspected, examining hand should be oriented perpendicular to
costal margin and feel from medial to lateral
2. Do Murphys sign: ask patient to take a deep breath and press finger at angle between costal margin and
border of rectal sheath. If inspiration is arrested, there is a positive sign (suspect cholecystitis)
Spleen
1. Place left hand on left costal margin and begin palpation from right iliac fossa
a. Enlarged spleen descends obliquely across the mideline (must enlarge by 2x for it to be palpate)
b. Can also feel enlarged para-aortic lymph nodes and abdominal aortic aneurysm)
2. Palpate deeply during inspiration and move fingers obliquely upwards during expiration
3. Percuss over lowest intercostals space in left anterior axillary line and spleen (both areas should be
resonant)
116
Ascites
1. Place left middle finger on umbilicus and start persussing to the other end (should be resonant out to the
flanks); dullness in the flanks means that there is at least 2L of ascitic fluid
2. If there is dullness before the flanks, ask patient to lie on right lateral position and wait for 30-60s for fluid
equilibration. Percuss form site of dullness back towards midline. If site of dullness becomes resonant in
this position, there is ascites. Percuss for new position of dullness (fluid level in this position)
3. Further test for ascites: ask patient to place right hand vertically in midline of abdomen, then place your
hand on left abdomen and flick fingers on right abdomen (can feel fluid thrill if there is ascites)
4. In this position, palpate for spleen
5. Check for sacral edema and scars (bone marrow biopsy ? myeloproliferative disease)
Kidneys
1. Bimanual palpation; place left hand under patient and right hand on the abdomen and push left hand
upwards twice during inspiration (do 2 time on each side)
a. If kidney enlarge, the righ hand will feel something hitting it
b. Enlarged kidney bulges forwards; perinephric abscess bulges backwards; transplanted kidneys
palpable in either iliac fossa
Ausculatation
1. Listen for bowel sounds (tinkling and hyper active = IO; absent over 3min period = paralytic ileus)
2. Listen for renal bruits
3. Hepatic arterial bruit = alcoholic hepatitis, HCC, liver mets
4. Abdominal venous hum = portal hypertension
Groin
1. Palpate for enlarge inguinal lymph nodes
2. Ask patient to cough to detect inguinal hernias
3. Inspect for testicular atrophy (CLD)
Legs
1. Look for bruising, scratch marks and edema (press thumb against the back of malleolus, look at patients
face for pain)
2. Inspect toe nails for clubbing, cyanosis, pallor, leukonychia
End
1. Sit the patient up
a. Hepatic asterixis for 15s (hepatic encephalopathy)
b. Cervical lymphadenopathy
c. Parotid/ submandibular gland enlargement)
2. Tell the examiners that you would like to complete the examination by doing a PR exam, taking blood
pressure and temperature. If patient has hepatomegaly, should examine JVP. If ascites/ pedal edema
present, check for pleural effusion
3. Thank patient for his help and dress him up properly
Template for presentation
On general inspection, the patient appears to be alert, comfortable, orientated and well at rest. There are no
signs of respiratory distress and the patient does not appear to be in any pain. The vital signs are stable (HR =...,
RR= ..., afebrile)
Examination of the peripheries did not show any signs of jaundice, pallor cyanosis, dehydration or stigmata of
chronic liver disease such as clubbing, leuconychia, palmar erythema, spider naevi, gynaecomastia etc.
Inspection of the abdomen did not reveal any surgical scars, abdominal distension, distended vein or any
visible masses or pulsations. The abdomen was symmetrical and moved well with respiration. On superficial
palplation, the abdomen was soft and non-tender with no guarding or rigidity of abdominal wall muscles. The
liver was found to be enlarged at 3cm below the right costal margin with a liver span of 16 cm as measured in
117
the mid-clavicular line. The surface of the liver was smooth with no nodules felt. It was non pulsatile and no
bruits were heard over the liver. The spleen and the kidneys were non-palpable. No ascites was detected. Bowel
sounds were normal and no renal bruits were heard.
Inguinal lympadenopathy and cough impulses suggestive of inguinal hernia were not detected in the groin.
Lower limb and sacral edema were absent. There was no hepatic flap.
In summary, the patient has features of _________ as evidenced by _________
118
119
8. Sister Joseph nodule = metastatic tumor deposit in the umbilicus (antatomical region where the peritoneum
is closest to the skin)
9. Cullens sign = blue black discolouration of umbilicus (extensive haemoperitoneum, acute pancreatitis)
10. Liver
a. Normal liver span = <13 cm as measure in the mid-clavicular line
b. Pulsatile liver = tricuspid regurgitation, HCC
c. Tender liver = hepatitis, rapid liver enlargement, hepatic abscess, cholangitis
11. Gallbladder
a. Courvosiers law= if the gallbladder is enlarged and the patient is jaundiced, unlikely to be
gallstones; gallbladder with stones is usually chronically fibrosed (small)
Gallbladder enlargement
With jaundice
1. Carcinoma of head of pancreas
2. Carcinoma of ampulla of Vater
3. Gallstones in CBD
4. Carcinoma of the gallbladder
Without jaundice
1. Mucocele/ empyema of gallbladder
2. Carcinoma of the gallbladder
3. Acute cholecysitits
12. Splenomegaly
Vascular
Infective
Trauma
Autoimmune
Metabolic
Infiltrative
Neoplastic
Haematological
Causes of splenomegaly
Portal hypertension
Viral hepatitis , EBV, CMV
Bacterial (SBE)
Protozoal (malaria, kala-azar)
Haematoma
SLE
RA (feltys syndrome)
Storage disorders (Gaucher, Neimann-Pick, glycogen storage, lipid storage)
Amyloidosis
Sarcodosis
CML (invasive)
Myelofibrosis (massive)
Lymphoma
Lymphoproliferative disorders
Polycythemia ruba vera (massive)
Chronic haemolytic anemia, (spherocytosis, G6PD deficiency, thalassaemia)
120
c.
d.
e.
f.
Dull percussion note over spleen but resonant over kidney due to gas filled fowel loops
Kidney is ballotable but not the spleen
Cannot get above the spleen (can get above the kidney)
Friction rub may be heard over the spleen but never over the kidney (too posterior)
121
History
1. Past medical history : To identify the system responsible for the ascites
Any past medical history of any disorder like coronary artery disease, hypertension, alcohol abuse. Is
the patient on any drug that can cause cardiac, hepatic or renal disease? Does the patient have renal
failure or go for dialysis. If suspicious, a history of HIV and TB should be obtained.
2. Ascites: Alcohol history, Hepatitis B status, any intra-abdominal masses and their associated symptoms.
3. Past medical history : Hepatitis Vaccinations, any recent drugs used
4. Any associated early satiety and shortness of breath
Physical Examination
General Appearance
Vital Signs
Any tachycardia
Respiratory rate for tachypnea
Blood pressure measurement for hypertension
CVS Examination
Checking for raised JVP will provide great yield here as it would indicate heart failure
Other signs to pick up will include displaced apex beat, gallop rhythm, bibasal crepitations and any
possible aetiology for heart failure like valvular heart disease
Abdominal Examination
122
Ask for site of most intense pain first. Palpate for presence or organomegaly. The live in alcoholic
cirrhosis is unlikely to be enlarged. However, other stigmata of chronic liver disease can be sought for
like caput medusae.
Percuss for ascites and shifting dullness
Palpate for any suspicious intra abdominal masses
Palpate for hepatosplenomegaly in portal hypertension
Lower Limbs
123
Pathological accumulation of fluid in the peritoneal cavity = clinically detectable when > 500mls
Pathogenesis
Under filling theory = inappropriate fluid sequestration within splancnic vascular bed secondary
to portal hypertension > decreased intravascular volume > kidneys retain more Na+ and water by
activating RAA system
Overflow theory = primary renal retention of Na+ and water
Complications
a) Peritonitis
b) Dyspnea secondary to splinting of diaphragm
c) Pre-renal failure secondary to intravascular volume depletion
d) Early satiety
Aetiology
Transudate vs Exudate
Transudative
Cardiovascular
Congestive cardiac failure
Right heart failure
Constrictive pericarditis
IVC obstruction
Portal/hepatic vein obstruction
Renal
Acute renal failure
Chronic renal failure
End stage renal failure
Nephritic syndrome
Nephrotic syndrome
GI
Chronic liver disease
Malnutrition
Protein-losing enteropathy
Exudative
Infection
TB peritonitis
Inflammation
Pancreatitis
Intra-abdominal malignancy
Pancreatic/gastric/colonic ca
Ovarian ca
Metastasis to liver
Metastasis to peritonium
Generalised vs Localised
Generalised
Cardiovascular
Congestive cardiac failure
Right heart failure
Constrictive pericarditis
Renal
Acute renal failure
Chronic renal failure
End stage renal failure
Nephritic syndrome
Nephrotic syndrome
GI
Chronic liver disease
Localised
Vascular
Portal HPT
a) IVC obstruction
b) Budd-chiari syndrome
c) veno-occlusive disease
d) Liver cirrhosis
e) Portal/splenic vein obstruction
Infection
TB peritonitis
Inflammation
Pancreatitis
124
Malnutrition
Protein-losing enteropathy
Intra-abdominal malignancy
Pancreatic/gastric/colonic ca
Ovarian ca
Metastasis to liver
Metastasis to peritonium
History
Name/age/race/gender/occupation
Drug allergy
Past medical history
Date of admission
Presenting complaint
Symptoms
1. Abdominal distension
duration
acute/gradual
quantity = how many inches? , weight gain
associated with LL edema, SOB (exertional, orthopnea, PND), faciel edema
fever and abdominal pain and diarrhea > SBP
Aetiology
1. CVS
History of heart disease
Chest pain, sob, diaphoresis
2. Renal
Urine output (oliguria, appears concentrated)
Hematuria and frothy urine
3. GIT
Chronic bloody diarrhea
LOA, LOW
History of liver disease jaundice, easy bruising, pruritis changes in uring and stool, fatigue
4. Infection
History of TB
5. Inflammation
Acute epigasttric pain radiating to the back
6. Malignancy
LOA, LOW, fever, fatigue, abdominal pain, jaundice, recent changes in bowel habits,
haematochezia, melena, irregular menstrual bleeding
BGIT
Sepsis
Recent drug intake
Recent surgery/trauma
125
Systemic review
Management prior and during admission
Has this happened before? Describe prior experiences
Differentials
Fat
Fetus
Flatus
Faeces
Fluid
Filthy big tumour
Investigations
ECG, Cardiac enzymes, CXR = CCF
Urine
Bloods
Imaging
Microbiology
Abdominal paracentesis
Both diagnostic and therapeutic
Clinical parameters
Appearance (straw coloured; turbid = pyogenic, TB; bloody = malignant, TB; chylous =
pancreatitis)
Clinical chemistry (cell count and differential; protein; albumin; glucose; amylase)
Gram stain, microscopy, c/s, AFB smear, TB c/s
Fluid cytology
Serum-ascitic albumin gradient = serum albumin ascitic albumin
Correlates directly with portal pressure
Transudate = gradient > 1.2 g/dl
Excudate = gradient < 1.2 g/dl
May be associated with a right pleural effusion via trans-diaphragmmatic lymphatics =
subpulmonic effusion
- Management = fluid restriction, strict I/O charting, vitals monitoring, IV albumin 20% with
diuretics
Management
Non-pharmacological
126
Pharmacological
Diuretic-resistant ascites
Approach to ascites
Abdominal masses
Epigastric mass (gastric ca)
RIF mass (ovarian ca, cecal ca)
LIF mass (desceding colonic ca, sigmoid ca)
If patient is jaundiced
a) Signs of CLD liver cirrhosis Cx portal HPT
b) Minimal signs of CLD + smooth tender hepatomegaly = budd-chiari syndrome
+ craggy liver = intra-abdominal malignancy with liver/peritoneal mets
Feel for supraclavicular LAD
If patient is not jaundiced and no signs of CLD
a) Leuconychia nephritic syndrome
b) Raised JVP constrictive pericarditis or right heart failure
If all negative
a) TB peritonitis = chest examination
b) Carcinomatosis peritoneii = paracentesis + FNAC to see malignant cells
127
Liver cirrhosis
Strict criteria
a. Diffuse fibrosis
o Occurs in portal tracts, central veins and space of Disse
o Inflammation stimulates stellate cells in space of Disse transforms into myofibroblasts
o Extension of fibrosis from space of Disse to other parts of lobule causes sinusoids to separate
from hepatocytes
o Venulization = sinusoids converted from fenestrated endothelial channels with free exchange of
solutes to high pressures and fast-flowing channels without such exchange
o Shunting of blood directly from portan vein to central vein = no detoxification of metabolites
hepatocytes derived of nutrients
b. Nodule formation = consisting of regenerating hepatocytes
c. Disruption of tissue architecture = bridging fibrosis and shunt formation
Results in subdivision of liver into nodules of regenerating hepatocytes surrounded by scar tissue
Aetiology
Vascular
o Tricuspid regurgitation/right heart failure (cardiac cirrhosis)
o Veno-occlusive disease
o Budd Chiari syndrome
Infective
o Hep B and C infection
Toxin
o Chronic alcoholism
o Drugs (methotrexate, amiodarone)
o alfatoxin
Autoimmune
o Autoimmune hepatitis
o Primary biliary cirrhosis
o Primary sclerosing cholangitis
o Secondary biliary cirrhosis (RPC or chronic CBD stones)
Metabolic
o Wilsons disease
o Secondary haemochromatosis (DO NOT mention HH as gene not found locally)
o Alpha1 antitrypsin deficiency
Cryptogenic
History
Aetiology
Vascular
o History of heart failure
Infective
o Personal history of Hep B/C infection
o History of Hep B vaccination
o Maternal history of Hep B infection
o History of blood transfusion, IVDA, CSW contact, tattooing
Toxin
o History of chronic alcoholism
o History of cytotoxic drug ingestion
Autoimmune
o History of rash, joint pain and swelling
Metabolic
128
Complications
Hypoalbuminaemia
o Lover limb edema
o Abdominal distension +abdominal pain/fever (SBP)
Bilirubin
o Jaundice
o pruritus
Coagulopathy
o Easy bruisability
o Petechiae may present like ITP
o Mucocutaneous bleeding
o menorrhagia
Bleeding varices - Haematemesis, haematochezia, melena
Encephalopathy - lethargy drowiness, confusion, sleep-wake inversion, personality change
Hepatorenal syndrome - oligouria
HCC
o LOA, LOW, fever, fatigue
o Regular f/u done? Annual U/S and AFP?
Physical examination
CLD = jaundice, clubbing, leuconychia, palmar erythema, bruising, scratch marks, fetor hepaticus, spider
naevi, gynaecomastia, loss of axillary hair, testicular atrophy, lower limb edema
Portal HPT = dilated veins, ascites, splenomegaly
Encephalopathy = terminal asterixis
HCC = hard and craggy hepatomegaly
Alcoholism = duputyrens contracture, parotid enlargement
Hep B/C infection = tattoos, IV needle marks
Investigations
Aims
Confirm diagnosis
Look for underlying aetiology
Assess severity
Look for complications
Bloods
FBC
o Hb decrease, WBC decrease, pII decrease (hypersplenism)
o WBC increase (SBP)
o Hb decrease (folate/iron-deficiency anemia)
o MCV decrease (alcoholism)
LFT
o Bilirubin increase
o AST>ALT (alcoholic liver disease)
o GGT increase (alcohol liver disease)
o ALP increase (biliary obstruction)
o Albumin (marker of synthetic function; malnutrition)
PT/PTT = prolonged PT (marker of synthetic function)
U/E/Cr = hepatorenal syndrome
Hepatitis serology
Autoimmune screen
Tumor markers = AFP
Imaging
129
U/S HBS
o Development of HCC
o Biliary obbstruction
Liver biopsy/ERCP
Assessing severity
Childs Pugh score
Measure
Albumin
Bilirubin
Coagulopathy (PT)
Distension (ascites)
Encephalopathy
1 point
>35
<34
1-4s
None
none
2 points
28-35
34-50
4-6s
Mild
Grade 1-2
Points
Class
Life expectancy
5-6
7-9
A
B
10-15
15-20 yrs
Candidate for
transplant
1-3months
3 points
<28
>50
>6s
Severe
Grade 3-5
Peri-operative
mortality
10%
30%
82%
Management
Ascites/Lower limb edema
Fluid restriction
Low-salt diet
Strict I/O charting and daily weights
IV diuretics = Furosemide +/- spironolactone
Abdominal paracentensis (intermittent peritoneal taps)
o Therapeutic = relieves SOB
o Diagnostic = rule out peritonitis
Peritoneovenous shunt
Portal HPT
Hepatic encephalopathy
Malnutrition
Pruritus
Ursodeoxycholic acid
Hepatic decompensation
Jaundice
Hepatic flap
Coagulopathy
Ascites
Lower limb edema
131
Moderate-large liver
a) Malignancy
b) Fatty liver (esp alcoholic liver disease)
c) Myeloproliferative disease
d) Right heart failure
Hard and knobbly liver
a) Malignancy
b) Macronodular cirrhosis
c) Cystic APKD, hydatid
d) Granulomatous/gummatous syphilis
e) Amyloidosis
# glass eye + hard knobbly liver = 1 ocular melanoma with liver metastasis
132
Sign
Xanthelesma
(females)
Aetiology to consider
Primary biliary cirrhosis
Slate-grey
Haemochromatosis
(males)
Parotidomegaly Alcoholic liver disease
Raised JVP
Limb
Lungs
Kayserfleischer rings
Duputyrens
contracture
Chorea
Tattoo
Pyoderma
gangrenosum
Lower zone
emphysema
Wilsons disease
Post-viral (likely Hepatitis B)
Ulcerative colitis
1-antitrypsin deficiency
-thalessemia major
Overall
Pituitary haemosiderosis
Cardiac haemosiderosis
Pancreatic haemosiderosis
Intervention
Request
Short stature
Hyperpigmented
Thalessemic facies (frontal bossing, flat nosebridge,
maxillary hyperplasia)
Looks younger for age
Hypopigmented areolae
Loss of axillary hair
JVP v wave
Pulsatile liver
Lower limb edema
Hypocount marks on fingers
Diabetic dermopathy
Splenectomy
Gonadal examination
Specific conditions
Haemochromatosis
Request to examine for:
a)
b)
c)
d)
Arthropathy pseudogout
CCFcardiomyopathy
Testicular atrophy pituitary involvement
Glycosuria with urine dipstick DM
133
Wilsons Disease
Area
Overall
Eyes
Sign
Short stature
Ptosis
Pallor and jaundice
Kayser-Fleischer rings
Face
Malar Rash
Upper limb
Tremor/chorea
Lower limb
Swollen knees
Request urinalysis for glycosuria (proximal RTA)
Interpretation
Rickets secondary to
proximal RTA
Penicillamine-induced MG
Coombs negative
haemolytic anaemia
Copper deposits in
Descemets membrane of
cornea predominantly at 12
and 6 oclock positions. Can
also occur in PBC and
cryptogenic cirrhosis. Look
out for sunflower cataract
as well
Penicillamine-induced
lupus
Penicillamine-induced
lupus
Extrapyramidal syndrome
Pseudogout
Chronic UC
CLD + pyoderma gangrenosum = chronic UC and
a)
b)
c)
d)
e)
Cirrhosis
Chronic active hepatitis
Primary sclerosing cholangitis
Cholangiocarcinoma
Metastatic colorectal cancer
Request to examine
a)
b)
c)
d)
In summary, this patient has hepatomegaly likely secondary to chronic liver disease. I say this because
a) Evidence of stigmata of CLD found on peripheral examination
b) Presence of hepatomegaly measuring ___cm along the mid clavicular line and of ___consistency
The aetiology is likely to be secondary to Hep B virus (high local endemicity) or alcohol (duputyrens
contracture, parotidomegaly). This is/is not complicated by portal hypertension and hypoalbuminemia.
In summary this patient has hepatosplenomegaly likely secondary to liver cirrhosis complicated by portal
hypertension. I say this because of
a) Evidence of stigmata of CLD found on peripheral examination
b) Presence of hepatomegaly measuring __cm along the mid-clavicular line and of ___consistency
c) Presence of splenomegaly measuring __cm
d) Features suggestive of portal HPT
This is/is not complicated by hypoalbuminaemia or hepatic encephalopathy
134
1. Jaundice
- Duration
- Onset=acute or gradual
- Skin and eyes affected?
- Progression getting better, worsening, fluctuating (periampullary ca, gallstones)
2. Obstructive
- Tea-coloured urine
- Acholic stools
- Steatorrhoea
- Pruritus
- Bleeding tendencies (gum bleeding, easy bruising)
3. Abdominal pain (epigastric/RHC pain) = obstructive/hepatic jaundice
4. Fever (a/w chills and rigors)
5. LOA, LOW, malaise
6. Nausea/vomiting
7. Changes in bowel habit (?CRC with liver mets)
8. Melena/PR bleeding (necrosis of periampullary ca? CRC with liver mets, portal HPT)
9. Abdominal distension and lower limb oedema
Aetiology
#drugs
-
#autoimmune
-
#neoplasia
Complications
135
CCF
Valve replacement mechanical haemolysis
DM, HPT, HCL, AMI, IHD, CVA, cancer, asthma
Previous hospitalizations and surgeries
Drug history
Social history
1.
2.
3.
4.
5.
6.
7.
8.
Smoker
Alcoholic drinker
Family set-up
Main caregiver
Finances
Type of housing
Lift-landing
Functional status
Family history
1. Gallstones
2. Cancers CRC, HCC
136
biliverdin
Heme
Biliverdin
bilirubin
Formed outside the liver in cells of mononuclear
system
oxygenase phagocyte
reductase
Causes of hyperbilirubinaemia
(a) Over-production of bilirubin haemolytic (pre-hepatic) jaundice
(b) Impaired hepatocyte uptake, conjugation or excretion of bilirubin hepatocellular (hepatic) jaundice
(c) Obstruction of bile outflow obstructive (post-hepatic) jaundice
Pathophysiological classification
Predominantly unconjugated hyperbilirubinaemia
- Unconjugated bilirubin tightly complexed to serum albumin insoluble in water not excreted in
urine
- Unbound albumin-free portion highly toxic deposited in brainkernicterus
- High affinity for basal ganglia choreoathetotic CP
Over production of bilirubin
- Haemolytic anaemia
o enzyme defects (G6PD deficiency, pyruvate kinase deficiency)
o Membrane defects (spherocytosis, elliptocytosis)
o Hb synthesis defects (thalassemia, sickle cell anaemia)
o Blood group and Rh incompatibility
o Immune-mediated (drug-induced, SLE, idiopathic)
Impaired hepatocyte uptake
- Drugs (interfere with membranous carrier systems) = rifampicin
- Gilbert syndrome (decreased uridine diphosphate-glucuronosyltransferase)
137
Acute
Usually present
Usually not the first time
Dark urine and stools
Usually present, +/- splenomegaly
Usually self-limiting and gradually improves once
precipitating factor is removed
Hepatic jaundice
138
Onset
Pain
Fever
Urine and stools
Progression
Post-hepatic jaundice
Onset
Pain
Fever
Urine and stools
Progression
Onset
Constitutional symptoms
Pain
Cholangitis
- Charcots triad
- Raynauds
pentad
2-hit phenomenon
Endocrine insufficiency
Migratory thrombophlebitis
Progression
Complications
1. Acute jaundice Acute liver failure
- Coagulopathy
- Ascites/LL oedema
- Encephalopathy=forgetfulness, confusion, drowsiness
- Hepatorenal syndrome renal failure due to liver impairment
o Oliguria/anuria (urine becomes lesser and more concentrated(
o Liver unable to detoxify blood either due to porto-systemic shunting or impaired
hepatocyte function
High levels of circulating endotoxins
139
2.
3.
4.
5.
Investigations
Blood:
1. FBC
- WCC (leucocytosis in infections; leucopoenia in biliary cirrhosis and hypersplenism)
- Hb (anaemia if there is haemolysis, bleeding or underlying malignancy)reticulocyte count
- Haptoglobin assay
- PBF
2. U/E/Cr
- Renal impairment (hepatorenal syndrome)
- Serum glucose (hypoglycaemia)
3. LFT
(a) Establish if it is a predominantly unconjugated/conjugated hyperbilirubinaemia
(b) Hepatocyte integrity AST, ALT, LDH
(c) Biliary obstructionALP, GGT
(d) Synthetic function
- albumin, PT/PTT
- ALT>AST in viral hepatitis
- AST>ALT in alcoholic hepatitis
- Raised ALP/GGT in obstructive jaundice
- GGT specific for alcoholic hepatitis
4. PT/PTT
- Measure of liver function (PT affected as factors 5&7 have the shortest t1/2)
140
5.
6.
7.
8.
Imaging:
1. AXR
- Gallstones
- Pneumobilia (cholecystenteric fistula, cholangitis with gas-producing organism)
2. U/S HBS
- Dilated intra-hepatic ducts (obstruction)
- Gallstones in gallbladder
- Liver cirrhosis and masses
- Ascites
3. CT AP
- Gallstones in gallbladder or biliary tree
- Liver and pancreatic masses
- Level of biliary obstruction
- Double-duct sign (dilatation of both CBD and pancreatic duct periampullary ca)
- LAD at porta hepatitis
- Ascites
4. CXR
- Lung primary or mets
5. ERCP (endoscopic retrograde cholangiopancreatography)
- If gallstones, lower CBD or pancreatic head pathology suspected
- Diagnostic
o Direct visualisation
o Obtain samples for histology/cytology (periampullary region, pancreatic fluid and bile)
- Therapeutic
o Remove gallstones
o Sphincterotomy
- Stenting of stricture at lower end
o Contraindications
o Gastrectomy (ECRP poses high risk of perforation as stomach is disconnected from
duodenum)
- Complications
o Traumatic pancreatitis
o Pancreatic/biliary sepsis
6. PTC
- If there is dilatation of intra-hepatic ducts or unsuccessful ERCP
- Diagnostic
o Direct visualisation
- Therapeutic
o Insert catheter for drainage
- Contraindications
o Coagulopathy
o Ascites (unable to tamponade liver puncture)
o HBS sepsis
7. MRCP
- If patient has contraindications to ERCP/PTC
8. Liver biopsy
- US/CT-guided core liver biopsy
141
142
Drug induced:
Autoimmune:
Metabolic:
Infiltrative:
Neoplastic:
Ischemia
Viral (hepatitis viruses, CMV, EBV, HSV, dengue)
Bacterial (salmonella, shigella)
Parasitic (malaria)
Alcohol, paracetamol, TCM, anti-TB drugs (e.g. isonazid, rifampicin, pyrazinamide),
anti-convulsants (e.g. sodium valporate), satins
Autoimmune hepatitis
Wilsons disease
Massive malignant infiltration
ALT-AST reversal
Most liver diseases are characterized by greater ALT elevations than AST elevations
Exception where AST: ALT 2
o Alcohol
o Drug induced
o Infections (e.g. salmonella, dengue)
143
144
o Spontaneous remission
o Indolent disease without progression
o Rapidly progressive disease cirrhosis
Causes of death
o Liver cirrhosis
o Liver failure
o Haematemesis
o Hepatocellular carcinoma
Hepatitis A virus
Epidemiology= usually found in developing world substandard hygiene & sanitation;
prevelance of seropositivity increases with age
Caused by picornavirus (ssRNA), 1 serotpe
Mode of transmission=
o faecal oral route
o food & water borne (e.g. eating partially cooked cockles & oysters/ contaminated food & water)
o person-person (e.g. sexual oral-anal)
Incubation period = 4-6 weeks
o HAV appears in faeces before clinical symptoms (usually 2-3 weeks before jaundice & 1 week after
onset of jaundice)
Clinical presentation
o Asymptomatic (most) = subclinical & milder than HBV infection
o Acute hepatitis= usually bengn and self limiting
o Worse if superimposed on chronic hepatitis
o Does not cause chronic hepatitis or carrier state
Complications: Fulminant hepatitis (rare)
Serological picture:
o Transient viraemia blood borne transmission rare
o IgM with acute infection fecal shedding ends as IgM increases
o IgG for long term immunity
Prevention
Avoid eating contaminated food or drinks
Boiling 5 mins
Immunization
o Passive immunization with Ig G
IgG collected from blood of persons who have been exposed to the hepatitis A
This method of immunization is getting obsolete because of the short supply of immune
globulin and the potential risk of transmission of other infection through blood products
o HAV vaccine
Inactivated virus
145
Given in 2 doses, with the second dose being given 6 - 12 months later. Immunity after
vaccine lasts for 10 - 20 years. Protection against hepatitis A begins 4 weeks after
vaccination
People at risk of HAV
Persons travelling to or working in countries that have high or intermediate rates of hepatitis A
Persons who work with hepatitis A virus infected primates or with hepatitis A virus in a
research laboratory should be vaccinated.
Persons with chronic liver disease eg. chronic hepatitis B carriers as these patients have been reported to
have a higher mortality.
Hepatitis B virus
Epidemiology: endemic in Africa and Asia;
Microbiology
Belongs to the Hepadnavirus family
Has 3 well characterized antigens:
o HBsAg (surface) stimulates anti-HBs
o HBcAg (core) stimulates anti-HBc
o HBeAg (core associated) stimulates anti-HBe
Dane particle = infectious spherical HBsAg particle containing HBcAg core
HBeAg arises from the same gene as HBcAg
o c gene has 2 initiation codons= precore and core region
o translation intitated at precore region = HBeAg signal peptide that facilitates secretion (can be
used as surrogate marker for presence of HBcAG)
o translation initiated at core region = HBcAg no signal peptide not secreted into serum
Nucleocapsid
o circular partially ds DNA
o DNA polymerase with reverse transcriptase activity
o HBcAg remains in hepatocytes for complete assembly of virions, only detected in liver biopsy
samples
146
Serology
147
Infants: 40-50%
Children: 30-40%
Adults: 5-10%
ii. Sex male: female 3:1
iii. Ethnicity Chinese> Malays> Indians; related to prevalence of female carriers and periantal
infx
iv. Impaired immune responses transplants, drugs
148
Chronic infection
Persistence of HCV RNA despite
neutralising Ab
Episodic elevations of HCV RNA
and transminases
Treatment
Ribavirin and IFN combination therapy partial efficacy
No vaccine available; difficult to cover agains the 6 major genotypes
149
Hepatitis D virus
Defective ssRNA virus requires HBsAg coat to infect cells
HBV serves as helper virus
Clinical presentation
1. Super infection: chronic HBV carrier exposed to HDV severe hepatitis
2. Co-infection: exposed to HBV & HDV at the same time
a. HBV must become established first to provide HBsAg required for HDV virion production
b. Chronic hepatitis rare
c. Higher rates of fulminant hepatitis (3-4%)
Serology
HDV RNA appears just before and during early acute symptomatic infection
IgM anti-HDV = recent HDV exposure
To differentiate co-infectin and super infection = correlate with HBV markers
Hepatitis E virus
Calicivirus, ssRNA
4 genotypes, endemic in India and the Middle East
Transmission: faecal-oral, water borne
Incubation period= 4-6 weeks
Clinical presentation
Acute hepatitis
o Usually self-limiting and benign
o Abs are non-protective
No chronic state or chronic hepatitis
High rate of fulminant hepatitis in pregnant women (25% fatal); foetal mortality also high
No vaccines
Serology
HEV RNA and HEV virions present in stool and liver before onset of symptoms
IgM anti-HEV present with rising transaminase IgG
Hepatitis Screen
HAV=
o Anti- HAV IgM (acute)
o Anti- HAV IgG (previous infection)
HBV=
o HBsAG, HBeAG, anti-HBc, IgM (acute)
o Anti-HBs IgG, anti-HBe, anti-HBc IgG (previous infection)
HCV=
o Anti-HCV IgM (acute)
o Anti-HCV IgG (previous infection)
CMV = anti-CMV IgM
EBV = anti EBV IgM
HSV = anti-HSV IgM, HSV PCR (if patient presents with acute liver failure)
150
Transmission
HAV
Icosohedral capsid,
ssRNA
Picornavirus
Faecal-oral
Incubation period
2 6 weeks
Carrier state
None
Chronic hepatitis
None
Fulminant hepatitis
0.1 0.4%
0.1 1% of blood
donors; 90 95% of
those infected at
birth (vertical
transmission); 1
10% infected as
adults (esp. If
immunecompromised)
5 10% of acute
infections (adults);
90% in infected
neonates
<1%
Hepatocellular Ca
No
Yes
Yes
Vaccine available
Others
Yes
Acute hepatitis
(symptomatic,
asymptomatic)
Yes
No
Fulminant hepatitis
almost never occurs
with HCV
Agent
HBV
Enveloped dsDNA
HCV
Enveloped ssRNA
Hepadnavirus
Parenteral, close
contact, vertical
4 26 weeks
Flavivirus
Parenteral, close
contact
2 26 weeks
0.2 1% of blood
donors; <1% are
healthy carriers
HDV
Enveloped ssRNA
HEV
Unenveloped ssRNA
Calicivirus
Parenteral, close
contact
4 7 weeks
(superinfection)
1 10% of drug
addicts,
haemophiliacs
Waterborne
Flavivirus
Parenteral
2 8 weeks
Unknown
Unknown / none
1 2% of blood
donors
<5% if co-infection
with HBV; 80% upon
super infection with
HBV
3 4% in coinfection
None
None
0.3 3%
20% in pregnant
females
Unknown, but
unlikely
No
Unknown
No increase above
HBV
No
HGV
ssRNA
None
No
At present, not
considered
pathogenic
151
Duputyrens contracture
Dilated cardiomyopathy displaced apex beat, signs of CCF
Cerebellar signs
Parotidomegaly
Proximal myopathy
Peripheral neuropathy
Dementia
Wernickes encephalopathy classic triad of:
1) encephalopathy (confusion, loss of short-term memory)
2) ataxia
3) ophthalmoplegia (nystagmus, gaze palsies)
Korsakoffs psychosis/syndrome
1) anterograde amnesia
2) retrograde amnesia
3) confabulation (invented memories which are then taken as true due to gaps in memory sometimes
associated with blackouts)
4) meagre content in conversation
5) apathy
6) lack of insight
152
*investigations*
*causes of death*
BGIT haematemesis
Hepatic encephalopathy
Hepatorenal syndrome
Sepsis
HCC
Type 1 ANA, anti-SMA (smooth muscle actin) Ab, increased frequency of HLA B8 and
HLA DRw3
Type 2 anti-LKM1 (liver kidney microsomal 1) Ab
*epidemiology
*clinical presentation
*associated with autoimmune disorders RA, thyroditis, scleroderma, IBD, pernicious anaemia, IDDM,
AIHA, PSC
*investigations
*treatment
(a) immunosuppression prednisolone, azathioprine (steroid-sparer)
(b) liver transplant
*prognosis if untreated severe disease:
153
2) Haemochromatosis
*excessive iron accumulation with subsequent deposition in various organs esp. liver and pancreas
*primary haemochromatosis (hereditary haemochromatosis)*
Repeated blood transfusions Thalassemia major, aplastic anaemia, sickle cell disease, myelodysplastic
syndrome, leukaemia, lymphomas
Increased Fe intake Fe-dextran injections
*investigations*
*management*
Early venesection beneficial especially in those who have not developed DM/cirrhosis
154
155
*Physical Examination*
Kayser-Fleischer rings: greenish yellow to golden brown pigmentation at the limbus of the cornea due
to deposition of copper in Descemets membrane
Proceed to look for:
o Jaundice
o Sunflower cataracts
o Hepatomegaly
o Signs of liver failure
o Neurological manifestations: tremor, chorea, mask-like
facies
*Presentation*
156
*Discussion*
Inheritance
o Autosomal recessive; chromosome 13
o A/w family history of consanguinity
Pathophysiology
o Excessive absorption of Cu from the small intestine with decreased excretion by liver
o Increased tissue deposition esp in brain, cornea, liver and kindey Fanconis Syndrome
(glycosuria)
o Cavitation and neuronal loss occurs within the putamen and globus pallidus (basal ganglia)
Biochemical changes
o Decreased serum ceruloplasmin
o Serum Cu concentration might be high, low or normal
o Increased urinary Cu excretion
o Increased liver Cu content
Diagnosis
o Kayser-Fleischer rings + serum ceruloplasmin levels < 20mg/l
o Serum ceruloplasmin level < 200mg/l + Cu concentration in liver biopsy sample > 250 g/g
o MRI (T2) shows thalamic and putaminal hyperintensity
Clinical stages
o Stage I: asymptomatic accumulation of Cu in liver
o Stage II: asymptomatic or manifests with haemolytic anaemia or liver failure
o Stage III: Cu accumulates in brain
o Stage IV: progressive neurological disease
Treatment
o Low Cu diet
o Chelating agent, eg. penicillamine.
-side effects: anaphylaxis, skin rash, bone marrow suppression and glomerulonephritis
alternate treatment: trientine.
-penicillamine has anti-pyridoxine effect, thus pyridoxine given together
o
o
o
o
157
*pathology
chronic granulomatous inflammation that destroys interlobular bile ducts fibrosis liver cirrhosis
*clinical presentation
fatigue
pruritus (main presenting complaint, may precede jaundice by mths/years)
occasionally jaundice, RHC pain, diarrhoea/steatorrhea
*complications:
*clinical signs:
Stigmata of chronic liver disease: palmar erythema, leukonychia, bruising, scratch marks, spider naevi,
gynaecomastia
Digital clubbing
Xanthelasma and xanthomata (over joints, skin folds and trauma sites)
Signs of portal HTN: dilated veins, hepatosplenomegaly (early stages), ascites
Request to examine for: proximal muscle weakness (osteomalacia)
peripheral neuropathy
RA
Systemic sclerosis
Hashimotos thyroiditis
Sjogrens syndrome
*investigations:
LFT
PT/PTT
Fasting lipid panel (should see raised TC levels)
Anti-mitochondrial Ab
U/S hepatobiliary system
Liver biopsy
*management
Nutrition: reduce fat intake, oral calcium, low-fat milk, vitamins A/D/K supplements , mid chain TG
supplements
Ursodeoxycholic acid (bile salt therapy): partial replacement of water-soluble bile acids may reduce
pruritus and damage to hepatocytes already affected by autoimmune processes
Pruritus (retention of bile acids with cholestasis: increase in concentration and up-regulation of
endogenous opioid receptors: 1st line cholestyramine, 2nd line ursodeoxycholic acid, rifampicin, 3rd
line naloxone, propofol
158
*prognosis
*clinical presentation
Chronic biliary obstruction secondary biliary cirrhosis liver cirrhosis chronic liver disease and
portal HTN
Bacterial cholangitis
Cholangiocarcinoma (20-30%)
*investigations
LFT
PT/PTT
Autoimmune screen (AMA ve; ANA and ANCA may be +ve)
ERCP
Liver biopsy (fibrous obliterative cholangitis w/ onion skin appearance)
*management
*epidemiology
*clinical presentation
159
*complications
*investigations
U/S HBS
CT A/P
ERCP/MRCP
*management
*Cholangiocarcinoma*
* arises from epithelial cells of the intrahepatic and extrahepatic bile ducts
*classification
Intrahepatic (10%)
o Least common
Extrahepatic (90%)
o Peri-hilar (65%) confluence to upper border of pancreas
o Distal (25%) upper border of pancreas to ampulla of Vater
^peri-hilar cholangiocarcinoma:
Most common
Also called Klatskin tumours (occur at bifurcation of right and left hepatic ducts)
Bismuth classification: Type 1 (below the confluence)
*associations
160
*management
Curative surgery (rarely possible) wide resection and reconstruction of biliary tree
o Indications:
inrahepatic tumour confined to 1 lobe of liver
Extrahepatic tumour
Patient fit for surgery
o Contraindications:
bilateral/multifocal intrahepatic disease
Invasion of portal vein/hepatic artery
Nodal involvement
Distant metastasis
Palliation
o Stenting
o Surgical bypass cholecystojejunostomy, choledochojejunostomy
Adjuvant therapy
o Radiotherapy
o Chemotherapy
*Periampullary carcinoma*
*includes: cholangiocarcinoma (involving distal common bile duct)
ampulla of Vater tumour
duodenal adenocarcinoma
*clinical presentation (presents early)
At time of diagnosis: if 80% are localized and small resectable for cure
50% 5 yr survival rates
*Mirizzi syndrome*
*rare cause of obstructive jaundice
*due to lodgement of gallstone in cystic duct/Hartmann pouch causing extrinsic compression of
common bile duct
*aetiology
Acute/chronic inflammation causing constriction of gallbladder which fuses with and causes secondary
stenosis of common bile duct
Cholecystocholedochal fistula secondary to direct pressure necrosis of adjacent duct walls
*classification
*investigations
U/S HBS
CT A/P
ERCP/PTC
162
163
detoxification of ammonia
Intra-hepatic shunting (venulization)
Extra-hepatic collaterals that bypass liver and enter into
systemic circulation
Results in elevated blood ammonia levels Neuronal function impaired
Generalised brain oedema
Triggers
a) Excess protein/urea load = excess dietary protein, constipation, BGIT,
uraemia
b) Infective = sepsis, HDV infection
c) Drug-induced = alcohol binge, sedatives, narcotics, anti-depressants
d) Trauma = surgery, paracentesis (>3-5 L), porto-systemic shunts
(non-selective)
e) Metabolic = hypokalaemia
f) Neoplastic = HCC
West Haven Classification
o Stage 0
Minimal hepatic encephalopathy lack of detectable changes
o Stage 1
Mild confusion
Decreased attention span
Disordered sleep (hypersomnia, insomnia or sleep-wake inversion)
o Stage 2
Lethargy
Moderate confusion
Disorientation
Personality changes and disinhibition
ASTERIXIS present
o Stage 3
Drowsy but arousable
Marked confusion
Disorientated to TTP
o Stage 4
Comatose
ASTERIXIS absent
Clinical features
a) Impaired consciousness
b) Limb rigidity and hyper- reflexia
c) Asterixis
d) Seizures
e) EEG changes
Management
o Treat precipitating cause
o Restrict protein intake
o Ensure adequate bowel movement (fleet enema)
o Liver transplant
Hepato-renal syndrome
- Life-threatening renal failure in patients with severe CLD no intrinsic renal causes
- Renal function improves with correlation of underlying liver failure
- Pathogenesis = imbalance between systemic vasodilation and renal vascular vasoconstriction results in
decreased renal perfusion pressure decreased GFR
- Clinical features
o Oliguria
o Rising BUN and creatinine
o Concentrating ability of kidney maintained= hyperosmolar urine; low urinary NA
- Poor prognosis median survival 2 weeks (rapid onset form) to 6 months (insidious-onset form)
164
Encephalopathy
166
History
Name/age/race/gender/occupation
Drug allergy
PMH
Presenting Complaint
Symptoms
1. Diarrhea
-duration
-baseline & current frequency
- onset (acute/ gradual/ congenital)
- description of stools ( volume, presence of blood, watery or bloody, floating, foul-smelling or hard to
flush)
2. Mucoid stools
3. Urgency (any incontinence?)
4. Abdominal pain (ask SOCRATES, relieved on defecation?)
Aetiology
1.infective
-fever,abdominal pain, LOW
-recent travel & contact hx
-sexual orientation & CSW contact
2. drug-induced
-laxative abuse
-antibiotic usage
-drug hx (recent & current)
3. metabolic
- hx of diabetes, gastroparesis, postural hypotension, urinary retention, impotence,numbness/peripheral
neuropathy
-polyphagia, LOW, insomnia, irritability, heat intolerance, swetating, palpitaitons, beck swelling, personal &
family hx of thyroid disease
4.lactose-intolerance
-recent change in diet
Complications
-dehydration
-electrolyte imbalance
Systemic Review
Management prior to & during admission
Has this happened before?
Physical Examination
1. General inspection
-general condition (goiter, thyroid eye disease)
-vitals
169
-hydration status
2. Peripheries
-eyes (thyroid eye disease)
-abdomen (tenderness, guarding, distension)
-PR examination (anal tone)
- LL (diabetic dermopathy)
Investigations
1.FBC
-WBC & differential count (chronic infx)
-incr HCl (in dehydration)
2. U/E/Cr
-incr urea > incr Cr (in dehydration)
-electrolyte abnormalities
3.LFT
-albumin (protein-losing enteropathy)
4.TFT
-thyrotoxicosis
5.BSL & HbA1c
-DM
6.Stool studies
-stool OB
-stool pH (<5.6 indicated carbohydrate intolerance)
-gram staining
-microscopy for ova, cysts & leukocytes
-culture/ sensitivity
-C. difficile toxin
7.AXR
-spurious diarrhea form fecal loading
170
-complications
a.primary sclerosing cholangitis (4%), hence incr risk of cholangiocarcinoma
b.incr risk of colorectal carcinoma, risk incr with duration & extent of disease (overall RR=8% ; for pancolitis
there is a 3% risk @ 15 yrs, 5% risk @ 20yrs & 9% risk @ 25 yrs)
* do yearly colonoscopy & biopsy ( @ every 10 cm of colon & @ raised/ulcerated areas) in pancolitis or 8
or more years duration
c.toxic megacolon (transverse colon diameter >6cm on AXR)
Crohns Disease
-recurrent inflammation that can affect any level of the GIT (but usually involves terminal ileum & colon)
-characterised by
a.sharply-demarcated transmural involvement of the bowel
b.skip lesions
c.non-caseating granulomas
d.fissuring with fistulae formation
-variable presentations of acute pain, diarrhea, LOW, malabsorption, I/O, appendicitis
-2 patterns of disease
Ileal disease
-complications
a.fistulae formation (entero-enteris,entero-vesical, entero-vaginal)
b.strictures (hence I/O)
c.lower BGIT
d.malignant change (lower risk than UC)
e.perianal disease (leading to perforation, acscess formation & peritonitis)
f. malabsorption syndromes (protein, Fe, vit B12)
172
1.Gross pathology
a. location
b. skip lesions
c.stricture formation
d.toxic megacolon
e.fistula/sinus formation
f.pseudopolyps
2.Microscopic Pathology
a. inflammation
b.non-caseating granulomas
c.ulceration
d.fibrosis
e.glands
3.Clinical
a. bloody diarrhea
b.abdominal pain
c.palpable mass
d.perianal disease
e.fat/vitamin malabsorption
f.malignant change
e.recurrence after surgery
UC
CD
Absent
Absent
Present
Absent
Present
Transmural
Present
Deep,linear serpentine
more
Intact glands
Very common
Pre-defecation urgency
Uncommon
Less common
Absent
Greater
Rare
Uncommon
Post-prandial
Frequent (RIF)
More common
Present (in small-bowel involvement)
Lesser
Common
Complications of IBD
Extraintestinal
Urinary calculi (esp oxalate in CD)
Liver (fatty liver, cirrhosis,PSC)
Cholelithiasis
Epithelium (oral aphthous ulcers
Retardation of growth & sexual maturation
Arthralgia (arthritis, AS, sacroilitis)
Trombosis (DVT, portal/mesenteric vein thrombosis)
Iatrogenic (steroids, blood transfustion, surgery)
Vitamin deficiencies
Eyes (uveitis,epicleritis,iridocyclitis,conjunctivitis)
Intestinal
Cancer
Obstruction (rare in UD, unless due to CRC. Common in CD)
Leakage (perforation)
Iron deficiency due to hemorrhage
Toxic megacolon (more in UC)
Inanition (severe wasting due to malabsorption & LOA)
Strictures, fistulas (enter-enteric, entero-vesical,entero-vaginal), perianal disease (CD)
173
History-taking
Name/age/race/gender/occupation
Drug allergy
Past medical history
Presenting complaint
Symptoms
1. Bloody diarrhea
- Duration = chronic if persists more than/equals to 4 weeks
- Baseline and current frequency
- Acute/gradual/congenital onset
- Describe stools = watery
volume of stools
Aetiology
ampicillin, cephalosporin)
Complications
Systemic Review
174
1. History of IBD
- Duration of disease
- Presenting complaint investigations management
- Currently on follow-up? Compliance
- Current medications = types
recent changes
compliance
side effects
175
Peripheries
Differentials
Investigations
Blood
Stools
Imaging
176
Management
Acute exacerbation
(a) Stabilize patients vitals esp circulation
- Set 2 large-bore IV cannulas
- Take bloods for investigations esp GXM
- Fluid resuscitation if in shock = crystalloids colloids PCT
(b) Keep NBM and maintain on IV hydration. Start I/O charting
(c) IV empirical antibiotics if febrile = Ciprofloxacin or Metronidazole (cover against E. coli)
(d) IV high-dose hydrocortisone x 5/7
If refractory IV cyclosporine (much faster onset than azathioprine)
(e) Monitor vitals q4hrly = inform doctor is SBP <100mmHg or HR>100/min
Place on stool charting
Long-term management
(a) Pharmacotherapy
1. 5 ASA (5-aminosalicyclic acid)
- prototype = sulfasalazine (5 ASA + sulfapyridine)
- MOA = blocks arachidonic acid metabolism to prostaglandins and leukotrienes
- Routes of administration = oral
suppository (proctitis covers 10-15cm from anal verge)
enema (proctosigmoiditis)
- Topical = very effective for distal disease (up to splenic flexure)
better than steroids
oral = effective for pancolitis
- S/E = nausea, vomiting, headache, rashes, haemolytic anaemia, agranulocytosis
Moderate disease
Severe disease
Oral 5 ASA
5 ASA/steroid enema
Oral prednisolone 40mg OM
IV hydrocortisone x 5/7
177
Maintain remission
Ulcerative colitis or
Crohns colitis
Crohns ileal disease
Sulphasalazine (usu
2g)
Steroids
Immunosuppressants
Prognosis
178
Repiratory Medicine
Medicine (Respi) = History Taking: Respiratory System (General)
Name/age/race/gender/occupation
Date of admission
Presenting complaint
1. Respiratory symptoms
(a) Fever = when did it happen
acute/gradual onset
T max? associated with chills and rigours?
symptoms of raised ICP = vomiting, headache, photophobia, neck stiffness
pattern (constant, swinging, spiking)
relieved with anti-pyretics?
progressively better or getting worse?
Management before coming into hospital
(b) Cough = productive/dry
colour of sputum? amount? Smell?
haemoptysis (exclude haematemesis and trauma)
character (barking/brassy/hollow)?
-
Barking = epiglottitis
Brassy = tracheal compression by tumor
Hollow = recurrent laryngeal nerve palsy (vocal cords are unable to close
completelybovine cough)
179
Drug history
3. TCM use
180
Social history
Family history
181
Toxic looking/well
Mental status: alert, orientated, drowsy, coma (narcosis in CO2 Retention)
Respiratory distress: resting posture (hunched forward with arms used to support), breathing
through pursed lips, tachypnoea, dyspnoea, receiving supplemental oxygen, cyanosis,
wheeze/stridor, use of accessory muscles of respiration (sternocleidomastoids, platysma, strap
muscles, tracheal tug), suprasternal/intercostal/subcostal retractions, inability to speak in full
sentences
Character of cough= chesty (chronic bronchitis, bronchiectasis, pneumonia)
dry (asthma, Ca bronchus, LVF, ACE inhibitors)
bovine (lack of the usual explosive beginning vocal cord paralysis)
Chest for scars like thoracotomy scar which may indicate lobectomy and pneumonectomy ,
deformities*, radiotherapy changes (erythema and thickening of irradiated area), asymmetry in
chest movement, paradoxical inward motion of the abdomen during inspiration (diaphragmatic
paralysis, severe flattening of diaphragm in hyperinflation)
*pigeon-chest (Pectus carinatum) = outward bowing of the sternum and costal cartilages, occurring
in rickets, chronic childhood respiratory disease, right ventricular hypertrophy
*funnel chest (Pectus excavatum) = localized depression of the lower end of sternum occurring in
marfans (MVP)
*Harrisons sulcus: linear depression of the lower ribs just above the costal margins at the site of
attachment of the diaphragm (severe childhood asthma/rickets)
IV lines, nebulizer, sputum mug on table
Respiratory rate
Hands
Face
1. Eyes- partial ptosis, papillary constriction, loss of sweating (horners syndrome with apical lung ca)
182
Neck
Chest
2. Palpate
- Apex beat (displaced in middle lobe or lower lobe pathologies)
- Parasternal heave of RVH
- Palpable p2 of pulmonary hypertension
- Symmetry of chest expansion and if it is reduced bilaterally. (place hands parallel to ribs with
thumbs meeting in midline and measure the distance moved during inspiration at least 5 cm)
3. Tell examiners that you would want to do tactile fremitus but acknowledge the fact that it is only useful
in cases of large pleural effusion or consolidations
- Place palms on either side of the chest while patient says 99, increased in consolidation, decreased
in pleural effusion
4. Percuss = apices, clavicles, anterior intercostal spaces and axillae
- Loss of cardiac and liver dullness 2 to hyperinflation in asthma/COPD/emphysema and
pneumothorax
- Dull: consolidation and collapse
- Stony dull: pleural effusion
5. Ascultate the apices (bell), anterior intercostal spaces, axillae
- Determine air entry and if expiratory phase is prolonged
- Breath sounds:
Vesicular (2/3
inspiration, 1/3 expiration with inspiration louder and with gap)
Bronchial (1/2 inspiration, 1/3 expiration, expiration louder, and hollow and blowing and with
audible gap in between, heard over areas of lung consolidation and just above a pleural effusion.
- Adventitious sounds like rhonchi, crepitations, pleural rubs
6. Vocal resonance= ask patient to say 99 and listen with stethoscope
- muffled in normal lung (low pitched components heard with booming quality, high pitched
components are attenuated
-increased in consolidation (clearly audible, aegophony with bleating quality; whispering pectoriloquywhispered speech is distinctly heard
- decreased in pleural effusion
Sitting up
1. Get patient to sit up, hug a pillow and fold hands across chest
2. Inspect chest for shape and symmetry: check for increased AP diameter and barrel shaped chest in
hyperinflation in diseases like severe chronic asthma, and COPD
3. Kyphoscoliosis
4. Anklysing spondylosis
5. Examine back for scars, radiotherapy changes, asymmetry of chest expansion
6. Measure chest expansion
7. Tactile fremitus (usually not done)
8. Percussion
9. Auscultation and vocal resonance
10. Check submental, cervical and supraclavicular LNs
183
Legs
End
1.
2.
3.
4.
Thank the patient for his help, help him button his shirt
Issues for discussion
184
Mediastinal
displacement
Chest wall
movement
Percussion
note
Breath sounds
Adventitious
sounds
Consolidation
None
dull
Bronchial with
increased VR
Moderate/coarse
Inspiratory
crepitations
Collapse
Ipsilateral shift
dull
Absent or reduced,
VR resonance
varies
Absent
Pleural
effusion
Apex beat
displaced to the
opposite side
(tracheal
deviation is
massive)
Tracheal
deviation to the
opposite side if
tension
pneumothorax
None
Reduced
over
affected
area
Reduced
over
affected
area,
flattening of
the chest
wall
Reduced
over
affected
area
Stony dull
Absent
Reduced
over
affected
area
Hyperresonant
with loss of
cardiac and liver
dullness
Absent/reduced
over fluid,
bronchial at the
upper border with
decreased vocal
resonance
Absent/reduced
Reduced
bilaterally
Normal/hyper
Resonant
Expiratory
rhonchi
Reduced
bilaterally
Normal/dull
Reduced with
prolonged
expiratory phase
Normal
Pneumothorax
Asthma
Pulmonary
fibrosis
Tracheal
deviation to
affected side if
apical lesion
Absent unless
subcutaneous
emphysema
Fine Inspiratory
crepitations
185
Definition = daily production of sputum for 3 months a year for at least 2 consecutive years
Clinical signs
a) Productive and chesty cough
b) blue bloaters = cyanotic
c) Hyperinflation = barrel-shaped chest (increased AP diameter), reduced expansion
symmetrically, loss of cardiac and liver dullness, liver ptosis, hyper-resonant percussion note,
decreased air entry, end-expiratory wheeze, early inspiratory crepitations
d) Right ventricular failure = raised JVP, peripheral oedema, hepatomegaly
186
Presentation
Mr ___(name)___ is a pleasant-looking ___(age/race/gender)___ who appears to be alert, well, comfortable and
orientated at rest. His vitals are stable with a HR of ______, regularly regular and not bounding in nature, RR of
______ and currently afebrile. He does not appear to be in any respiratory distress: he is pink on room air and is
not on any supplemental oxygen. He also does not appear cachexic. There were no signs of cyanosis, pallor,
jaundice or dehydration.
On examination of the peripheries, there were no signs of clubbing or wasting of the small muscles of the hand.
There were no tar stains or flapping tremor seen. Tracheal tug and deviation were absent.
On inspection of the chest, I did not observe any surgical scars or chest wall deformities. Chest wall movement
was equal bilaterally. There was no displacement of the apex beat or signs of pulmonary hypertension. Chest
movement was adequate on deep inspiration and equal on both sides. Percussion note was normal. On
auscultation, normal vesicular breath sounds were heard with no adventitious sounds. Vocal resonance was
normal.
No lymphadenopathy was found. There was no peripheral oedema which could indicate right heart failure. I
would like to end my examination by requesting for the sputum mug as well as the temperature and BP charts.
187
CVS
Bleeding diatheses
3. Investigations
Bloods
a) FBC
b) U/E/Cr
c) PT/PTT
d) GXM
e) ABG
f) Cardiac enzymes
g) D-dimer for pulmonary embolism
ECG
PE = sinus tachycardia, S1Q3T3, right axis deviation, right BBB, p pulmonale, S1S2S3
Imaging
a) CXR = lung abscess, bronchiectasis, consolidation, TB, lung ca, APO
b) CT thorax = locate site of bleeding
c) Bronchial/ pulmonary artery angiogram = locates site of bleeding, allows for embolisation
d) Bronchoscopy = locate site of bleeding, allows for endobronchial tamponade
Specific
a) PE spiral C/T, V/Q scan
b) Wegeners granulomatosis ESR, CRP, ANCA
c) Goodpastures syndrome anti-GBM antibodies
d) Chest infection sputum gram-staining, c/s
4. Management
Airway = head tilt and chin lift (if bleeding profusely left lateral position)
Breathing = ensure that patient is breathing spontaneously, give supplemental oxygen, obtain
saturation and monitor SpO2
Circulation = obtain ECG (r/o PE), HR, BP, large bore IV access fluid resuscitate if in shock, obtain
bloods for investigation
Monitor in MICU/HD
Monitor vitals closely
Correct coagulopathy
Definitive management
Bronchial artery embolisation
Surgery = lobectom
188
CCF
Airway
Asthma
COPD (chronic bronchitis, emphysema)
Bronchiectasis
Foreign body obstruction
Cystic fibrosis
Laryngeal/pharyngeal tumor
Bilateral vocal cord palsy
Tracheal obstruction/stenosis
Tracheomalacia/ laryngomalacia
Parenchyma
Pneumonia/TB
Pneumothorax
Pulmonary fibrosis
Pulmonary oedema
Lung ca
Respiratory distress syndrome
Allergic alveolitis
Sarcoidosis
Circulation
Pulmonary embolism
Pulmonary AV malformation
Pulmonary arteritis
CVS
189
3. Systemic review
Recent changes in urinary/bowel habits
4. Management prior and during admission
5. Has this happened before? Describe? Investigations? Management?
Past medical history
Asthma, COPD, TB, ca
HPT, HCL, DM, AMI/IHD
Previous hospitalisations and surgeries
Drug history
Any known drug allergy
Current medications
Recent drugs = beta blockers, NSAIDs, aspirin, thyroxine
Social history
Smoker (significant smoking history of >10 pack years)
Alcohol
Occupational history
Family set up
Main caregiver
Type of housing/lift landing
Finances
Functional status
Family history
TB, lung ca, asthma, DM, HPT, HCL, AMI/IHD
Investigations
1. ECG and cardiac enzymes = ACS, PE
2. FBC = Hb (anemia), WBC (leucocytosis in infections)
3. U/E/Cr = electrolyte disturbances in acidosis/alkalosis
4. ABG =acidosis/alkalosis, types 1 or 2 resp failure
5. CXR = hyperinflation, rib fracture, pneumothorax, consolidation,
pleural effusion, mass, cardiomegaly, CCF
6. D-dimer = if PE suspected
7. -natriuretic peptide = if CCF suspected
Management
1. Secure patient airway = head tilt chin lift, finger sweep, exclude upper
airway obstruction esp if stridor present, give supplemental oxygen
(COPD/smoker O2 28% by Venturi mask), place on pulse oximetry
2. Ensure pt is breathing spontaneously = auscultate lungs
3. Haemodynamically stable = look for signs of shock, HR/RR/BP, set
large bore IV access, obtain bloods for investigations
4. Resuscitate pt if necessary
5. Obtain history and physical examination once pt is stable
190
Respiratory
Angina
Acute Coronary Syndromes (unstable angina, AMI)
Valvular disease
cardiomyopathy
Airway
Asthma
COPD
Bronchiectasis
Parenchyma
Pneumonia
Pneumothorax
Lung cancer
Circulation
Pulmonary embolism
Others
History
Name/age/race/gender/occupation/drug allergy
Date of admission
Presenting complaint
1. Chest pain
Mode of onset
Frequency
Duration
Triggers (exertion, palpitations, anxietyCVS, food GIT etc)
Constant/intermittent
Increasing in frequency/severity
Site and radiation
Character
Pain score/severity
Aggravating factors (coughing, deep inspiration, movement respi, sitting up and leaning forward
CVS, lying down, alcohol GIT)
Relieving factors (GTN, rest CVS, bronchodilatorsrespi)
2.
Dyspnea
Mode of onset
Frequency
Duration
Acute/gradual onset
Progressively worsening/getting better
Severity (able to speak in full sentences, phrases or words?)
Triggers (exertion, rest. Quantify the effort tolerance!)
Aggravating factors
Relieving factors (bronchodilators, rest)
191
3. Etiology
CVS= nausea/vomiting, diaphoresis, palpitations, giddiness, syncope, ankle edema, fatigue,
intermittent claudications
Respiratory tract= fever, cough, hemoptysis, recent URTI, hoarseness, noisy breathing, chest pain,
night sweats, LOA, LOW, malaise, history of trauma, history of immobility, recent travel, major
surgery, OCP/HRT
GIT= epigastric pain, nausea/vomiting, reflux symptoms, dysphagia
Others= anemia (pallor, chest pain, SOB, giddiness, palpitations, fatigue, PR bleed, menorrhagia)
4. Systemic changes= recent changes in urinary/bowel habits
5. Management prior and during to admission
6. Has this happened before? Describe? Investigations? Management?
Past Medical History
Asthma, COPD, TB, cancer
HTN, HL, DM, AMI/IHD
GERD, PUD
Previous hospitalisation and surgeries
Drug history
Drug allergies
Current medications
Recent drugs = B-blockers, NSAIDs, aspirin, thyroxine
Social history
Smoker (significant smoking history more than 10 pack years)
Alcohol, occupational history, family set up, main caregiver, type of housing, lift landing, finances, functional status
Family history
TB, lung cancer, asthma, DM, HTN, HL, AMI/IHD
Investigations
1.ECG and cardiac enzymes= angina, ACS, pulmonary embolism
2.FBC (low Hb anemia, high WBC leukocytosis during infection)
3.U/E/Cr electrolyte disturbances
4.ABG alkalosis/acidosis, type 1 or 2 respiratory failure
5. CXR hyperinflation, rib fracture, pneumothorax, consolidation, pleural effusion, mass, cardiomegaly, CCF
6. D-dimer if PE is suspected
Management
Secure airway patency give supplementary O2 (COPD/smoker O2 28% by venturi mask). Start pulse oximetry
Ensure patient is breathing spontaneously= auscultate lungs
Haemodynamically stable= look for signs of shock, HR/RR/BP, ECG monitoring, set large bore IV access, obtain
bloods for investigation
Resuscitate patient if necessary
Obtain history and perform physical examination once patient is stable
192
193
194
Complications
Chronic Bronchitis
Type 2 respiratory failure: low paco2 due to v/q
mismatch from mucous plugging.
Short term: increased paco2 stimulates respiration
Long term: insensitive to high paco2 levels, hence
depend on hypoxic drive
polycythemia
Pulmonary hypertension-> cor pulmonale
Respiratory infections
Obliterative bronchitis(due to mucous plugging)
Emphysema
Type 1 respiratory failure: low po2 and low/normal
paco2
195
Classification of Severity
Global Initiative for Chronic Obstructive Lung Disease(GOLD) Staging:
Stage/Severity
FEV1/FVC FEV1
Treatment
I=mild
<70%
80%
Short acting bronchodilators:
1)SABA(salbutamol,fenoterol,terbutaline)
2)SAC(ipratropium bromide)
3)Combivent (SABA+SAC)
II=moderate
<70%
50-80%
III=severe
<70%
30-50%
<70%
LAB + ICS
Theophylline
Pulmonary rehabilitation
Long term oxygen therapy
Management
Acute Exacerbations:
1) Supplemental O2
a) Controlled oxygen therapy=ventimask (start from Fio2 28% and monitor before escalating, ensure
paco2 does not increase)
b) Keep spo2 >92% (Aim 90-95%)
2) Nebulised salbutamol + Ipratropium bromide + N/S (1:2:1) for symptomatic relief
- use air driven nebuliser (less o2)
3) Assisted ventilation
a) Aim is to rest respiratory muscles and restore gas exchange
b) Types
-Non invasive ventilation(BiPAP-> Bilevel positive airway pressure; CPAP)
Advantages=reduced mortality, need for intubation and length of hospitalisation
Contraindications= facial trauma, drowsy patient
Indicated in the presence if all the following depite 2-3 nebulisations:
Tachypnea(>25 breaths/min)
pH <7.35
PaCO2 >45mmHg
-Endotracheal intubation
Indications:
If NIV fails
pH<7.25
respiratory arrest
somnolence
severe hemodynamic instability
c) Cut offs=
-pH< 7.35 (consider NIV)
-pH<7.30 (must use NIV)
-pH<7.25 (consider intubation)
-pH<7.20 (must intubate)
196
197
Inhaled SABA
-Examples=salbutamil,terbutaline,fenoterol
-Fastest onset ~15 min (DOA 4-5 hours)
-May be ued up to max of 4-6times/day
-S/E: tremors,palpitations,hypokalemia
Inhaled SAAC
Combination of SABA
and SAAC
-example=combivent
-adv: greater and sustained improvemtns in FEV1 than with either drug alone
Inhaled LABA
Inhaled LAAC
-example=tiotropium
-Long DOA of ~ 24hrs
Oral theophylline
c) Inhaled Corticosteroids:
- Examples=beclomethasone, budesonide, fluticasone
- Recommended for patients with FEV1 <50% predicted value and experience freq
exacerbations
- Only a modest effect on lung function in COPD as compared to asthma
d) Combination of ICS and LABA
- Examples=seretide (salbutamol+ fluticasone) , symbicort (budesonide + formoterol)
3) Surgical
a) Indications: recurrent pneumothorax (from emphysema), isolated bullous disease
b) Types:
- Bullectomy
- Insertion of endobronchial valves
- Lung volume reduction surgery (thoracoscopic resection of 20-30% of poorly
functioning lung tissie in each lung -> reduce thoracic volume)
- Lung transplant (only if patient is <65y/o and has no serious co-morbidity)
198
Persistent necrotizing
inflammation
Obstruction
Bronchial
dilation
199
Morphology
Macroscopic features
- cystic, smooth, glistening honeycomb appearance of cut surface of lung
- bronchi= grossly dilated up to 4 times the usual diameter , can be traced to pleural surface (normally can
only trace till 2-3 cm from pleura), thick fibrous walls, most severe distally
- obliteration of intervening lung parenchyma
- affects bilateral lower lobes
Microscopic features
- intense acute and chronic inflammatory exudates within bronchial and bronchiolar walls
- capillary congestion, interstitial oedema and hemorrhage
- +/- squamous metaplasia
- Hyperplasia of goblet cells increased mucous secretion
- Destruction of elastic tissue
- Fibrosis
Reids classification
(a) cylindrical= uniformly dilated bronchi that end abruptly instead of tapering
(b) varicose = dilated bronchi with irregular bulging contours that end in bullae
(c) cystic =most severe form where dilated bronchi end in cystic pus- filled cavities
Clinical features
History
- Current symptoms= severe persistent cough with copious purulent sputum, haemoptysis, fever, dyspnoea,
pleuritic chest pain, wheeze, precipitated by URTI
- Aetiology = fever, LOA, LOW, night sweats, history of TB, travel and contact history, history of chronic cough
and purulent sputum since childhood (CF, Kartageners syndrome)
- Management of current episode= chest physiotherapy, antibiotics, bronchodilators
- History of prior episodes = treatment given, investigation conducted (CT chest, bronchoscopy)
- Past medical history = hypogammaglobulinaemia, COPD, asthma, allergies
- Drug history
- Social history = chronic smoker
- Family history
Physical examination
- fever, clubbing, central/ peripheral cyanosis
- coarse pan- inspiratory/ late inspiratory crepitations that does not clear with coughing
- rhonchi (mucous plugging/asthma/COPD/ABPA)
- sputum mug (voluminous, purulent, foul-smelling, blood- stained, layering of sputum)
- severe disease= cor pulmonale (raised JVP, parasternal heave, palpable and loud P2, peripheral oedema),
amyloidosis (splenomegaly)
- Presentation of findings:
200
In summary, this patient most likely has an infective exacerbation of bronchiectasis. I say
this because:
(a) presence of IV antibiotics
(b) bilateral coarse pan-inspiratory crepitations that does not clear with coughing
(c) digital clubbing
The patient is currenly not in any respiratory distress and his condition is not complicated
by pulmonary hypertension or cor pulmonale.
Request to examine:
(a) anterior chest
(b) temperature chart
(c) sputum mug
(d) raised JVP for cor pulmonale
(e) splenomegaly 20 amyloidosis
Differentials:
1. Pulmonary fibrosis- distinguishing features
Pulmonary fibrosis
Bronchiectasis
Dry cough
Productive cough
Fine end-inspiratory creps
Coarse pan-inspiratory +/- expiratory
creps
Steroid toxicity
Splenomegaly
2. Infective exacerbation of COPD
*look for signs of hyperinflation, expiratory mucus, with prolonged expiratory phase
Complications
- Haemoptysis
- Pneumonia
- Pleurisy
- Pleural effusion
- Pneumothorax
- Lung abscess
- Empyema
- Bacteremia cerebral abscesses and meningitis
- Extensive lung destruction Pulmonary hypertension and cor pulmonale
- Amyloidosis
Investigations
- Bloods= FBC, ESR, CRP, blood c/s, ABG
- Sputum = gram stain, c/s, AFB stain, TB c/s
- CXR = cystic shadows, thickened bronchial walls (tramline and ring shadows), air fluid levels
- High resolution CT (HRCT) thorax= assess extent and distribution of disease; slices are 1-2 mm thick CF
standard CT (10mm)
- Bronchoscopy = locate site of haemoptysis and exclude obstruction; largely superceded by HRCT
- Spirometry = obstructive picture
Management
Acute
- Give supplementary 02
- If rhonchi present nebulized salbutamol
- Start IV antibiotics
- Chest physiotherapy = aid sputum expectoration and mucous drainage
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202
Cor pulmonale
- right heart failure cause by chornic pulmonary hypertension due to disorders in the lung, chest wall or
pulmonary circulation
- Aetiology:
Lung diseases
Chronic severe asthma
COPD
Bronchiectasis
Pulmonary fibrosis
Lung resection
Pulmonary circulation
Recurrent pulmonary embolisms
Pulmonary vasculitis
Primary pulmonary hypertension
Acute respiratory distress syndrome
Chest wall disorders
Neuromuscular
Myasthenia gravis
Poliomyelitis
Motor neurone disease
Duchenne muscular dystrophy
Chest wall
Kyphoscoliosis
Obesity
Hypoventilation
Obstructive sleep apnoea
Cerebrovascular accident
Clinical features
Symptoms
- exertional dyspnoea
- chronic productive cough
- ankle oedema
- Abdominal distension
Signs
-
203
Complications
(a) right heart failure
(b) respiratory failure
(c) secondary polycythaemia
Investigations
Bloods
- FBC= raised Hb and hematocrit (hct)
- ABG= hypoxia +/- hypercapnia
ECG
-
p pulmonale (relatively narrow P wave with increased amplitude indicating R atrial dilation), RAD, RBBB, RVH+/- strain
CXR
-
Management
(a) treat underlying cause
(b) treat respiratory failure
Give supplementary 02 cautiously if Pa02 < 60 mmHg
- Start at Fi02 = 24% and monitor with ABG 30 mins later
- Escalate oxygen if PaC02 remains stable
- If PaC02 increases give doxapram (a respiratory stimulant)
- Consider assisted ventilation
(c) treat cardiac failure
- fluid restriction
- diuretics
(d) venesection if hct >55%
(e) heart- lung transplant in young patients
Prognosis
Very poor (50% mortality within 5 yrs)
204
205
Due to hypersensitivity, bacilli excite a prompt and marked tissue response that tends to wall off the
focus (hence the regional LN are less prominently involved in early secondary TB compared to in early
primary TB)
Cavitation occurs, erosion and dissemination along the airways -> sputum positive, person can spread
the disease.
Complications
Progressive pulmonary tuberculosis: apical lesion enlarges, erodes into surrounding tissue
o Erosion into bronchus creates a ragged irregular cavity
o Erosion of blood vessels leads to hemoptysis
o Dissemination by blood or lymphatics
Miliary pulmonary disease
Pleural involvement: effusions, tuberculous empyema or obliterative fibrous pleuritis
Lymphadenitis: the most common form of extrapulmonary TB
o Typically occurs in the cervical region (scrofula)
Endobronchial, endotracheal and laryngeal TB
Intestinal tuberculosis
Pott disease: TB abcesses in the vertebrae (may spread along tissue planes to form cold abscesses
which present as a pelvic lump)
Systemic military tuberculosis
o Hematogenous spread to other organs esp liver, bone marrow, spleen, meninges, adrenals,
kidneys -> fatal without treatment
Clinical features
Pulmonary TB
Symptoms
o Fever, persistent cough, hemoptysis, pleural pain, spontaneous pneumothorax, non-resolving
pneumothorax, lethargy, LOW, night sweats
Signs
o Crepitations, signs of consolidation, +/- signs of fibrosis, +/- signs of pneumothorax, +/- signs of
effusion
Miliary TB
Persistent cough, SOB, crepitations, tachycardia, anaemia, hepatosplenomegaly, choroidal tubercles on
opthalmoscopy, fever, LOW, night sweats, lymphadenopathy
Extrapulmonary TB
GI (intestine or peritoneum)
o Diarrhoea, malabsorption, I/O, ascites
o Management: Peritoneal fluid for AFB
Pericardium
o Pericardial effusion or tamponade, constructive pericarditis due to post-infectious fibrosis
o Management: Requires steroids to reduce need for pericardiectomy
GU
o Haematuria, frequency, dysuria, sterile pyuria, salpingitis, tubal abscess, epididymal TBswelling/sinus formation
o Management: 3 early morning urine for AFB, renal U/S, IVU
CNS
o Headache, meningism, altered mental state, vomiting, neurological deficits
o Management: CSF for AFB fibrin web, mononuclear cells, cell count 10-1000, decreased
glucose, normal or increased protein
Lymph node
o Usually cervical lymph node, swelling and sinus formation
Bone/Joint
o Vertebral collapse, pyrathrosis, osteomyelitis, cold abscess formation, bone marrow: anaemia,
thrombocytopenia
o Management: X-ray, MRi to determine extent of involvement, culture biopsies
Others
o Adrenal gland destruction -> Addisons disease
206
o
o
Symptoms of compression by lymph nodes eg. Monophonic wheeze, bronchiectasis, lung collapse
Symptoms of affected organ systems eg. Headaches and seizures for TB meningitis, paraplegia for Pott
disease
Risk factors: contact/travel history, crowded living conditions, HIV/immunocompromise, malnutrition,
alcoholism, steroid therapy, DM, previous TB
Investigations
CXR
o Cavitation in the apices of the lung
o Calcification
o Reticulonodular shadowing (for military TB)
o Fibrosis (scarring) with traction
o Enlargement of hilar and mediastinal lymph nodes
o Cavity with aspergilloma: air crescent sign
(CXR does not give indication of the activity of the disease; it is not diagnostic)
FBC
LFT
CRP
Sputum AFB smear: MTB binds to Ziehl-Neelson stain and resists decolorisation (acd fast)
o Positive AFB smear makes a presumptive diagnosis of TB in a high risk patient, although a
positive stained smear is not specific for M. Tuberculosis
o 50% of AFB positive locals have MOTT (Mycobacteria other than TB)
o Most AFB positive foreign workers have MTB
o If the patient is not able to produce sputum, sputum induction with nebulized, hypertonic 3%
saline in a negative pressure isolation room is an alternative before more invasive procedures
(bronchoscopy)
Sputum culture is the gold standard (culture on Lowenstein Jensen media requires 12 weeks; PCR can
provide faster results) *only culture can provide info on drug sensitivity
Early morning gastric aspiration: most useful in young children where sputum is more difficult to
obtain, and is best performed following at least nine hours of fasting
Nucleic acid amplification tests (NAAT), can provide rapid diagnostic information to the clinician,
generally within 24 to 72 hours
Tuberculin skin test: TB antigen is injected intradermally and the cell mediated response at 48-72 hours
is recorded. A positive test indicates that the patient has immunity (ie, previously exposed or
vaccinated). A strong positive test suggests active disease. False negatives occur in immunosuppression
eg. Miliary TB, AIDS
In HIV patients, atypical features include sputum smear negative for AFB; false negative tuberculin test
cos of tuberculin anergy, lack of granulomas in tissues
Management
Notify CDC, refer to TBCU
Contact tracing
o Household contacts of sputum smear positive PTs
o 2/3 step contact tracing
Week 0: Do Mantoux, read at day 2-4
If >15mm, means seroconvert give prophylaxis
If <15mm, repeat Mantoux
Week 2: Do Mantoux
If increase of week 0s test by >10mm, means that first Mantoux reactivated
previously exposed immune system, now pt is displaying competent immune
response dont need prophylaxis
If <10mm, do third Mantoux
Week 12: Do Mantoux
207
TB drugs
Aims of therapy
o Successful treatment requires more than one drug to which the organisms are susceptible
o Sufficient dose
o Sufficient duration
o Compliance -> DOT (polyclinic DOT) directly observed therapy
TB drugs
o First line:
Isoniazid (H): 15mg/kg PO 3x/week
RIfampicin (R): 600-900mg PO 3x/week
Pyrazinamide (Z): 2.5g PO 3x/week
Ethambutol (E): 30mg/kg PO 3x/week
Streptomycin (S): 0.75-1g/day IM
Amikacin
Kanamycin
o Pyridoxine is given to reduce peripheral neuropathy induced by isoniazid
o Pyrazinamide is given for the first 2 months to kill intracellular bacilli
o 6 month treatment
o Titrate according to body weight
o Initial drug regimen is based on knowledge of the likely drug susceptibility
o Four drugs are used in the initial phase of treatment when the total duration of treatment is 6
months, because of the high incidence of isoniazid-resistant organisms in most communities
o Usually RHZ or RHEZ for 2/12 followed by RH for 4/12
Drug resistant TB
o Initial drug regimens need to be modified in areas with a known high prevalence of MDR-TB
o Development of drug resistance after initial drug sensitivity (secondary drug resistance) occurs
in patients who do not comply with treatment regimens, occurs mainly in HIV patients
o Nosocomial transmission significant
o Use 4 drugs, treat for 2 years
o Follow up for 1 year after eradication
o Second line drugs: Ofloxacin, Ciprofloxacin, Cycloserine, Ethionamide, Azithromycin
Drug side effects
o Rifampicin
Induces liver enzymes -> caution in drugs and OCP
Stop if liver enzymes are more than 3x elevated
Orange tears, sweat, sputum, urine
o Isoniazid
Peripheral neuropathy
Skin rash
Hepatitis -> stop drug
o Pyrazinamide
Precipitates gout
Liver toxicity
o Ethambutol
208
Dose related optic retrobulbar neuritis, presents with colour blindness, central scotoma,
reduction in visual acquity
Streptomycin
Irreversible damage to the vestibular nerve
Allergic reactions are more common
TB and HIV
TB in an HIV patient is an AIDS defining condition
4 drugs are used instead of the usual 3
Adverse reactions are common and the prognosis is poor
Multiple drug resistance occurs in 6%
M. avium intracellulare is another mycobacterium that can cause pulmonary infection in AIDS patients
Negative Mantoux test
Positive reactivation of TB
Atypical presentation
Negative smears for AFB
Atypical CXR
Extrapulmonary and disseminated disease common
Increased toxicity from anti-TB and anti-RV therapy
Immune reconstituition inflammatory response = anti-RV therapy reconstitutes CD4 count and immune
function. Therefore paradoxical worsening of TB symptoms
Absence of caseating granulomas
Prevention
BCG vaccination: live attenuated vaccine -> only protects against childhoos military and CNS TB. Repeat
vaccination in adolescence not found to affect outcome/ risk of TB, and is no longer indicated
Contact tracing: CXR, Mantoux test
Chemoprophylaxis for contacts and for HIV patients
o Isoniazid 200mg/day PO for 9 month/ rifampicin 4 months if Mantoux positive as descrbed
Mantoux test
Used to identify patients with latent TB (useful for screening)
Positive tuberculin test indicates infection with M. tuberculosis; it does not diagnose active disease
Intradermal injecion of 0.1 ml of PPD (type 4 hypersensitivity reaction)
Interpreted 48-72 hours after intradermal administration = wheal and flare reaction
Transverse diameter of wheal should be measured and recorded in millimetres
False negatives: newly diagnosed TB, HIV, TB meningitis, malnourished, immunosuppressed,
lymphoma, sarcoidosis, military TB
Children who have received the BCG vaccine generally demonstrate PPD skin test reactions of 3-19mm
several months after vaccination. Most of these reactions wane significantly with time. Responses
indicative of a new infection include: >10mm induration in persons less than 35 years of age or >15mm
induration in >35 years old.
209
< 5mm of
induration
Patient is
a child,
adolesce
nt,
and/or is
immunoc
ompromi
sed and
had close
contact
with TB
Initiate
treatment of
latent
tuberculosis
infection
All others
No therapy
10 mm or
more of
induration
5 to 9mm of
induration
All others
Is known to
have or
suspected of
having HIV
infection or
another
cause of
immunocom
promise, is a
close contact
of a person
with
infectious TB
or has a chest
radiograph
suggestive of
previous TB
No therapy
Less than 15
mm of
induration
No therapy
15 mm or
greater of
induration
Initiate
treatment of
latent
tuberculosis
infection
Initiate
treatment of
latent
tuberculosis
infection
Initiate
treatment of
latent
tuberculosis
infection
Pulmonary TB
Sputum culture after 2 months of antibiotic treatment
o Decrease if positive
o Increase: continuation phase to 7months (therefore total treatment 9 months)
Unable to tolerate pyrazinamde
o 2 months of RHE
o 7 months of RH
Patient taken out of isolation once sputum culture negative
Extrapulmonary TB (10%)
6-9 months regimens
12 months = military TB, bone/ joint TB, TB meningitis
Adjunctive treatment
o Corticosteroids = TB pericarditis/ meningitis
o Surgery = constructive pericarditis, spinal cord compression
210
1. Differential diagnosis
-upper lobe consolidation and lymph nodes a) Neoplastic Lymphoma, b)
Infective-TB, pneumonia, lung abscess, aspergillosis, hydrated cyst
-Upper lobe collapse -> consolidation
a)Luminal- Foreign body, tumour, mucous lung
b) Mural= Structure (TB, sarcoidosis, iatrogenic)
= Vasculitis (Wegeners granulomatosis)
c) Extrinsic- Lymphadenopathy, medialstinal masses, aortic aneurysm
2. Request to examine- Vitals, sputum mug, posterior chest-pleural effusion, pembertons sign, abdomenhepatomegaly, vertebreal column-mets, paraneoplastic syndromes->Pigmentation of palmar creases,
gynacomastia, cerebellar syndrome, peripheral neuropathy
211
Clinical features
History
-asymptomatic
-pleuritic Chest pain
-Dyspnea
-Fever, LOA, LOW, Night sweats, cough, haemoptysis
Physical exam
-Usually would be asked to examine the back
-Trachea deviation away from side of effusion
-Decreased chest movement/expansion
-Stony dullness
-decreased/absent breath sounds -> Bronchial breath sounds may be heard above the effusion
-Decreased vocal resonance-> Aegophony may be heard above the effusion
-Aetiology
212
Investigations
1. Erect CXR(PA and lateral)
-Findings on PA CXR =Blunting of the costophrenic angles, meniscus sign
-Findings on Lateral CXR =Obliteration of posterior costophrenic angle then hemidiaphragm
-If column of fluid visible and 5cm in height from posterior costophrenic angle of contralateral lung Lateral
decubitus view not required
-Subpulmonic effusion Raised hemidiaphragm
-Loculated pleural effusion Accumulation of fluid between major/minor fissures or along lateral chest wall
(With obtuse angles of interface)
*may be mistaken for tumour
*Invx = U/S
2. Lateral decubitus CXR
-indications = Very small pleural effusions, alternative is U/S
-Findings =Layering of pleural effusion
Layering of free fluid> 10mm before blind thoracocentesis may be attempted safely
3. Pleural tap
-Both diagnostic and therapeutic
-Procedure= Infiltrate skin, periostuem of rib and pariatal pleural with 1% lignocaine
Insert needle into 1-2 intercostal space below level of dull percussion note
-dry tap=absence of fluid, incorrect needle placement, inappropriately short needle
-Investigations
(a) Clinical chemistry
Protein, albumin, LDH, Glucose, cholesterol
Empyema =pH (taken in a ABG tube and sent in ice)
Pancreatitis, malignancy, oesophageal rupture = Amylase
Autoimmune =Rh factor, ANA
(b) Gram staining
(c) culture and sensitivity
(D) fluid cytology
-send blood simultaneously for protein, albumin, LDH and glucose
213
4. Aetiology
CT thorax=useful for visualizing underlying lung parenchyma obscured on CXR by large pleural effusions
Video assisted thoracoscopy(VAT)
-Indications=Unknown etiology, lung malignancy, mesothelioma, pleural malignancy, TB
Closed pleural biopsy(CT or US guided)
-Indications=malignancy, TB pleurisy, pleural tap inconclusive
Transudate vs Exudate
Parameter
Transudate
Gross appearance Straw coloured clear
Cytology
Clinical chemistry
Immunology
Exudate
Yellow turbid
Bloody (trauma, malignancy, TB, PE)
Normal
High WBC
* Neutrophils infection, PE
* Lymphocytes TB, malignancy
* Eosinophils presence of air/blood
Malignant cells
Microorganisms
Protein <30g/L
Protein >30g/L
Lights criteria (any 1 criteria met)
* Used to prove exudate
* Pleural:serum protein ratio >0.5
* Pleural:serum LDH ratio >0.6
* pleural LDH >2/3 upper limit of serum LDH
Serum-effusion albumin gradient >1.2 Serum-effusion albumin gradient <1.2
Low glucose
* Infection
* Malignancy
Low pH (<7.2 = indication for drainage)
* Empyema
High amylase
* Pancreatitis
* Malignancy
* Oesophageal rupture
High cholesterol
* Malignancy
* Chylothorax
Negative
Postive for Rh factor and ANA
214
Management
* Important to distinguish transudate from exudates
- transudate = treat underlying cause
- exudate = investigate aetiology and treat
* General measures
- Ensure close monitoring of vital signs
- supplemental O2
- large-bore IV excess and GXM (if haemothorax suspected)
- antibiotics for parapneumonic effusion and empyema
* Principles of treatment
1. Removing pleural fluid
- Indications for urgent drainage of parapneumonic effusions = frank pus
Pleural fluid pH <7.2
Loculated effusions
Positive bacterial cultures
- Complications = pneumothorax, haemothorax, re-expansion pulmonary oedema
(a) Thoracocentesis (pleural tap) = alleviate dyspnoea in symptomatic effusions
Prevent ongoing inflammation and fibrosis in exudative effusions
~ ensure that platelet count, PT/PTT are satisfactory
(b) Chest tube insertion
2. Prevention of recurrence pleurodesis (tetracycline, bleomycin or talc)
- Indications = recurrent effusions (malignant effusions); >2x
* Surgical
- indications = persistent effusions
Increasing pleural thickness (on ultrasound)
Monitoring
* Monitor
(a) patients vitals
(b) amount of fluid drained
(c) quality of fluid drained
(d) air-leak (bubbling through water seal)
* Repeat CXR when drainage <100ml/day = evaluate if effusion has been fully drained
Causes of dullness at lung bases
* Pleural effusion (stony dullness)
* Consolidation
* Collapse
* Raised hemidiaphragm (usually 2 to phrenic nerve injury; usually the only clue is a supraclavicular scar)
* Lobectomy
* Pleural thickening
215
Aetiology
Types of pneumothorax
Open
- Open communication between airways and pleural space (broncho-pleural fistula)
persistant air-leak
Closed
- No communication
- Air is reabsorbed at a rate of 1.25% of the total radiographic hemithoracic volume per
day
Tension
- Valvular mechanism develops such that air is sucked into the pleural space during
inspiration but not expelled
- Results in = mediastinal shift, tracheal deviation
Increasing respiratory and cardiac embarrassment
Clinical features
History
- Asymptomatic
- Acute pleuritic chest pain
- Sudden onset/rapidly progressing dyspnoea
- Triggers = trauma, IJ (internal jugular) line insertions, recent H&N surgery
- Underlying lung disease asthma, COPD, TB, CF, lung cancer
- Previous episodes of pneumothorax
- History of Marfans or Ehlers-Danlos syndrome
Physical examination
- Vital signs = tachycardia, tachypnoea, hypotension, pulsus paradoxus (inspiration: VR
(systemic venous return causing lung pooling) systolic BP missing radial pulses;
seen in tension PTX)
- Signs of respiratory distress
- Decreased chest expansion, hyper-resonant percussion note, decreased breath sounds
- Subcutaneous emphysema
- Tracheal and mediastinal deviation if tension PTX
Investigations
Erect CXR
- Radiological findings
(a)
Ipsilateral lung edge seen parallel to chest wall
216
(b)
No lung markings in pleural space
(c)
Contralateral mediastinal and tracheal shift if tension PTX
(d)
Deep sulcus sign = costophrenic angle is significantly lower than that on
contralateral side
(e)
Contralateral lungs gets entire cardiac output and vascular markings become
more prominent
ABG
From:
http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Mechanisms/Atelecta
sis1.htm
Assess rotation obscure PTX and mimic mediastinal shift
Side of PTX
(i) Small = apex-cupola distance < 3cm,
Visceral-parietal pleural separation < 2cm (BTS)
(ii) Large = apex-cupola distance 3cm,
Visceral-parietal pleural separation 2cm
Evidence of underlying lung disease e.g. bullae, hyperinflation
Management
Supportive
- Supplementary O2 = 100% oxygen by NRM creates concentration gradient N2 diffusion
from PTX into alveoli decreases size
Tension pneumothorax
- Immediate needle decompression in the 2nd intercostals space along mid-clavicular line (14
gauge needle)
- Followed by chest tube insertion
217
(i)
-
Simple Aspiration
Infiltrate with lignocaine
Push 16 F gauge cannula into pleural space
Connect cannula to three way tap and 50ml syringe
Aspirate up to 2.5 L of air slowly stop if there is resistance or patient coughs excessively
Repeat expiratory CXR film
(ii)
-
(iii)
Surgical pleurodesis
- Indications = persistent PTX on day 5
Recurrent PTX ( > 2x)
- Apical bullae = bullectomy
(iv)
-
Chemical pleurodesis
Done when surgery is contraindicated
Avoided in patients with cystic fibrosis difficult lung Tx in future
Less effective (80-90%) than surgical pleurodesis (95-100%)
Only done when lung has fully re-expanded so that pleural surfaces are apposed
Injected into pleural cavity via chest tube
218
Decreased
surfactant
Sudden re-expansion
Alveolar distension
squeezes capillaries
Pulmonary oedema
Practical points
1) Indications for chest tube insertion
(a) Pneumothorax = large, tension, traumatic, failed aspiration
(b) Haemothorax
(c) Symptomatic pleural effusion
(d) Rib fractures and mechanically ventilated patients
Contraindications = bleeding diathesis
2) Apply suction if lung fails to re-expand after chest tube insertion
3) Haemopneumothorax (flat meniscus on CXR) additional chest tubes required to drain blood and clots
second chest tube should be directed inferiorly and posteriorly to diaphragm
4) Things to check for during ward rounds
- Patency of chest tube = air bubble should oscillate with respiration/coughing
- Amount and type of drainage = continuous bubbling indicates open air leak
- Drains < 100ml/day order repeat CXR to check for resolution
5) Indications for chest tube removal
- Chest tube stops draining for at least 6 hours (after 4-6 hours of clamping)
- CXR shows resolution of PTX
6) Steps in chest tube removal
i)
Requires 2 people
ii)
Discontinue suction
iii)
+/- clamping of chest tube (controversial)
iv)
Cut anchoring sutures
v)
Tell patient to breath in or out deeply and hold his breath
vi)
Pull out tube and simultaneously secure purse string
vii)
STO 10 days
219
221
This is the erect AP/PA chest x-ray of Mr/Mdm __________ taken on the _______.
The quality of the film is good = with no rotation, good penetration and taken on full inspiration.
3. Mediastinum
a. Trachea = should lie in the mid-line
i. Comment on the presence of ETT
ii. Pushed away by large pleural effusion, pneumothorax, mediastinal mass or tumour
iii. Pushed by lung collapse or fibrosis
b. Thin and slender mediastinum = COPD
4. Hilum
a. Characteristics = mostly formed by the pulmonary arteries with the upper lobe veins superimposed +
left hilum slightly higher than right
b. Hilar enlargement = lymphadenopathy, large pulmonary artery
5. Heart
a. Characteristics
i. Straddles mid-line with 1/3 to the right and 2/3 to the left
ii. Right heart border formed by right atrium; left heart border by left ventricle
iii. Transthoracic diameter -> widest diameter above the costophrenic angles
iv. Cardiac diameter -> draw a vertical line from the trachea to the heart (assuming no deviation)
1. Sum of the 2 greatest lengths from the vertical line to both heart borders
b. Cardiomegaly = cardiothoracic diameter >50%
6. Diaphram
a. Characteristics = right hemidiaphragm should be higher than the left (due to liver)
b. Loss of costophrenic angle with meniscus = pleural effusion
c. Loss of diaphragmatic outline = lower lobe consolidation
d. Low and flat hemidiaphragms = COPD
e. Air below the diaphragm = free peritoneal gas (likely perforation)
7. Lung fields
222
a. Division
i. Apices lie above the level of the clavicles
ii. Upper zone include the apices to the level of the 2nd costal cartilage
iii. Middle zone lie between 2nd and 4th costal cartilage
iv. Lower zone lie between 4th and 6th costal cartilage
b. Loss of cardiac silhouette middle lobe consolidation
c. Increased translucency hyperinflation
8. Bone and soft tissue
a. Rib fractures
b. Bone metastasis
c. Subcutaneous emphysema
223
1. Cardiovascular symptoms
(a) Chest pain
Onset, frequency, duration
Sudden/gradual onset
What were you doing at onset
Progressively better/worse
Site and radiation of pain
Character of pain
Severity
Precipitating (none, exertion, palpitations, emotions -> cardiac symptoms)
(food, alcohol, lying down - > reflux symptoms)
Aggravating (inspiration, coughing, movement of shoulders)
Relieving factors (rest, GTN, antacids)
Effort tolerance (level ground and climbing up stairs) -> significantly different from last time?
224
Any learned manoeuvres (valsalva, carotid massage, coughing, swallowing cold water/ice cubes)
(g) fatigue (reduced cardiac output and poor blood supply to skeletal muscles)
(h) intermittent claudication (PVD with poor blood supply to affected muscles)
areas affected
claudication distance
must rest for how long
2. Aetiology
(a) Trauma = musculoskeletal injury
(b) Fever and productive cough = pneumonia causing pleurisy
(c) Preceding URTI = viral mycarditis/pericarditis
(d) Nausea, vomiting, epigastric pain, acid regurgitation, dysphagia = GERD
(e) Triggers = anaemia (PR bleeding), sepsis, hyperthyroidism
3. Systemic review
225
Drug History
1. Any known drug allergy
2. Long-term medications
- CNS = ACE inhibitors, B-Blockers, CCB, diuretics, GTN
- Other types of medications (indications for use)
- Dose, frequency of dosing
- Compliance with use
- Side-effects
3. Use of TCM
Social History
1.
2.
3.
4.
5.
Smoking
Alcohol drinking
Family set-up (main caregiver, health of family members, finances)
Lift-landing
Functional status
Family history
226
2.
General appearance
Comfortable/in pain
Jaundice
Hands
1.
2.
3.
4.
Pulse rate: hold patients hand with your right hand and take pulse with your left hand (15s)
Regular = normal rhythm, sinus arrhythmia (increases with inspiration, decreases w expiration)
Radio-radial delay (aortic arch aneurysm, aortic dissection)
Clubbing (IE)
Oslers nodes (IE) = red raised tender nodules on finger pulps, thenar and hypothenar eminences
Head
1.
2.
Check eyes:
Look down and pull up upper eyelid jaundice (mechanical haemolysis by prosthetic valve; congestive
cardiac failure; hepatic congestion)
Look up and pull down lower eyelid pallor (anaemia)/spinter haemorrhages (IE)
Xanthelasma (hyperlipidaemia)
Check mouth: lips and tongue central cyanosis; teeth, gums, pharynx IE
227
Neck
1.
Abdominojugular reflex: compress the abdomen over the liver to see if there is an increase in JVP
Chest
Palpation
1.
Palpate for the apex beat (feel with the whole hand and localise with 1 finger). If cannot find on the left side,
check the R side for dextrocardia
character
heaving = pressure loaded e.g. HPT,AS -> forceful, sustained, not displaced
trusting = volume loaded e.g. MR, AR -> forceful, not sustained, displaced downwards and laterally
tapping (MS)
if apex beat is non palpable: thick chest wall, emphysema, pericardial effusion, dextrocardia (palpable to
the right of the sternum)
Parasternal heave for RVH (place hand vertically over sternum for 3-5s PS, pulmonary hypertension
Palpable tap of P2 over pulmonary area -> pulmonary hypertension
Thrills for palpable murmurs (place hand horizontally over base of heart) systolic/diastolic
2.
3.
4.
Auscultation
228
4. Ask the patient to hold his breath and auscultate the neck for carotid bruits and radiation of AS
- Radiation = same intensity as the original murmur
- Transmitted = lower intensity than the original murmur
5. Auscultate lungs
- Decreased air entry
- Crepitations
- Stony-dull percussion
6. Check sacral oedema
Murmurs
Timing, area, pitch, loudness, effect of dynamic manoeuvres
Aortic
High-pitched early-diastolic murmur
regurgitation Loudest with patient sitting up and in full expiration
Collapsing pulse
Aortic
stenosis
Mitral
stenosis
Loud S1
Low-pitched mid-diastolic murmur
Mitral
Soft/ absent S1
regurgitation Pansystolic murmur maximal at apex beat radiating to mid-axillary line
Tricuspid
Pansystolic murmur maximal over left sternal edge
regurgitation Large v waves
Pulsatile liver
In general:
Low-pitched murmurs indicate turbulent flow under low pressure
High-pitched murmurs indicate high velocity flow
Non-valvular murmurs
Pericardial
Superficial scratching sound not confined to systole or diastole
fiction rub
Caused by movement of inflamed pericardial surfaces
Can vary with posture and respiration (louder when patient is sitting up and in full
expiration)
Heard in pericarditis
Continuous
Present throughout systole and diastole (permanent pressure gradient)
murmurs
Communication existing between both parts of the circulation
Heard in PDA, AVF, ruptured sinus of Valsalva into right atrium/ventricle
Aortopulmonary connection (congenital, Blalock shunt)
Abdomen
229
Legs
1.
2.
3.
4.
End
1. Tell examiners that you would like to complete the examination by checking for hepatomegaly, chest (pleural
effusions and crepitations), blood pressure, temperature, fundoscopy (roths spots in IE = retinal infarcts) and
urinalysis (haematuria in IE)
2. Thank patient for his help and help him button up shirt
3. Shake his hand before you go
230
GIT
Others
Infective endocarditis
Congenital cyanotic heart disease
Suppurative conditions (empyema,
bronchiectasis, abscess)
Lung carcinoma
Idiopathic pulmonary fibrosis
Cystic fibrosis
Inflammatory bowel disease (eg.
Crohns)
Celiac disease
Biliary cirrhosis
Thyrotoxicosis (acropachy)
Idiopathic
Grading
Grade 1 = fluctuance at nail bed
Grade 2 = loss of nail bed angle
Grade 3 = Increased curvature of nail
(drumstick)
Grade 4: HPOA (Hypertrophic
Pulmonary Osteoarthropathy)
Examination
-
Inspect fingernails from the side to determine loss of angle between nail bed and finger
Compress nail bed and rock it from side to side (increased sponginess of proximal nail bed)
Hold nails of both hands together facing each other (clubbing present if no gap is seen)
Pulses
-
231
Blood pressure
Pulse pressure
-
Postural hypertension
-
Korotkoff sounds
Korotkoff 1 = pressure at which a sound is first heard over the artery (SBP)
Korotkoff 2 = sound increases in intensity
Korotkoff 3 = sound decreases in intensity
Korotkoff 4 = sound becomes muffled
Korotkoff 5 = pressure at which sound disappears (DBP)
Jugular venous pressure
-
Characteristics
a.
b.
c.
d.
e.
Measuring height
Procedure = Observe the patient at 45 degrees with his head turned slightly to the left
Right IJV lies medial to the clavicular head of the SCM
Measure the vertical height of the pulse above the sterna angle (raised JVP >3cm)
Recognising waveform
232
Heart sounds
S1
S2
233
Cardiac murmurs
ESM (Ejection systolic
murmur)
Waveform/ Crescendo-decrescendo
Character
murmur with S2 heard
Occurs
when
Causes
Turbulent flow
through the
aortic/pulmonary
valve orifices
Or greatly increased
flow through the
heart
Innocent murmur
(esp in children)
High-output states
(anemia, pregnancy)
Organic (AS, PS,
HOCM)
PSM (Pan-systolic
murmur)
Uniform murmur
which merges with S2
High-pitched and
easily missed (listen
for absence of
silence in early
diastole
Organic (AR, PR)
A ventricle leaks to a
lower pressure
chamber/ vessel
Graham-Steell
murmur = mitral
stenosis
pulmonary
hypertension
pulmonary
regurgitation
MDM (Middiastolic
murmur)
Low-pitched and
rumbling with an
opening snap after
S2
Impaired flow
during ventricular
filling
234
Presentation
Mr (name), a pleasant looking age/gender/race appears to be alert, well, comfortable and orientated at
rest. His vital signs are stable: HR is ___, regularly regular, RR is ___ and he is currently afebrile. He does
not appear to be in any respiratory distress and is pink on room air. He does not appear cachexic. On
inspection, there are no signs of cyanosis, jaundice, pallor, dehydration or peripheral oedema.
On examination of the peripheries, there was no clubbing observed or stigmata of infective endocarditis
such as splinter haemorrhages, osler nodes or janeway lesions. There was no radio-radio or radiofemoral delays. Collapsing pulse was absent.
On inspection of the praecordium, there were no signs of surgical scars or chest wall deformities. The
apex beat was not displaced = it was in the left 5th intercostals space. There was no parasternal heave or
thrills were felt over the pulmonary or aortic areas.Palpable P2 was not felt. On auscultation, normal
S1S2 was heard. Loud P1 was not heard. There were no additional heart sounds or murmurs detected. No
bruit was heard over the carotids
There was no evidence of right heart failure = JVP was not raised and there was no sacral or pedal
oedema. Air-entry was good on auscultation of the lung bases. Normal vesicular breath sounds were
heard and there was no inspiratory crepitation sor wheeze detected.
I would like to end my examination by requesting for the temperature and BP charts.
235
Respiratory
Chest wall
Gastrointestinal
1. Angina
a. Usually a central dull ache in the retrosternal area
b. May radiate to the jaw or left arm
c. Characteristically occurs with exertion and relieved by rest or nitrates
d. GTN is not specific as it can also relieve esophageal spasm
2. Myocardial infarction
a. Often comes on at rest
b. Pain is more severe and lasts longer (>30mins)
c. Associated with dyspnoea, sweating, nausea, giddiness
3. Pleuritic pain
a. Made worse by inspiration, coughing and movement of shoulders
b. Due to pleurisy (pneumonia) or pericarditis
c. Often relieved by sitting up and leaning forward
4. Musculoskeletal
a. Sharp pain localised to a small area of the chest wall
b. Associated with respiration, coughing or movement of shoulders
5. Dissecting aneurysm
a. Shearing pain greatest at onset
b. Radiates to back (distal to left subclavian artery)
c. Think of this if patient presents with chest pain suggestive of AMI but with neurological symptoms as
well
6. Massive pulmonary embolism
a. Pain of very sudden onset
b. Associated with collapse, dyspnoea, cyanosis
7. Spontaneous pneumothorax
a. Sharp and localised pain
b. Associated with severe dyspnoea
8. Oesophageal spasm
a. Rare and difficult to distinguish from angina
b. Precipirated by food, alcohol and lying down
236
History taking
Name/age/race/gender/occupation
Date of admission
Presenting complaint
1. Cardiovascular symptoms
Triggers = Anaemia,
a. Chest pain, sob, palpitations, ankle oedema, nausea, vomiting
Sepsis, Hyperthyroidism
b. Diaphoresis, giddiness, syncope, fatigue, intermittent claudication
2. Management prior to hospitalisation
3. Aetiology
a. History of trauma (muscular strain, rib #, oesophageal rupture)
b. Fever, URTI, productive cough (viral myocarditis, pneumonia)
c. Nausea, vomiting, epigastric pain, acid regurgitation, dysphagia (GERD)
4. Systemic review
5. Current management in hospital
6. Details of previous similar episodes
Physical examination
1. Vitals
- Heart rate
a. tachycardia (tachydysrhythmia -> AF; sinus tachycardia -> pain; SVT; VT)
b. Bradycardia (AV nodal ischaemia 2o AMI, B-Blockers, CCB)
- BP
a. Usually normal
b. Hypertension must treat if a/w AD(aortic dissection) or AMI
c. Hypotension AMI, massive PE, tension pneumothorax, AD resulting in cardiac tamponade
d. Wide pulse pressure proximal AD -> aortic insufficiency
e. Pulsus paradoxus pericardial effusion/cardiac tamponade 2o AD, constrictive pericarditis, TP
- RR
a. Tachypnoea usually a/w chest pain
- SpO2
2. Body habitus = tall, thin, patient with long limbs and arachnodactaly AD
3. CVS examination
- Radio-radio delay/radio-femoral delay = AD
- Diminised femoral pulses = AD
- Unequal carotid pulses = AD
- Raised JVP = RVF 20 AMI, RVF 20 PE, tension pneumothorax (TP)
- Right ventricular heave = RVF 20 PE
- Left ventricular heave = CHF
- Displaced apex beat = TP
- Loud P2 = acute cor pulmonale 20 massive PE
- S3, gallop rhythm = CHF
- PSM = MR 2ndary to papillary muscle ischaemia/infarction (mitral valve prolapsed)
238
4.
5.
6.
7.
- AR = proximal AD
- Pericardial rub = pericarditis
- Peripheral oedema = CHF, RVF, DVT
Chest examination
- Tender costal cartilage, erythema, swelling = costochondritis
- Localised rib pain = rib #
- Deviation of trachea = TP
- Unequal chest expansion = TP
- Hyper-resonant percussion note = TP
- Decreased air-entry = pneumonia, TP
- Bronchial breathing = pneumonia
- Crepitations = CHF 2ndary to AMI, pneumonia
- Pleural rub = PE, pneumonia
- Pleural effusion = PE< pneumonia
Abdominal examination
- Guarding and rebound = perforated ulcer
- Epigastric tenderness = PUD
- Generalised abdominal pain = mesenteric infarction from AD
CNS
- Hemiplegia = AD involving carotid artery
Skin
- Herpes zoster = unilateral maculopapular rash/vesicles in dermatomal pattern
239
1. ECG stat
2. O2 by facemask or nasal prongs (2L/min)
- Keep SpO2 > 95%
3. S/L GTN 0.3-0.6mg every 5 mins (keep SBP >90mmHg; CI = hypotension)
#investigations to order
1.
2.
3.
4.
Specific management
1. AMI (MONA)
- CRIB
- Supplemental O2 (keep SpO2 >95%)
- Aspirin 300mg stat followed by 100mg OM (CI = asthma, BGIT, anaemia)
S/L GTN stat and ISDN 10mg TDS (CI = hypotension, tachycardia; relative CI = inferior MI with possible RV
involvement)
Atenolol 100mg OM (CI = asthma, COPD, complete heart block, severe heart failure)
240
Captopril 12.5mg BD if anterior AMI 9CI = CRF, bilateral renal artery stenosis)
General measure =
input/output chart
Fluid restriction (<1L/Day)
Soft diet/diabetic diet/low-salt diet
Stool softener (senna 2 tablets ON)
2. Angina
- CRIB
- Supplemental O2 (keep SpO2 >95%)
- S/L GTN stat
- Serial ECGs and cardiac enzymes (q8h x 3)
- Review precipitating cause, adjust anti-anginal medications, assessment by ICU/CCU staff if angina
occurred at rest or 1st episode of angina
3. Aortic dissection
- Arrange for CT thorax or TEE
- Trans-thoracic echocardiogram if neither can be arranged within the next house
#detect dilated aortic root, aortic regurgitation, pericardial effusion
- Refer cardio-thorax = confirm diagnosis with MRI or aortography
4. Pericarditis
- Non-urgent echocardiogram = pericardial effusion, haemodynamic compromise
- PO Idomethacin 25-50mg TDS/aspirin 650mg q4hrs
a. CI = samters syndrome (aspirin sensitivity, asthma, nasal polyps), BGIT, on anti-coagulation
b. Used with caution = CHF sodium retaining properties
CRF inhibit renal prostaglandins which maintain perfusion in those with pre-renal
conditions
5. Pneumothorax
- Order erect inspiratory and expiratory chest films
- Chest-tube insertion
- Tension pneumothorax = immediate needle decompression, chest-tube insertion
6. GERD
- Antacids = magnesium-containing ones cause diarrhoea; aluminium-containing ones cause constipation
- Elevation of head of bed
- Avoid night time snack
- H2 receptor blocker
- PPI
- OGD KIV biopsy if PUD suspected
7. Costochondritis
- NSAID e.g. naproxen
8. Herpes zoster
- Unilateral chest pain in dermatomal distribution may precede typical skin lesions by 2-3 days
(maculopapular rash that rapidly evolves into vesicular lesions)
- Neuritis = narcotic analgesia, amltrityline HCL, steroids
- Antivirals (acyclovir) may reduce severity and duration
241
1. Chest pain
- Mode of onset
- Duration
- Frequency
- Sudden/gradual onset
- Constant/intermittent
- Progressively worse/better
- Site and radiation
- Character
- Pain score and severity
- Triggers
CVS -> exertion (quantify), cold exposure, emotion, palpitations, rest
GIT -> food
- Aggravating factors
RT -> deep inspiration, coughing, moving of shoulders
GIT -> alcohol, lying down
- Relieving factors
CVS -> rest, GTN
GIT -> antacids, food
2. Dyspnoea
- Mode of onset
- Duration
- Frequency
- Sudden/gradual onset
- Progressively worse/better
- Severity
- Triggers = exertion (quantify and ?decrease in ET), emotion, rest
- Reliving factors = rest
- a/w orthopnoea and PND
3. Nausea vomiting
- Diaphoresis (excessive sweating)
- Palpitations, giddiness, syncope (loss of consciousness)
- Ankle oedema
- Intermittent claudication
Aetiology
1. Triggers
- Anaemia = chest pain, SOB, giddiness, palpitations, fatigue, pallor, BGIT, menorrhagia, gross haematuria
- Sepsis = fever
- Hyperthyroidism = goitre, fidgety, insomnia, increase in appetite, LOW, diarrhoea
242
Complications
Systemic review
Management prior and during hospitalisation
Has this happened before?
Drug History
Drug allergies
Current medications
Social history
Smoking
Alcohol
Diet
Physical activity
Family set-up
Main caregiver
Finances
Lift-landing
Functional status
Family history
243
Causes
Reduced coronary blood flow = atheroma, thrombosis, embolus, vasospasm, arteritis
Decreased oxygenation = anaemia, CO poisoning, V/Q mismatch
Increased myocardial demand = ventricular hypertrophy, HOCM, thyrotoxicosis
Accumulation of metabolites from ischaemic muscles -> stimulate cardiac sympathetic nerves -> pain
(patients with cardiac transplants who develop CAD do not feel angina as heart is denervated)
Types of angina
1. Typical angina =
2.
3.
4.
5.
Pathology
- Stable angina = ischemia due to fixed atheromatous stenosis of 1 or more coronary arteries
- Prinzemetal angina = ischaemia due to coronary vasospasm
- Unstable angina = ischaemia due to plaque rupture with superimposed thrombosis (dynamic
obstruction)
Risk factors
Modifiable
Smoking
- Risk of Ami same as non-smokers
after 2 years
- Risk of angina same as non smokers
after 10 years
Alcohol
Obesity
Physical inactivity
Hypertension
Hyperlipidaemia
Diabetes mellitus
Non-modifiable
Gender (men)
Ethnicity (Indians)
Age (older)
Family history of IHD/AMI
Personal history of IHD/AMI
Homocysteinaemia
244
Clinical Presentation
History
1. Chest pain
- Location = central substernal chest pain
- Character = crushing
- Radiation = left jaw and arm
- Duration = 5-10mins (AMI -> 30mins)
- Triggers = exertion, cold exposure, emotional stress, palpitations
- Relieved = rest, GTN
- ? recent changes in character of pain
2. Exertional dyspnoea (due to elevated end-diastolic pressure 2ndary to ischaemia
- Not a/w orthopnoea and PND
- ? decrease in effort tolerance
3. Intermittent claudication
4. No symptoms of nausea, vomiting, diaphoresis, giddiness/syncope, ankle oedema, fatigue
5. Triggers = anaemia -> recent BGIT/menorrhagia/gross haematuria
Recent illness/sepsis
Hyperthyroidism -> palpitations, fidgety, insomnia, increased appetite, LOW, diarrhoea
6. Risk factors
- Hypertension
- Hyperlipidaemia
- Obesity
- Smoking
- Alcohol
- Sedentary lifestyle
- Family history = 1st degree relatives (women <65 years old; men<55 years old)
- Personal history
Physical Examination
1. General inspection = obese
Signs of thyrotoxicosis (goitre, thyroid eye disease)
2. Peripheries = anaemia, tar stains, xanthoma, xanthelesma, carotid bruit
3. CVS = cardiomegaly, valvular heart disease, cardiomyopathy
4. Lower limbs = signs of PVD
Investigations
Immediate
1. ECG
- Normal
- Previous AMI (pathological Q waves, LBBB)
- Ischemia (T wave invesion, ST segment depression)
- Left ventricular hypertrophy
2. Cardiac enzymes = not raised in stable angina
3. CXR = cardiomegaly
4. Underlying conditions
- FBC = Hb (anaemia); WBC (leucocytosis)
- TFT = hyperthyroidism
Later
1. Stress test
- Exercise ECG = planar/down-sloping ST segment depression indicative of ischemia
- Dobutamine
245
2.
3.
4.
5.
- Nuclear medicine
- MRI
2D-echocardiogram
- Left ventricular ejection fraction
- Valvular heart disease
MIBI perfusion scan
MUGA functional scan (multiple gated acquisition scan)
Coronary angiogram (delineate exact coronary anatomy in patients going for revascularisation)
Management
Acute
1. Stabilise patient if necessary
- Ensure patent airway
- Ensure spontaneous breathing ->
-
Give supplemental O2
Place on SpO2 monitoring (keep SpO2 >95%)
Obtain vitals
Obtain ECG
Place on continuous ECG monitoring if necessary
2. S/L GTN
- MOA = relieves coronary vasospasm & pulmonary congestion; vasodilation
- Absolute contraindications = hypotension; tachycardia (SBP<90mmHg)
3. B-Blockers
- 1st line therapy (not GTN)
4. Aspirin
- MOA = anti-platelet
- Contraindications = anaemia; BGIT; Asthma
#other anti-platelets (e.g. clopidogrel, ticolpidine, Gp2b/3a inhibitors) given only when patient is going
for interventional procedures
5. ACE inhibitors
6. CCB (if pain is not relieved by above measures)
Long term
1. Patient education
2. Control risk factors
- Lifestyle modifications = quit smoking, drink less alcohol, exercise regularly, lose weight, healthy diet
- Hypertension
- Hyperlipidemia
- Diabetes
3. Medical Treatment
- Symptomatic relief = S/L GTN
- Prophylaxis
Anti-platelet therapy = aspirin 75-150mg OM/Clopidogrel 75mg OM
Anti-anginal therapy
B blockers = atenolol 50-100mg *drug of choice in previous AMI)
LA nitrates = ISMN (vasodilatation, relaxes coronary arteries)
CCB = amoldipine (vasodilatation, relaxes coronary arteries, decreases contractility, slows
HR
ACE inhibitors
4. Surgical treatment
- Percutaneous trans-luminal coronary angioplasty (PTCA)
Ideal for a single and discrete lesion
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Use of balloon dilatation to relieve arterial obstruction (KIV stent placement ot prevent
re0obstruction)
# stent coated with sirolimus -> prevents proliferation of endothelial fibroblasts -> reduces risk of
stenosis
Effective symptomatic treatment for chronic stable angina
No evidene that it improves survival
Acute CX = occlusion of target vessel/side branch by thrombus or loose intimal flap -> ischemia
Long term CX = re-stenosis
Coronary artery bypass graft (CABG)
Ideal for patients not suitable for PTCA or severe triple vessel disease
Use of alternative arteries to bypass proximal stenosis
#left internal mammary artery (LAD) aka internal thoracic artery
Right internal mammary artery (RCA) aka internal thoracic artery
Reversed segments of saphenous veins
Operative mortality = 1.5%
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Obesity
Smoking
Alcohol
Sedentary lifestyle
Family history = 1st degree relatives (women < 65 yrs old; men < 55 yrs old)
Personal history
Physical examination
1. General inspection = dyspnoeic and tachypnoeic
sweating
2. Cardiogenic shock = altered mental state
Hypotensive
Thin and thready pulse
Pale, cool and clammy extremities
Reduced capillary refill time
Reduced urine output
3. Hands = tar staining, peripheral cyanosis
4. Face = xanthelesma, central cyanosis
5. Neck = raised JVP
6. Praecordium = cardiomegaly
Additional heart sounds (S3, gallop rhythm)
Systolic murmurs (new onset VSD, MR)
7. Lungs = bibasal inspiratory crepitations
8. Abdomen = tender hepatomegaly
9. Lower limbs = bilateral ankle pitting oedema
PR = BGIT
Management
Acute
1. Stabilize patient
- Ensure patent airway
- Ensure spontaneous breathing Give supplemental O2; place on SpO2 monitoring (keep SpO2 > 95%)
- Ensure good circulation Obtain vitals (HR, BP, RR); Obtain ECG; place on continuous ECG monitoring if
necessary; create venous access and take bloods for investigations
- Resuscitate if patient is in cardiogenic shock (papillary muscle dysfunction/rupture, septal rupture, cardiac
tamponade)
# call cardiologist and CT surgeon
# start inotropic support = IV dobutamine/dopamine 5-20 g/kg/min
# catheterize patient to monitor urine output
2. IV morphine for pain relief
- Give with IV maxolon (anti-emetic)
3. Nitrates
- S/L GTN = relieve coronary vasospasm
- IV GTN = for ongoing chest pain, HTN and pulmonary congestion
Absolute CI: Hypotension (SBP <90mmHg), tachycardia
Relative CI: Inferior AMI with possible RV involvement
4. Aspirin 300mg stat followed by 100mg OM (can also give clopidogrel, ticlopidine, LMWH)
- Anti-platelet effect starts 1hr after ingestion
- Decreases mortality and re-infarction rate
- CI: asthma, anaemia, BGIT
5.
-blocker atenolol 100mg OM
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Advantages
Disadvantages
Thrombolysis
Rapid administration
Widely available
Convenient
Does not require expertise
PTCA
Better clinical efficacy
# superior vessel patency
# reduced re-occlusion rates
Less haemorrhagic risk
Early definition of coronary
anatomy
# allows tailored therapy
# more efficient risk stratification
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Contraindications
Do not administer thrombolytics if the answer to any of the
following is yes
Suspected AD
Previous CVA
Known intracranial neoplasm
Recent head trauma
Other intracranial pathology
Severe hypertension (BP>180/110)
Hypotension (SBP<90)
Acute peptic ulcer
Acute internal bleeding
Recent internal bleeding (<1 month ago)
Recent major surgery (<1 month ago)
Current use of anticoagulants
Known bleeding diasthesis
Prolonged CPR (>5 mins)
Previous administration of thrombolytics
Pregnancy
Diabetic retinopathy
LBBB on ECG
No contraindications
Streptokinase
Most commonly used
Cost-effective
Therapy of choice when risk of
intracranial haemorrhage is high
e.g. elderly patients
Recombinant tPA
< 50 yo
Anterior AMI
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General measures
1. Monitored in CCU for at least 2 days
-short term complications of AMI = arrhythmias, CCF, cardiogenic shock, pericarditis
-monitor vitals q4rly
-I/O chart
-fluid restriction < 1L/day
-low-salt diet
-stool softener
Investigations
Immediate
1. ECG
-a single ECG cannot rule out AMI
Serial ECGs can rule out STEMI but not NSTEMI
-unstable angina = normal, ST depression, T wave inversion
NSTEMI = ST depression, T wave inversion
STEMI = ST elevation of >2mm in 2 or more contiguous leads
New-onset BBB
Posterior AMI (ST depression in leads V1+V2)
-do right-sided ECG in inferior AMI to exclude concomitant RV infarct (GTN is contraindicated)
2. Cardiac enzymes (serial CE q8hrly)
- 1st set of CE can miss up to 40-60% of AMI
- 2nd set of CE can pick up 98% of AMI
(a) Myoglobin = detected within 1-2 hrs, peak at 6-9hrs, normalized by 24-36hrs
-earliest marker to rise in AMI
Useful in ruling out AMI early (raised in nearly all AMIs at 6hrs)
Disadvantages = not specific for cardiac muscle (skeletal muscle injury, NM disorders, renal failure, IM
injections, strenuous exercise, post-coronary bypass surgery
(b) Creatine kinase (CK-MB)= detected within 4-6hrs, peak at 18-24hrs, normalized by 48-72 hrs
-serological gold standard of AMI
-disadvantages = not specific for cardiac muscle, false positive values in CRF patients (renal failure),
narrow diagnostic window, failure of total CK to rise to abnormal values in all AMI
-relative % index = CKMB/total CK x 100% ( 5% suggestive of AMI)
(c) Troponin T = detected within 4-6hrs, peak within 12-120 hrs, normalized by 10-14 days
-useful for late presenting AMI
-Prognostic indicator in unstable angina
-Specific for cardiac muscle
-false positive values in CRF and dialysis patients
(d) Troponin I = detected within 4-6 hrs, peak at 12-36 hrs, normalized by 7-9 days
-the most cardiac-specific marker
-no false positive values in renal failure patients
-prognostic indicator in unstable angina
-not very widely available
3. CXR
-cardiomegaly
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(c) Right-sided
LV failure (most common cause)
Cor pulmonale
Pulmonary stenosis
Pulmonary embolism
(d) Left-sided
Hypertension
Aortic/mitral stenosis
High-output states
(a) Severe anaemia
(b) Thyrotoxicosis
(c) Large AV shunts
(d) Pregnancy
Left-sided HF
Right-sided HF
Biventricular
HF
High-output HF
Systolic dysfn
Diastolic dystn
Decreased LV output
Increased LA or pulmonary venous pressure
Acute = APO
Gradual = reflex pulmonary vasoconstriction pulmonary HPT
Decreased RV output
Causes = dilated CMP, IHD
Impaired myocardial contraction
May be associated with diastolic dysfunction
More likely in younger patients, history of MI, displaced apex beat, S3
gallop, cardiomegaly on CXR
Defective diastolic filling due to decreased LV complianceimpaired LV
filling
Elevated left atrial and pulmonary venous pressures
Causes = LVH due to HPT or IHD or HOCM
Findings = LVH, dilated left atrium, normal ejection fraction
More likely in older patients, history of HPT, thrusting apex beat, S4 gallop,
LVH on ECG
Clinical presentation
Name/age/ethnicity/gender/occupation
Drug allergy
Past medical history
Date of admission
History of presenting complaint
Symptoms
Left-heart failure
(a) Dyspnoea = duration, triggers (exertional or at rest), effort tolerance, severity (NYHA classification),
aggravating and relieving factors, associated with orthopnoea and PND
(b) Chest pain, nausea/vomiting, diaphoresis, giddiness recent AMI
(c) Palpitations (fast AF can trigger CCF) = giddiness and syncope
(d) Fatigue
Right-heart failure = ankle oedema, abdominal distension, facial oedema, RHC pain (tender hepatomegaly
cardiac cirrhosis nutmeg liver)
Hypoperfusion = giddiness, confusion, oliguria
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Aetiology
Recent AMI
Sepsis = fever, RTI (productive cough), UTI (FUN, dysuria, haematuria)
Anaemia = PR bleeding
Non-compliance with fluid and salt restrictions
Non-compliance with medications
Compliance
Systemic review
Management of current episode
Has this happened before?
When was CCF first diagnosed?
- Presenting complaint
- Investigations done = ECG, treadmill ECG, 2DE, nuclear scans (MIBI/MUGA)
- Current management = follow-up with whom? Compliance? Medications (type, dosage, recent changes,
compliance), fluid and dietary restrictions (compliance)
- Level of control = number of relapses? Treatment
Past medical history
DM, HPT, HCL, IHD, AMI, CVA
Valvular heart disease
Previous admissions and surgeries
Drug history
Social history
Smoking
Alcohol
Family set-up
Main caregiver
Lift-landing
Type of housing
Financial status
Functional level
Family history
Physical examination
Vitals = HR, RR, BP, T, SpO2
General condition = mental state, anasarca, respiratory distress (tachypnoea, dyspnoea, use of accessory
muscles of respiration, pursed lip breathing, intercostals/subcostal retractions, cyanosis), midline sternotomy
scar with saphenous vein harvest site (previous CABG)
Peripheries = pulse (tachycardia, AF, weak and thready), cold and clammy skin, prolonged capillary refill time,
conjunctival pallor
Signs of fluid overload = facial oedema, raised JVP, pleural effusion/pulmonary oedema, tender hepatomegaly,
ascites, sacral oedema, bilateral lower limb pitting oedema
Praecordium = displaced and heaving apex beat, S3/4 heart sound, gallop rhythm, heart murmurs (valvular
heart disease)
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Differentials
1. Pulmonary embolism
2. Fluid overload = renal (nephrotic syndrome, ESRF), GIT (liver cirrhosis, protein-losing enteropathy, IBD)
3. Cor pulmonale
4. COPD
Investigations
Heart failure is principally a clinical diagnosis!
Bloods
Cardiac enzymes = AMI
FBC = Hb (anaemia), WBC (sepsis)
U/E/Cr = hypokalaemia from RAAS activation and K+-losing diuretics, hyponatraemia (fluid overload), renal
impairment from hypoperfusion
LFT = hepatic congestion, cardiac cirrhosis
Serum NT-pro-BNP
- Peptide hormone secreted by ventricular myocytes play key role in volume homeostasis
- Plasma concentration reflects ventricular pressure raised in heart failure
- Actions = increases GFR, decreases renal sodium reabsorption
- High negative predictive value = useful in excluding diagnosis of heart failure in patients with dyspnoea/
fluid retention
ABG (if SpO2 < 92%)
Blood c/s if in sepsis
Imaging
ECG
- MI(old infarcts pathological Q waves; new infarcts ST hyperacute changes)
- Arrhythmias (AF, heart block)
- LVH
- Goldbergs triad for dilated CMP (poor R progression, small limb voltages, large chest voltages)
- Electrical alternans (cardiac tamponade, pericardial effusion)
CXR
- Cardiomegaly, upper lobe diversion, peri-hilar bats wing shadow (alveolar oedema), Kerley B lines
(interstitial oedema), pleural effusion, pneumonia
2D-echo
- Assess cardiac morphology
- Global and regional function
- Identify causes of heart failure (myocardial, vascular or pericardial origin)
Identify underlying ischaemia and myocardial viability revascularization
(a) 2D-echo = treadmill, dobutamine
(b) Radionuclide studies = MIBI (perfusion), MUGA (multiple gated acquisition scan) functional
(c) MRI = useful for quantifying myocardial necrosis, perfusion and function; usually indicated in cardiac
masses, complex congenital heart disease or pericardial disease
(d) CT = calcifications (coronary artery, pericardium)
(e) Coronary angiogram and cardiac catheterization = indicated in patients with angina, history or MI or at
high risk for coronary artery disease.
Acute management
Acute decompensation of chronic heart failure
Stabilize patients vitals
(a) Secure airway if unconscious
(b) Ensure that patient is breathing spontaneously
- Place on continuous pulse oximetry monitoring
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Sit in upright position with legs hanging down to reduce venous return
Give supplemental O2 via non-rebreather mask non-invasive positive pressure ventilation
(BiPAP/CPAP)
- IPPV if patient is in respiratory distress and acute heart failure-induced respiratory muscle fatigue
(c) Obtain patients vitals = HR, RR BP, T
- Place on continuous ECG monitoring
- Examine for signs of shock = altered mental state, cold clammy peripheries, weak thread pulse,
prolonged capillary refill time, reduced urine output
- Set IV cannula = take bloods for investigation
- CXR, ABG
Specific measures
(a) Diuretics = IV Lasix (40-80 mg bolus; onset in 20 mins; lasts for 6 hrs)
- Catheterize patient
- Monitor vitals and urine output to avoid volume contraction
- Achieve negative balance of 1-2L/day
(b) ACE inhibitors = captopril
- Monitor for hypotension (esp postural), hyperkalaemia and worsening renal function
(c) Nitrates = IV GTN (lower LV EDVrelieve symptoms of pulmonary congestion)
- IV nitroglycerine/nitroprusside
- Contraindicated in inferior/right ventricular infarct or hypotension (SBP must be >90mmHg)
- Continuous BP monitoring needed
(d) Digoxin if hypotensive
(e) - Complete rest in bed
- Fluid restriction (<1L/day)
- Low-salt diet (<2g/day)
- Strict I/O charting and daily weights
- Monitor vitals q4hrly (inform doctor if SBP < 100mgHg or HR > 100/min)
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(b)
(c)
(d)
(e)
(f)
-
Long-term management
Conservative
Control risk factors = HPT, HCL, DM
- Obesity (weight loss, exercise, healthy diet)
- Stop smoking and drinking alcohol
Fluid restriction only if oedematous
Salt restriction (<2g/day)
Influenze immunisation
Monitoring = daily weights (avoid > 2kg/wk), symptoms and signs
Medical (started if EF < 40%)
(a) First-line therapy
1. Diuretics
- Mechanism of action = reduce preload BUT may cause hypovolaemia
- Agents = frusemide (Lasix)
spironolactone (indications = patients with NYHA class 3/4) hypokalaemia, predisposition to
arrhythmias, concurrent digoxin therapy
2. ACE inhibitors
- Mechanism of action = reduce afterload by preventing RAA axis and sympathetic activation
- Agents = captopril, enalapril, lisinopril
- Advantages = survival benefit
- S/E = first-dose hypotension, dry cough, maculopapular rash, fetotoxic, nephrotoxic,
hyperkalaemia, neutropenia
- Contraindications = bilateral renal artery stenosis
3. -blockers
- Mechanism of action = reduce sympathetic stimulation to increase EF
- Agents = carvedilol, metoprolol, bisoprolol
- Advantages = survival benefit when taken together with ACE inhibitors
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Hyponatraemia
Impaired liver
function
Thromboembolism
Arrhythmias
K+-losing diuretics
Hyperaldosteronism (due to RAAS activation)
Impaired aldosterone metabolism due to hepatic
congestion
Diuretics
ADH secretion
Failure of cell membrane ion pump due to ischaemia
Hepatic venous congestion
Ischaemic hepatitis
Low cardiac output
Immobility
Arrhythmias and AF
Intracardiac thrombus due to MS or LV aneurysms
Electrolyte changes
Structural heart disease
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but also on the presence of other risk factors, target organ damage, concomitant disease such as diabetes and
cardiovascular or renal disease, as well as other aspects of the patients individual and medical circumstances.
Factors influencing prognosis
Risk Factors for Cardiovascular Disease
Renal disease
Microalbuminuria (microalbumin-creatinine
ratio > 30 mg/g) or Proteinuria (>0.5 g/24hrs)
Renal impairment [plasma creatinine
concentration > 132 mmol/L(>1.5mg/dl)]
Diabetic nephropathy
Retinopathy
Generalized or focal narrowing of the retinal
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Coronary revascularization
Congestive heart failure
Vascular disease
Dissecting aneurysm
Symptomatic arterial disease / PVD
arteries
Haemorrhages or exudates
Papilloedema
Atherosclerosis
Ultrasound or radiological evidence of
atherosclerotic plaque (carotid, iliac, femoral
and peripheral arteries, aorta)
Risk assessment
Besides the level of BP, it is also important to assess the overall cardiovascular risk of a patient prior to definitive
therapy in order to optimize risk-benefit ratio. Adding the numbers of traditional, documented risk factors in a
person is one such way. The use of well tested and accepted risk tables, charts or formulae to estimate a patients
absolute risk is encouraged. In individuals such as those with known or established coronary heart disease (CHD),
atherosclerotic disease, diabetes mellitus, familial hypercholesterolemia or malignant hypertension, the overall
cardiovascular risk assessment may not be necessary as the risk is already high and treatment should be started as
soon as the diagnosis of hypertension is confirmed.
Risk stratification and treatment plan
BP Category
Risk Group A
(No risk factors)
Systolic
BP
130- LM
139mmHg/ Diastolic
BP 80-89mmHg
Systolic
BP
140- LM + Rx*
159mmHg/ Diastolic
BP 90-99mmHg
Systolic
BP
>160 LM + Rx
mmHg/ Diastolic BP
>100 mmHg
Risk Group B
(1-2 risk factors)
LM
Risk Group C
(>3 risk factors or
Diabetes Mellitus or
TOD/ACC)
LM + Rx
LM + Rx
LM + Rx
LM + Rx
LM + Rx
Moderate risk
High risk
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Hypertension = 3 or more elevated BP readings taken on 3 or more different settings separated by at least 2
hrs
Hypertensive crisis
o Hypertensive emergency
Life-threatening and severe hypertension (diastolic BP ~ 120-130 mmHg) associated with
acute progressive end-organ damage
Characterized by accelerated microvascular damage with fibrinoid necrosis in vessel walls of
small arteries and arterioles resulting in intravascular thrombosis
Clinical features
# CVS = Hypertensive left ventricular failure (APO)
Acute aortic dissection
Acute myocardial infarction
# CNS = Stroke } needs to be differentiated as BP lowering is contraindicated to stroke
Hypertensive encephalopathy
# Renal = acute renal failure
#eyes = papilloedema
# eclampsia
Requires prompt BP reduction (ICU setting)
o Hypertensive urgency
Severe hypertension without acute end-organ damage
Clinical features
Hypertensive retinopathy
Chronic renal failure
Pre-ecampsia
Accelerated hypertension = grade 3 hypertensive retinopathy
Malignant hypertension = grade 4 hypertensive retinopathy
BP should be reduced within 24 hrs (outpatient basis)
Patients with accelerated/malignant hypertension should be admitted
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Epidemiology
Local prevalence rate = 24.9% (Singapore NHS 2004)
Males > females
Chinese > Indians > malays
Aetiology
Primary Hypertension
Accounts for 95% of the cases
No underlying cause found
Possible aetiology
o Increased sympathetic neural activity with enchances beta-adrenergic responsiveness
o Increased angiotensin II activity and excess mineralcorticoids
o Genetic factors = strong family history, ethnicity
o Environmental influences = obesity, smoking, excessive alcohol consumption, lack of physical
exercise, diet
Secondary hypertension
Accounts for 5% of the cases
Must investigate for the following causes in a young hypertensive patient (<40 years old)
Renal = Renal impairment (glomerulonephritis, diabetic nephropathy, analgesic nephropathy, chronic
pyelonephritis, APKD, obstructive uropathy, reflux uropathy)
Renal Artery stenosis (atheroma, fibromuscular dysplasia)
Endocrine = Cushings syndrome
Conns syndrome
Phenochromocytoma
Acromegaly
Thyroid disorders (primary hypothyroidism, thyrotoxicosis)
Toxaemia of pregnancy (pre-eclampsia, eclampsia)
Drugs (OCP, steroids, cocaine, amphetamines)
Neurogenic = Raised ICP
Obstructive sleep apnoea
Aortic = Coactation of aorta
Atherosclerosis
Labile = Pschogenic
Stress-related
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Complications
Cardiovascular
Heart failure
Ischaemic heart disease/coronary artery disease
AMI
Cardiac arrhythmias
Peripheral vascular disease
CNS
CVA
TIA
SAH
Hypertensive encephalopathy
Renal
Chronic renal failure -> hypertensive nephrosclerosis -> ESRF
# can directly cause renal failure eand accelerate disease progression
Eyes
Blindness
Hypertensive crisis
History
Name/age/ethnicity/gender/occupation
Drug allergy
Past medical history
Presenting complaint
Symptoms
Cardiovascular = chest pain (radiating to the back), SOB, palpitations, ankle oedema, intermittent claudication,
fatigue, giddiness, nausea/vomiting, diaphoresis
CNS = headache, nausea/vomiting, giddiness, blurring of vision, focal neurological deficits, seizures
Renal = haematuria, oliguria/polyuria
Eye = decreased visual acuity
Aetiology
Renal
Haematuria, proteinuria, polyuria/nocturia, flank pain, ankle oedema
History of renal impairment
GN = vascular (childhood rash on legs)
Infective (Hep B, Hep C, HIV)
Toxin (recent drug intake)
Autoimmune (rash, joint pain and swelling, SLE)
Metabolic (DM)
History of DM
History of long-term analgesia
History of urinary stones causing obstruction
History of APKD
History of reflux disease (recurrent UTI)
History of kidney infection
History of renal artery stenosis
Endocrine
Systemic review
Management prior and during admission
Has this happened before
Duration of hypertension
Initial presentation, investigations and management
Follow-up with whom
Frequency of follow-ups
Compliance with follow-ups
Annual investigations
Level of control
Home-monitoring system in place
Conservative = weight loss, exercise, diet, compliance
Medical therapy = types of drugs, dosages, side effects, recent changes, compliance
Complications
CVS = History of angina or AMI
Chest pain, Sob, palpitations
Peripheral vascular disease = intermittent claudication, poor wound healing, pain, parasthesiae
CNS = history of TIA/CVA/SAH
Headache, nausea/vomiting, BOV, focal neurological deficits
Renal = history of CRF/ESRF
Eyes = poor visual acuity, frequent DRP screening?
Hypertensive emergency = history of such episodes
Presenting complaint, investigations and management
Past medical history
DM, HCL, IHD/CAD, AMI, CVA
Pre-eclampsia or eclampsia
Drug history
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Social history
Smoking
Alcohol consumption
Occupation -> stressful
Diet
Physical activity
Family history
Physical examination
Blood Pressure
Procedure
- Refrain from smoking or ingesting caffeine 30 mins preceding BP measurement
- Ensure that patient is well-rested and not anxious -> white coat hypertension
- Use appropriate cuff = bladder within cuff should encircle at least 80% of arm
- Place sphygmomanometer at heart leavel
- Measure BP in both arms at first visit -> Coarcation of aorta
Aortic dissection
Patent ductus arteriosus
Thoracic outlet syndrome
- Take 2 or more readings separated by 2 mins and obtain average measurement (obtain more
readings if differ by >5mmHg)
Take BP in both standing and supine positions for elderly and DM
- Increase DBP on standing = Primary HTN
- Decrease DBP on standing = secondary HTN
Postural hypotension 2ndary to anti-hypertensive medications
General inspection
Sallow appearance, AV fitula/tenchkoff catheter, bruises and scratch marks = ESRF
Round-like facies, central obesity, violaceous abdominal striae = cushings syndrome
Prognathism, frontal bossing, large hands and feet = acromegaly
Caf au lait spots = NF-1 (renal artery stenossis, pheochromocytoma, coarctation of aorta)
Peripheries
Pulse
Radio-radio delay and radio-femoral delay = coarctation of aorta
CVS examination
Raised JVP
Displaced apex beat LV hypertrophy
Mitral regurgitation
S4 heart sound
Bibasal inspiratory crepitations
Peripheral oedema
Carotid bruit
Abdomen
Bilateral ballotable kidneys = APKD
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Lower limb
Neurological examination = deep tendon reflexes, focal neurological deficits
Evidence of peripheral vascular disease = trophic skin changes, temperature gradient, capillary refill time,
pulses
Fundoscopy
Grade 1 = silver wiring of arteries (sclerosed vessel wall reduces transparency -> central light streak appears
broader)
Grade 2 = arteriovenous nipping
Grade 3 = flame-shaped haemorrhages
Soft exudates (cotton wool spots due to ischaemia)
Hard exudates (lipid residues from leaky vessels)
Grade 4 = papilloedema
Hypertensive crisis
History
Physical examination
Mental state
Takes BP on both arms
CVS = heart failure, AR
CNS = focal neurological deficits, confusion, coma, seizures
Eyes = fundoscopy
Investigations
Bloods
FBC
U/E/Cr
Cardiac enzymes
Urine
Urine dipstick
Imaging
ECG
CXR
CT head = hypertensive encephalopathy, stroke, SAH
2D-scho/CT thorax = ? New onset AR (aortic dissection)
Causes
Poor control of pre-existing hypertension = not detected
Inadequate treatment
Non-compliance with medications
Secondary causes of hypertension
Management
Stabilize patients vitals
o Secure airway if patient unconscious
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o Ensure patient is breathing spontaneously -> give supplymental O2, monitor pulse oximetry
o Obtain patients vitals (HR, RR, BP, SpO2)
o Obtain Ecg and place on continuous ECG monitoring
o Set IV canula -> take blood for investigation
2 most urgent indications for immediate BP reduction = Hypertensive encephalopathy
Aortic dissection
Hypertensive emergency
Target
Lower MAP by 20-25% or DBP to no less than 100-110 mmHg within a few hours
Aim for 160/100 mmHg over the next 2-6 hrs
Sodium
nitroprusside
Labetalol
Esmolol
Indications
o Use with nitroprusside for thoracic aortic dissection
o Used with phentolamine (alpha blocker) for pheochromocytoma
crisis
Nitroglycerine
Disposition
Admid ICU/CCU
Hypertensive urgency
Target
Lower DBP to 100mmHg over 24-48hrs
Oral Felodipine
PO Captopril
Disposition
If BP improves in monitored area -> discharge with review in next 1-2 days
If BP does not improve -> admit
Malignant/accelerated hypertension -> admit
272
Angiotensinogen
Renin
Angiotensin I
Angiotensin II
Aldosterone
Vasoconstriction
b) Prototypes
i) Enalopril
- Pro-drug that is converted by de-esterification to
elanoprilat (only IV use)
ii) Captopril
- Competitive ACE inhibitor
- Short T1/2 : TDS dosage
c) Side effects
i) Dry cough
ii) First dose hypotension
iii) Hyperkalemia & metabolic acidosis
iv) Macular rash
v) Neutropenia
vi) Fetotoxicity
vii) Nephropathy
- Reduces glomerular filtration pressure
- Precipitates ARF in patients with impaired renal function
or RAS
- Contraindicated if Cr > 300mmol/L
- Check u/e/cr before and 1-2 weeks after starting Rx
d) Advantages
i) Very effective especially when given with diuretics
ii) Renoprotective = prevents/reduces proteinuria
Stabilies renal function
iii) Extremely useful in Tx of heart failure
iv) Greater fall in Bp in high rennin states
4) Angiotensin 2 Receptor blockers
a) Mechanism of action = competitive inhibition of angiotensin 2
receptors G protein linked
i) Lorsartan
ii) Irbesartan
b) Side effects
i) Hyperkalemia and metabolic acidosis
ii) Nephropathy
iii) Fetoxicity
c) Advantages
i) No dry cough of ACE inhibitors
ii) Renoprotective
iii) More selective than ACE inhibitors for angiotensin effects
iv) More complete inhibition of angiotensin effects of ACE
inhibitors
5) B Blockers
a) Mechanism of action = blocks B-adrenergic actions
i) Negative inotropic and chronotropic effects
- Decrease Hr (decrease Av and SA conduction velocity)
- Decrease contractility decrease cardiac output
- Vasodilatation
- Increase diastolic time increase coronary perfusion
ii) Inhibits B mediated rennin release
b) Contraindications
i) Asthma/COPD
ii) Severe bradycardia
iii) Complete heart block
iv) Peripheral vascular disease
v) Diabetes
c) Drug-drug interactions
i) Avoid verapamil and diltiazam = excessive negative inotropic
effect
ii) Effects decreased in presence of NSAIDS = reduced
production of prostaglandins (vasodilators)
iii) Metabolized by liver = increased concentrations if given with
cimetidine
d) Side effects
i) CVS = bradycardia, hypotension, syncope
ii) CNS = giddiness, irritable, hearing and visual disturbances,
confusion - usually with chronic treatment
iii) GIT = nausea, vomiting, abdominal pain, constipation,
diarrhea
iv) DM = hypoglycemia, mask positive signs of hypoglycaemia
v) Asthma = bronchoconstriction
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- Metabolic alkalosis
- Auditory and vestibular toxicity
- Venodilatation and hypovolaemia
- Hyperglycemia
- Hyperuricaemia
- Hyperlipidemia
vi) Indications
- CCF
- Oedema
- Acute hyperkalemia and hypercalcemia
d) Thiazides
i) Example = hydrochlorothiazide
ii) Distal tubule = active NaCl reabsorption/impermeable to
water
iii) Mechanism of action = inhibits NaCl cotransporter
Reduces peripheral resistance with
chronic use
iv) Side effects = hypo Na, hypo K, hypo Cl, hypo Mg
Reduced urinary Ca2+
Metabolic alkalosis
Photodermatitis
Venodilatation and hypovolemia
Hyperglycemia, hyperuricaemia,
hyperlipidaemia
e) Aldosterone antagonists (K+ sparing)
i) Examples
- Spironolactone
- Amilonide
Mechanism of action = decreases synthesis of aldosterone
sensitive proteins involved in Na+/K+ ATPase & apical Na+
channels
276
Recommended drugs
Diuretics
ACE inhibitors
Angiotensin II receptor blockers
Beta blockers
Calcium channel blockers
Beta-blockers
ACE inhibitors
Angiotensin II receptor blockers
Diuretic
Calcium channel blockers
ACE inhibitors
Angiotensin II receptor blockers
ACE inhibitors
Angiotensin II receptor Blockers
ACE inhibitors
Angiotensin II receptor blockers
Calcium channel blockers
Diuretics
ACE inhibitors
Contraindicated drugs
Calcium channel blockers
Beta Blockers
Diuretics
Beta Blockers
Beta blockers
Calcium channel blockers
Diuretics
ACE inhibitors
Angiotensin II receptor blockers
B Blockers
ACE inhibitors
Angiotensin II receptor blockers
Increased LDL
Increased Cholesterol
Increased VLDL
Increased TG
Chylomicrons
Increased TG
Increased TG
Decreased HDL- C
Increased TG
Increased Total Cholesterol
Increased Total Cholesterol
Increased TG
Increased TG
Increased Total cholesterol
Increased TG
May increased Total Cholesterol
Decreased HDL - C
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5. Lipid Measurements
- TC and HDL C can be measured at any time of the day
- TG must be obtained after 10-12hrs of fasting
- Direct measurements = TC, HDL C, TG
- Indirect measurements = LDL C
Friedwald Formula
LDL C = TC [HDL C + (TG/2.2)]
*formula cannot be used if TG > 4.5 mmol/L
6. Risk stratification
- Catagories
Low-risk = 10 year CHD risk < 10%
Moderate risk = 10 year CHD risk 10-20%
High risk = 10 year CHD risk > 20%
Algorithm
Step 1 = identify individuals in high risk category
Established CHD
CHD-like equivalents
(a) DM
(b) CVS
(c) PVD
(d) AAA
Statin, ezetimibe
Statin + fibrate/nicotinic acid
Fibrate =/nicotinic acid
Fibrate/nicotinic acid + omega 3 fish oils
Fibrate/nicotinic acid
279
Side effects
-
Ezetimibe
-
Mechanism of action = selectively inhibits intestinal absorption of cholesterol and related plant steroids
E.g. cholestyramine
Mechanism of action = binds bile acids and increases excretion
Increases cholesterol conversion to bild acids
Offset by increased intrahepatic cholesterol synthesis & up-regulation of LDL
receptors
# effect enhanced if given with statins
Effective in lowering LDL C & TC by 15-20%
#If combined with statins = 50%
Only drugs that eliminate cholesterol from the body
Infrequently used due to side-effects
GIT = nausea, vomiting, constipation, steatorrhoea , sand like taste
Fibrates
-
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Transaminitis
Myopathy
Gasllstone disease
Usually started when TG > 4.5 mmol/L
Gemfibrozil should never be combined with a statin***
Principles of combination therapy
Start the 2nd drug at a lower dosage & increase gradually until goal level achieved
Nicotinic acid/Niacin
-
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Outcomes/complications
Outcomes = usually recover without sequelae
Some may develop intractable chronic CCF
Complications = arrhythmias, dilated CMP, sudden death
283
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Anticoagulation
Implantable cardio-defebrillator, biventricular cardiac resynchronizing therapy
Septal myomectomy
Restrictive cardiomyopathy
Epidemiology = least common
Pathology
- Primary decrease in ventricular compliance -> impaired diastolic filling
Aetiology
a) Idiopathic
b) Infiltrative = amyloidosis, sarcoidosis, scleroderma
c) Radiation-induced fibrosis
d) Endomyocardial fibroelastosis
e) Endomyocardial fibrosis
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Complications
Course
Asian females
40-45 years old
Early = non specific (fatigue, weight loss, fever)
Vascular symptoms = markedly lower BP and weaker pulses in upper extremities
compared to lower extremities with coldness or numbness of
fingers
Ocular disturbances = visual defects, retinal hemorrhages, total blindness
Neurological deficits
Involvement of root of aorta -> aortic regurgitation
Narrowing of coronary ostia -> AMI
Involvement of distal aorta -> intermittent claudication
Involvement of pulmonary arteries -> pulmonary hypertension
Renal artery narrowing -> RAS
Variable = may be slow or rapidly progressing
Management
Symptomatic treatment
Treat complications
Large vessels
Takayasus arteritis
Giant cell arteritis
Medium vessels
Polyarteritis nodosa
Kawasakis disease
Small vessel
HenochSchnlein purpura
Wegeners granulomatosis
Infective endocarditis
Cryoglobulinaemia
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Ejection
systolic
- Crescendodecrescendo
Location of max
intensity
Apex (heard with
bell)
Diagnosis
Signs
Mitral
stenosis
Aortic area
Radiation to carotids
Aortic
stenosis
(ddx: HOCM)
Aortic area
No radiation to
carotids
Pulmonary area
Aortic
sclerosis
Innocent
Pulmonary
stenosis
ASD
Innocent
Innocent
Aortic
General:
Mitral facies (malar flush purple cheeks)
Bruising (from warfarin anticoagulation)
Pulse:
Small volume, slow-rising (anacrotic)
Atrial fibrillation
Auscultation:
MDM accentuated when patient turned to left lateral position/ exercise (flow)
Loud S1 (occurs when leaflets are mobile, slammed shut during ventricular
systole)
Opening snap (opening of stenosed mitral valve, indicates pliable leaflets)
Loud P2 (if pulmonary HPT present)
Graham-Steell murmur (EDM; MS pulmonary HPT PR)
Functional TR
Lungs bibasal crepitations (pulmonary congestion)
BP narrowed pulse pressure
Signs of RV failure raised JVP, hepatomegaly, ascites, peripheral edema
Pulse:
Small volume, slow-rising (anacrotic)
Apex beat:
heaving, not displaced
Palpable thrill over aortic area
Auscultation:
ESM accentuated with patient sitting up in full experiation
Usu a/w loud S2
Lungs bibasal crepitations
BP narrowed pulse pressure
Pulse normal
Auscultation: normal S2
Apex
Auscultation:
ESM accentuated with patient sitting up in full inspiration (pulmonary stenosis)
Fixed wide splitting of S2 (ASD)
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Pansystolic
Apex
LLSE
sclerosis
Mitral
regurgitation
Tricuspid
regurgitation
VSD
Early diastolic
Usually middle/
upper LSE
Aortic
regurgitation
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Management :
o Asymptomatic:
Anticoagulants (warfarin)
Antibiotic prophylaxis against IE before surgery and invasive procedures (amoxicillin)
o AF:
Rate control (digoxin, beta-blockers, CCB)
Warfarin
o Mild
Diuretics (reduce LA pressure)
o Moderate- severe pulmonary HPT
Percutaneous mitral balloon valvuloplasty
Mitral valvotomy (open/closed)
Valve replacement
History:
o Asymptomatic
o Dyspnoea (pulmonary venous congestion)
o Palpitations (AF, increased stroke volume)
o Fatigue (reduced cardiac output)
o Edema, ascities (right heart failure)
o History of AMI
Investigations:
a) ECG LVH, atrial fibrillation
b) CXR cardiomegaly, pulmonary congestion, pulmonary edema
c) 2D-echocardiography severity & etiology
d) Cardiac catheterization dilated LV/ LA, mitral regurgitation, pulmonary HPT, coexisting coronary
heart disease
Complications:
o Left ventricular hypertrophy LA dilation Atrial fibrillation
* MR can cause CCF
o Left heart failure pulmonary edema pulmonary hypertension
CCF can cause MR
o Infective endocarditis
Management:
o Asymptomatic = antibiotics prophylaxis before surgeries (amoxicillin). Follow up 6 monthly with
2DE
o AF = rate control, anticoagulant
o Heart failure = diuretics, inotropes
o Surgery: if moderate symptoms persist despite medical therapy and ejection fraction (EF) is adequate
Valve repair or replacement if LV EF <55% or LV end systolic diameter more than 45mm
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Aortic stenosis
Aetiology:
o Rheumatic heart disease
o Infective endocarditis
Features indicating severity:
o Degenerative calcification
Small volume an slow rising pulse
o Calcification of congential bicuspid valve
(narrowed pulse pressure)
History:
Heaving apex beat, systolic thrill
o Asymptomatic
Soft S2 with narrow/ reverse split
Long ESM
o Syncope during or immediately after exercise
S4, left heart failure
o Fatigue (due to reduced cardiac output)
Narrow pulse pressure
o Dyspnoea = exertional, orthopnoea, PND
o Extertional angina
o CVA
Differential: HOCM
Investivgations:
a) ECG LVH
b) CXR cardiomegaly
Post-stenotic dilatation of the ascending aorta
Calfcification of the aortic valve
c) 2D-echocardiograpy severity, etiology
a. Grading = mild (valve area >1.5cm2)
Moderate (1.0 cm2 < valve area < 1.5cm2)
Severe (valve area <1.0cm2)
d) Cardiac catheterization raised right heart pressures
Complications:
a) Left ventricular hypertrophy and failure pulmonary edema
b) Infective endocarditis
c) Syncope (due to electro-mechanical dissociation/ cardiac arrhythmia/ marked peripheral vaso dilation
w/o concmitnat increase in CO)
d) Angina
e) CVA (due to embolisation from disintergrated vavle apparatus)
f) Sudden death (due to conduction abnormality: ventricular arrhythmia, heart block)
g) Microangiopathic haemolytic anemia
h) Associated with angiodysplasia of the colon PR bleeding
Management:
a) Asymptomatic = antibiotic prophylaxis (amoxicillin)
b) Symptomatic = balloon valvuloplasty or
valve replacement (indicated if valvular gradient > 50mmHg or valve area less than
0.8cm2)
# Gallavardin phenomenon = high-frequency components of ESM radiating to apex
Aortic regurgitation
Aetiology:
o Intrinsic valvular disease=
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Tricuspid regurgitation
Aetiology:
o Primary:
Rheumatic heart disease
Infective endocarditis: assoc with IV drug abusers; check for needle marks & damaged veins
Congenital Ebstein anomaly
Carcinoid heart disease
o Secondary:
Cardiomegaly (producing functional TR)
Cor pulmonale due mitral valve diseases or lung pathology (COPD, bronchiectasis,
fibrosis)
Cardiomyopathy associated with MR
AMI with papillary muscle infarct; IHD
Usually a/w mild mitral stenosis
History:
o IV drug abuser
o Right heart failure = peripheral edema (LL swelling, abdominal distention)
o h/o COPD
Complications:
a) Right heart hypertrophy & failure peripheral edema + raised JVP pulsatile liver
b) Infective endocartitis
Management
a) If cause is due to RV dilation correct cause of RV overload (e.g. diuretics + vasodilators in CCF)
b) Surgery: valve repir/ valve replacement
Mixed mitral valve lesion (MR, MS)
Aetiology:
o Rheumatic heart disease (common)
o Calcific degeneration
o If a scar is present, it may be a dysfunctional mitral valve repair or replacement
Clinical features:
PSM + MDM at apex. Possiblities are:
292
o MR + MS
o Severe Mr with functional MS. No opening snap is heard in this case
If there is concurrent MR and MS, determine which is predominant by the clinical signs:
Clinical signs
Apex
S1
S3
MR predominant
Deviated, thrusting
Soft
Present
MS predominant
Not deviated, tapping
Loud
Absent
Clinical signs
Pulse
Apex beat
Pulse pressure
AS predominant
Small volume
Not deviated, heaving
Decreased
AR predominant
Large volume (bounding)
Deviated, thrusting
Increased (wide)
Rheumatic fever
1. Jones criteria for the diagnosis of rheumatic fever
2 major criteria:
Carditis
Arthritis (migratory polyarthritis)
Subcutaneous nodules
Erythema marginatum
Syndnhams chorea
OR
2. Pathophysiology
Due to pharyngeal infection with Group A beta-haemolytic streptococci (S. pyogenes) which triggers
rheumatic fever 2-4 weeks later
Results in molecular mimicry: Ab to carbohydrate cell wall of streptococcus cross reacts with heart valve
tissues
Also causes acute glomerulonephritis (1-2 weeks later)
3. Epidemiology
Peak incidence = 5 15 years old
2% of the population
4. Valves affected: (60% with carditis develop chronic RHD)
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Mitral 70%
Aortic 40%
Tricuspid 10%
Pulmonary 2%
5. Investigations
Evidence of systemic illness (non-specific)
o FBC for leukocytosis, raised ESR and CRP
Evidence of preceding streptococcal infection (specific)
o Throat swab culture: group A beta haemolytic streptococci
o ASOT: rising titres or levels of >200 U (adults) or >300U (children)
Evidence of carditis
o CXR: cardiomegaly; pulmonary congestion
o ECG: first- and rarely second-degree AV block; features of pericarditis; T-wave inversion; reduction
in QRS voltage
o Echocardiography: cardiac dilation and valve abnormalities
6. Management
Single does benzyl penicillin 1.2million U i.m. OR oral phenoxymethylpenicillin 250mg 6 hourly for 10 days
o If penicillin allergic give erythromycin or cephalosporin
Carditis: symptomatic treatment for CCF + aspirin
Arthritis:
o Analgesia (aspirin/ NSAIDs)
o Immobilization in severe cases
Chorea: haloperidol/ diazepam
Secondary antibiotic prophylaxis for dental or other surgery
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No need for chronic anticoagulation unless AF (anti-coagulation usually only for 3 months
post replacement)
safe in elderly and women of childbearing age
o Disadvantages:
Less durable (requires replacement within 7-10 years)
Higher rate of re-operation cf prosthetic prostheses
Calcification
o Suitable patients:
Unable to anti-coagulate
Not expected to live more than 7-10 years
Elderly patients (slower rate of degeneration)
Homografts
o Cadaveric aortic or pulmonary valve
o First choice treatment in a young patient requiring aortic valve replacement
o Advantage = more resistant to re-infection therefore useful in replacing infected valves
Complications
1. Thromboemoblism (esp with mechanical valves req anticoagulation; INR usu kept at 2.5-3.5)
2. Valvular dysfunction (esp with bioprosthetic valves)
a. Leaking
b. Dehiscence
c. Fracture
d. Stiffening/ calcification stenosis
e. Perforation regurgitation
3. Haemolysis (esp with mechanical valves)
a. Haemolytic jaundice
b. Anemia
4. Infective endocarditis (involves suture line and adjacent perivalvular tissue)
a. Systemic emboli
b. Valvular destruction/ regurgitation/ obstruction
5. Complications of anti-coagulation
a. BGIT anemia
b. Intra-cranial bleed stroke
Causes of anemia
1. Bleeding from anticoagulation
2. Haemolysis with the mechanical valves
3. Bacterial endocarditis
Physical examination
I say this is a prosthetic heart valve because of
(a) Audible metallic click
(b) Midline sternotomy scar
(c) Metallic S1/S2 on auscultation
MS
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CCF
Extension of infection into adjacent myocardium ring abscess conduction disturbances
Embolism brain, kidneys, lungs, spleen, bowel
Entrapment of infected emboli in walls of blood vessels mycotic aneurysms
Metastatic seeding of distal organs cerebral abscess
Glomerulonephritis (deposition of immune complexes and subsequent complement activation)
Clinical features
History
Non-specific symptoms = fever a/w chills & rigors, malaise, symptoms of anemia, LOW, LOW
Heart failure = dyspnoea, LL swelling, abdominal distension
Symptoms suggesting embolism= to large vessels (e.g. brain, lungs) or small vessels (e.g. kidney with
haemturia or loin pain)
Risk factors = IVDA, childhood RHD, cardiac abnormalities (ostium primum ASD, VSD, TOF), prosthetic
valve replacement
Precipitating factors = recent dental/surgical procedures (time between procedure and diagnosis may be
up to 3 months)
? history of other major disease, esp those assoc with immune suppression (e.g. renal transplantation or
steroid use)
Drug history= ?antibiotic allergies, use of antibiotics for prophylaxis
How diagnosis was made (if known case) including number of blood cultures, use of transthracic or
transoesophageal echocardiography (TOE)
Management since admission to hospital, including the names of antibiotics used, the duration of treatment
and whether possibility of valve replacement has been discussed
Physical examination
1. Examine peripheral stigmata of endocarditis
Hands:
o Clubbing (late sign)
o Splinter haemorrhages in nail beds
o Oslers nodes on the finger pulp (always painful and palpable; prob an embolic phenomenon and
are rare)
o Janeway lesions (non-tender erythematous maculopapular lesions containing bacteria on the palms
or pulps; rare)
Eyes:
o Roth spots in the fundus (retinal infarcts)
o Conjunctival petechiae
Abdomen:
o Splenomegaly (late sign)
Urine analysis: for haematuria and proteinuria
Neurological signs of embolic disease
2. Examine heart to assess for predisposing cardiac lesions
Acquired :
o Prosthetic valve (mechanical)
o MR, MS
o AS, AR
o Prosthetic valve (tissue
o Repaired mitral valve
o Mitral valve prolapsed with MR
Congential
o Bicuspid aortic valve
o PDA
o VSD
o Coarctation of the aorta
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3. Examine for sings of cardiac failure. Look for signs of a prosthetic valve and for scars that may present from
previous valvotomy or repair operations
4. Look for source of infection and take patients temperature
# ostium secunndum ASD almost always never have IE
Investigations
1. 3-6 blood cultures over 24 hours at least 1 hour apart(98% of culture positive cases will give positive
results in the first 3 bottles)
2. FBC, ESR, CRP= NCNC anemia, neutrophilia, raised ESR, raised CRP.
a. ESR may remain elevated for months even after treatment has been successful but CRP levels falls
quite quickly useful in assessing the effectiveness of treatment
3. Urine dipstick= microscopic haematuria
4. ECG= atrial fibrillation in the elderly; conduction defects may occur but are not specific
5. Chest xray= cardiomegaly, pulmonary edema
6. Echocardiography= vegetations (negative study does not rule out IE as vegetations must be larger than
2mm to be detected)
Diagnostic criteria
Pathological criteria
1. Positive microbial culture = vegetation, embolus, intra-cardiac abscess
2. Histological confirmation = vegetation, intra-cardiac abscess
Diagnosis usually a clinical one. The Dukes criteria is often used
Dukes criteria (Clinical criteria)
1. Major
Typical organisms in 2 separate blood cultures
Evidence of endocardial involvement: 2D-echo showing mobile intra-cardiac mass on a valve or in path
of a regurgitant jet or an abscess or new valvular regurgitation
2. Minor
Predisposing cardiac condition or IVDA
Fever >380C
Vascular phenomena or stigmata= major arterial emboli, septic pulmonary infarcts, mycotic aneurysm,
intracranial hemorrhage, conjuncitval haemorrhages and Janeway lesions
Immunological phenomena: glomerulonephritis, Osler nodes, Roth spots and rheumatoid factor
Serological or acute phase abnormalities
2D echo results abnormal but not meeting major criteria
Diagnosis: 2 major OR
1 major + 3minor
OR
5 minor
Management
IV antibiotics: benzylpenicillin (for S. viridians) and gentamicin (for enterococcus) + cloxacillin (for S.
aureus)
Follow progress by looking at temperature chart, serological results and haemoglobin values
Indications for surgery:
o Resistant organisms (e.g. fungi)
o Valvular dysfunction causing moderate-to-severe cardiac failure
o Persistent positive blood cultures despite treatment
o Invasive paravalvular infection causing conduction disturbances or
o Paravalvular abscess or fistula
o Recurrent major embolic phenomena
Prognosis
30% mortality with staphylococci
14% mortalitiy with enteric gram ve rods
>70% with endogenous infection survive
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Libman-Sacks endocarditis
Sterile vegetations in patients with SLE or anti-phospholipid syndrome
Not along lines of valve clousure
Uncommon due to steroid therapy for SLE
Usually a post-mortem finding
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6. Radioisotope scan
Only done in hyperthyroid patients
Procedure:
Radioactive iodine (131I) injected intravenously
Thyroid gland scanned with a detector to map out areas of
high or low uptake
hot nodule
hyper-functioning area; almost never malignant (<5%)
cold nodule
neutral
diffuse uptake
Graves disease
multiple hot
nodules
MNG
increased uptake by
adenoma with
decreased uptake by
remaining tissues
toxic adenoma
300
CT
MRI
PET
Interpretation of tests
TSH + T4
(inappropriately high
T4)
Isolated TSH
suppression
Isolated TSH
elevation
a)
b)
c)
d)
a)
b)
c)
TSH-secreting tumour
thyroid hormone resistance
TSH + T4
primary hypothyroidism
TSH + normal T4
subclinical hypothyroidism
TSH + T3/T4
TSH + normal T4
primary hyperthyroidism
subclinical hyperthyroidism
T3 thyrotoxicosis
pituitary disease (pituitary tumours, postpituitary surgery, post-NPC radiation)
sick euthyroidism (in systemic illness;
typically for everything to be low)
TSH + T3/T4
normal TSH +
abnormal T4
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302
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Movement
Gait
Arms
Legs
Spine
History
1. Pain / Stiffness in muscle / joints / back
Cardinal symptoms of rheumatic disease
2. Ability to wash and dress completely without difficulty
ADL: Assessing functional problem of UL
3. Ability to get up and down stairs easily and ability to squat
ADL: Assessing functional problem of LL
Physical Examination
Gait
1. Ask patient to stand
Ease of transfer from chair / lying position to standing position
2. Get patient to walk and turn around
Smoothness and symmetry of leg
Pelvis and arm movement
Normal stride length
Ability to turn quickly
Without pain
Spine
1. Inspection (from back and from sides)
Start from back
Abnormal scoliosis curvature of spine
Symmetry of paraspinal muscles and girdle muscles
Symmetrical pelvic position, level iliac crests
Inspect from sides
Normal curvature in the neck and thoracic spine
Normal lumbar lordosis
Symmetry of paraspinal muscles
From front
Lateral cervical flexion ('Place your ear on your shoulder)
Hyperalgesic response of fibronyalgia (Squeeze over midpoint of supraspinatus
muscle) If tender proceed to other sites, e.g. below medial epicondyle
2. Movement
Put finger at spine along 2 lumbar vertebrae and ask patient to 'Bend forward and touch
toes'
Finger to floor distance less than 15cm, lumbar expansion >6cm
Arms
1. Inspection
Arm:
From front: Normal girdle muscle bulk and symmetry
From back: Normal acromioclavicular sternoclavicular and glenohumeral joints; Full
elbow extension
Examine dorsal surface. Squeeze at carpal region
304
No swelling, deformity
Turn over to palmar surface.
Supination movement (Arms and elbow)
Palmar surface.
Redness over palms in inflammatory arthritis, swelling, deformity
Squeeze acoss MCP joint
Early arthritis: pain and tenderness on squeezing before other abnormalities seen
2. Movement
Make a fist. Spread out.
Detection of power grip
Pinch in pincer manner
Impt for fine movements
Spread elbows straight out
Test shoulders. Put arms behind head and elbows back.
Putting elbows back test full degree of external rotation
Legs
1. Inspection
Leg
From front: No knee, forefooting or mid foot abnormalities
Knee: Bulk of quadriceps muscle, normal concavities on each side of the patella (
concavities lost with effusion at knee joints)
Feet
Pay special attention to soles of feet. Deformity change pressure points
thickening of skin
2. Movement
Bend leg up and twist
Internal rotation first to go in hip disease
Hand on knee joint feels for crepitus
Look at knees and feel across lateral border
Back of hand sensitive to temperature changes
Squeeze across MTP joints
Early arthritis: pain and tenderness on squeezing before other abnormalities seen
History
History of Presenting Complaint
Pain
Aspect
Distribution and Joint
Involvement
N.B. arthralgia = presence of
joint pain wout swelling;
arthritis = pain + swelling
Acute / chronic
Getting better / worse
Differential
Acute monoarthritis
Septic arthritis, traumatic, gout/pseudogout, haemarthrosis
Chronic monoarthritis
Chronic infection e.g. TB, sero-ve spondyloarthritis,
pigmented villonodular synovitis
Acute polyarthritis
Infection, onset of chronic polyarthritis
Chronic polyarthritis
RA, sero-ve spondyloarthritis, OA, gout, pseudogout, CTD e.g.
SLE, infection
RA symptoms worse aft rest
OA symptoms worse aft exercise
RA/OA symmetrical
Sero-ve spondyloarthritis asymmetrical
305
Type
Mechanical
Subset
Characteristics
Well localised
Aggravated by mvt, coughing, straining
Pain in dermatomal distribution
Progressive and unremitting pain
306
Subtalar joint
Inversion and eversion
Squeeze MTPJ
Tenderness inflammation e.g.
RA
Press upwards from sole of foot just
proximal to the MTPJ of 3rd and 4th
toes
Pain Mortons metatarsalgia
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CUTANEOUS MANIFESTATIONS
Heliotrope rash
Periungual telangiectasia
Gottrons papules
310
INVESTIGATIONS
Confirm diagnosis
o Serum CK elevated. Levels mirrors disease activity
Also in DMD, drugs (statins, chloroquine,
colchicines, px on chronic haemodialysis)
o EMG myopathic changes (spontaneous fibrillation, salvos of
repetitive potentials, short duration of polyphasic potentials of
low amplitude)
o Muscle biopsy necross and phagocytoss of muscle fibres,
interstitial and perivascular infiltration of inflammatory cells.
o Myositis specific auto-antibodies - the aminoacyltransfer RNA
(tRNA) synthetases (anti-Jo-1), the nuclear Mi-2 protein, and
components of the signal recognition particle (SRP).
o CXR
o Serum aldolase, LDH, ALT, AST, FBC, ANA/ENA, U/E/Cr
o Urinalysis, urine myoglobin
TREATMENT
Steroids most patients respond
o Prednisolone is first line drug
Overlap syndrome
Dermatomyositis overlaps with systemic sclerosis and mixed connective
tissue dz
o Signs
Sclerotic thickening of dermis
Contractures
Oesophageal hypomotility
Microangiopathy
311
Calcium deposits
Prognosis
Dermato/polymyositis a/w malignancy
o risk of malignancy if age > 50, DMY> PMY, normal CK,
refractory disease
o 2.4-6.5 fold risk of underlying malignancy usu in internal
organs
DIFFERENTIAL DIAGNOSES of Dermatomyositis
312
name/age/ethnicity/gender/occupation
date of admission
Presenting complaint
Symptoms
Priscilla says stupid individuals dont do NS
5. Deformity
- kyphosis
1. Pain
- mode of onset
- frequency
- duration
- acute/sudden onset
- constant/intermittent
- progressively worsening/improving
- site and radiation
- character
- pain score and severity
- triggers = movement (OA), rest (inflammatory arthritis)
- aggravating factors = movement (OA)
- relieving = analgesia, rest (OA), movement (inflammatory arthritis)
2. Swelling
- acute/gradual onset
- history of trauma
- frequency
- duration
- site
- associated with pain, redness and increased warmth
- progressively worsening/improving
3. Stiffness
- duration of early morning stiffness = > 1hr (inflammatory arthritis), < 30
mins (OA)
- site
6. Disability
- functional status = ability to dress, write, bath, transfer, feed
- require walking aids/splints
- ability to stand, walk , run and climb stairs
- impact on social and recreational activities
- mobility within home
- mobility outside home
7. Neurological symptoms
- numbness
- parasthesiae
- weakness
Aetiology
Vascular = bleeding disorder, easy bruisability
Infective = fever, chills, rigors
dysuria, urethral discharge, red eyes, recent URTI/GE (reactive
arthritis)
prolonged cough, haemoptysis, night sweats, LOA, LOW, malaise
Trauma = history of trauma
Autoimmune = other joint involvement (see systemic review)
Metabolic = h/o gouty attacks (gout)
Neoplasia = LOA, LOW, malaise, changes in urinary/bowel habit
Complications (depends on underlying aetiology)
Systemic review
constitutional = LOA, LOW, fever, fatigue
313
smoker
alcoholic drinker
occupation
family set-up and main caregiver
financial status
type of housing and lift-landing
Family history
SLE, RA, gout, TB
DM, HPT, HCL, IHD/AMI, CVA, cancer
314
Sitting
Exposed elbows
The hand is a complex instrument with intricate function. There are 14 joints in the hand excluding the carpus.
The carpus itself is a complex articulation which comprises eight bones linked by ligaments which provide
three degrees of motion. The approach to examination of the hand is thus different and must be preceded by a
hand screen. The hand screen is still based on the basic principles of an orthopaedic examination, namely look,
feel and move.
Look
Skin
Swellings
Scars
Deformities
Alignment
Effusion
- rheumatoid hand
Atrophy
Discontinuity
Nerves
Attitude
Vessels
Venous
Arterial
Lymphatic
Feel
Skin
Temperature
- red, dry skin
Characterise swellings
Bony outline
Tenderness
Effusion
Muscles & Tendons
Subluxation
Tenderness
Thickening
- ulnar at elbow
Nerve
315
Gross sensation
Vessel
Pulse
Pitting edema
- capillary refill
Move
PROM & AROM
Flexion/ extension
Abduction/ adduction
Rotation
Special tests
Stability
Anterior/ posterior
Lateral
Impingement
- Finkelsteins
Fixed deformity
Neurovascular assessment
Pulses
Peripheral nerve
Functional assessment
prehension
316
Hand Screen
1. Palms up
4
1
3
Zones
1. thenar- wasting, crease
scar
2. fingers- attitude
3. hypothenar- wasting
4. wrist- scars
2. Finger flexion
Zones
1. joint ROM
2. trigger
317
3. Dorsum up
3
Zones
1. 1st web &
intermetacarpal
spaces- wasting
2. fingersarthropathy
3. wrist dorsumganglion
Zones
1. subcutaneous border
of ulna and elbowrheumatoid nodules
318
Nerve screen
Median nerve
Ulnar nerve
Radial nerve
319
Vessel screen
Pulses
Cap refill
320
321
322
Nerve examination
Once a neuropathy has been identified, one must determine the level and the severity. Nerves have
essentially two functions, sensory and motor. As such, deficits from both these areas must be actively
sought.
Median
Look
1. wasting of the thenar eminence
Feel
2. light touch (median three and half fingers vs thenar eminence)
Move
3. Test for the FPL and FDP to index with Osign
4. Test the power of the APB
Provocative tests
5. Tinels test
6. Phalens test
Ulnar
Look
1. ulnar claw
2. wasting of hypothenar eminence
Feel
3. light touch (ulnar one and a half vs dorsal ulnar aspect of hand)
Move
4. FDP to little finger
5. Abductor digiti minimi
6. Finger crossing (palmar interossei)
7. Froments test
Provocative tests
8. Tinels at the elbow
9. elbow flexion test
Radial
Look
1. wrist and finger drop
2. wasting of triceps and forearm extensor compartment
Feel
3. light touch (1st dorsal web space)
Move
4. elbow extension
5. extension of the wrist
6. EPL
Provocative
7. Tinels at the spiral groove
323
Wrist
Permission (& presence of Pain)
Position
Exposure
Examination
Sitting
Elbows on the table, exposed
Look
Skin
Swellings
Scars
Deformities
Alignment
Effusion
Attitude
Venous
Arterial
Lymphatic
Feel
Skin
Temperature
- radiocarpal joint
Characterise swellings
Bony outline
Tenderness
Effusion
Subluxation
Tenderness
- FCR, FCU,
- 1st extensor compartment, ECU
Nerve
Thickening
Gross sensation
324
Vessel
Pulse
Pitting edema
Move
PROM & AROM
Flexion/ extension
Ulnar/ radial deviation
Supination/ pronation
Special tests
Stability
Impingement
- Finkelsteins
Fixed deformity
Neurovascular assessment
Pulses
Peripheral nerve
Motor
Sensory
Reflexes
Functional assessment
Grip strength
325
Wrist
Permission (& presence of Pain)
Position
Exposure
Examination
Sitting
wrist on the table with elbows exposed
Look
1. Look for discrete and diffuse swellings over the dorsal and volar surfaces.
2. Look scars over the dorsal and volar surfaces.
3. Look dinner fork deformity.
Feel
4. Feel temperature of radiocarpal joint.
5. Feel for tenderness over the anatomical snuffbox.
*change position to elbows on the table with wrists off the table in neutral.
6. Feel for tenderness over radiocarpal joint line
7. Feel for tenderness over FCR, FCU and 1st extensor compartment, ECU
Move
8. Assess for passive extension/flexion, ulnar/radial deviation and pronation/supination.
Special tests
9. Finkelsteins test
326
Wrist
Permission (& presence of pain)
sitting
Examination
1. swellingsdiscrete and
diffuse
2. scars
Look
3. dinner fork deformity
4. temperatureradiocarpal joint
Feel
5. Bony tenderness
anatomical snuffbox
327
Wrist
6. radiocarpal joint
tenderness
Feel
Move
Special test
7. tenderness- FCR,
FCU, ECU, 1st extensor
comprtment
8. ROM- extension/flexion,
ulnar/radial deviation,
pronation/supination
9. Finkelsteins test
328
Wrists
Look
Characteristic features in hands & wrists
Muscle wasting
Feel
Move
Examine
Knees for genu valgus
Elbow for rheumatoid nodules
C-spine (atlanto-axial subluxation, basilar invagination by dens protrusion, sub-cervical spine)
X-rays
Early stages
Soft-tissue swelling
Periarticular osteoporosis
Later
Last stage
Joint deformity & dislocation
Zig-zag deformity (ulnar deviation of fingers & radial deviation of wrist)
329
Management
1. Central synovitis
NSAIDs
Low-dose corticosteroids
2nd-line drugs
H&L injections synovectomy
Physiotherapy
3. Reconstruction
Arthrodesis
Arthroplasty
Osteotomy
2. Prevent deformity
Splintage
Tendon repairs/transfers
Joint stabilization
Physiotherapy
4. Rehabilitation
Physiotherapy
Occupational therapy
RA shoulder
Acromioclavicular joint, shoulder joint and various synovial pouches around the shoulder are
frequently involved in RA
Chronic synovitis rupture of rotator cuff muscles, progressive joint erosion
RA C-spine
Severely affected in 30% of patients with RA
Types of lesions
1. Atlanto-axial subluxation
Erosion of atlantoaxial joints & transverse ligament
2. Basilar invagination by dens protrustion
Erosion of atlanto-occipital articulations
3. Subcervical spine
4. Erosion of facet joints subluxation
Clinical features
Middle-aged/elderly female with RA
c/o neck pain & stiffness
decreased ROM
signs & symptoms of nerve root tension: UL numbness, parasthesiae & weakness
cervical myelopathy (cord compression)
cervical spondylosis
X-rays
1. AP
2. Lateral
3. Flexion & extension news reveal subluxation/cervical instability
Treatment
Serious complications are uncommon!
Cervical collar (pain relief)
Spinal fusion (persistant & severe pain; a/w neurological deficits)
RA Hip
Hip joint is frequently affected in RA
Hallmark: progressive bone destruction bilaterally
Osteophyte formation (unless 2 OA)
330
Clinical features
Rheumatoid disease affecting many joints
Insidious onset of pain in the groin
Limp
Difficulty getting out of chair
Marked muscle wasting of buttock & thigh
Limb is held in fixed flexion and external rotation
Movements are restricted & painful
Treatment
1. Conservative
If disease has not caused bone/articular erosion
General treatment to arrest progression of RA can slow down hip deterioration
Once bone/cartilage has been eroded, treatment can stop joint destruction
2. Surgical
Total hip replacement
Even in younger patients (polyarthritis has already limited activity that implants will not be
unduly stressed even after op)
X-ray
Early Stages
osteoporosis (loss of radiological density;
rarefaction)
Loss of joint space
Bilateral involvement
Later Stages
Erosion of femoral head & acetabulum
Gross bone destruction
Can resemble TB arthritis
331
Neurological exam
Complications
DKA
Fluid, electrolyte and acid-base disturbances
Congestive cardiac failure
332
From treatment
Cerebral edema
Aetiology = over-rapid correction of fluids
Use of hypotonic saline
Rapid correction of hyperglycemia
Clinical presentation = early irritable, stuporous, drop in GCS
Late raised ICP
Usually occurs 6-12 hours after DKA Rx
Mx = elevate head of bed
Intubate and hyperventilate
IV mannitol
Hypoglycemia
Hypokalemia (serum K<3 : arrhythmia, death)
Hypophosphatemia
Management
The principles of treatment can be divided into 5 main areas the diabetic pentathlon
1) Water and Na replacement
2) K+ replacement
3) Correction of acid-base imbalances
4) Insulin administration
5) Prevention of treatment complications
Supportive measures
1. Assess patient vitals and resuscitate when necessary
2. A = ensure airway patent
B = ensure spontaneous breathing
Oxygen supplementation
Monitor SpO2
C = obtain ECG and place on continuous monitoring
Create 2 large-bore IV cannula
Obtain bloods for investigation
Fluid resuscitation if in shock (ensure good cardiac function first)
NGT if N/V, unconscious
3. Monitor
(a) strict I/O charting = catheterise if necessary
(b) urine dipstick
(c) BSL
(d) Vital parameters
4. Investigations
(a) Confirm diagnosis = plasma glucose
Urinary and serum ketones
ABG (metabolic acidosis)
(b) Assess severity = U/E/Cr (dehydration, electrolye abnormalities, glucose, Ca/Mg/PO4)
(c) Underlying etiology = ECG, cardiac enzymes (AMI)
CXR (pneumonia)
FBC (leukocytosis, raised Hct)
Blood c/s if septic
UFEME and urine c/s (UTI)
333
Specific measures
1. IV volume replacement
1st hour = 0.9% N/S @ 5-20ml/kg/hr (change to colloids if still hypotensive)
Aim to correct estimated water loss (4-6L) within 24 hours
2nd-4th hrs = 0.45% N/S @ 10-20ml/kg/hr
Monitor urine output hourly
Check U/E/Cr every 2-4hrs till stable
Beware of over-rapid correction (esp in elderly, CCF) = serum osmolality not to >3
mOsm/kg/hr (may ppt cerebral edema)
2. Restoration of electrolye balances
K+ replacement (low intracellular stores as acidosis increases extracellular
concentrations)
o ensure urine output first
o serum K+ < 3.3 mmol/L = 20-40 mEq KCL/hr
o serum K+ 3.3-4.9 mmol/L = 10-20 mEq KCL/hr
o serum K+ > 5mmol/L = check serum K+ every 2 hours
3. restoration of acid-base balance
NaHCO3- only if arterial pH <7
4. Insulin administration
bolus dose of IV soluble insulin 0.15U/kg
continuous low-dose insulin infusion of 0.1 U/kg/hr
o adjust infusion rate to obtain drop in BSL of 3-4 mmol/L/hr
o monitor BSL hourly
BSL<14mmol/L
o Do not stop insulin infusion (goal is not to achieve euglycemia, but to clear
acidosis)
o Halve infusion dose to 0.05 U/kg/hr
o Add D5% in IV fluids maintain BSL @ 8-12 mmol/L
o Maintain insulin infusion till acidosis clears
Convert to subcut insulin when
o Prerequisites = ketones 1 +
Patient able to eat
o total sc insulin = 2/3 total IV dose
o stop IV insulin infusion 30min after SC insulin
5. treat possible complications
thromboembolism = subcut LMW heparin until mobile
6. treat precipitating factors
sepsis Abx
AMI MONA
DKA
> 14 mmol/L
<135 (pseudohypoNa+)
Normal/
Increased
Increased
300-320
< 7.3
<15
++++
4-6 L
Increased
HHNK
>33mmol/L
135-145
Normal
Very Increased
Very Increased
>330
> 7.3
>15
+ or ++
6-10L
Markedly Increased
334
8-12
1 U/hr
12-14
2U/hr
14-16
3U/hr
16-18
4U/hr
>18
5U/hr
12-16
6U
16-20
8U
>20
Call Dr
4-8
Off
8-12
4U
335
Complications
HHNK
Fluid and electrolyte disturbances
Congestive cardiac failure
Acute renal failure
Thromboembolism (secondary dehydration, occurs on D3) DVT, PE, AMI, CVA
From treatment
Cerebral oedema
336
337
338
339
340
341
Insulin glargine
- insulin analogue
- features = slow and prolonged absorption (soluble at pH 4 micro-precipitates at physiological pH releases
small amounts of insulin slowly)
peakless
duration of action 24 hrs
- better than ultra-lente = less variability in PK profile
Mixtard 30 (premixed insulin = 30% short-acting; 70% intermediate-acting)
- consists of Actrapid and Insulatard
- features = onset within 30 mins
duration of action 24 hrs
- disadvantage = pre-mixed formulation
side-effects = factitious hypoglycaemia
true hypoglycaemia
lipodystrophy (lipoatrophy anti-insulin abs attacking adipose tissue
lipohypertrophy insulin increases fat stores)
peripheral oedema
weight gain (anabolic hormone)
hypokalaemia can precipitate cardiac arrest in heart failure patients
allergy
fasting hyperglycaemia
(a) Somogyi effect = rebound morning hyperglycaemia following nocturnal hypoglycaemia
caused by release of counter-regulatory hormones
Tx reduce ON insulin dose
(b) Dawn phenomenon = early morning hyperglycaemia in the absence of nocturnal hypoglycaemia
Tx increase insulin without causing hypoglycaemia
Monitoring of blood glucose control
Targets of glucose control
tight glucose control reduces risk of microvascular disease (i.e. retinopathy, neuropathy, nephropathy)
- Diabetes Control & Complications Trial (DCCT) in type 1 DM
- UK Prospective Diabetes Study (UKPDS) in type 2 DM with either sulphonylureas or insulin
but increases risk of hypoglycaemia targets must be individualized
indications for suboptimal target levels
(a) older patients with significant atherosclerosis
(b) severe DM complications or co-morbidities
(c) pre-adolescent children = unpredictable food intake and activity level
poor compliance to treatment
Ideal
4.66.4%
Optimal
< 7.0%
Suboptimal
7.18.0%
> 8.0%
Unacceptable
Monitoring
indications = patients on insulin therapy (type 1 DM 3-4 times daily; type 2 DM 2-3 times/day on 2-3
days/week)
pregnant women with GDM or pre-gestational DM
patients who failed to achieve glycaemic control
markers
(a) blood glucose levels
(b) HbA1c= measure of glycaemic control over the previous 3 months
(c) fructosamine (glycated plasma protein) = reflect control over the previous 2-3 weeks
useful in pregnancy to assess short-term control and in
342
343
Diabetic foot
foot ulcers and amputations are major causes of disability & mortality in diabetic patients
5% of all diabetics develop foot ulcers eventually
approximately 700 lower extremity amputations performed in diabetic patients annually
2 types = ischaemic foot (painful, cool peripheries)
neuropathic foot (painless punched-out ulcer, normal skin temperature)
indications for amputation = dead, dangerous, damn nuisance
Risk factors for lower limb amputation
Ulceration or prior LEA
Peripheral vascular
Symptoms
disease
intermittent claudication
rest pain
6 Ps = pallor, pain, paralysis, parasthesiae, perishingly
cold, pulseless
Peripheral neuropathy
Signs
diabetic dermopathy
pale and cool peripheries
loss of hair, shiny/dry skin, muscle atrophy, trophic nail
changes
absent/reduced peripheral pulses
positive Buergers test
reduced ABPI
Symptoms
numbness and parasthesiae over palms and soles
burning sensation in soles
Signs
foot deformities = calluses
bunions
hallux valgus
pes cavus
pes planus
344
Poor footwear
hammer toes
clawed toes
charcots joint (rockerbottom feet)
loss of ankle jerks (1st thing to go)
negative monofilament sensation (glove and stocking
distribution)
negative pin prick sensation
negative turning fork sensation
loss of proprioception
open-toe shoes = slippers, flip-flops, thong
tight or ill fitting shoes
management
- optimize glycaemic control
- smoking cessation will worsen PVD
- footcare education
~ inspect feet daily for cuts and injuries especially in between toes
~ dry feet properly after bathing
~ apply moisturizer if skin is dry
~ cut toenails straight across
~ do not use corn plasters or cut calluses
~ f/u with a podiatrist regularly
~ proper footwear = do not go barefooted
wear wide-toed covered shoes
~ do not walk on reflexology footpaths barefooted
~ if a cut is found ( wash with saline and cover with light dressing
see doctor if it does not start to heal within 2 days
not at risk
at risk
DM footcare education
Annual screening (ankle jerk,
monofilament, vibration sense, ABPI)
DM footcare education
Annual screening (ankle jerk,
monofilament, vibration sense, ABPI)
orthoses / insoles for pressure
distribution
I&D/wound debridement/amputations
Diabetic retinopathy
leading cause of blindness in Singaporean adults
pathophysiology
cataracts
- increased metabolism of glucose to sorbitol via polyol pathway
- increased osmotic pressure within the lens accumulation of water lens swells cataracts
retinopathy
- hyperglycaemia increases retinal blood flow damages retinal endothelial cells and pericytes
- results in impaired vascular auto-regulation and uncontrolled blood flow
- increased production of vasoactive substances and endothelial cell proliferation
~ capillary occlusion
~ chronic retinal ischaemia stimulate production of growth factors increases vascular permeability
stimulates angiogenesis
risk factors for progression
- duration of DM
- glycaemic control = poor glycaemic control in type 1 DM patients increases risk of retinopathy by 8x
intensive glycaemic control reduces risk by 50-75%
1% reduction in mean HbA1c leads to 37% reduction in risk of retinopathy
- HPT = 10mmHg reduction in BP leads to 13% reduction in risk of retinopathy
- HCL = treatment may retard progression of retinopathy
- microalbuminuria and proteinuria = presence should allude to the presence of retinopathy
no clear evidence that treatment has any impact on retinopathy
345
- pregnancy
- anaemia = treatment may retard progression of retinopathy
- smoking
long-standing poor glycaemic control = intensive insulin therapy and rapid normalisation of blood glucose a/w
worsening retinopathy; especially if retinopathy is past pre-proliferative
stage
- Mx = laser photocoagulation first followed by intensive treatment
usually develops 10-20 years after onset of DM type 2
eye examination = fundal photography
indirect ophthalmoscopy with slit-lamp
direct ophthalmoscopy through dilated pupils
Type 1 DM
Type 2 DM
Pregestational DM
classification
Non-Proliferative
Retinopathy
(NPDR)
Proliferative
Retinopathy (PDR)
Clinically
Significant Macular
Oedema
1st examination
3-5 yrs after diagnosis
At diagnosis
Prior to conception &
during 1st trimester
Mild
Moderate
Severe
microaneurysms only
more than just microaneurysms but less than severe NPDR
Any of the following (4-2-1 rule)
> 20 intra-retinal haemorrhages in each of the 4 quadrants
venous beading in 2 quadrants
prominent intra-retinal microvascular abnormalities (IRMA)
in 1 quadrant and no signs of proliferative retinopathy
1 or more of the following
neovascularisation
- at the disc
- elsewhere e.g. rubeosis iridis (may obstruct draining angle of eye 2 glaucoma)
vitreous/pre-retinal haemorrhage
Mild
some retinal thickening or hard exudates in posterior pole
but distant from macula
Moderate
retinal thickening or hard exudates in posterior pole
approaching the centre of the macula
Severe
retinal thickening or hard exudates in posterior pole
involving centre of the macula
management
- refer ophthalmologist with annual eye screening
- lifestyle modifications = smoking cessation, medical nutritional therapy, physical activity
- optimal glycaemic control
- control risk factors = HPT, HCL
Macular oedema (moderate-severe)
NPDR mild-moderate
severe
PDR
advanced proliferative DR
vitreous haemorrhage
traction RD
# Focal/Grid laser treatment for macular oedema results in at least 50% reduction in risk of visual loss
# Laser photocoagulation should be instituted for severe NPDR and proliferative DR as it results in 50%
reduction
in risk for severe visual loss and need for vitrectomy
~ destroy areas of retinal ischaemia = prevent release of growth factors that stimulate angiogenesis
~ seal leaking microaneurysms
~ obliterate new vessels directly on retina
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DM nephropathy
leading cause of ESRF in Singapore (> 47% of cases in 2000)
stages of DM nephropathy
- stage 1 = glomerular hyperfiltration (increased GFR)
- stage 2 = microalbuminuria (30-299 mg/day)
- stage 3 = proteinuria (irreversible from here onwards)
- stage 4 = renal impairment (Cr > 200)
- stage 5 = ESRF (Cr > 900 start preparing for dialysis when Cr ~ 600-700)
pathophysiology
- hyperglycaemia increases renal blood flow = afferent arteriole vasodilates
efferent arteriole vasoconstricts
- increased intraglomerular pressure increased single nephron GFR glomerular hyperfiltration and
hypertrophy microalbuminuria
- nephrotic range proteinuria lasts ~ 14 yrs
- vessel walls get damaged thickening of basement membrane, glomerulosclerosis, hyaline arteriosclerosis,
tubular atrophy ESRF
Dipstick test
Type 1= annually after 5 yrs
Type 2 = at diagnosis, yrly
Dipstick
Urine PCR (protein:creatinine
Dipstick +
24h UTP
Creatinine clearance
ratio)
Positive
Repeat 2x over 3 mths
Negative
Repeat test yearly
management
- tight glycaemic control = may be better in ESRF (reduced insulin breakdown in PCT may have to reduce
insulin and OHGA dosage)
- control HPT = aim for BP < 125/75 mmHg
ACE inhibitors preferred as 1st-line drug (vasodilates efferent arteriole reduces intraglomerular
pressure; slows rate of GFR decline; reduces proteinuria)
renoprotective effects are independent of BP control
check U/E/Cr 7 days after starting worsening Cr function, hyperkalaemia
alternative can be non-dihydropyridine CCB (diltiazem, verapamil)
- control HCL = reduces proteinuria and slows rate of GFT decline
- stop smoking
- low-protein diet (0.8 g/kg/day)
- refer nephrologist
DM neuropathy
can affect sensory, motor and autonomic nerves
(a) sensory
- glove and stocking distribution of sensory loss
- parasthesiae and burning sensation in soles
- impaired monofilament sensation, pinprick sensation, vibration and proprioception
- loss of distal reflexes (ankle jerks first to go)
- Charcots joint (damage to joint due to impaired sensation)
(b) motor
347
348
349
1. Physiology
Adrenal cortex produces androgens, glucocorticoids (e.g. cortisol) and mineralcorticoids (e.g. aldosterone)
Cortisol is excreted as urinary free cortisol
ACTH Cortisol
Hypothalamus
CRF
Adrenal cortex
Cortisol
Cushings disease
Adrenal tumour
Ectopic ACTH
Exogenous use
Peripheral tissues
2. Cushings syndrome = chronic glucocorticoids excess from any cause
a. Cushings disease ACTH secreting pituitary adenoma
i. Epidemiology = females > males, 30-50 years old
ii. Clinical features = hypopituitarism, hyperpigmentation at back of hands
b. Adrenal cortical tumour adrenal adenoma/carcinoma
i. Clinical features = abdominal pain & distension, virilisation
c. Ectopic ACTH production small cell lung carcinoma/ bronchial carcinoid tumour
i. Clinical features = hyperpigmentation at back of hands
d. Exogenous glucocorticoids
i. Hirsutism uncommon due to suprresion of adrenal androgen secretion
3. Etiology of Cushings syndrome (Rule of 9s)
Etiology
90% exogenous steroid use
90% ACTH-dependent
90% pituitary
90% microadenoma
10% ectopic
10% macroadenoma
350
Complications
Abnormality
Fat metabolism
Carbohydrate
metabolism
Clinical features
Moon-like facies, central obesity, dorsal fat pads,
supraclavicular fat pads
Thick violaceous abdominal striae, skin atrophy,
bruising, proximal myopathy
DM (increased hepatic gluconeogenesis + antiinsulin effect)
Others
Hypertension
Protein catabolism
History
Inappropriate fat deposition
Weight gain
Easy bruising
Proximal muscle weakness
History of DM
Hyperglycemia (polyphagia,
polydipsia, polyuria, LOW, fatigue)
Recent BSL
History of HPT
Recent BP reading
Management (diet, medications)
Abdominal pain
Haematemesis
Melena
Nausea/ vomiting
Immunosuppression
Recurrent infections
Poor wound healing
History of cataracts
Regular f/u with ophthalmologist
Poor vision
Acne
Hirsutism
Menstrual irregularities/
amenorrhaea
Adrenal androgen
production
MSH activity in
ACTH precursor
molecule
4. Investigations
a. Screening tests
i. Overnight dexamethasone suppression test
1. Give PO DExamethasone 1mg at midnight
2. Check serum cortisol before and at 8 am
3. If cortisol suppressed no Cushings syndrome
ii. 24 hour urinary free cortisol
1. Most reliable and practical
2. Accounts for circadian rhythm lost in Cushings
3. Positive test = 3x upper limit of normal (>280nmol/24hr)
4. If raised but < 3x upper limit of normal measure serum cortisol in late evening
a. If normal no further testing
b. Mildly raise re-evaluate in several weeks
b. Localization tests
351
Plasma
ACTH
Undetectabl
e
Detectable
? Adrenal Tumour
Ultrasound/CT/MRI adrenals
Suppresse
d
Plasma ACTH
CRH test
Inferior petrosal
sinus sampling
Unsuppresse
dd
352
5. Management
(a) Cushings disease:
Surgical resection resection of pituitary adenoma (trans-sphenodial/ frontal approach)
Pituitary radiation (in children)
Bilateral adrenalectomy (primary evacuation not possible)
(b) Adrenal tumors:
Surgery (curative for adenomas; rarely so for carcinomas chemo + RTx)
(c) Ectopic ACTH:
Surgery
(d) Exogenous steroids:
Taper corticosteroid therapy while managing primary pathology
(e) Medications to reduce plasma cortisol
Ketoconazole
6. Pseudo-cushings syndrome = increased 24hr urinary free cortisol + absent circadian rhythm + cortisol
suppressed positive DST
D= depression, drugs
O= obesity, OCP
A= alcoholism, acute illness
7. Nelsons syndrome = rapid enlargement of pituitary adenoma after bilateral adrenalectomy
a. Characterized by: rapidly growing pituitary adenoma, very high ACTH levels, hyperpigmentation
b. Incidence as high as 50% regular f/u f plasma ACTH level and imaging for pituitary tumors
353
History
Somatic effects
o Excessive sweating (hyperhydrosis)
o Acral and facial changes =
Increased dental problems (malocclusion)
Enlarged face, jaw, hands and feet
Outgrowing wedding ring, dentures, shoes
o OSA = snoring, morning somnolence
o Musculoskeletal=
Numbness and parasthesia (carpal tunnel syndrome)
Chronic back ache, radicular pain (spinal stenosis)
Urinary and bladder problems (spinal cord compression)
Joint pain (20 OA, chondrocalcinosis)
Metabolic effects
o Hypertension
o DM = polyuria, polyphagia, LOW, fatigue
Local pressure effects = headache, visual field defects
Hypopituitary effects = menstrual disturbances, galactorrhoea, impotence
Tumors = uterine leiomyomata, colonic polys, CRC
354
Signs/physical examination
Hand
Shake hands
Macroglossia
Acromegaly
Hypothyroidism
Amyloidosis
Downs syndrome
Indicators of acitivity
1. Skin tags
2. Hypertension
3. Glycosuria & hyper glycemia
4. Increase goiter/ tumor (with headache, visual field defect)/ hands, feet, mandible
5. Increased sweatiness
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Investigations
Diagnostic
Etiology
Complications
Serum IGF-1
OGGT with GH measurement
MRI pituitary fossa
Serum Ca (hyperparathyroidism a/w MEN1
syndrome)
CT chest/ abdomen
ECG, CXR
U/E/Cr
TFT, LH/FSH, testosterone, prolactin, short
synacthen test (ACTH def), triple
stimulation test
Skull x-ray
Hand x-ray
Knee x-ray
Feet x-ray
Cardiomegaly
Hyperglycaemia (DM)
Hypopituitarism:
Sequence:
o gonadotrophins
o prolactin
o TSH
o ACTH
Large skull
Unusually large frontal sinuses
Frontal bossing
Thick skull table
Occipital prominence
OA c-spine
Prominent jaw
Malocculusion
Dental fillings
Enlarged pituitary fossa
Large spade like hands
turfting to terminal phalanx)
Chondrocalcinosis, OA
Large feet, thickened heel pad (lat view)
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357
358
Hypokalemia
Hyponatremia
Hypoglycemia
Plasma ACTH , renin , aldosterone
Imaging
o AXR, CXR (if suspecting TB)
o CT abdomen = adrenals
Management
Patient education
o Warn against stopping steroids abruptly
o Give glucocorticoids IM/suppositories in cases of vomiting
o Medik Awas card
o Double/ triple dose of hydrocortisone during episodes of febrile illness/ injury
Pharmacotherapy
o Fludrocortisones
Postural hypotension
Hypo Na+
Hyper K+
plasma renin
o Hydrocortisone replacement
Addisonian crisis
Acute adrenocortical failure characterized by nausea, vomiting, hypotension, shock
Triggers in unknown patient = infection, trauma, burns, surgery
o 1st presentation = bilateral adrenal haemorrhage
Rare in patients with 20/ 30 adrenalcortical insufficiency
o Pituitary apoplexy
o Sheehans syndrome
o Withdrawal of chronic glucocorticoids suddenly
Clinical evaluation
o Known patient with Addisons disease = infection, trauma, burns, surgery
o Signs of Cushings syndrome = sudden withdrawal of glucocorticoids
Investigations
o FBC
o U/E/Cr
o Cortisol
o ACTH
Management
o IV hydrocortisone 100mg start then every 6 hours
o Fluid resuscitation with IV 0.5 % N/S
o Correct hypoglycaemia
o Treat precipitating cuase
o Start mineralocorticoid therapy = fludrocortisones
o Refer endocrinology
359
360
Etiology
Brain damage
Pituitary tumors
Non-pituitary tumors
Misc
Pituitary tumors are classically the most common caus e of hypopit but new findings imply that causes like
brain damage might outnumber pituitary adenomas in causing hypopituitarism
Traumatic brain injury
SAH
Neurosurgery
Irradiation
Stroke
Adenomas
Others
Craniopharyngiomas
Meningiomas
Gliomas
Chordomas
Ependymomas
Metastases
Infection abscess, meningitis, encephalitis
Infarction --- apoplexia, Sheehans syndrome
Idiopathic
Clinical presentation
o May be subclinical or present acutely
ACTH, TSH, ADH are potentially life-threatening
gonadotropin and GH cause chronic morbidity
o Signs and symptoms of underlying diseases
Tumor in sellar region
Bitemporal hemianopia
Headace
Signs of culomotor nerve impairment/ damage to CN 3,4,5,6 in cavernous sinus
o Clinical features/ investigative findings
Clinical features
Corticotropin deficiency
Chronic
Acute
Investigative findings
Investigation
o Imaging
MRI brain to exclude tumors
o Diagnostic tests
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<100nmol/L: hypocortisolism
>500 nmol/L: hypocortisolism excluded
Below upper reference range: secondary adrenal insufficiency
Cortisol < 500nmol/L
Cortisol <500nmol/L after 30min
Low (< 11pmol/L)
Low or normal (occasionally slightly raised)
Oligoamenorrhoea, oestradiol < 100pmol/L, LH and FSH inappropriately low
LH and FSH inappropriately low
Low (<10-12 nomol/L), LH and FSH inappropriately low
Below or in the normal reference range
Adults: growth hormone 3g/L
Children: growth hormone 10g/L
Transition phase: growth hormone 5g/L
Underweight or normal weight (BMI 25): 11.5g/L
Overweight (BMI 25 to <30): 8.0 g/L
Obese (BMI 30): 4.2 g/L
Growth hormone 10g/L
Urine volume (40ml/kg bodyweight per day) + urine osmolality
<300mOsm/kg water + hypernatremia
Urine osmolality <700mOsm/kg
Raito of urine to plasma osmolality <2
Management
o Treatment of cause
Non-functioning pituitary adenoma Transsphenoidal or transcranial surgery
Craniopharyngioma difficult to access
Prolactinoma medical treatment with dopamine agonist
o Hormone substitution
o Follow-up
Adequate hormone replacement should be monitored at regular intervals
Tumor regular ophthalmological f/u & MRI
Prognosis
o Generally, hypopituitarism is chronic and lifelong, unless successful surgery or medical treatment of
the underlying disorder can restore pituitary function
o Increase mortality
Always replace steroids first before L-thyroxine or else patient can die!
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363
Uncontrolled HPT
NSAIDs
Aminoglycosides
Contrast
Urinary obstruction LUTS
Haematuria
Backpain
Constipation
Urinary instrumentation
Glomerulonephritis Rash
haemoptysis
Lab findings to suggest ARF
Increased Urea and Cr above baseline
Increase K+ (impaired renal excretion)
Increased PO4 (secondary to decreased secretion from tubule
damage)
Decreased CA2+
Causes of ARF
Pre-renal (40%)
Intrinsic renal (up to 50%)
Post renal (5-10%)
Vomiting
Diarrhea
Poor fluid intake
Fever
Use of diuretics
CCF
Haemoptysis/melena/haematemesis
Compliance with medications
Fluid and salt restrictions
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Aetiology
Clinical
features
Pre Renal
Decreased renal
perfusion
Sepsis
Dehydration
Shock
Uncontrolled HPT
Post Renal
Urinary Tract Obstruction within the
lumen
Bladder calculi
Bladder tumour
Papillary necrosis
Crystalluria
Urinary tract obstruction within the
wall
Urethral stricture
Bladder neck stenosis
Neurogenic bladder
Urinary Tract obstruction outside the
wall
BPH
Prostate CA
Constipation
CA Cervix/uterus
CA colon
Retroperitoneal fibrosis
LUTS (storage and voiding symptoms
Intrinsic Renal
Acute tubular necrosis
Ischaemia
Nephrotoxins
o Aminoglycosides
o Contrast
o Chemo RX
o Rhabdomyolysis
Acute GN
Post strep GN
IgA nephropathy
Rapidly progressive GN
Haematuria
Dehydration =
increased thrist, dry
mucous membranes
Decreased skin turgor,
prolonged capillary
refill time, altered
mental state
Urine Na
(mmol/L)
Urine
osmolality
(mosm/kg)
Sediment
Distended bladder
Enlarged prostate
Shock = tachycardia,
hypotension
<20 (can concentrate
urine)
>500
Variable
<20
>20
<350
<350
>500
<350
Benign/hyaline casts
Normal/RBC/WBC
Granular casts
RBC casts
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Investigations
Urine
UFEME
Haem -> rhabdomyolysis
Casts
o Granular (acute TN)
o RBC (acute GN)
o WBC + Eosinophillia (acute IN)
Urine Osmolality and urine Na+
High/low (pre-renal + acute GN)
Low/High (post renal + acute TN + acute IN)
Complications
Electrolyte imbalances
Hyper/hyponatraemia
Hyperkalaemia
Metabolic acidosis
Hypermagnesaemia
Hyperphosphataemia
Hypocalcemia
Bloods
FBC
Imaging
KUB or CT KUB
Hb (distinguish from CRF)
Eosinophillia (acute IN)
CKMM
Rhabdomyolysis
Bladder catheterization
Rule out urethral
obstruction
Renal U/S
Small atrophied kidneys (CRF)
Hydronephrosis (post-renal)
U/E/Cr
Urea > creatinine (pre-renal)
Electrolyte abnormalities
Autoimmune screen
ANA
Anti-dsDNA
Complement levels
ANCA
Anti-GMB Ab
Fluid overload
Hypertension
Uraemia
Pericarditis
Pleuritis
Encephalopathy
Peripheral neuropathy
Platelet dysfunction
Pruritus
Oesophagitis/gastritis/colitis
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Management
(a) Treat underlying cause (especially if post renal obstruction)
(b) Catheterize and monitor hourly urine output
(c) Fluid replacement must be balanced against volume status of the patient and ability to PU
Indications for urgent haemodialysis
(a) HCO3 < 10 mmol/L
(b) Urea >20 mmol/L
(c) K+ > 6.0 mmol/L
(d) Uraemic complications = pericarditis, encephalopathy
(e) Oliguria
(f) Pulmonary oedema
(g) Severe and refractory hypertension
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Etiology:
Common causes
DM
HTN
GN
o VITAMIN
Vascular (HSP) purpuric rash, joint pain,
abdominal pain
Infections hx of Hep B/C infection
Toxin (gold, penicillamine) drug hx
Autoimmune (SLE) malar rash,
photosensitivity, oral ulcers, joint pain
Metabolic (DM)
Renal
Renovascular disease
Interstitial nephritis drug history
Polycystic kidney hematuria, loin
pain, headache
Analgesic nephropathy analgesic use
Pyelonephritis hx of kidney infection,
fever, loin pain
Reflux nephropathy enuresis,
childhood UTI, cystoscopy treatment
Obstruction dysuria, hematuria, loin
to groin pain, hx of stones/BPH,
symptoms of obstruction
Extrarenal
Systemic sclerosis
Multiple myeloma
Amyloidosis
Investigations done
o U/S anatomical malformations
o Biopsy GN
EPO injections
368
Hemodialysis AV fistula/graft, frequency per week, duration per session, weight gain in between HD
sessions, complications (bleeding/thrombosis/infections/problems with vascular access), fluid and dietary
restrictions, compliance
Peritoneal dialysis type of PD (CAPD/APD), type and volume of dialysate used, complications (infections,
catheter blockade), fluid and dietary restrictions, compliance
On the transplant waiting list?
Renal transplant when (year), where (local/overseas), type (cadaveric/living related transplant), recent
graft function (graft pain and swelling, proteinuria, creatinine levels), rejection episodes and treatment,
immunosuppressants (steroids = diabetes, HPT, HCL, obesity, easy bruising, cataracts, proximal myopathy,
osteoporosis, AVN, susceptibility to infections, SCC)
Current symptoms urine output, fluid overload, uremia
Complications of disease
Growth
Osteodystrophy
Nutrition
Anemia
Cardiovascular
Skin
Neurology
GIT
Height, weight
Bone pain, fractures
Malnutrition (LOA, LOW)
Pallor, chest pain, SOB, palpitations, giddiness, fatigue
AMI/CCF, HPT, HCL, peripheral vascular disease (intermittent claudication, pain
at night/rest, parasthesia, paralysis, pallor, perishingly cold)
Pruritus, bruising
CVA, seizures secondary to electrolyte disturbances, uremic encephalopathy,
peripheral neuropathy, restless leg syndrome (frequent need to change
position)
Uremic esophagitis/gastritis/colitis (melena, hematemesis, hematochezia,
abdominal pain)
Drug history
Family history
Social history
Smoker
Alcohol drinker
Days off work/school
Financial difficulty
Family set-up and caregiver
Type of housing and lift-landing
Functional status
Renal failure
Renal diseases APKD, Alports syndrome, IgA
nephropathy
Deafness
DM, HPT, HCL
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Physical examination
General
(adequate
exposure with
patient inclined at
45 degrees)
Hands/Arms
Face/Chest
Heart
Lungs
Abdomen
Legs
Others
Height, weight
Sallow complexion (dirty-brown appearance due to deposition of urinary
pigments and anemia)
Cachexia
Cushingnoid appearance secondary to steroids
Edema (facial/ascites)
Vital signs (PR, RR hyperventilation), temperature, BP
Mental state (orientated, confused, drowsy, comatose)
Leuconychia
Terrys nails (brown arc near the ends of nails)
Palmar crease pallor
Carpal tunnel syndrome
AV fistula thrill and bruit are important signs of patency
Scratch marks
Bruising
Subcutaneous nodules (calcium phosphate or amyloid deposition)
Asterixis (in terminal CRF)
Fundoscopy HTN/DM changes (at the end)
Penguinculae (amino acid deposits)
Band keratopathy (calcium deposition in the cornea)
Conjunctival pallor
Uremic fetor (musty smell)
Central line tunneled/non-tunnelled catheter (HD)
Dehydration poor skin turgor, dry skin
Tanner staging (breast development)
Rickety rosary ribs
Raised JVP fluid overload, right heart failure
Carotid artery bruit atherosclerosis
Pericardial rub
Upright position basal crepitations (APO, pneumonia), stony dull percussion
(pleural effusion)
Upright position nephrectomy scar (usually postero-lateral)
Supine position scar (usually iliac fossa) overlying transplanted kidney
Tenchkoff catheter (PD)
Enlarged bladder
Ascites and fluid thrill
Ballotable kidneys APKD (look for hepatomegaly)
Renal artery bruit (usually systolic) RAS
Enlarged prostate (PR)
Scratch marks
Edema
Neuropathy sensory > motor deficits
PVD hairless, shiny/dry skin, pallor, cool, gangrene, amputations
Genu varum
Bony tenderness (strike vertebral column gently)
Manifestations of DM, HTN, SLE
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Investigations
Diagnosis
Etiology
U/E/Cr
Bloods
Urine
Radiology
Complications
Biopsy
Bloods
Radiology
Management
Refer early to nephrologist
Treat reversible causes = relieve obstruction, stop nephrotoxic drugs, treat hypocalcemia + HPT
Growth failure
Malnutrition inadequate protein
Anemia
Osteodystrophy
GH resistance
Osteodystrophy
Low phosphate diet avoid dairy products (milk, cheese, eggs)
Phosphate binders (CaCO3, Ca acetate, aluminium hydroxide)
Calcium supplements (CaCO3, Ca acetate) decrease renal
osteodystrophy, decrease tertiary hyper-pTH
Vitamin D supplementation
Nutrition
Protein restriction
o HD/PD = give RDA + additional to compensate for dialysis loss
o Restrict in glomerulonephritis (0.8g/kg/day)
Na+ restriction (2g/day) control BP, prevent edema
K+ restriction only if hyperkalemic or acidotic
Phosphate restriction (800mg/day)
Fluid restriction in ESRF + fluid overload type CRF = 500ml/day, wt gain <
1 kg/day
Encourage fluid intake in salt-losing type CRF
Anemia
Keep Hb > 11g/dL
Work-up (PBF, serum Fe, ferritin/transferrin/TIBC, serum vitamin
B12/folate, UFEME, stool OB, stool microscopy, OGD/colonoscopy)
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CVS
Prepare for
dialysis
Reduce drug
dosages
Discussion
A)
Chronic renal failure = substantial, irreversible and usually long-standing loss of renal function, KDOQI
defines CRF as GFR < 60 ml/min/1.73m2 for 3 or more months
Azotemia = raised level of urea and creatinine without symptoms (GFR 20-35% of normal)
Uremia = raised level of urea and creatinine with symptoms (GFR < 20% of normal)
B) Glomerular filtration rate (GFR)
Defined as volume of blood filtered by the kidneys per unit time
Estimated by calculating the clearance of creatinine from the blood
Measure of the adequacy of renal function
Normal range = 90-120ml/min
Methods: MDRD study equation, Cockroft-Gault formula
Creatinine clearance = (140-Age) X Mass (in kg)
______________________
X 0.85 if female
72 X plasma creatinine (in mg/dL)
C) Stages of CKD
Stage
1
2
3
4
5 = ESRD
GFR (ml/min/1.73m2)
90
60-89
30-59
15-29
< 15
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D) Complications of CRF
373
F) Anemia in CRF
374
Decreased renal
excretion of PO4
Decreased GI Ca
absorption
Decreased serum
Ca
Decreased renal
mass
Acidosis secondary
to decreased H+
excretion
Decreased
hydroxylation of
Vitamin D
Increased iPTH
secretion
Increased bone
osteoclastic activity
Management:
Diet
o First-line therapy
o Low phosphate diet (800mg/day) = avoid milk, cheese and eggs
Phosphate binders
o CaCO3 (Calcichew)
Higher elemental Ca load and better tasting
Taken with meals reduce phosphate
Taken without meals increase calcium
o Ca acetate = higher phosphate binding capacity but large and bad tasting
o MgSO4 = bad tasting, risk of Mg toxicity, common S/E of diarrhea
o Al(OH)3 = aluminium toxicity (encephalopathy, adynamic bone, constipation, dialysis dementia
slurring of speech, facial grimacing, jerks), anemia, poor BP control, not for use for > 6 weeks
o Seralamer = amino acid polymer, good for control of acidosis but expensive
o Dialysis
o Calcium-phosphate binding product = [Ca] X [PO4]
Calcium product > 55 (calculations in mmol) OR if [Ca] 2.50 mmol/L avoid Ca-based phosphate
binders in view of risk of metastatic calcium product deposition and accelerated atherosclerosis
o Targets = Stage 3-4 keep [PO4] < 1.5, Stage 5 keep [PO4] < 1.8
Calcium supplementation
o CaCO3/Ca acetate between meals
o Vitamin D products (Calcitriol)
Give if iPTH > 21 or 3X normal upper limit
Contraindications = Ca-PO4 > 55, PO4 > 2.0 or iPTH < 15 (further suppression will impair
bone remodeling and increase risk of fractures)
Monitoring = 6-monthly in stage 4, 4-6 monthly in stage 5
Tertiary hyperparathyroidism
o iPTH usually > 100
o Perform U/S or Sestamibi scan to locate pTH glands
o Tx = surgical removal +/- partial reimplantation in deltoids
Hypocalcemia
o IV CaCl2 = preferably given via CVP or large-bore IV cannula, risk of phlebitis and subcutaneous
necrosis
375
376
377
Determine Etiology
RCC = cachexic looking
APKD = hepatomegaly, splenomegaly, signs of ESRF
DM = diabetic dermopathy
Renal abscess = positive Murphys sign, tenderness
Signs of ESRF
AVF/AVG -> palpable thrill, signs of recent cannulation
Sallow appearance, conjunctival pallor
Uraemia -> bruising, scratch marks, asterixis
Fluid overload -> able to lie flat, ascites, lower limb oedema
Request
Vitals = temperature, BP, HR, RR
Fluid overload = Raised JVP, bibasal inspiratory crepitations
FUndoscopy = diabetic and hypertensive retinopathy
Urine dipstick = glycosuria, haematuria
APKD = CVS (MVP) + Neurological examination ( 3rd nerve palsy, focal neurological deficits, craniotomy)
378
Eyes
Conjunctival pallor and penguinculae ESRF
Posterior subcapsular cataract -> long term steroid therapy
Oral cavity
Oral thrush -> steroid therapy
Gingivial hyperplasia -> cyclosporine A
Raised JVP -> fluid overload
Buffalo hump, supraclavicular fat pads -> long term steroid therapy
Kyphoscoliosis, step deformity, bony tenderness -> long term steroid therapy
Lungs
o Crepitations -> infection/fluid overload
Lower limbs
o Oedema -> fluid overload
379
Request to
o Measure BP for HPT -> long term steroid therapy
o DO bedside hypocount and urine dipstick -> aetiology (DM)
o Fundoscopy -> aetiology (DM, HPT)
Presentation
Mdm XXX is a (age)(race)(gender) who has a transplanted kidney and is on immunosuppressive therapy.
I say this because she has a J-shaped scar in her left iliac fossa, overlying a rounded mass x cm by x cm, non
tender and firm to touch. She also has evidence of immunosuppression with a characteristic rounded facies,
central obesity, violaceous abdominal striae, oral thrush, gum hypertrophy, bruising and thin skin.
Otherwise, on examination of her abdomen, there is no hepatosplenomegaly or ascites noted.
I looked for but was unable to find any signs suggestive of the aetiology of end stage renal failure such as
bilaterally enlarged ballotable kidneys and diabetic dermopathy.
Functionally, I note that she has a left arteriovenous fistula with a palpable thrill. There are no signs of recent
cannulation which suggests that the graft is functioning well. This is supported by the fact that she does not
have any evidence of uraemia. Her appearance is not sallow, there are no visible bruising or scratch marks and
there is no bilateral lower limb pitting oedema.
Discussion
Criteria for transplant
Recipient
Living related doner
ADL independent
Offsprings
No malignancies
Parents
No PVD
Spouses
No IHD
1st or 2nd degree relatives
No CVA
No DM
No Active liver disease
No HPT
No HBsAg or HBeAg
No Hepatitis
No HIV
No Mental retardation
Medical priority cases = vascular access problems, anaemia < 7g%
Cadaveric doner
No hepatitis B or C
No HIV
No systemic infections
380
If external iliac vessels too small to allow implantation e.g. paediatric pation -> aorta and IVC
used
o 2nd warm ischemia time = time taken to perform vascular anastomosis after removal from cold
perfusion solution
Location
o Usually in RIF/LIF
o Easy surgical/biopsy access
o Attached to femoral/common iliac vasculature
o Note that the original kidney is usually left in the abdominal cavity
o
Complications
Steroid toxicity
o Cosmetic effects
o Increased protein catabolism = proximal myopathy, paper thin skin
o Endocrine = HPT, DM, obesity, Addisonian crisis, menstrual irregularities
o Cardiovascular = premature coronary artery disease
o Bone = osteroperosis, aseptic necrosis
o Immunosuppression = opportunistic infections, lymphoma, SCC
o Others = gastritis, posterior subcapsular cataracts, steroid psychosis
Cyclosporin toxicity
o Hepatomegaly
o Hirsutism
o Hyperplastic gums
o Hypertension
o Hypercholesterolaemia
o Hyperkalaemia
o Hyperuricaemia
o Hypomagesaemia
o Haemolytic uraemia syndrome
o Osteoporosis
o Hiccupping
o Neurological
o Nephrotoxicity
o Neoplasia lymphoproliferative
Graft rejection
o Acute or chronic -> falling urine output, rising creatinine levels
o P/E = tender graft, signs of fluid overload, presence of Tenchkoff/vascular catheter
o Invx = graft biopsy
Gradually increasing Cr level -> cyclosporine toxicity? Chronic rejection?
Influences management -> either stop cyclosporine or increase immunosuppression
Recurrence of GN = FSGS, IgA nephropathy, Goodpastures syndrome, MPGN, Alports
syndrome, HUS, TTP
Mx = methylprednisolone, monoclonal antibody, azathioprine
381
Investigations
U/E/CR
o Rising creatinie trend (slightly elevated level is acceptable in patients on cyclosporine A
o Electrolyte disturbances
FBC
o Leucocytosis
Infection
Steroids (increased release of mature neutrophils from BM)
o Leucopenia
Azathioprine (dosing adjusted according to neutrophil count)
LFT (may be deranged with use of cyclosporine A and steroids)
Urine dipstick/UFEME/urine c/s
U/S Kidneys
Prognosis
2 year renal graft survival from LRDT -> 85% cadaveric transplant -> 70%
Poor prognostic indicators for post transplant survival
o Previous rejection
o Host vs Donor disease
o Delayed graft function -> usually presents with oliguria
o Hep B & C infection -> need to treat Hep C with interferon for a year before transplant is carried
out. Treatment not available for Hep B
o Paid donor transplant (e.g. China, India) -> due to higher rates of Hep B, Hep C and HIV
infections and tendency for over immunosuppression
382
383
384
385
Investigations
Urine
urine dipstick = proteinuria, haematuria, glycosuria
UFEME
urine phase contrast microscopy = dysmorphic/isomorphic RBC
urine c/s (mid-stream catch) = UTI
24hr UTP/CCT or urine PCR = nephrotic syndrome
Bloods
FBC = anaemia/leucopenia/thrombocytopenia (SLE)
U/E/Cr = renal impairment
Ca/PO4/Mg = renal impairment
LFT = hypoalbuminaemia
ESR and CRP
Hepatitis screen = HBsAg, HBeAg, anti-HCV Ig G
AI screen = anti-ds DNA, ANA, C3/C4, anti-GBM, ANCA
fasting glucose and HbA1c = diabetes
myeloma screen (for those > 45 yrs old) = serum and urine protein electropheresis
Others
Renal U/S
Renal biopsy
Management
orthostatic proteinuria (a/w upright position and in adolescents) = good renal prognosis
no follow-up required
intermittent isolated proteinuria (a/w stress and exercise) = favourable prognosis
follow-up till proteinuria resolves
persistent isolated proteinuria = follow-up indefinitely with monitoring of BP and U/E/Cr
combined microscopic haematuria and proteinuria = most common presentation of GN (esp Ig A
nephropathy)
fluid overload = fluid restriction
low-salt and protein diet
strict I/O charting with daily albusticks and weights
monitor vitals q4hrly
diuretic therapy (PO Lasix 40mg OM with PO Span K 0.6mg OM)
ACE inhibitors/ARB (PO Losartan 25mg OM)
386
387
Aetiology
Renal
o Vascular = purpuric rash over lower limbs, lower limb oedema, joint pain, abdominal pain (HSP)
Haemoptysis (Goodpastures syndrome)
o Infective = recent fever and URTI (post-streptococcal GN)
Ongoing fever and URTI/GE (IgA nephropathy)
o Autoimmune = history of SLE
Rash, joint pain and swelling
o Neoplasia = fever, flank pain, palpable abdominal mass (RCC)
o Familial = personal and family history of APKD
History of deafness (Alports syndrome)
Urinary tract
o History of TB
o Infective/stones = frequency, urgency, nocturia, dysuria, urethral discharge, obstructive
symptoms,
loin to groin pain, fever, nausea, vomiting, diarrhea
o History of trauma = history of urinary catheterisation, flexible cystoscopy, TURP
o Tumour = LOA, LOW, fatigue, back pain
Systemic
o Bleeding diasthesis = gum bleeding, epitaxis, menorrhagia, easy bruising
Systemic review
Management
Has this happened before? Please describe
Past medical history
Adult polycystic kidney disease
Hypertension
Deafness (Alports syndrome secondary membranous GN)
Urolithiasis
Menstrual history
Last menstrual period could be menstrual blood
Drug history
Drug allergies
Current medications = penicillamine, rifampicin, hydralazine
Anticoagulants = TCM, NSAIDs, warfarin, aspirin
Social history
Family history
388
Physical examination
Skin = purpuric rash, digital vasculitis
Mouth = injected pharynx, tonsillitis
Fluid overload = raised JVP, lower limb oedema, hepatomegaly, bibasal inspiratory crepitations
Enlarged ballotable kidneys
PR = prostate enlargement
Vitals = temperature, BP
Investigations
Urine
Urine dipstick = proteinuria, haematuria
UFEME
Urine phase constrast microscopy
o Predominantly dysmorphic glomerular origin
o Predominantly isomorphic or mixed isomorphic/dysmorphic urinary tract origin
Urinary c/s = rule out UTI
Bloods
FBC = WCC (UTI)
Hb (anemia)
Platelet (thrombocytopenia)
U/E/Cr = renal impairment
Glomerular origin
24hr UTP/CCT or urine PCR if urine dipstick 2+ proteinuria
ESR, CRP
AI screen = anti-ds DNA, ANA, C3/C4, ANCA, anti-GBM Ab
Renal U/S = polycystic kidneys, RCC
Renal biopsy = glomerulonephritis
Non-glomerular origin
KUB
U/S or CT KUB (without constrast)
IVU
Urine cytology
Flexible cystourethroscopy
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390
(c)
(d)
(e)
(f)
(g)
(h)
391
392
Histological
chronic tubulo-interstitial fibrosis
extensive crescents (> 30-50%)
advanced glomerulosclerosis (>
20%)
medial hypertrophy of arterioles
393
394
395
High dependency
Low dependency
(ie relatively healthy)
Eg malignancy, HPT, DM ,
IHD, ADL dependent
Unsuitable for transplant
Perform dialysis (HD or PD)
Cadaveric donor
<65 YO
no hepatitis B or C
no HIV
no systemic infections
396
Check CVP
Check perfusion scan
If CVP > 10 cm H2O
Give IV Lasix 80-120mg stat
Impaired
perfusion
Surgery
Normal
perfusion
Lasix
responsive
PRA 25
FK506
+ Azathioprine
+ prednisolone
PRA < 25
Cyclosporine A
+ Azathioprine
+ prednisolone
+ Zenapax
Lasix
unresponsive
+ Delayed
graft function
Determine level of
immunosuppression required based
on PRA
PRA 25
Cyclosporine A
+ MMF
+ prednisolone
+ Zenapax
Determine level of
immunosuppression required based
on PRA (?antigen levels)
PRA < 25
Cyclosporine A
+ Azathioprine
+ prednisolone
+ Zenapax
Day 5-7
PT still dialysis
dependent
PT recovering
Renal biopsy of
allograft kidney:
Check for rejection
397
-thalessemia major
Overall
Pituitary haemosiderosis
Cardiac haemosiderosis
Pancreatic haemosiderosis
Intervention
Request
Short stature
Hyperpigmented
Thalessemic facies (frontal bossing, flat nosebridge,
maxillary hyperplasia)
Looks younger for age
Hypopigmented areolae
Loss of axillary hair
JVP v wave
Pulsatile liver
Lower limb edema
Hypocount marks on fingers
Diabetic dermopathy
Splenectomy
Gonadal examination
398
Subset
Respiratory
Parenchyma
Airway
Pleura
Haematological
Vasculature
Anemia
Neuromuscular
Psychological
Hyperventilation
Question
Any chest pain? Character?
Any PND?
Any Orthorpnoea?
Leg swelling?
Cough?
Phlegm?
Haemoptysis?
Fever?
Wheeze?
Stridor?
Trauma?
Acute pain followed by SOB?
Prolonged immobility?
Palpitations
Giddiness / Light headedness
Bleeding PR, Menses
Generalised weakness?
Association with certain situations
Tingling in hands / feet?
Cramps?
Severity
NYHA Score / Effort Tolerance
Impact on ADL
399
Aspiration
Pathogenesis
due to diffuse alveolar damage (epithelial endothelial damage)
lungs particularly vulnerable to inflammatory injury = mediators released into bloodstream and
lungs receive entire cardiac output
pathology = hyaline membrane formation
increased capillary permeability and oedema
interstitial inflammation and fibrosis
damage to type 2 pneumocytes (surfactant abnormalities and alveolar collapse)
results in hypoxia due to V/Q mis-match and reduced lung compliance
3 stages
1. Exudative stage (0 7 days)
- capillary congestion, oedema (increased permeability) and haemorrhage
2. Proliferative stage (1 3 weeks)
- proliferation of interstitial fibroblasts and type 2 pneumocytes to replace sloughed type 1 cells
3. Resolution
- diffuse interstitial fibrosis interspersed with dilated distorted air spaces (honeycomb lung)
Complications
Reduction in lung compliance (stiff lungs) = diffuse interstitial fibrosis
Respiratory failure = V/Q mismatch
Pulmonary hypertension = hypoxic vasoconstriction
vascular compression by positive airway pressure
lung parenchymal destruction
Cor pulmonale = rare but associated with increased mortality if present
Death
400
Clinical features
History
- Acute onset of breathlessness
Physical examination
- Cyanosis
- Tachypnoea
- Bilateral fine end-inspiratory crepitations
Investigations
FBC
U/E/Cr
LFT
PT/PTT
CRP
ABG
Bld c/s
Amylase
CXR
- diffuse bilateral fluffy alveolar infiltrates with prominent air bronchograms
- absence of heart failure
Pulmonary artery catheter to measure pulmonary capillary wedge pressure
Management
Admit to ICU
Respiratory support = mechanical ventilation
Rescue therapy
Recruitment of alveoli = PEEP
Prone positioning
High frequency ventilation
Circulatory support = haemodynamic monitoring, inotropic support, vasodilators, blood
Treat underlying cause e.g. sepsis
401
402
7. Lung fields
division = apices lie above the level of the clavicles
upper zone include the apices to the level of the 2nd costal cartilage
middle zone lie between 2nd and 4th costal cartilage
lower zone lie between 4th and 6th costal cartilage
loss of cardiac silhouette middle lobe consolidation
increased translucency hyperinflation
8. Bone and soft tissue
rib fractures
bone metastasis
subcutaneous emphysema
The heart
lateral film
- posterior border of heart shadow made up of left ventricle
- anterior border of heart shadow made up of right ventricle
- mitral/aortic valve = draw imaginary line from apex of heart to hilum
# above line aortic
# below line mitral
Causes of a white lung
consolidation
pleural effusion
collapse
fibrosis
pneumonectomy
raised hemidiaphragm
Lung collapse
PA film
(a) lung fields smaller on the side of collapse
(b) elevation of hemidiaphragms left may be higher than the right if there is left lung collapse
(c) horizontal fissure (runs from centre of right hilum to level of 6th rib in the axillary line) pulled up
in right
upper lobe collapse; pulled down in lower lobe collapse
(d) mediastinal deviation heart should straddle midline with 1/3 to the right and 2/3 to the left
(e) heart borders blurring of right heart border (right middle lobe collapse)
blurring of left heart border (lingular collapse)
(f) tracheal deviation
lateral film
(a) displacement of horizontal and oblique fissures
Consolidation
radiological features
(a) heterogenous shadowing = gets denser and more clearly demarcated at lower border (fluid sinks)
(b) air bronchogram
(c) demarcated by horizontal fissure in right upper lobe pneumonia
Coin lesion
discrete opacity situated within a lung field
causes
(a) benign tumour = hamartoma
(b) malignant tumour = bronchial carcinoma, single secondary
403
404
Bronchiectasis
ring shadows
- bunches of grapes appearance
- represent diseased bronchi seen end on
tramline shadows
- seen at lung peripheries
- consists of 2 thick white parallel lines
separated by black
- represent diseased bronchi seen side on
tubular shadows
- solid thick white shadows
- represent bronchi filled with secretions
seen side on
glove finger shadows
- represent group of tubular shadows seen
end on
Pulmonary fibrosis
radiological features
(a) fine reticulonodular shadows
extending into axillary aspect of
each hemithorax
(b) decrease in lung volume
(c) early ground-glass appearance
late honeycomb appearance
(d) mediastinal shift towards
shadowing
405
406
407
Complications
Local growth and spread
(a) Bronchial obstruction bronchiectasis, lobar collapse, pneumonia
(b) Erosion of vessels haemoptysis
(c) Parapneumonic pleural effusion
(d) Rib destruction
(e) Dysphagia (oesophageal involvement)
(f) Cardiac involvement pericardial effusion, pericarditis, tamponade
(g) Pancoast tumour compression of lower brachial plexus (C8, T1)
ipsilateral Horners syndrome
SVCO
(h) Hoarseness (recurrent laryngeal nerve involvement or vocal cord invasion)
(i) Hemidiaphragmatic palsy (phrenic nerve involvement)
Metastasis
(a) Lymphatic spread to regional LN
(b) Haematogenous spread to distant organs brain, bone, liver, adrenals
(c) Transcoelemic spread to pleural space
Paraneoplastic syndrome
# clinical syndrome due to ectopic production of humoral substances from a malignancy of nonendocrine origin
(a) Endocrine = ACTH Cushings syndrome
ADH SIADH
pTH related-peptide hypercalcaemia
hCG gynaecomastia
(b) Neuromuscular = cerebellar degeneration
peripheral neuropathy
proximal myopathy
Lambert Eaton myasthenic syndrome
(c) Connective tissue = clubbing, HPOA, scleroderma, dermatomyositis, acanthosis nigricans
(d) Haematological = polycythaemia, anaemia, DIVC
(e) Vascular = migratory thrombophlebitis (Trousseaus syndrome)
Investigations
Bloods
1. FBC = Hb (NCNC anaemia)
2. U/E/Cr = hyponatraemia (SIADH)
3. Ca/PO4/Mg and serum acid phosphatase = hypercalcaemia
bone metastasis
4. LFT = liver metastasis
Sputum cytology/broncho-alveolar lavage (BAL)
- good for endobronchial tumours (SCC and small cell lung carcinoma)
- poor yield for adenocarcinoma
Imaging
1. CXR = primary or secondary lung carcinoma
location
complications (pleural effusion, consolidation, collapse, bony secondaries)
hilar LAD
# If pleural effusion present thoracocentesis or chest tube insertion
- drain before doing CT
- send fluid for = gram staining, culture/sensitivity, AFB, TB culture, cytology
2. CT thorax = determine exact location and features of lung ca
staging (LN involvement, local spread, distal mets)
408
409
410
411
412
Management
- Notify CDC, refer to TBCU
- Contact tracing
- Advise HIV testing
- Isolation while infectious
- Ishihara colour vision testing before initiating therapy with ethambutol
- Give anti-TB drugs (directly observed therapy to improve compliance) + monitor liver function
- Monitor CXR weekly during treatment, monthly sputum AFB smear and cultures till two consecutive
negative cultures
- Most persons diagnosed with TB are begun on specific treatment before the diagnosis is confirmed by
the laboratory
TB drugs
Aims of therapy
- Successful treatment requires more than one drug to which the organisms are susceptible
- Sufficient dose
- Sufficient duration
- Compliance DOT (polyclinic DOT)
TB drugs
- First line: Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), Ethambutol (E), Streptomycin (S), Amikacin,
Kanamycin
- Pyridoxine is given to reduce peripheral neuropathy induced by isoniazid
- Pyrazinamide is given for the first two months to kill intracellular bacilli
- 6 month treatment
- Titrate according to body weight
- Initial drug regimen is based on knowledge of the likely drug susceptibility.
- Four drugs are used in the initial phase of treatment when the total duration of treatment is six
months, because of the high incidence of isoniazid-resistant organisms in most communities.
- Usually RHZ or RHEZ
413
Drug resistant TB
Initial drug regimens need to be modified in areas with a known high prevalence of MDR-TB
Development of drug resistance after initial drug sensitivity (secondary drug resistance) occurs in
patients who do not comply with treatment regimens, occurs mainly in HIV patients
Nosocomial transmission significant
Use 4 drugs, treat for 2 years
Follow up for 1 year after eradication
Second line drugs: Ofloxacin, Ciprofloxacin, Cycloserine, Ethionamide, Azithromycin
Drug side effects
Rifampicin
- induces liver enzymes caution in drugs and OCP
- stop if liver enzymes are more than 3x elevated
- orange tears, sweat, sputum, urine
Isoniazid
- peripheral neuropathy
- skin rash
- hepatitis stop drug
Pyrazinamide
- precipitates gout
- liver toxicity
Ethambutol
- dose related optic retrobulbar neuritis, presents with colour blindness, central scotoma, reduction in
visual acuity
Streptomycin
- irreversible damage to the vestibular nerve
- allergic reactions are more common
TB and HIV
TB in an HIV patient is an AIDS defining condition
4 drugs are used instead of the usual 3
Adverse reactions are common and the prognosis is poor
Multiple drug resistance occurs in 6%
M. avium intracellulare is another mycobacterium that can cause pulmonary infection in AIDS patients
Prevention
BCG vaccination: live attenuated vaccine protects against miliary and meningeal TB
Contact tracing
Chemoprophylaxis for contacts and for HIV patients
414
Mantoux test
- used to identify patients with latent TB
- positive tuberculin skin test indicates infection with M. tuberculosis; it does not diagnose active
disease
- intradermal injection of 0.1 ml of PPD
- interpreted 48 to 72 hours after intradermal administration
- transverse diameter of induration should be measured and recorded in millimetres
- False negatives: newly diagnosed TB, HIV, TB meningitis
- Children who have received the BCG vaccine generally demonstrate PPD skin test reactions of 3 to
19 mm several months after vaccination. Most of these reactions wane significantly with time.
Responses indicative of a new infection include: > 10 mm induration in persons less than 35 years
of age or > 15 mm induration in >35 years old
415
416
Bronchopneumonia
Etiology/epidemiology
- Causative agents: Staph aureus, H influenzae, Strep, Pseudomonas (low virulence organisms)
Predisposing factors
- Extremes of age
- Immunosuppression/immunocompromised eg. Chronic disease
- Loss of cough reflex eg. Coma, anaesthesia
- Injury to mucociliary apparatus eg. Smoking, viral disease, genetic disease (CF)
- Interference with phagocytosis or bactericidal action eg. Alcohol, smoking
- Splenectomy
- Pulmonary congestion eg. Cardiac failure
- Accumulation of secretions eg. Bronchial obstruction, prolonged bed rest
- In hospital (nosocomial infections)
Atypical pneumonia
Etiology/epidemiology
- Causative agents: mycoplasma, chlamydia, viruses (influenza, parainfluenza, RSV, adeno)
- Affects school going children and young adults
Clinical features
- Presents as first as URTI eg. pharyngitis and flu-like symptoms laryngitis tracheobronchitis +
pneumonia (LRTI)
- May have headaches and malaise (typical of mycoplasma), erythema multiforme, arthralgia,
autoimmune haemolytic anaemia, myocarditis, hepatitis, DIC
- Cough, fever, modest sputum production, non-specific CXR changes (transient, ill-defined patches),
WBC count only moderately elevated, non-response to antibiotics
- Because the edema and exudatation are both in a strategic position to cause an alveolocapillary
block, there may be respiratory distress out of proportion to the physical and radiologic findings
- Cold agglutinins, rising antibody titre
Complications
- ARDS
Aspiration pneumonia
Usually in the right middle lobe cos the right bronchus is straighter
Especially in unconcscious, drunk, epileptic, stroke patients; may follow after gen anaesthesia, partial
drowning
Gastric contents: can cause asphyxia if massive; can cause pulm edema + infection
Necrotising pneumonia, pursues a fulminant clinical course
Complications: lung abscess, death
Nosocomial pneumonia
Common in patients with underlying disease, immsuppression, prolonged antibiotic therapy, invasive
devices/foreign bodies, mechanical ventilation
Commonest causative organisms: Pseudomonas, S aureus and enterobacteriaceae
Clinical features
History
Symptoms: Fever, rigors, cough, purulent sputum, malaise, dyspnea, pleuritic chest pain
Diarrhea (legionella)
Confusion in elderly
Preceding viral illness
Hospitalisation/insitutionalisation
Smoking/alcohol
Co-morbidities
Contact/travel/sexual history
417
Physical examination
Fever, confusion (in the elderly), tachypnea, tachycardia
Consolidation: diminished chest expansion, dull percussion note, increased vocal fremitus/resonance,
bronchial breathing
Pleural rub
Sputum mug
Differentials (non-infectious)
Chemical pneumonitis / inflammation due to radiotherapy
Allergic mechanisms, asthma
Lung cancer
COPD
Investigations
FBC: leukocytosis with left shift, CRP
Bld c/s
Viral serology if suspected
CXR: lobar/patchy consolidation (opacity with air bronchograms)
multicentric, likely hematogenous route IVDA (Staph aureus)
cavitating: TB, anaerobic, kleb, meliodosis, staph aureus
+/- parapneumonic effusions
- CXR changes lag behind clinical course, hence initial CXR may not show typical changes
- CXR may show consolidation after resolution of symptoms, but should clear by 6 wks
Sputum for microscopy and c/s, AFB smear and culture, TB PCR
- should have < 10 epithelial cells
- > 25 WBCs are abnormal
- lancet shaped diplococci = S pneumoniae
Urine antigen for legionella, pneumococcus
Bronchoscopy for immunocompromised patients
Pleural fluid for analysis (thoracocentesis) if effusion present
Severity
Two scoring systems to decide outpatient vs inpatient treatment; also of prognostic value
CURB 65 score
- Confusion (abbreviated mental test score < 8)
- Urea > 7 mmol/L
- Respiratory rate > 30/min
- BP systolic < 90 mmHg
0-1: treat as outpatient
2: inpatient treatment
3 or more: admit to ICU
PSI (see attached)
- PORT study (Patient Outcomes Research Team)
- Risk class I: no co-morbidities, normal phy exam and age < 50
- Risk class II V: points are assigned for different comorbidities and abnormal lab findings
Direct ICU admission if patient is in septic shock requiring vasopressors or intubation
Management
Outpatient antibiotic treatment: amoxicillin
Hospitalised patients are generally begun on intravenous antibiotics (ceftriaxone + azithro OR
levofloxacin). Patients who are improving clinically, hemodynamically stable, and able to take oral
medications can be switched to oral therapy.
If no improvement within 72 hours, consider an organism that is not covered by the initial antibiotic
regimen, including unusual pathogens or drug-resistant organisms
418
Antibiotic selection
Community acquired
- Mild
Oral amoxicillin and/or erythromycin, or ciprofloxacin
- Severe
IV augmentin or cefuroxime AND erythromycin
- Atypical
Clarithromycin (Legionella), tetracycline (Chlamydia), bactrim (PCP)
Nosocomial
- Gm negs, Pseudomonas, IV aminoglycoside + 3rd gen cephalosporin
IV ciprofloxacin for pseudomonas
Anaerobes IV metronidazole
** if TB cannot be ruled out then do not give quinolones as it may mask the AFB smear
Complications
Complete resolution is rare in bronchopneumonia focal fibrosis or bronchiectasis
Pleural effusion
Empyema
Lung abscess
Respiratory failure
ARDS
Sepiticemia
Brain abscess
Pericarditis
Cholestatic jaundice
Causes of poorly resolving pneumonia
Lung Ca
Aspiration of foreign body
Inappropriate antibiotic
419
Mortality %
0.1
0.6
2.8
8.2
29.2
420
Aetiology
Extrinsic (allergic) asthma
- Definite external cause
- Type 1 hypersensitivity reaction
- Elevated serum IgE and eosinophils
- Mediated by Th2 cells release IL 4, IL5 IgE synthesis
sensitization of mast cells
- Triggered by allergen exposure in a sensitised individual mast cell
degranulation
- Early phase (within 1 hr): release of leukotriene D4, PGE2, histamine
- Accompanied by reflex bronchoconstriction due to stimulation of
vagal receptors
- Late phase: recruitment of leukocytes: leukotriene B4, platelet
activating factor, TNF
- Leukocytes damage the epithelium, reducing production of NO, thus
causing smooth muscle contraction
- Eosinophils perpetuate the inflammation
- Eg. Atopic asthma, occupational asthma, allergic bronchopulmonary
aspergillosis
- Often has family history of allergy/atopy
- Develops in childhood
Epidemiology
o Prevalence is increasing
o More common in developed countries
421
Pathogenesis
Atopy
- individuals who readily develop IgE antibodies against common
materials in the environment
- runs in the family
- childhood exposure to allergens has an influence on IgE production:
growing up in a clean environment predisposes towards IgE response
to allergens
Airway hyperresponsiveness
Small airway obstruction due to bronchospasm and thick tenacious
mucous plugs, progressive hyperinflation with air trapping
Remodelling
- deposition of matrix proteins beneath the epithelium
- epithelial metaplasia and increase in goblet cells
- thickened basement membrane
- smooth muscle hyperplasia
Precipitating factors
Environmental allergens: pollen, house dust mite, pets
Occupational: isocyanates (varnish), flour, animals
Atmospheric: cigarette smoke, pollutants
Cold air, exercise (at the end of exercise), emotion
Viral infections: rhinovirus, parainfluenza
Drugs: Aspirin (imbalance in metabolism of arachidonic acid), beta
blockers
Physical examination
Tachypnea
Wheeze, cough
Hyperinflated chest, hyperresonance, diminished air entry
Polyphonic wheeze
Clinical severity: able to complete sentences? Silent chest, bradycardia,
PEF < 33%, cyanosis, feeble respiratory effort, confused
Investigations
FBC: eosinophils
Sputum culture and cytology: eosinophils
Serial peak expiratory flow measurements
- Diurnal variation >20% on 3 days a week for 2 weeks: marked
morning dipping of peak flow
Lung function tests
- Decreased FEV1/FVC ratio and increased residual volume
- Before bronchodilator, after bronchodilator variable airflow
limitation, >15% improvement in PEFR after bronchodilator
CXR: hyperinflation, exclude pneumothorax or allergic
bronchopulmonary aspergillosis
Skin prick test: helps to identify allergens
Histamine or methacholine challenge: to test airway
hyperresponsiveness
Clinical features
History
Dyspnea (esp expiration), nocturnal cough, wheezing, chest tightness
Severity, frequency
Precipitants: Exercise, cold, stress, infection, drugs eg. aspirin
Allergens, occupational exposure, better when on holiday
Diurnal variation: worse in the morning
Other atopic disease: eczema, allergic rhinitis
Family history
Social history: occupation, impact on lifestyle
422
Classification of asthma
New GINA guidelines
Management
Allergen avoidance eg dust mite, smoking, drugs
Pharmacologic therapy depending on severity/frequency of asthma
symptoms
- use step-up or step-down approach
Education of patient and family:
- Check inhaler technique (avoid excess deposition in mouth)
- Use of spacer to increase lung deposition, decrease the need for
coordination
- Compliance with steroid inhalers
Asthma action plan
- grades patients severity of asthma into the green, yellow and red
zones, according to their symptoms + peak flow rates
- describes the dose, frequency and duration of the appropriate
treatment
- main aim of the asthma action plan is to abort exacerbations by rapid
step up of both reliever and preventor
- also prompts the patient to seek urgent hospital treatment in case of
severe exacerbations and/or failure of self medication.
SMART approach to asthma (Symbicort Maintenence and Reliever
Treatment)
o 2 puffs BD for maintenence
o 4 puffs BD in exacerbation for rapid relief
o 2 puffs BD when symptoms resolve
o Symbicort = budesonide + formoterol
- Better compliance when using a combined inhaler than two separate
inhalers
423
Asthma drugs
Beta-2 agonists
- selective for bronchial smooth muscle relaxation and
bronchodilation
- for symptomatic relief (2 puffs prn)
- effective up to 6 hrs
- excessive use (>2 canisters per month) is associated with increased
mortality
Anticholinergic (ipratropium bromide)
- muscarinic receptor antagonists
Long acting beta-2 agonists
- effective up to 12 hours
- for patients who cannot be controlled on 800mcg/day of ICS
Sodium cromoglycate and nedocromil
- blocks chloride channel prevent mast cell activation
Inhaled corticosteroids (ICS)
- any form of persistent asthma (needing relief meds at least once a
week) requires steroid inhaler treatment
- beclometasone, budesonide, fluticasone, triamcinolone
- most of the dose is swallowed or exhaled
- adding a long acting beta-2 agonist is more effective than doubling the
dose of ICS
- side-effects: oral candidiasis, hoarseness, subcapsular cataract,
avascular necrosis of the femoral head, osteoporosis, growth
retardation
- step down treatment after the condition is under control
Oral corticosteroids
- keep the dose as low as possible
- for those who cannot be controlled on ICS
Leukotriene-receptor antagonists
- add on therapy
- good for aspirin-intolerant asthma
Status asthmaticus
Poor response to drug therapy after 24 hours
Signs of respiratory failure: ABG: PaCO2>6kPa, PaO2<8kPa, pH low and
falling
Risk factors for death from asthma
Past history of sudden severe exacerbation
Prior intubation for asthma
Two or more hospitalisations for asthma in the past year
Three or more emergency care visits for asthma in the past year
Hospitalisation or an emergency care visit for asthma within the past
month
Use of >2 canisters per month of inhaled short-acting B2-agonist
Current use of systemic corticosteroids or recent withdrawal from
systemic corticosteroids
Known difficulty perceiving airflow obstruction or its severity
Comorbidity, as from cardiovascular diseases or chronic obstructive
pulmonary disease
Serious psychiatric disease or psychosocial problems
Low socioeconomic status
Illicit drug use
ABG: PaCO2>6kPa, PaO2<8kPa, pH low and falling
424
Feeble
Silent
chest
<30%
425
426
427
Clinical syndromes of PE
Massive pulmonary embolism
PE associated with a systolic blood pressure <90 mmHg or a drop in systolic blood pressure of 40
mmHg from baseline for a period >15 minutes, which is not otherwise explained by hypovolemia,
sepsis, or a new arrhythmia
- a catastrophic entity that often results in acute right ventricular failure and death
Submassive pulmonary embolism
- All PE not meeting the definition of massive PE are considered submassive PE.
Pulmonary infarction
- Infarction only occurs if bronchial circulation is impaired
- The more peripheral the embolic occlusion, the more likely is infarction
Chronic pulmonary embolism
- Occurs when acute PE does not resolve, lasts for years
Clinical features
History
Acute breathlessness, pleuritic chest pain, hemoptysis, dizziness, syncope
Risk factors
Physical examination
Tachypnea, pyrexia, tachycardia, hypotension
Cyanosis
Raised JVP, loud P2, 4th heart sound
Pleural rub or effusion
Signs of DVT
Recent surgical scar
Clinical scoring
Wells score
Previous DVT/PE
Immobilization or surgery in previous 1 month
Malignancy
Clinical symptoms of DVT
Hemoptysis
Heart rate >100
Other diagnosis less likely than PE
1.5
1.5
1
3
1
1.5
3
Geneva score
Age > 65
Previous DVT or PE
Surgery (under GA) or lower limb fracture within 1 month
Active malignant condition or cured in < 1 yr
Unilateral lower limb pain
Pain on lower limb deep venous palpation and unilateral edema
Hemoptysis
Heart rate 75-94 bpm
Heart rate 95 bpm
1
3
2
2
3
4
2
3
5
428
Investigations
Nonspecific lab findings
ESR raised
BNP raised
Trop T raised
Specific investigations
CXR
- Normal
- Atelectasis
- Oligemia of affected segment
- Dilated pulmonary artery
- Small effusion
- Wedge shaped opacities
ECG
- S1Q3T3 pattern, right ventricular strain, new incomplete RBBB (classical but rare)
- Atrial arrhythmias
- T wave inversion, ST changes
D dimer: degradation product of cross-linked fibrin
- Sensitivity 95%
V/Q perfusion scan: look for perfusion defects without corresponding ventilation defects
CT pulmonary angiography (gold standard)/ spiral CT
Lower limb Doppler ultrasound
Differential diagnoses
PE
Acute coronary syndrome
COPD
Myocarditis
DVT
Cellulitis
Superficial thrombophlebitis
429
Suspicion of PE
Perform Wells/Geneva
score
Low/intermediat
e probability
High probability
Start tx
D Dimer assay
D Dimer
negative
CTPA
D Dimer
positive
No tx
CTPA
negative
CTPA
CTPA
negative
CTPA
positive
No tx
Start tx
Lower limb
DVT scan
Scan
negative
Stop tx
CTPA
positive
Continue tx
Scan
positive
Continue tx
430
Management
Assess ABCs
Stabilise the patient
- supportive measures eg. supplemental O2
- cautiously administer intravenous fluids (avoid ppting right heart failure)
- vasopressor therapy
Anticoagulation
- Reduces mortality by preventing recurrent PE
- In those with high probability of PE, start anticoagulation before investigations
- Greatest efficacy if therapeutic heparin levels are initiated within 24 hours
- In hemodynamically stable patients with PE, SC LMWH is preferred
- Patients in whom anticoagulation was initiated during the resuscitative period should remain
anticoagulated during the diagnostic evaluation. Anticoagulation should be discontinued of PE
is excluded
- Long-term anticoagulation with warfarin is indicated if PE is confirmed
Inferior vena caval filter placement should be considered if anticoagulation is contraindicated (patient
has active bleeding), fails, or causes complications (eg, severe bleeding)
- results in less recurrence of PE
- but recurrent DVT was more common among patients who received an IVC filter
Thrombolysis should be considered once PE is confirmed
- Accelerates the lysis of acute pulmonary emboli
- Increased likelihood of major hemorrhage
- If thrombolysis is chosen, anticoagulation should be temporarily discontinued then resumed
- No mortality benefit, but shown to improve RV function
- Persistent hypotension due to massive PE is a widely accepted indication for thrombolysis
Embolectomy
- Removal of embolus using catheters or surgically
- When thrombolysis either fails or is contraindicated
- Catheter emboleeectomy: injecting pressurized saline through the catheter's distal tip, which
macerates the embolus. The saline and fragments of clot are then sucked back into an exhaust
lumen of the catheter for disposal
Preventive management: elastic stockings, leg exercises, ambulation, long term anticoagulation with
warfarin
431
Anticoagulation regimes
DRUG THERAPY
LMWH (fraxiparin, enoxaparin)
- results in lower mortality, fewer recurrent thrombotic events, and less major bleeding than UFH
- greater bioavailability, once or twice daily administration, fixed dosing (ie, dose does not require
adjustment), no required laboratory monitoring, and decreased likelihood of thrombocytopenia
- exception: patients who are pregnant or have severe renal failure require anti-Xa assay monitoring
after administration of SC LMWH
Unfractionated heparin (continuous iv infusion)
- preferred in patients with persistent hypotension due to massive PE; severe renal failure (aPTT
monitoring is easier than anti-Xa assay)
- target 1.5-2.3 x the control aPTT
- protamine sulphate is the antidote for heparin (cannot fully reverse LMWHs anti-Xa effects)
Fondaparinux (new)
- synthetic heparin pentasaccharides that catalyse factor Xa inactivation by antithrombin, without
inhibiting thrombin
- may be a viable alternative to unfractionated heparin
Warfarin
- risk factors for bleeding: age >75, concurrent aspirin therapy, hypertension, CVA, renal insufficiency,
heart disease, cancer
- Vit K and FFP are antidotes for warfarin
DURATION
First episode of
PE/DVT
Reversible risk
factor eg. recent
surgery
Warfarin
3-6 months
No identifiable risk
factor
Recurrent episode of
PE/DVT
Irreversible risk
factor eg. ptn C
deficiency, APS
Warfarin
6-12 months,
consider indefinite
therapy
Indefinite therapy
Treatment duration among patients with a first episode of PE or deep vein thrombosis (DVT) is
determined by whether a risk factor can be identified and, if so, whether the risk factor is reversible.
Reversible risk factor eg, immobilization, surgery, trauma: warfarin for 3-6 months
No identifiable risk factors ie, idiopathic PE or DVT: at least 6 to 12 months, consider indefinite
anticoagulation
Irreversible risk factor eg. protein C deficiency, protein S deficiency, factor V Leiden gene mutation: at
least 6 to 12 months, consider indefinite anticoagulation
Indefinite therapy should be administered to patients with recurrent PE or DVT.
Prognosis
30% chance of developing a second embolus
Mortality rate of approximately 30 % without treatment, due mainly to recurrent embolism
Accurate diagnosis followed by effective therapy with anticoagulants decreases the mortality rate to 2
to 8 %
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