By David Hui (auth.)

This booklet presents an built-in symptom-based and issue-based technique with easy accessibility to excessive yield medical info. for every subject, rigorously equipped sections on varied diagnoses, investigations and coverings are designed to facilitate sufferer care and exam instruction. - a variety of scientific pearls and comparability tables aid improve studying. - overseas devices (US and metric) facilitate program in daily medical perform. - Many hugely very important, not often mentioned subject matters in drugs are coated (e.g., smoking cessation, weight problems, transfusion reactions, needle stick accidents, code prestige dialogue, interpretation of gram stain, palliative care). - crucial reference for each scientific scholar, resident, fellow, working towards health care provider, nurse, and health care professional assistant. - 3rd version has new layout with reader pleasant improvements.

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PULMONARY HYPERTENSION DUE TO CHRONIC THROMBOTIC DISEASE, EMBOLIC DISEASE, OR BOTH—thromboembolic obstruction of proximal pulmonary arteries, thromboembolic obstruction of distal pulmonary arteries, pulmonary embolism (tumor, parasites, foreign material) GROUP V. MISCELLANEOUS—sarcoidosis, pulmonary Langerhans cell histiocytosis, lymphangiomatosis, compression of pulmonary vessels (adenopathy, tumor, fibrosing mediastinitis) CLINICAL FEATURES (CONT’D) murmur, Graham Steell murmur (high-pitched, decrescendo diastolic rumble over LUSB), crackles, congestive liver, ascites, ankle edema INVESTIGATIONS BASIC  LABS—CBCD, lytes, urea, Cr, AST, ALT, ALP, bilirubin, INR, albumin, ANA, RF, anti-CCP, anti-SCL 70, anticentromere antibody, ESR, HIV serology, TSH  IMAGING—CXR, CT chest, V/Q scan or CT chest PE protocol, echocardiogram  ECG  OVERNIGHT POLYSOMNOGRAPHY—if suspect OSA  ABG  PFT SPECIAL  RIGHT HEART CATHETERIZATION PATHOPHYSIOLOGY DEFINITION OF PULMONARY HYPERTENSION— mean pulmonary arterial pressure (PAP) >25 mmHg at rest or mean PAP >30 mmHg with exercise measured with right heart catheterization CLINICAL FEATURES HISTORY—unexplained dyspnea on exertion, cough, chest pain, hemoptysis, dizziness, syncope, hoarseness, past medical history (cardiac and respiratory diseases, thromboembolic diseases, HIV, cirrhosis, autoimmune and rheumatologic disorders), medications (amphetamine, diet pill such as dexfenfluramine) PHYSICAL—vitals (tachypnea, tachycardia, atrial fibrillation, hypoxemia), peripheral cyanosis, small pulse volume, elevated JVP (prominent a wave or absent if atrial fibrillation, large v wave), right ventricular heave, palpable P2, narrowly split or paradoxically split S2, right-sided S4, tricuspid regurgitation MANAGEMENT SYMPTOM CONTROL—O2, calcium channel blockers if positive vasoreactivity test (high doses), vasodilators (prostacyclin, sildenafil, bosentan, NO), anticoagulation TREAT UNDERLYING CAUSE ATRIAL SEPTOSTOMY LUNG TRANSPLANT SPECIFIC ENTITIES EISENMENGER SYNDROME—left-to-right shunt leading to pulmonary hypertension and eventually right-to-left shunt THYROTOXIC-ASSOCIATED PULMONARY HYPERTENSION—pulmonary artery hypertension and isolated right-sided heart failure are associated with hyperthyroidism.

Efferent signals travel down the vagus, phrenic, and spinal motor nerves ! expiratory muscles ! 03% 2 sprays/nostril BID– TID, nasal corticosteroids, nasal saline rinses BID), surgical correction for anatomical abnormalities    INVESTIGATIONS BASIC  MICROBIOLOGY—sputum Gram stain/AFB/C&S Hemoptysis DIFFERENTIAL DIAGNOSIS DIFFERENTIAL DIAGNOSIS (CONT’D)  INFECTIONS—necrotizing NON-CARDIOPULMONARY—epistaxis, upper GI bleed, coagulopathy CARDIAC—HF, mitral stenosis PULMONARY  AIRWAY—bronchitis (acute, chronic), bronchiectasis, malignancy, foreign body, trauma  PARENCHYMA  MALIGNANCY—lung  cancer, metastasis pneumonia (Staphylococcus, Pseudomonas), abscess, septic emboli, TB, fungal  ALVEOLAR HEMORRHAGE—Wegener’s granulomatosis, Churg–Strauss, Goodpasture disease, pulmonary capillaritis, connective tissue disease VASCULAR—pulmonary embolism, pulmonary hypertension, AVM, iatrogenic 13 Solitary Pulmonary Nodule PATHOPHYSIOLOGY MASSIVE HEMOPTYSIS—100–600 mL blood in 24 h.

Monitor over time with serial CT/MR chest Related Topics Acute Coronary Syndrome (p. 26) Stroke (p. 7 APPROACH—‘‘radiation of chest pain, diaphoresis, hypotension, and S3 suggest acute MI. Chest pain that is pleuritic, sharp or stabbing, positional or reproduced by palpation decreases likelihood of acute MI. On ECG, any ST ", new Q waves, or new conduction D make acute MI very likely. Normal ECG is very powerful to rule out MI’’ JAMA 1998 280:14 INVESTIGATIONS BASIC  LABS—CBCD,    lytes, urea, Cr, glucose, troponin/ CK Â3 q8h, AST, ALT, ALP, bilirubin, INR/PTT, Mg, Ca, PO4, albumin, lipase, fasting lipid profile, HbA1C IMAGING—CXR, echocardiogram (first 72 h), MIBI/thallium (>5 days later) ECG—q8h Â3 or with chest pain STRESS TESTS—ECG, echocardiogram, MIBI once stable (>48 h post-MI)  CORONARY CATHETERIZATION DIAGNOSTIC AND PROGNOSTIC ISSUES RATIONAL CLINICAL EXAMINATION SERIES: IS THIS PATIENT HAVING A MYOCARDIAL INFARCTION?

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