Download Approach to Internal Medicine: A Resource Book for Clinical by David Hui, Alexander A. Leung, Raj Padwal PDF

By David Hui, Alexander A. Leung, Raj Padwal

This absolutely up-to-date 4th version of offers an built-in symptom- and issue-based process with quick access to excessive yield scientific info. for every subject, conscientiously geared up sections on assorted diagnoses, investigations, and coverings are designed to facilitate sufferer care and exam education. a variety of scientific pearls and comparability tables are supplied to aid increase studying, and overseas devices (US and metric) are used to facilitate software in daily scientific practice.

The e-book covers many hugely vital, hardly ever mentioned subject matters in drugs (e.g., smoking cessation, weight problems, transfusion reactions, needle stick accidents, code prestige dialogue, interpretation of gram stain, palliative care), and new chapters on end-of-life care and melancholy were further. The fourth variation comprises many reader-friendly advancements corresponding to greater formatting, intuitive ordering of chapters, and incorporation of the newest instructions for every subject. method of inner drugs maintains to function a necessary reference for each clinical pupil, resident, fellow, training surgeon, nurse, and surgeon assistant.

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PROGNOSIS · TYPE A—with surgery, 1-month survival 75–80%, 10-year survival 55% Acute Coronary Syndrome CARDIAC MYOCARDIAL —myocardial 1-month survival >90%, 10-year survival 56% MANAGEMENT ABC—O2 to keep sat >95%, IV, antihypertensive therapy (keep HR <60 and SBP <120 mmHg. 25–3 μg/ kg/min, maximum 10 μg/kg/min) TREAT UNDERLYING CAUSE—Type A (emergent surgical repair, endovascular stenting, longterm blood pressure control). Type B (medical blood pressure control).  337) ACCF/AHA 2013 STEMI Guidelines ACCF/AHA 2007 UA/NSTEMI Guidelines ACCF/AHA UA/NSTEMI 2012 Focused Update DIFFERENTIAL DIAGNOSIS OF CHEST PAIN infarction, angina (atherosclerosis, vasospasm), myocarditis · VALVULAR—aortic stenosis · PERICARDIAL—pericarditis · VASCULAR—aortic dissection RESPIRATORY · PARENCHYMAL—pneumonia, cancer · TYPE B—with aggressive hypertensive treatment, · DIFFERENTIAL DIAGNOSIS OF CHEST PAIN CONT’D PLEURAL—pneumothorax, pneumomediastinum, pleural effusion, pleuritis · VASCULAR—pulmonary embolism GI—esophagitis, esophageal cancer, GERD, peptic ulcer disease, Boerhaave’s, cholecystitis, pancreatitis OTHERS—musculoskeletal (costochondritis), shingles, anxiety · PATHOPHYSIOLOGY Pathologic changes Clinical presentation Pre-clinical Atherosclerosis Asymptomatic Angina Luminal narrowing Central chest discomfort; worsened by exertion, emotion, and eating; relieved by rest and nitroglycerine Unstable Plaque rupture Worsening pattern or rest pain; no elevation in troponin, angina or thrombus with or without ECG changes of ischemia NSTEMI Partial occlusion Non-ST elevation MI; elevation in troponin, with or without ECG changes of ischemia STEMI Complete occlusion ST elevation MI; elevation in troponin, with distinct ST segment elevation in ≥2 contiguous leads, new LBBB, or posterior wall MI with reciprocal ST depression in precordial leads on ECG 29 Acute Coronary Syndrome PATHOPHYSIOLOGY CONT’D THIRD UNIVERSAL DEFINITION OF MYOCARDIAL INFARCTION (MI) · TYPE 1—spontaneous MI due to a primary coronary event (atherosclerotic plaque rupture or erosion with acute thromboembolism) · TYPE 2—MI secondary to an ischemic imbalance (supply demand mismatch) · TYPE 3—MI resulting in death when biomarker values are unavailable (sudden unexpected cardiac death before serum biomarkers collected for measurement) · TYPE 4—MI related to PCI (4A) or stent thrombosis (4B) · TYPE 5—MI related to CABG RISK FACTORS · MAJOR—diabetes, hypertension, dyslipidemia, smoking, family history of premature CAD, advanced age, male gender · ASSOCIATED—obesity, metabolic syndrome, sedentary lifestyle, high-fat diet · EMERGING—lipoprotein abnormalities, inflammation (↑ CRP), chronic infections, chronic kidney disease POSTMI COMPLICATIONS—arrhythmia (VT/ VF, bradycardia), sudden death, papillary muscle rupture/dysfunction, myocardial rupture (ventricular free wall, interventricular septum), ventricular aneurysm, valvular disease (especially acute mitral regurgitation), heart failure/cardiogenic shock, peri-infarction pericarditis, post-cardiac injury pericarditis (Dressler’s syndrome) CLINICAL FEATURES CHEST PAIN EQUIVALENTS—dyspnea, syncope, fatigue, particularly in patients with diabetic neuropathy who may not experience chest pain NEW YORK HEART ASSOCIATION (NYHA) CLASSIFICATION · I = no symptoms with ordinary physical activity · II = mild symptoms with normal activity (walking >2 blocks or 1 flight of stairs) · III = symptoms with minimal exertion · IV = symptoms at rest CANADIAN CARDIOVASCULAR SOCIETY CCS CLASSIFICATION · I = angina with strenuous activity · II = slight limitation, angina with meals/cold/ stress · III = marked limitation, angina with walking <1–2 blocks or 1 flight of stairs · IV = unstable angina · IVA = unstable angina resolves with medical treatment CLINICAL FEATURES CONT’D IVB = unstable angina on oral treatment, symptoms improved but angina with minimal provocation · IVC = unstable angina persists, not manageable on oral treatment or hemodynamically unstable KILLIP CLASS CLASSIFICATION · I = no evidence of heart failure · II = mild to moderate heart failure (S3, lung rales less than half way up, or jugular venous distension) · III = overt pulmonary edema · IV = cardiogenic shock · RATIONAL CLINICAL EXAMINATION SERIES: IS THIS PATIENT HAVING A MYOCARDIAL INFARCTION?

105) Approach to Chest Imaging APPROACH TO CHEST XRAY INTEPRETATION 1. ID—note patient’s name, date/time, technique (PA + lateral, or AP); if not stated, assume PA + lateral by default 2. QUALITY OF CXR · ROTATION—equi-distance between clavicular heads and spinous process · PENETRATION—intervertebral space seen behind cardiac silhouette · INSPIRATION—at least 6–8 ribs anteriorly, or 9–11 ribs posteriorly · FIELD—ensure the entire thorax is captured on film 3. DEVICES—previous sternotomy, mechanical valves, pacemaker, central lines (tip at level of carina), PICC line, Swan Ganz, endotracheal tube (two vertebral spaces above carina or aortic notch), NG tube, ECG leads, pacer wires, O2 tubing, nipple markers (used to differentiate nipple shadows from pulmonary nodules) 4.

E. positive portion of the flow–volume loop) RESTRICTIVE DISEASE—expiratory portion of curve appears relatively tall (preserved flow rates), but narrow (↓ lung volumes) SPIROMETRY AND LUNG VOLUME PATTERNS OBSTRUCTIVE DISEASE—↓ FEV1/FVC ratio (↓ FEV1 out of proportion to ↓ FVC); definitions vary but GOLD criteria define ↓ FEV1/FVC as <70%. If improvement SPIROMETRY AND LUNG VOLUME PATTERNS CONT’D >12% and 200 mL post-bronchodilator, consider diagnosis of asthma (reversibility). Note that mild obstructive (small airways) disease may have normal FEV1/FVC with ↓ FEF 25–75% RESTRICTIVE DISEASE—↓ TLC, defined as <80% predicted (only applies to plethysmography); 70–79% = mild; 60–69% = moderate; <60% = severe.

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