By David Hui, Alexander A. Leung, Raj Padwal
This totally up to date 4th version of offers an built-in symptom- and issue-based procedure with quick access to excessive yield scientific info. for every subject, rigorously geared up sections on diversified diagnoses, investigations, and coverings are designed to facilitate sufferer care and exam education. various medical pearls and comparability tables are supplied to aid increase studying, and foreign devices (US and metric) are used to facilitate program in daily medical practice.
The publication covers many hugely vital, hardly mentioned themes 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 contains many reader-friendly advancements corresponding to higher formatting, intuitive ordering of chapters, and incorporation of the latest instructions for every subject. method of inner medication keeps to function an important reference for each scientific scholar, resident, fellow, working towards medical professional, nurse, and health care professional assistant.
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Extra info for Approach to Internal Medicine: A Resource Book for Clinical Practice (4th Edition)
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 POSTMI 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?
Urgent interventional bronchoscopy (cold saline, topical epinephrine, cautery, airway blocker, double lumen endotracheal tube). Angiographic arterial embolization. ]. If <3 cm, 20–50% malignant. If ≥3 cm, 50% malignant TIMING—if malignant, usually able to detect an increase in size of SPN between 30 days and 2 years. Unlikely to be malignant if significant change in <30 days or no change in 2 years CALCIFICATION CLUES · MALIGNANCY —eccentric calcification or noncalcified · TUBERCULOSIS OR HISTOPLASMOSIS—central/ complete calcification · BENIGN HAMARTOMA—popcorn calcification · · MANAGEMENT TREAT UNDERLYING CAUSE —if low probability, observation with serial CT scans.
PFT shows mainly restrictive lung disease pattern TREATMENTS—prednisone 1 mg/kg PO daily Obstructive Sleep Apnea DIFFERENTIAL DIAGNOSIS OF SLEEP DISORDERS HYPERSOMNOLENCE · SLEEP DISRUPTION—obstructive sleep apnea (OSA), periodic limb movement disorder · INADEQUATE SLEEP TIME—medicine residents, shift workers · INCREASED SLEEP DRIVE—narcolepsy, primary CNS hypersomnolence, head injury, severe depression, medications INSOMNIA · ACUTE—stress, travel through time zones, illness, medications (steroids), illicit drugs (stimulants) · CHRONIC—conditioned, psychiatric disorders, poor sleep hygiene, medical disorders, pain, restless leg syndrome, circadian rhythm disorder PARASOMNIA—sleep walking, sleep terrors, nocturnal seizures, rapid eye movement behavior disorder PATHOPHYSIOLOGY ABNORMAL PHARYNX ANATOMY—decreased upper airway muscle tone and reduced reflexes protecting pharynx from collapse, increased hypercapnic set point → airway collapse with hypoxemia and hypercapnia → partial collapse leads to snoring and hypopnea, full collapse leads to apnea → terminated with arousal → repeated arousals lead to hypersomnolence.
Approach to Internal Medicine: A Resource Book for Clinical Practice (4th Edition) by David Hui, Alexander A. Leung, Raj Padwal