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Author 7 Posts
James
Senior Member

Topics: 14
Posts: 127
Posted 12/13/11 - 12:07 AM report   #1
Manifestations of fat emboli.

Typically a patient with trauma to the tibia or femur who has altered sensorium WITH pulmonary infiltrates and ARDS like picture. Very hypoxic.

You may be shown a picture of the fundus with a yellowish/whitish fat embolus seen in one of the retinal arteries.

It is unlikely that they describe shimmering fat globules in urine as the diagnosis will then be too easy.

CT head will be normal and no bacteria will grow out of any cultures.

Treatment is supportive. (To learn any more about this condition is useless for internal medicine)


James
Senior Member

Topics: 14
Posts: 127
Posted 12/13/11 - 12:09 AM report   #2
Asthma

Spirometry has been strongly recommended in cases where diagnosis of asthma is being considered as most physicians are not good at diagnosing if obstruction of airways is reversible or not. The following findings are important indicators of reversibility of broncho-constriction in a case of asthma.

1) Peak Flow variation by more than 20% from pre inhaler PF in AM compared to PF post inhaler in mid afternoon

2) After bronchodilator, FEV 1 increases either by more than 200cc or by more than 12% of pre-bronchodilator value.

Spirometry is better for diagnosing because peak flow varies from manufacturer to manufacturer. Spirometry can be considered after age 4 (some kids at 7).

It is critical for the exam to know when you must start a preventive therapy like inhaled steroids:

Preventive therapy should be initated if symptoms occur more than twice a WEEK in the daytime or more than twice a MONTH at night-time. Another critereon is usage of more than 2 inhaler canisters in a year. At this stage - asthma is considered persistent as opposed to intermettent.

Other preventive measures include LtD4 inhibitors, Salmeterol and Theophylline. In non responders, oral steroids can be used.


James
Senior Member

Topics: 14
Posts: 127
Posted 12/13/11 - 12:11 AM report   #3
Obstructive: FEV1/FVC reduced < 70% predicted

Restrictive: FEV1/FVC normal or increased but both are reduced compared to predicted.

Cystic fibrosis: Mixture of restrictive and obstructive

Scleroderma: Restrictive, HRCT very suggestive.

Emphysema: Obstructive, DLco decreased, HRCT diagnostic, Compliance increased.

Chronic bronchitis: Obstructive, Reids index increased (ratio of bronchial wall mucus secreting layer thickness total thickness).

Pulmonary Hemorrhage: DLco increased only in this condition. Please remember that there is pulmonary hemorrhage in goodpasture's syndrome.
James
Senior Member

Topics: 14
Posts: 127
Posted 12/13/11 - 12:14 AM report   #4
Drugs and Lung disease

Pulmonary infiltrates- Amiodarone, Nitrofurantoin, Methotrexate, Methysergide.

DRY Cough, Angioedema- ACE Inhibitors

Respiratory depression- Aminoglycosides due to NM Junction blocking effect.
Hypnotics/sedatives/opiates

Bronchospasm- Beta blockers, NSAIDs, Cholinergic meds e.g. Bethanechol used in urinary spasm or eye drops for glaucoma e.g. pilocarpine or cholinesterase inhibitors like Edrophonium

Churg-Strauss syndrome- Leukotrine inhibitors e.g. Zafirlukast.

Pleural and pericardial effusion- Minoxidil, Hydralazine.

James
Senior Member

Topics: 14
Posts: 127
Posted 01/31/12 - 06:35 PM report   #5
Contraindications to Noninvasive Positive-Pressure Ventilationa

Medical Instability
Respiratory or cardiac arrest
Severe respiratory acidosis (pH <7.10)
Hemodynamic instability
Cardiogenic shock
Cardiac arrhythmia
Upper gastrointestinal bleeding
Unable to Protect Airway
Excessive secretions
Severe bulbar dysfunction
Excessive somnolence/encephalopathy
Mechanical Issues
Unable to fit mask/large air leak
Recent facial trauma or surgery
Facial deformity
Upper airway obstruction
James
Senior Member

Topics: 14
Posts: 127
Posted 01/31/12 - 06:37 PM report   #6
Findings Suggestive of the Need for Invasive Mechanical Ventilation
Clinical Parameters
Lack of improvement after 2 hours of noninvasive positive-pressure ventilation
Difficulty maintaining airway
Decreased level of consciousness
Narrowed upper airway
Excessive secretions
Impaired cough
Hemodynamic instability
Prominent accessory muscle use
Laboratory and Ventilatory Parameters
Severe respiratory acidosis (pH <7.20)
Severe hypoxemia (PO2/FiO2 <200)
Rise in PCO2 >10 mm Hg
Respiration rate >35/min
Unable to generate negative inspiratory force >30 cm H2O
James
Senior Member

Topics: 14
Posts: 127
Posted 01/31/12 - 07:55 PM report   #7
Laboratory Abnormalities in Rhabdomyolysis
Elevated total serum creatine kinase level
Hyperkalemia
Positive serum myoglobin
Myoglobinuria
Hyperphosphatemia
Hypocalcemia
Elevated lactate dehydrogenase, aminotransferases, aldolase, carbonic anhydrase III, and hydroxybutyric acid
Hyperuricemia
Anion gap metabolic acidosis
Elevated serum creatinine and a decreased blood urea nitrogen/serum creatinine ratio
Prolonged prothrombin time and activated partial thromboplastin time and thrombocytopenia








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