By Y. Dan. Southern Wesleyan University. 2018.
The late inspiratory crackles are typical of pulmonary oedema and the chest X-ray confirms this showing hilar flare with some alveo- lar filling purchase clindamycin 150mg overnight delivery, Kerley B lines at the lung bases and blunting of the costophrenic angles with small pleural effusions clindamycin 150mg on-line. The first four of these could produce pulmonary oedema and a raised jugular venous pressure as in this man. Pulmonary embolism would be compatible with a raised jugular venous pressure but not the findings of pulmonary oedema on examination and X-ray. Acute mitral regurgitation from chordal rupture and ischaemic perforation of the inter- ventricular septum both produce a loud pansystolic murmur. The site of maximum inten- sity of the murmur may differ being apical with chordal rupture and at the lower left sternal edge with ventricular septal defect, but this differentiation may not be possible with a loud murmur. The management of acute ventricular septal defect or chordal rupture would be similar and should involve consultation with the cardiac surgeons. Milder degrees of failure with a pansystolic murmur may occur when there is ischaemia of the papillary muscles of the mitral valve. This is managed with anti- failure treatment, not surgical intervention, and can be differentiated by echocardiography. He has complained of general pains in the muscles and he also has some pains in the joints, particularly the elbows, wrists and knees. Three weeks earlier, he fell and hit his leg and has some local pain related to this. He is a non-smoker who does not drink any alcohol and has not been on any medication. Twelve years ago he had a myocardial infarction and was put on a beta-blocker but he has not had a prescription for this in the last 6 years. Examination He is tender over the muscles around his limb girdles and there is a little tenderness over the elbows, wrists and knees. There are no other abnormalities to find in the cardiovascular, respiratory or alimentary systems. There are some larger areas of bruising on the arms and the legs which he says have not been associated with any trauma. He lives alone on a second-floor flat which may make it difficult for him to get out. He has a petechial rash which could be related to coagulation problems, but the platelet count is normal. It would be important to examine the rash carefully to see if it is distributed around the hair follicles. A number of the features suggest a possible diagnosis of scurvy from vita- min C deficiency. The rash, muscle and joint pains and tenderness, poor wound healing and microcytic anaemia are all features of scurvy. The classic feature of bleeding from the gums would not be present in an edentu- lous patient. Plasma measurements of vitamin C are difficult because of the wide range in normal sub- jects. In this patient, replacement with ascorbic acid orally cleared up the symptoms within 2 weeks. It would be important to look for other nutritional deficiencies in this situation and to make arrangements to ensure that the situation did not recur after his discharge from hospital. A used packet of paracetamol and dihydrocodeine is found in one of his pockets but no illicit drugs and no means of identification. Examination Tendon reflexes are present and equal except the ankle reflexes which are absent. Little history is available, but the tablets in his pocket might suggest that he has a problem with a painful condition. There are a number of possible causes for his unconsciousness including a cere- brovascular problem, deliberate or accidental drug overdose, including alcohol poisoning, metabolic or endocrine disturbance or hypothermia. The slow respiratory rate could be compatible with an opiate excess suppressing ventilation. It would be appropriate to measure the paracetamol level in the blood and it would be worth giving the opiate antagonist naloxone if there remained a likelihood of overdose. Most cerebrovascular problems would be expected to produce some localizing neuro- logical signs on careful examination even in an unconscious patient. He could have hyperosmolar non-ketotic coma detected by a high glucose and evidence of haemoconcentration. Indeed, in this case, repeat of the rectal temperature measurement with a low-reading thermometer showed a tem- perature of 30. No paracetamol was detected in the blood and his alcohol level was low at 11 mg/100 mL. If this is not achieved by covering the patient with blankets, then warmed inspired oxygen, warm intravenous fluids, bladder or peritoneal lavage might be consid- ered.
Allergens detected in association with airborne particles capable of penetrating into the peripheral lung discount clindamycin 150mg otc. Airborne concentrations and particle size distribution of allergen derived from domestic cats (Felis domesticus) buy 150mg clindamycin amex. The bronchial late response in the pathogenesis of asthma and its modulation by therapy. Exposure to an aeroallergen as a possible precipitating factor in respiratory arrest in young patients with asthma. Exposure to house-dust mite allergen (Der p I) and the development of asthma in childhood: a prospective study. Wheat sensitization and work-related symptoms in the baking industry are preventable. Respiratory function and immunologic status in workers processing dried fruits and teas. Exposure: sensitization relationship for a-amylase allergens in the baking industry. The development of respiratory syncytial virus-specific IgE and the release of histamine in nasopharyngeal secretions after infection. Sibling, day-care attendance, and the risk of asthma and wheezing during childhood. Aspirin-sensitive rhinosinusitis asthma: a double-blind crossover study of treatment with aspirin. Precipitating factors in asthma: aspirin, sulfites, and other drugs and chemicals. Overexpresssion of leukotriene C 4 synthase in bronchial biopsies from patients with aspirin-intolerant asthma. Patterns of improvement in spirometry, bronchial hyperresponsiveness and specific IgE antibody levels after cessation of exposure in occupational asthma caused by snow-crab processing. Reactive airway dysfunction syndrome in three police officers following a roadside chemical spill. A longitudinal study of the occurrence of bronchial hyperresponsiveness in Western red cedar workers. Montelukast, a leukotriene-receptor antagonist, for the treatment of mild asthma and exercise-induced bronchoconstriction. Cigarette smoking and ozone-associated emergency department use for asthma by adults in New York City. Combined nasal challenge with diesel exhaust particles and allergen induces in vivo IgE isotope switching. Regular use of inhaled albuterol and the allergen-induced late asthmatic response. Long-term effects of a long-acting b 2-adrenoceptor agonist, salmeterol, on airway hyperresponsiveness in patients with mild asthma. Lack of subsensitivity to albuterol after treatment with salmeterol in patients with asthma. Continuously nebulized albuterol in severe exacerbations of asthma in adults: a case-controlled study. Dose-response evaluation of levabuterol versus racemic albuterol in patients with asthma. Corticosteroids in the emergency department therapy of acute adult asthma: an evidence-based evaluation. Efficacy of short-term corticosteroid therapy in outpatient treatment of acute bronchial asthma. Effect of a short course of prednisone in the prevention of early relapse after the emergency room treatment of acute asthma. Inhaled budesonide in addition to oral corticosteroids to prevent asthma relapse following discharge from the emergency department: a random controlled trial. Double-blind evaluation of methylprednisolone versus placebo for acute asthma episodes. An inhaled corticosteroid, budesonide, reduces baseline but not allergen-induced increases in bone marrow inflammatory cell progenitors in asthmatic subjects. Addition of salmeterol versus doubling the dose of beclomethasone in children with asthma. Comparison of prednisolone kinetics in patients receiving daily or alternate-day prednisone for asthma. Effects of reducing or discontinuing inhaled budesonide in patients with mild asthma.
Addison s disease might be linked with respiratory problems through adrenal involvement by metastases or tuberculosis proven clindamycin 150mg. This can be confirmed by measurement of serum and urine osmolarities to show serum dilution while the urine is concentrated buy generic clindamycin 150 mg. Fluid restriction to 750 mL daily produced an increase in serum sodium to 128 mmol/L with improvement in the confusion and weakness. Such treatment often produces a response in terms of shrinkage of the tumour, improved quality of life and increased survival. Small-cell undifferentiated carcinomas of the lung are fast-growing tumours, usually unresectable at presentation. Her 20-year-old son has asthma and she has tried his salbutamol inhaler on two or three occasions but found it to be of no real benefit. She has tested herself on her son s peak flow meter at home and she has obtained values of about 100 L/min. On direct question- ing she says that the shortness of breath tends to be worse on lying down but there are no other particular precipitating factors or variations through the day. There is a generalized wheeze heard all over the chest but no other abnormalities. It is similar in both inspiration and expiration as shown in the flow volume loop (Fig. The spirometry trace of volume against time in such cases shows a straight line of the same reduced flow right up to the vital capacity. On examination, this airway narrowing is likely to produce a single monophonic wheeze which may be heard over a wide area of the chest. Differential diagnosis of rigid large-airway obstruction The situation may easily be confused with asthma if the peak flow and the wheezing are accepted uncritically. The wheezing in asthma comes from many narrowed airways of different calibre and mass, and the wheezes are often described as polyphonic. The fixed flow in inspiration and expiration in this case suggest a rigid large-airway nar- rowing. If the narrowing can vary a little with pressure changes, then the pattern will depend on the site of the narrowing (Figs 99. If it is outside the thoracic cage, as in a laryngeal lesion, it will be more evident on inspiration. Large-airway narrowing can be caused by inflammatory conditions such as tuberculosis or Wegener s granulomatosis, damage from prolonged endotracheal intubation or by extrinsic pressure such as a retrosternal goitre. The great majority of symp- tomatic lung tumours are visible on plain chest X-ray but central lesions in large airways may not be seen. In this case, fibre-optic bronchoscopy showed a carcinoma in the lower trachea reducing the lumen to a small orifice. Treatment was by radiotherapy with oral steroids to cover any initial swelling of the tumour which might increase the degree of obstruction in the trachea. She has had two previous admissions to hospital within the last 6 months, once for an overdose of heroin and once for an infection in the left arm. The heart sounds are normal and there are no abnormal findings on examination of the respiratory system. The respiratory rate is18/min, jugular venous pressure is not raised, there are no new heart murmurs and oxygen saturation is 97 per cent on room air. This complication is not unusual in intravenous drug users and can be associated with sepsis although there was no sign of this on the initial investigations. She has been treated for the thrombosis and for alcohol withdrawal and her opiate use. The deep vein thrombosis would have predisposed her to a pulmonary embolus, but the normal respiratory rate, lack of elevation of jugular venous pressure and normal oxygen saturation make this unlikely. As an intravenous drug user she might have taken more drugs even under supervision in hospital. The tachycardia and lowered blood pressure raise the possibility of haemorrhage which might be precipitated by the anticoagulants. In an intravenous drug user one would think of infective endocarditis which may occur on the valves of the right side of the heart and be more difficult to diagnose. Lung abscesses from septic emboli are another possibility in an intravenous drug user with a deep vein thrombosis, and a chest X-ray should be taken although the lack of respiratory symptoms makes this less likely. In this case the intravenous line has been left in place longer than usual because of the difficulties of intravenous access and it has become infected. Lines should be inspected every day, changed regularly and removed as soon as possible.
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