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By E. Ketil. Judson College, Marion AL. 2018.

The alveolar filling process of ARDS affects all lung units equally C ginette-35 2mg without prescription. Gas exchange in ARDS is characterized initially by hypoxemia that is refractory to increasing concentrations of inspired oxygen discount 2 mg ginette-35 mastercard, imply- • • ing the presence of V/Q mismatching D. Respiratory failure is the most common cause of death in patients with ARDS 34 BOARD REVIEW Key Concept/Objective: To understand the diagnosis and management of ARDS In ARDS patients, the underlying inflammatory response causes high levels of neu- trophils and their secretory products in bronchoalveolar lavage liquid; this characteris- tic distinguishes noncardiogenic from cardiogenic edema. Typically, portable antero- posterior chest radiography reveals a diffuse and homogeneous alveolar filling process. When examined by CT, however, the air-space filling pattern frequently appears less homogeneous. Radiographs with the patient in the supine position typically show a greater degree of consolidation in posterior lung zones than in anterior lung zones. Gas exchange in ARDS is characterized initially by hypoxemia that is refractory to increas- ing concentrations of inspired oxygen, implying the presence of increased intrapul- monary shunting. Sepsis is the most common cause of death during the course of ill- ness. As a result of state-of-the-art ventilatory-support techniques, respiratory failure is the cause of death in fewer than 20% of cases—a fact that highlights the importance of dysfunction of other organ systems in causing morbidity and mortality. A 65-year-old man presents to the emergency department complaining of progressive shortness of breath and lower leg swelling. Evaluation reveals increased jugular venous pressure, bilateral crackles, an S3 gal- lop, and moderate lower extremity edema. A chest radiograph shows cardiomegaly and bilateral pulmonary edema. What is the most common cause of cardiogenic pulmonary edema? Pulmonary venous obstruction Key Concept/Objective: To understand the most common cause of cardiogenic pulmonary edema Cardiogenic pulmonary edema is caused by increased capillary pressure (hydrostatic forces); fluid accumulates first in the airways, then in the alveolar interstitium, and finally in the alveolar space. The most common cause of cardiogenic pulmonary edema is left ventricular dysfunction. In congestive cardiomyopathy, the systolic performance of the left ventricle is impaired, the ventricle is dilated, and left ventricular end-dias- tolic pressure (LVEDP) is increased. The rise in LVEDP leads to an increase in pulmonary capillary pressure. The family of a 72-year-old female patient meets with you to discuss her condition. The patient was admitted to the intensive care unit with ARDS 2 days ago and has required mechanical ventilation and vasopressors. Which of the following is NOT a factor associated with a worse prognosis? Longer duration of positive pressure ventilation Key Concept/Objective: To know the factors associated with a worse prognosis for patients with ARDS ARDS is frequently part of a systemic inflammatory response syndrome. This highlights the importance of multiple organ systems in the course of the disease. Factors associat- ed with higher mortality in patients suffering from ARDS include a higher number of organ systems in failure, a higher number of days of organ-system failure, and age 14 RESPIRATORY MEDICINE 35 greater than 65 years. A longer duration of positive pressure ventilation is associated with a worse pulmonary functional outcome. The most common cause of death in patients with ARDS is sepsis. A 34-year-old woman with a diagnosis of primary pulmonary hypertension returns for evaluation. She has had a progressive increase in her dyspnea over the past 6 months. Evaluation by an otolaryngologist led to a diagnosis of Ortner syndrome. One week ago, she had onset of chest pain and an episode of syncope. Of the symptoms this patient has had, which one suggests the worst prognosis?

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For instance cheap ginette-35 2 mg overnight delivery, the Ottawa ankle and foot rules are described in the discussion of musculoskeletal pain in Chapter 13 buy ginette-35 2mg on line. The Gail model, a well-established rule relevant to screening for breast cancer is discussed in Chapter 8. Many of the rules involve complex mathematical calculations, but others are simple. In addition to discussions of tools in the text, there are several sources of electronic “calculators,” based on rules. Box 1-1 includes a limited list of sites with clin- ical prediction calculators. These resources should be accompanied with information describing the methods by which the rule was validated. Clinical practice guidelines have also been developed for the assessment and diagnosis of various conditions. They are typically developed by national advisory panels of clinical experts who base the guidelines on the best available evidence. An easily accessible source of evidence-based guidelines is the National Guideline Clearinghouse, which provides summaries of individual guidelines, as well as syntheses and comparisons on topics if mul- tiple guidelines are available. Like decision trees and diagnostic rules, guidelines should be accompanied by a description of their supporting evidence and the situations in which they should be applied. These resources are not without limitations, and it is essential that they be applied in the situations for which they were intended. In applying these to clinical situations, it is essential that the diagnostician determine the population in which the tool was developed and that it is applicable to the case at hand, as well as have accurate data to consider in their application. For instance, a clinical prediction rule based on a population of young adult college students is not valid if applied to an elderly patient. The provider must also recog- nize that these resources are intended to assist in the interpretation of a range of clinical evidence relevant to a particular problem, but that they are not intended to take the place of clinical judgment, which rests with the provider. THE DIAGNOSTIC PROCESS As noted earlier, the process of diagnostic reasoning begins when the patient is first encoun- tered. As data is collected through the history and physical examination, providers tailor their approach to subsequent data collection. They begin to detect patterns that guide the Copyright © 2006 F. This means that conditions considered are those that most commonly cause the perceived cluster of data (probability), as well as conditions that may be less common, but would require urgent detection and action (prognosis). Several adages are frequently used when teaching health assessment, to encourage novice diagnosticians to always consider clinical explanations that are most likely to explain a patient’s situation. For instance, students often hear that, “Common diseases occur com- monly. This text describes common conditions that should be considered in the differential diagnosis of common complaints, as well as some of the less common pos- sibilities. With the emergence of conditions, zebras may well be responsible for findings and providers must always maintain some level of suspicion for these less common expla- nations. Moreover, even though it is definitely appropriate that conditions with high probabili- ties be considered in the differential diagnosis, it is also vital that those conditions that put the patient at the highest risk also be considered in the diagnostic process. To do otherwise places the patient in jeopardy of life-threatening or disabling complications. These life- threatening situations are often referred to as “red flags,” which are clues signaling a high likelihood of an urgent situation, requiring immediate identification and management. This text also includes red flags for the various systems to promote their recognition in clin- ical practice. As the potential list of conditions in the differential diagnosis develops, the provider determines what, if any, diagnostic studies are warranted to confirm or rule out specific diagnoses. A knowledge of the tests’ specificity and sensitivity is helpful in the selection process. The diagnostician then combines the knowledge gained through the history and physical with the findings from any diagnostic studies to assess the probability for the con- ditions remaining in the differential diagnosis.

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In addition cheap 2 mg ginette-35 with amex, because the findings associated with the vasculitides often overlap buy 2mg ginette-35 amex, renal biopsy findings are not usually diagnostic. Abdominal CT scanning is not sensitive enough to pick up the microaneurysms of pol- yarteritis nodosa. ANCA with a perinuclear staining pattern is more likely to be present in microscopic polyarteritis than in the classic form of polyarteritis nodosa. Electro- 10 NEPHROLOGY 21 myopathy can assist in determining whether nerve damage is axonal or demyelinating, although it is rarely diagnostic. A 21-year-old college student reports abdominal pain, bilateral ankle and knee pain, bloody urine, and a worsening rash that began on his lower legs and has spread to his trunk. He denies having had any recent infectious exposures or infections; he also denies using I. On examination, the patient is afebrile, his blood pressure is 120/80 mm Hg, and his pulse is 76 beats/min. Skin examination reveals raised, indurated, purple coalescing papules on his anterior shins, lower legs, and abdomen. Urinalysis shows moderate levels of hemoglobin and protein with red blood cell casts on microscopic examination. Stool guaiac results are positive; CBC is normal, with a normal WBC differential; creatinine is 0. Skin biopsy results reveal an intense neu- trophilic infiltrate surrounding dermal blood vessels, confirming leukocytoclastic vasculitis. Renal biopsy is diagnostic for Henoch-Schonlein purpura B. Polyclonal IgG deposits on skin biopsy confirm Henoch-Schonlein purpura C. Empirical treatment for gonococcal infection should be started D. The extent of renal involvement is the most important prognostic factor E. Prednisone and cyclophosphamide therapy should be started as soon as possible Key Concept/Objective: To know the diagnosis and prognosis of Henoch-Schonlein purpura Henoch-Schonlein purpura is diagnosed on the basis of the classic tetrad of skin rash, abdominal pain, arthralgias and arthritis, and glomerulonephritis. The extent of renal involvement is the most important prognostic factor in Henoch-Schonlein purpura. Renal biopsy results are not diagnostic of Henoch-Schonlein purpura, as such results can be identical with the results obtained in cases of IgA nephropathy with IgA depo- sition in the mesangium and in cases involving severe crescent formation. Skin biopsy results also show IgA (not IgG) deposition on immunofluorescence. This patient does not have any risk factors or signs of sepsis; if there is any suspicion that gonococcal or rickettsial infection is causing the palpable purpura, empirical therapy should be start- ed immediately. Most cases of Henoch-Schonlein purpura resolve spontaneously, although prednisone and cyclophosphamide should be considered for use in the few patients with acute renal failure. A 67-year-old black man with a history of tobacco abuse and ethanol abuse is admitted for gradually worsening esophageal dysphagia complicated by a 1-day history of shortness of breath, productive cough, and fever. On examination, the patient has a temperature of 101. Chest radiography reveals a right lower lobe infiltrate consistent with aspiration pneumonia. He is placed on piperacillin-tazobactam and oxy- gen, and he gradually improves. By hospital day 3, he experiences defervescence, but on hospital day 10 he is noted to again have a fever (100. In addition, the patient has a rash, and peripheral blood eosinophilia and acute renal insufficiency are present. This patient will likely progress to end-stage renal disease 22 BOARD REVIEW B. Standard of care would include stopping the piperacillin-tazobac- tam and starting high-dose I.

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