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Q uantitative reasoning in the use and interpret at ion of test s was discussed in Part 1 3mg stromectol fast delivery. Clinically cheap 3 mg stromectol with amex, the t iming and effort wit h wh ich one pursues a definit ive diagnosis using object ive dat a depend on several fact ors: the potential gravity of the diagnosis in question generic 3mg stromectol mastercard, the clinical state of the patient, the potential risks of diagnostic testing, and the potential benefits or harms of empiric treatment. For example, if a young man is admitted to the hospital with bilateral pulmonary nodules on chest x-ray, there are many possibilities including metastatic malignancy, and aggressive pursuit of a diagnosis is necessary, perhaps -including a thoracotomy with an open-lung biopsy. Decisions like this are difficult, require solid medical knowledge, as well as a thorough understanding of one’s patient and the patient’s background and inclinations, and constitute the art of medicine. Some diseases, such as congestive heart failure, may be designat ed as mild, moderat e, or severe based on the pat ient ’s func- tional status, that is, their ability to exercise before becoming dyspneic. With some infect ions, such as syphilis, the st aging depends on t he durat ion and ext ent of t he infection, and follows along the natural history of the infection (ie, primary syphi- lis, secondar y, lat ent period, and t ert iar y/ neurosyph ilis). If neither the prognosis nor the treatment was affected by the stage of the disease process, there would not be a reason to subcat - egorize as mild or severe. The treatment should be tailored to the extent or “s t a g e ” o f the d i s e a s e. In mak- ing decisions regarding t reat ment, it is also essent ial t hat t he clinician ident ify t he therapeutic objectives. W hen patients seek medical attention, it is generally because they are bothered by a symptom and want it to go away. When physicians institute therapy, they often have several other goals besides symptom relief, such as prevention of short- or long-term complications or a reduction in mortality. For example, patients wit h congest ive heart failure are bothered by the symptoms of edema and dyspnea. Salt restriction, loop diuretics, and bed rest are effective at reducing these symptoms. It is essential that the clinician know what the therapeutic objective is, so that one can monitor and guide therapy. Some responses are clinical, such as the patient’s abdominal pain, or temperature, or pulmonary examination. Obviously, the student must work on being more skilled in eliciting the data in an unbiased and standardized manner. The student must be prepared to know what to do if the measured marker does not respond according to what is expected. Is the next step to retreat, or to repeat the metastatic workup, or to follow up with another more specific test? Ap p ro a ch t o Re a d in g The clinical problem– oriented approach to reading is different from the classic “s y s t e m a t i c ” r e s e a r c h o f a d i s e a s e. P a t i e n t s r a r e l y p r e s e n t w i t h a c l e a r d i a g n o s i s ; hence, the student must become skilled in applying the textbook information to the clinical setting. In ot her words, t he student should read with t he goal of answering specific quest ions. One way of att acking this problem is t o develop st andard “approaches” t o common -clinical problems. With no other information to go on, the student would note that this woman has a clinical diagnosis of pancreatitis. Using the “most common cause” informa- tion, the student would make an educated guess that the patient has gallstones, because being female and pregnant are risk factors. If, instead, cholelithiasis is removed from the equation of this scenario, a phrase may be added such as: “T h e ult rasonogram of the gallbladder sh ows no st ones. Now, the student would use the phrase “patients without gallstones who have pancreatitis most likely abuse alcohol. This question is difficult because the next step may be more diagnostic informa- tion, or staging, or therapy. It may be more challenging than “the most likely diag- nosis,” because there may be insufficient information to make a diagnosis and the next step may be to pursue more diagnostic information. Another possibility is that there is enough information for a probable diagnosis, and the next step is to st age t he disease. H ence, from clin ical dat a, a ju dgment n eed s t o be r en d er ed r egar din g h ow far alon g on e is on the road of: Make a diagnosis ã Stage the disease ã Treatment based on stage ã Fo ll o w res po ns e Frequent ly, the st udent is “t aught ” t o regurgit at e the same informat ion that someone has written about a part icular disease, but is not skilled at giving t he next st ep. T his t alent is learned opt imally at t he bedside, in a support ive environment, wit h freedom to make educated guesses, and with const ruct ive feedback. Make the diagnosis:“ B a s e d o n the i n f o r m a t i o n I h a v e, I b e l i e v e t h a t M r. S m i t h h a s stable angina because he has retrosternal chest pain when he walks three blocks, but it is relieved within minutes by rest and with sublingual nitroglycerin. Stage the disease:“ I d o n ’t b e l i e ve t h a t t h i s i s s e ve r e d i s e a s e b e c a u s e h e d o e s n o t have pain lasting for more than 5 minutes, angina at rest, or congestive heart failure. Treatment based on stage:“ T h e r e f o r e, m y n e x t s t e p i s t o t r e a t w i t h a s p i r i n, b e t a - blockers, and sublingual nitroglycerin as needed, as well as lifestyle changes. Fo l lo w res po ns e : “I wan t t o follow the t r eat m en t by assessin g h is p ain ( I will ask him about the degree of exercise he is able to perform without chest pain), performing a cardiac stress test, and reassessing him after the test is done. The next step depends upon the clinical state of the patient (if unst able, the next st ep is t h erapeut ic), the potential severity of the disease (the next step may be staging), or the uncertainty of the diagnosis (t h e next step is diagnost ic). This question goes further than making the diagnosis, but also requires the student to understand the underlying mechanism for the process. The student is advised to learn the mechanisms for each disease process, and not merely memorize a constellation of symptoms. The platelet- antibody complexes are then t aken from the circulation in the spleen. Because the disease process is specific for platelets, the other two cell lines (erythrocytes and leukocytes) are normal. Also, because the thrombocytopenia is caused by excessive platelet peripheral destruction, the bone marrow will show increased megakaryocytes (platelet precursors). Understanding the risk factors helps the practitioner to establish a diagnosis and to determine how to interpret tests. For example, understanding the risk factor analysis may help to manage a 45-year-old obese woman with sudden onset of dyspnea and pleuritic chest pain following an orthopedic surgery for a femur fracture. T his pat ient has numerous risk fact ors for deep venous t hrombosis and pulmonary embolism. T h u s, the n u m b er of r isk fact ors h elps t o cat egorize t he likelihood of a disease process. A clinician must understand the complications of a disease so that one may moni- tor the patient. Sometimes the student has to make the diagnosis from clinical clu es an d t h en apply h is/ h er kn owled ge of the sequ elae of the pat h ological pr ocess. For example, the st u dent sh ou ld kn ow that ch ron ic h ypert en sion may affect vari- ous end organs, such as the brain (encephalopathy or stroke), the eyes (vascular ch an ges), the kid n eys, an d the h ear t. Un d er st an din g the t ypes of con sequ en ces also helps the clinician to be aware of the dangers to a pat ient.

The midwife is auscultating the baby’s heartbeat order stromectol american express, which has been 70 bpm for 5 minutes buy stromectol with visa. The mother’s pulse is 90 order stromectol 3 mg with amex, her blood pressure is stable, and the cervix is 8 cm dilated. She collapses in the waiting room, and when you attend to sort out the situation she appears confused and is asking where she is. Earlier, in antenatal clinic she was found to have a breech presentation confirmed by scan and is await- ing a consultant outpatient appointment arranged for tomorrow. On admis- sion she experiences spontaneous rupture of membranes and the cervix is found to be 6 cm dilated. The placenta is still in situ and the midwife tells you that she has just noticed a large amount of blood in the bed. Both mother and baby are stable at the moment, but the haematology technician has just contacted you to say that the clotting screen you sent to the lab an hour ago is not normal. Her blood pressure has dropped to 70/40 and she has become unre- sponsive to questions. During the last 15 minutes the woman started bleeding heavily and so far has lost 3 litres of blood. The consultant obstetrician has been called and the 2 units of blood stored on the labour ward have already been transfused. In each scenario, choose the most appropriate immediate action that you think the obstetric team (not necessarily you personally) should take. You are asked to site an intravenous cannula whilst the midwife removes the pessary. Although the contractions lessen in frequency to 3 in 10 minutes, the baby becomes bradycardic and you can hear that the fetal heart rate has been running at 90 bpm for 4 minutes so far. The liquor is clear and intermittent auscultation of the fetal heart is reassuring. The cervix is now 8 cm dilated and the baby appears to be lying in the occipito-posterior position. On examination it is apparent that the second twin is lying transversely in the uterus. The midwife has noted meconium in the liquor and there are late decelerations on the cardiotocograph. The woman has asked for more analgesia and the midwife says that she is becoming more and more uncooperative. Answer [ ] A Abruption of the placenta B Cervical laceration C Disseminated intravascular coagulation D Placenta accreta E Placenta praevia F Retained succenturiate lobe of placenta G Rupture of the uterus H Uterine atony I Vasa praevia J Velamentous insertion of the cord Given the clinical information provided, select the most likely diagnosis for each of these obstetric patients experiencing vaginal bleeding. The mid- wife points out to you that there are blood vessels running through the membranes. Despite her epidural she seems to be in a great deal of pain and there are unmistakeable signs of severe fetal distress on the cardiotocograph. Her first baby was delivered by caesarean section because of fetal distress related to chorioamnionitis at 6 cm dilatation in the first stage. This time the cervix has reached 7 cm dilatation but the contractions have stopped. You are called because the midwife is concerned that the liquor is very heavily bloodstained. The uterus is nontender, contracting 4 in 10 minutes and the fetal heart rate has risen from a baseline of 120 before amniotomy to 180 bpm with late decelerations. For each patient select the most appropriate management plan to prevent early-onset neonatal group B streptococcal disease. She was found to have group B streptococcus on a high vaginal swab done a few weeks previously when she was seen in another maternity unit in Skegness on holiday. In her previous pregnancy she had a swab done in the first trimester that grew group B streptococcus; then she delivered at term and the baby was fine. Her previous baby developed meningitis after delivery that was subsequently found to be due to group B streptococcus. Following that delivery, she developed a rash when she was given penicillin in the puerperium to prevent her developing endometritis. Learning Outcomes Even in the past when women stayed in hospital for days ‘lying-in’ (and acquir- ing venous thrombosis! Some patients are even leaving hospital the following day when they have been delivered by caesarean section. She is considering bottle feed- ing instead and the midwife asks you to see her on a home visit. Which of the following statements is correct advice regarding breast- feeding in her situation? She had a normal birth with no stitches and was sent home 6 hours post- partum, when it seemed that all was well. The baby should be isolated from the mother until she has stopped bleeding Answer [ ] 62 09:33:08. On examination her legs are of normal size and she is wearing antiembolism stockings. She should be fully anticoagulated whilst awaiting the results of tests Answer [ ] 5. The midwifery staff on the postnatal ward telephone to expedite your attendance as they are becoming concerned about her condition. She was given antibiotics in labour and tells you that the baby was admitted to the neonatal intensive care unit shortly after delivery. Her partner is not keen for her to have this done as he is having trouble coping with their toddler and wants her to go home immediately. Whilst you are counselling her about puerperal sterili- sation, which of the following statements is correct about this situation? Clip sterilisation is more likely to fail if it is done now as the fallopian tubes are thicker B. She should defer the decision 24 hours for further discussion to avoid regret Answer [ ] 5. On the third day she complains of discomfort and swell- ing in her right leg, which is clearly larger than the left leg, with a tender calf. The most appropriate medication whilst awaiting the results of further investigation is: A. Which of these statements contains correct advice regarding the management of her diabetes in the puerperium? On examination the newborn infant is well but the genitalia are ambiguous with a small phallus and some scrotal-like development of the skin. She delivered her first baby 6 weeks ago and is very upset that she has had to give up breast-feeding as she felt unable to cope. She is at present on the High Dependency Unit having a blood transfusion but her condition seems to have stabilised and her husband is at her bedside looking after the newborn baby. His mother came into hospital with them but only one person was allowed into the operating theatre with her.

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Because an increase in potassium can impair therapeutic responses discount stromectol 3mg free shipping, whereas a decrease in potassium can cause toxicity cheap 3mg stromectol with visa, it is imperative that potassium levels be kept within the normal physiologic range: 3 purchase discount stromectol online. By increasing contractility, digoxin shifts the relationship of fiber length to stroke volume in the failing heart toward that in the healthy heart. Consequently, at any given heart size, the stroke volume of the failing heart increases, causing cardiac output to rise. Consequences of Increased Cardiac Output As a result of increased cardiac output, three major secondary responses occur: (1) sympathetic tone declines, (2) urine production increases, and (3) renin release declines. Decreased Sympathetic Tone By increasing contractile force and cardiac output, digoxin increases arterial pressure. In response, sympathetic nerve traffic to the heart and blood vessels is reduced through the baroreceptor reflex. Second, afterload is reduced (because of reduced arteriolar constriction), thereby allowing more complete ventricular emptying. Third, venous pressure is reduced (because of reduced venous constriction), thereby reducing cardiac distention, pulmonary congestion, and peripheral edema. Increased Urine Production The increase in cardiac output increases renal blood flow and thereby increases production of urine. The resultant loss of water reduces blood volume, which in turn reduces cardiac distention, pulmonary congestion, and peripheral edema. The decrease in aldosterone reduces retention of sodium and water, which reduces blood volume, which in turn further reduces venous pressure. Neurohormonal Benefits in Heart Failure At dosages below those needed for positive inotropic effects, digoxin can modulate the activity of neurohormonal systems. As a result, less sodium is presented to the distal tubule, so renin release is suppressed. However, they are probably just as important as inotropic effects, and perhaps even more important. Electrical Effects on the Heart The effects of digoxin on the electrical activity of the heart are of therapeutic and toxicologic importance. It is because of its electrical effects that digoxin is useful for treating dysrhythmias (see Chapter 41). Ironically, these same electrical effects are responsible for causing dysrhythmias, the most serious adverse effect of digoxin. In these various regions, digoxin can alter automaticity, refractoriness, and impulse conduction. Whether these parameters are increased or decreased depends on cardiac status, digoxin dosage, and the region involved. Although the electrical effects of digoxin are many and varied, only a few are clinically significant. This change in ion distribution can alter the electrical responsiveness + + of the cells involved. In the ventricular myocardium, digoxin acts to shorten the effective refractory period and (possibly) increase automaticity. Adverse Effects I: Cardiac Dysrhythmias Dysrhythmias are the most serious adverse effect of digoxin. Fortunately, when used in the dosages recommended today, dysrhythmias are uncommon. Because serious dysrhythmias are a potential consequence of therapy, all patients should be evaluated frequently for changes in heart rate and rhythm. P a t i e n t E d u c a t i o n Monitoring Heart Rate Patients should be taught to monitor their pulses and instructed to report any significant changes in rate or regularity. Predisposing Factors Hypokalemia The most common cause of dysrhythmias in patients receiving digoxin is hypokalemia secondary to the use of diuretics. Because low potassium can precipitate dysrhythmias, it is imperative that serum potassium levels be kept within the normal range. If diuretic therapy causes potassium levels to fall, a potassium- sparing diuretic (e. Elevated Digoxin Levels Digoxin has a narrow therapeutic range: drug levels only slightly higher than therapeutic greatly increase the risk for toxicity. Possible causes of excessive digoxin levels include (1) intentional or accidental overdose, (2) increased digoxin absorption, and (3) decreased digoxin elimination. If digoxin levels are kept within the optimal therapeutic range—now considered to be 0. However, it is important to note that careful control over drug levels does not eliminate the risk. As discussed previously, there is only a loose relationship between digoxin levels and clinical effects. As a result, some patients may experience dysrhythmias even when drug levels are within what is normally considered a safe range. Heart Disease The ability of digoxin to cause dysrhythmias is greatly increased by the presence of heart disease. The probability and severity of a dysrhythmia are directly related to the severity of the underlying disease. Because heart disease is the reason for taking digoxin, it should be no surprise that people taking the drug are at risk for dysrhythmias. Diagnosing Digoxin-Induced Dysrhythmias Diagnosis is not easy, largely because the failing heart is prone to spontaneous dysrhythmias. Hence, when a dysrhythmia occurs, we cannot simply assume that digoxin is the cause: the possibility that the dysrhythmia is the direct result of heart disease must be considered. Compounding diagnostic difficulties is the poor correlation between plasma digoxin levels and dysrhythmia onset. Because of this loose association, the presence of an apparently excessive digoxin level does not necessarily indicate that digoxin is responsible for the problem. Laboratory data required for diagnosis include digoxin level, serum electrolytes, and an electrocardiogram. Managing Digoxin-Induced Dysrhythmias With proper treatment, digoxin-induced dysrhythmias can almost always be controlled. Basic management measures are as follows: • Withdraw digoxin and potassium-wasting diuretics. To help ensure that medication is stopped, a written order to withhold digoxin should be made. Quinidine, another antidysrhythmic drug, can cause plasma levels of digoxin to rise and so should not be used. Accordingly, patients should be taught to recognize these effects and instructed to notify the prescriber if they occur. These responses result primarily from stimulation of the chemoreceptor trigger zone of the medulla. If a potassium supplement or potassium-sparing diuretic is part of the regimen, it should be taken exactly as ordered. Drug Interactions Digoxin is subject to a large number of significant drug interactions.

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Cardiovascular • If echocardiography is normal buy stromectol online now, repeat during a spontaneous breathing trial purchase stromectol cheap online. Chapter 27 287 Circulatory support Pharmacological support 288 Mechanical circulatory support: extracorporeal life support 294 288 ChaPter 27 Circulatory support Pharmacological support there is a lack of robust clinical evidence demonstrating a positive impact on survival concerning the use of vasoactive agents buy online stromectol. Inotropic agents Catecholamines Catecholamines exert their cardiovascular efects via activity at specifc adr- energic (a, β, β2) and dopaminergic (D) receptors. Sensitive β receptor efects are evident at low plasma concentrations while α efects become more prominent at higher concentrations. Clinical indications • Pulmonary hypertension and/or rV dysfunction with potential reversibility, e. Clinical use • Initial dose: 20ppm, with subsequent reduction to achieve minimum efective dose (usually –5ppm). Where recovery or transplantation is not anticipated in a period of 28 days but is likely to occur, a long-term VaD may be used. Contraindications • Severe aortic regurgitation • Severe calcifc aorto-iliac disease and/or peripheral vascular disease • Disease of the descending aorta (aortic coarctation or aneurysm) • Sheathless insertion in severe obesity. Despite this anticoagulation with unfractionated heparin is required which must be carefully monitored by frequent activated partial thromboplastin times (aPtts). Treatment strategy • Bridge to decision • Bridge to recovery • Bridge to bridge (long-term device) • Bridge to transplantation. Indications • Dilated cardiomyopathy: • Ischaemic • Myocarditis • Peripartum • Post cardiotomy • Congenital heart disease • Primary graft failure post cardiac transplantation. Worldwide as the survival on VaDs has improved, the use of long-term VaDs for destination therapy has i. Complications were common and tended to be infection, bleeding or thromboembolic related. Risks and complications • air embolism • Bleeding • thrombotic risk • Stroke • Ischaemic limbs • haemolysis • Infection • Immobility. Cannulation is by percutaneous cannulation of a major vein (internal jugu- lar and/or femoral) with fuoroscopic (or tOe) guidance. Indications are ventilator refractory respiratory failure with predominant hypercapnia and respiratory acidosis. Some patients need it for longer and there may be an eventual need for a permanent pacemaker due to com- plications of surgery. The majority of patients never require pacing and it is difcult to predict which patients may need pacing. So, most surgeons implant ventricular wires (at least one) in all patients while some do so only when patients required pacing immediately prior to chest closure. Should a patient with a single ventricular wire require pacing a wire is placed under the skin and the pacing circuit completed by attaching the ventricular wire to the negative terminal of the pacing box. Also, when atrial wires are avoided to decrease possible complications when need for pacing is predicted to be of short duration or to suppress ectopic beats with overdrive pacing. There is a risk of ventricular tracking of atrial tachyarrhythmias which is of-set by setting a ‘maximum tracking rate’. The cardiac rate is captured by pac- ing at 20% of the intrinsic rate and then gradually reduced, establishing stable sinus rhythm. Manoeuvres which may be helpful: • Increasing pacemaker output • Correction of exacerbating factors listed earlier • reversing polarity of bipolar pacing wires • Changing to unipolar pacing with subcutaneous return pacing wire • Temporary transvenous or oesophageal pacing if threshold progressively increasing • Transcutaneous pacing in an emergency. Failure to sense This must be distinguished from normal pacemaker function with inappro- priate settings. Cross-talk This occurs in dual-chamber pacing modes when the atrial pacing spike is sensed by the ventricular wire and inhibits ventricular output. Stimulation threshold checked in all patients and sensing threshold once an intrinsic rhythm has been established. The underlying rhythm should be checked regularly by turning down the pacing rate and letting the endog- enous rhythm to emerge, thereby assessing ongoing need for pacing. Stimulation threshold This is the minimum output (mA) needed to consistently capture the heart. Sensing threshold This is the least sensitive setting (biggest mV value) at which the pacemaker can detect a heartbeat. Temporary epicardial pacing after cardiac surgery: a practical review: Part : General considerations in the management of epicardial pacing. Temporary epicardial pacing after cardiac surgery: a practical review: Part 2: Selection of epicardial pacing modes and troubleshooting. Chapter 29 313 Sedation and pain relief Introduction 34 Patient assessment 35 Pharmacology 37 Clinical protocols 39 314 ChaPter 29 Sedation and pain relief Introduction after cardiac surgery, patients require a short period of sedation or symp- tom control to minimize oxygen consumption while they re-establish their normal physiology. Patients after minimally invasive and of-pump procedures can be consid- ered for early extubation but still have to be supported with a satisfactory analgesic protocol. Principles of sedation We must diferentiate short-term sedation in the uncomplicated patient from long-term sedation in unstable patients who develop critical illness. Principles of pain relief experience of postoperative pain is often complex and multifactorial. Modern con- cepts of postoperative analgesia are based on • Multimodal approaches including local anaesthetics • Favourable pharmacokinetics and pharmacodynamics • Good ability to titrate to patient’s requirements • No or minimal adjustments in patients with organ dysfunction • Pharmaco-economics. It is based on a com- bined assessment of the mental status beyond the infuence of pharmaco- logical sedation. Normally used as an -point scale with 0=no pain and 0 (00) represent- ing the worst imaginable pain. Optimizing patient recovery this includes faster achievement of recovery goals such as extubation and mobilization, but also allows more efective physiological and functional recovery, e. Further reading haenggi M, Ypparila-Wolters h, hauser K, Caviezel C, takala J, Korhonen I, et al. Most drugs work synergistically when used together, so lower doses/concentrations of each component is advisable. Opioids Morphine Popular and efective opioid that also has sedative characteristics. Mainly used intravenously by nurse-controlled boluses or patient-controlled anal- gesia. Unsuitable for long-term exposure due to high variability in pharmaco- dynamics and metabolism. Shallow dose–response curve allows it to be used in spontaneously breathing patients. Remifentanil Ultra-short-acting fentanyl congener with context-sensitive half-time of only 3–4 minutes. Increasingly used for short-term postoperative sedation until and after extubation. Pethidine (meperidine) a relatively old phenylpiperidine with characteristics similar to morphine. Sedatives/hypnotics Propofol Popular hypnotic that is easy to titrate and rapid to recover from. When used for long-term sedation, triglyceride levels should be checked regularly. Midazolam Widely used short-acting benzodiazepine that acts as sedative, anxiolytic, amnesic, and anticonvulsant.

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