By V. Domenik. University of Maryland at Baltimore. 2019.

Most available scoring systems will provide good outcome estimates in a population of patients; however inderal 40 mg line, they are not designed to predict out­ comes for individual patients cheap inderal 40mg with visa. Mortality prediction using serial severity scores have been evaluated by a number of groups inderal 40mg free shipping. Which ofthese scoring systems is most usefl for mainte­ nance of quality control in this unit? The Glasgow coma score isnot a general-risk prognostication scoring system; whereas, all the other scoring systems listed are general-risk prognostication scores. Outcome prediction in critical care: the simplified acute physiology score models. On the second hospital day, he suddenly develops chest pain, shortness ofbreath, and a change in mental status. The cardiac examination reveals a regular rhythm, a normal 51 and accentuated 52, and a new 53 gallop. The legs are noted to have bilateral pitting edema to the level ofthe knees, and palpa­ tion reveals cool extremities and weak pulses. Co nsiderations This is a 55-year-old man with unstable angina requiring a nitroglycerin drip. On the second hospital day, he suddenly decompensates and is noted to be in cardia­ genic shock. He is in need for quick reversal of organ hypoperfsion with fluids and vasopressors, including the possible use of an intra-aortic balloon pump to bridge him to a definitive intervention such as open heart surgery with coronary artery bypass. At this juncture, the patient is critically ill, and timely and accurate diagnosis and intervention are critical to his survival. Invasive hemodynamic monitoring helps optimize fluid and vasopressor/inotropic intervention. Tech­ niques such as echocardiography, transesophageal echocardiography, Doppler, and volume-based monitoring can be used. Tme is crucial for an early diagnosis of a hemo­ dynamic catastrophe and the early detection and application of efective therapy. Monitor Critically ill patients require continuous monitoring to diagnose and manage their complex medical conditions. Co ntinuous Vital Signs Modem electronic devices continually monitor up to 5 vital signs (heart rate, res­ piration rate, skin temperature, oxygen saturation, and blood pressure). Nursing staf can review these vital signs and the patient status index regularly to identif patients expe­ riencing distress. This improves the prospect to stabilize the patient and initiate goal-directed therapy to recover from these abnormalities. Monitoring of Ca rdiac Fu nction The assessment of ventricular function is based on the measurement of both blood volume and pressure. Measurement of left ventricular dp/dtmax is a satisfactory index of ventricular contractility. The diagnosis of arrhythmias and the commencement of rapid treatment is a goal of hemodynamic monitoring. If no collateral cir­ culation exists and the cannulated artery becomes occluded, ischemia and infarc­ tion of the area distal to that artery could occur. To check collateral circulation to the hand, use the Allen test to evaluate the radial and ulnar arteries or use an ultrasonic Doppler to evaluate any of the arteries. Complications in the use of arterial lines include local obstruction with distal ischemia, external hemorrhage, massive ecchymosis with compartmental syn­ drome, dissection, air embolism, blood loss, pain, arteriospasm, and infection. Blood pressure readings are more commonly obtained by automatic self-inflating cuff devices. Under most circumstances these produce comparable blood pressure results when compared to arterial lines. Complications arose in approximately 20% of the instances in which a catheter was left in place for more than 6 days. Mixed Ve nous Oxygen Saturation Continuous monitoring of venous oxygen saturation (Svo ) by reflectometry imme­2 diately detects trends and abrupt changes in the oxygen supply-to-demand ratio. A normal2 2 Svo value does not rule out an impaired oxygen supply to individual organs. The2 pulmonary artery carries blood from all vascular beds of the body; thus, Svo repre­2 sents the amount ofoxygen in the systemic circulation that is left after passage of the blood through the tissues. Interpretation of Svo2 values might be difficult in conditions where D0 N0 relationships are altered. Arterial-venous microcircula­2 2 tory shunting in sepsis may increase Svo2 tissue oxygenation while regional tissue dysoxia is present. Monitoring of the Right Ve ntricle The right ventricle is responsible for accepting venous blood and pumping it through the pulmonary circulation. Circulatory homeostasis depends on an adequate func­ tion and synchronization of both ventricles. Intrathoracic blood volume appears to be a more reliable indicator of preload than cardiac filling pressure. Twe-dimensional echocardiography provides significant information including left ventricular cavity size, fractional shortening, and abnormalities in regional wall motion. The presence and extent of ischemic heart disease is determined by monitor­ ing segmental wall motion. These abnormalities are indirect markers of myocardial perfsion that can persist for prolonged periods in the absence of infarction. Valvular abnormalities and functionally important heart disease can be readily determined. Monitoring of Organ Peiusion and Microcirculation Monitoring of tissue oxygenation and organ fnction in the clinical setting is based on measuring variables of global hemodynamics, pulse oximetry, capillary refill, urine output, or by the use of indirect biochemical markers. These param­ eters remain insensitive indicators of dysoxia and are considered poor surrogates for measuring 0 at the tissue levels. The net balance between cellular 0 supply and2 2 0 demand determines the status of2 tissue oxygenation. Regional tissue dysoxia can persist despite the presence of adequate systemic blood flow, pressure, and arterial oxygen content. Oxygen Delivery and Oxygen Consumption To tal body perfsion and oxygenation relies on an adequate arterial oxygen satura­ tion (Sa0 ),2 appropriate hemoglobin (Hb) concentration, and cardiac output. The relationship between 00 and V0 can therefore be used to assess the2 2 2 adequacy of tissue oxygenation. A lactate concentration >2 mmol/L is generally considered a biochemical indicator of inad­ equate oxygenation. Circulatory failure with impaired tissue perfsion is the most common cause of lactic acidosis. Mechanisms other than impaired tissue oxygen­ ation may cause an increase in blood lactate, including an activation of glycolysis, a reduction in pyruvate dehydrogenase activity, or liver failure. The complex process of tissue lactate production and its utilization mandates an understanding of the use­ fulness and limitations of blood lactate levels.

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However 80 mg inderal with mastercard, patients with chronic hypercapnia due to underlying lung disease will have insufficient respiratory capacity to cope with this increased drive and should be corrected close to their normal level of metabolic compensation order inderal 80mg mastercard. Approach in the delayed wean As well as the specific issues outlined above inderal 40 mg sale, an individual plan must be drawn up for the patient encompassing the whole environment, the structure of the day, and the ethos of the medical and nursing care. Weaning pattern Weaning and periods of increased work for the slow-weaning patient should be conducted during daylight hours, including: • Reductions in pressure support • Increasing periods of time off ventilatory support. The overnight period should focus on: • Rest • Ensuring sleep • Correction of hypercapnia • Re-recruitment of alveoli. It is particularly distressing to the weaning patient to be repeatedly woken from sleep by ventilator alarms. A ventilator with a mandatory back-up rate to prevent apnoeas during sleep is helpful. Peak cough expiratory flow >60L/min is only a useful measure of cough strength in extubated patients. Laryngeal oedema Laryngeal oedema may cause extubation failure and post-extubation stridor. Cuff leak test In a formal cuff leak test, the patient should be ventilated on a manda- tory mode with a low respiratory rate (8 breaths/min) and 8–10mL/kg tidal volume. Several measures have been described: • Auscultation • No leak audible • Audible on auscultation of neck • Audible at bedside • Absolute volume leak <110mL is predictive of post-extubation stridor • Percentage volume leak (pre vs post cuff deflation) <18% is predictive of post-extubation stridor. Limitations • Although the cuff leak test is good for predicting post-extubation stridor, it is less able to predict the need for reintubation. Steroids for laryngeal oedema Laryngeal oedema and post-extubation stridor may be reduced with the administration of corticosteroids. A recent meta-analysis looking spe- cifically at re-intubation attributable to laryngeal oedema showed benefit with intravenous corticosteroids prior to extubation in those at risk of laryngeal oedema. Process of extubation Extubation should be a simple smooth process if the pre-conditions have been satisfied and adequate preparations have been made. Preparation • Drugs and equipment for reintubation should be immediately available, including bag valve mask and airway adjuncts. This may be because of the direct complications of re-intubation, an association of re-intubation with unidentified patient factors leading to a worse outcome (the patients who are re-intubated are more unwell), or the development of a new complication post extubation. It is manifested by: • Dyspnoea • Tachypnoea • Tachycardia • Hypoxaemia: reduced saturations or increased oxygen requirement • Stridor • Wheeze • Noisy or retained secretions. Stridor Post-extubation stridor occurs in 2–16% of patients extubated after more than 24h of ventilation and accounts for up to 38% of early re-intubations. Factors associated with the development of post-extubation stridor include long-term mechanical ventilation, high cuff pressure, difficult or traumatic intubation, periods of ‘fighting the ventilator’, and female sex. Management of upper airway oedema If it is possible to examine the airway with a fibreoptic laryngoscope, it allows a dynamic assessment of the cause of stridor. Adrenaline is traditionally the levo-isomer, although evidence for increased efficacy or reduced side-effects compared with racemic adrenaline is weak. Inadequate assessment Inevitably some patients will be extubated when the assessment of the pre-extubation conditions (above) has been incorrect. The most common causes of extubation failure in this situation are: • Neurological failure (and failure to keep the airway patent/protected) • Respiratory muscle weakness • Poor cough with secretion retention • Inadequate resolution of underlying pathology. The clinical priority of treating the respiratory distress often takes precedence. Often useful in weak patients, although the only published evidence is for post-thoracic surgical patients. Re-intubation This should not be unduly delayed while a cause is found and intubation equipment should be immediately available when any patient is extu- bated. Consideration should be given to the choice of muscle relaxant as life-threatening hyperkalaemia has been described with the use of suxamethonium in patients with critical illness polyneuropathy requiring reintubation. It can be delivered in the non-hospital environment and is the fastest growing sector of the ‘home care’ economy, with an estimated prevalence of 6 patients per 100,000 population across Europe. In certain patient groups, such as motor neurone disease, it improves survival and enhances quality of life. In other circumstances it may be used as a bridge to definitive treatment, such as heart–lung transplantation. The principal pathophysiological problem is that of alveolar hypoventilation leading to hypercapnic respiratory failure, but it may be compounded by a loss of respiratory drive secondary to chronic hypercapnia. Individual diseases • Patients with neuromuscular disorders and kyphoscoliotic patients will generally present semi-electively with significant symptoms. Patients with tracheostomies are usually those who are unable to wean from acute ventilatory support. The response is monitored clinically in terms of subjective patient response and comfort. In patients with volume-supported ventilation, large preset tidal volumes are required (10–15mL/kg) to deliver adequate actual tidal volumes due to leaks. Methods of long-term ventilation Non-invasive ventilation • Usually only used for nocturnal ventilation or up to ∼16h per day. Non-invasive ventilators and modes • The choice of ventilator is determined by the degree of dependence the patient has on this equipment. Treatments include chin straps, preventing neck flexion with collars, semi-recumbent positioning, decreasing peak pressures, increasing ramp time, increasing delivered volume, and changing interface. Invasive (tracheostomy) ventilation • Used in patients without intact bulbar function or requiring more than 16h of ventilation per day. Tracheostomy interface • Generally an uncuffed tracheostomy tube is used to allow speech and facilitate swallowing. Invasive ventilators and modes • Complex ventilators with comprehensive alarms are generally used in pressure-control mode to compensate for leak. If volume modes are used typically values up to 15mL/kg are required to compensate for the leak. General considerations for the long-term ventilation patient • Patients are commonly ventilator dependent so provision for power and equipment failure must be made. Ventilators must have internal and external batteries (to allow charging and changing when out and about). Carers themselves will often need to be resident or able to attend rapidly in the event of alarm. Their use is not associated with a reduced microbiological load and hence is thought to improve mucosal integrity and immune response, as well as reduce inflammation. This requires a dedicated home ventilation team, including: • A consultant with specific commitment and appropriate experience. There should also be support services: • A minimum of yearly attendance at an outpatient clinic to facilitate holistic care: clinical assessment, input from other medical specialities, equipment monitoring and update, compliance with therapy, screening for common complications of underlying disease, e.

A: As follows: • Two commonest causes are viral hepatitis (commonly B and E buy inderal 80mg visa, rarely A) and paracetamol toxicity discount 40mg inderal amex. Features of cerebral oedema due to raised intracranial pressure buy generic inderal 80mg, such as: • Hyperventilation. A: Constructional apraxia means inability to perform a known act in the absence of any motor or sensory disturbance. A: It is tested in the following way (the patient is unable to do so): • Ask the patient to draw a star. Presentation of a Case: • The abdomen is distended, fanks are full and skin is hyperpigmented. It may be associated with other autoimmune diseases such as: • Sjogren’s syndrome. Urinary tract infections (caused by E coli or Lactobacillus delbrueckii), smoking and possibly hormone replacement therapy, hair dye are risk factors. A: When cirrhosis develops due to prolonged obstruction of the large biliary ducts. Other causes are Sjögren’s syndrome, systemic sclerosis, asymptomatic recurrent bacteriuria in women, pulmonary tuberculosis and leprosy. A: Actual cause is unknown but probably due to upregulation of opioid receptors and increased level of endogenous opioids. Other antibodies such as anti-smooth muscle antibody (35%) and anti-nuclear antibody (25%) may be present. Main dose (8 gm) is given before and after breakfast (as duodenal bile acid secretion is more). Rifampicin 300 mg/day or naltrexone (opioid antagonist) 25 mg/day up to 300 mg/day may be given. In intractable itching, plasmapheresis, liver-support device (molecular absorbent recirculating system) or liver transplantation may be considered. A: As follows: • Advanced liver disease (increasing jaundice with serum bilirubin. A: It is a chelating agent, acts by binding pruritogens in intestine and increases excretion in stool. A: As follows: • If asymptomatic or if the patient presents with pruritus: Survive for more than 20 years. Risk factors for malignancy are older age, male sex, prior blood transfusion, signs of cirrhosis and portal hypertension. Presentation of a Case: • The abdomen is distended, fanks are full with everted umbilicus. However, liver is enlarged if cirrhosis is due to haemochromato- sis and primary biliary cirrhosis. Secondary: Causes are— • Haemolytic anaemia such as:b-Thalassaemia major, chronic haemolytic anaemia due to other cause, pyruvate kinase defciency. A: In haemochromatosis, absorption of iron is more and inappropriate to the body needs. Ultimately progressive and excessive accumulation of iron causes elevation of plasma iron, increase saturation of transferrin and high level of ferritin, which is deposited in different organs of the body. In general population, serum iron and transferrin saturation are the best and cheapest tests available. A: As follows: • Avoid foods rich in iron (such as red meat), alcohol, vitamin C, raw shellfsh, also iron therapy. Then, venesection is continued as required to keep the serum ferritin normal (usually 3 to 4 venesections/year is needed). Following venesection, most of the symptoms improve or disappear, except testicular atrophy, diabetes mellitus and chondrocalcinosis. It removes 10 to 20 mg of iron/day, mainly used if the patient cannot tolerate venesection, especially those with cardiac disease or severe anaemia. Oral chelators, deferasirox, 20 mg/kg once daily and deferiprone, 25 mg/kg three times daily, may be given. Even in cirrhotic patients, prognosis is good compared to other causes of cirrhosis. Once a mass is visible or palpable in the abdomen, ensure whether it is intra-abdominal or extra-abdominal, while the patient is in supine position. For this, ask the patient to keep the arms across the upper chest and raise the head upward up to halfway (rising test). Or, ask the patient to raise both the extended legs from the bed (leg lifting test). Intra- abdominal mass will either disappear or decrease in size and extra-abdominal mass will be more prominent. You must mention the possible common differential diagnosis according to the site of the mass and also the age of the patient (cause may be different in young middle aged or elderly). Another example of mass in the anterior abdominal wall (in or under skin) Instruction by the examiner: • Look at the abdomen, what are your fndings? Presentation of a Mass in Anterior Abdominal Wall: • There is a mass in the right upper abdomen, 4 3 5 cm, surface is smooth, margin is slightly irregular, frm in consistency, non-tender and fxed to the overlying skin. A: As follows (mention according to the fndings and also age of the patient): If the patient is young, causes are: • Lymphoma of stomach. If the patient is middle-aged or elderly, the causes are: • Mass in left lobe of liver: Hepatoma, secondaries and hydatid cyst. Other investigations according to the fndings in ultrasonography: • If gastric mass: Endoscopy and biopsy (to diagnose carcinoma of stomach and lymphoma). A: Tell the causes according to the age of the patient: If the patient is young or early-aged: • Appendicular lump (tender). A: Causes are (mention according to the age of the patient): If the patient is young (or also any age), the causes are: • Thick colon (in irritable bowel syndrome). Mass in left iliac fossa If the patient is elderly, the causes are: • Faecal mass. A: It is as follows: • In a jaundiced patient with palpable, non-tender gall bladder, the cause is unlikely to be gall stones, rather it is due to carcinoma of head of the pancreas, cholangiocarcinoma, carcinoma of ampulla of Vater and extrinsic pressure in bile duct. Reverse of the law is: • Obstructive jaundice without palpable gallbladder is unlikely to be carcinoma head of pancreas and extrinsic pressure in common bile duct. Exception of the law is: • Double impaction: Stones, simultaneously occluding the cystic duct and distal common bile duct. A: Gall stone is associated with chronic cholecystitis and gall bladder is fbrosed, which is unable to enlarge. Causes of mass in central abdomen (according to the age and sex): If the patient is young or early-aged, the causes are: • Lymphoma. If the patient is elderly or middle-aged, the causes are: • Intra-abdominal malignancy. A: As follows (mention according to your fndings, considering the age and sex of the patient): • In female: Pregnancy in young, fbroid uterus, ovarian cyst or other ovarian mass (e. A: As follows: Causes of unilateral renal mass: • Renal cell carcinoma (in middle-aged or elderly), Wilm’s tumour (in children). Presentation of a Case: • There is a mass in epigastric region, 9 3 7 cm, irregular, non-tender, margin is ill-defned, frm in consistency and not freely movable.

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