By Lawrence M. Tierney, Clinton E. Thompson, Sanjay Saint
Univ. of California, San Francisco. Pocket-sized define covers information at the prognosis and remedy of greater than 500 scientific problems. contains tabs for speedy reference. earlier version: c1997. Now contains 'a pearl in keeping with page', a geriatrics bankruptcy, and a genetics bankruptcy. Softcover.
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PMID: 10410287] 1 32 Essentials of Diagnosis & Treatment Constrictive Pericarditis 1 ■ Essentials of Diagnosis • A thickened fibrotic pericardium impairing cardiac filling and decreasing cardiac output • May follow tuberculosis, cardiac surgery, radiation therapy, or viral, uremic, or neoplastic pericarditis • Symptoms include gradual onset of dyspnea, fatigue, weakness, pedal edema, and abdominal swelling; right-sided heart failure symptoms often predominate, with ascites sometimes disproportionate to pedal edema • Physical examination reveals tachycardia, elevated jugular venous distention with rapid y-descent, Kussmaul’s sign, hepatosplenomegaly, ascites, “pericardial knock” following S2, and peripheral edema • Pericardial calcification on chest film in less than half; electrocardiography may show low QRS voltage; liver function tests abnormal from passive congestion • Echocardiography can demonstrate a thick pericardium and normal left ventricular function; CT or MRI is more sensitive in revealing pericardial pathology; cardiac catheterization demonstrates dip-and-plateau pattern to left and right ventricular diastolic pressure tracings with a prominent y-descent (in contrast to restrictive cardiomyopathy) ■ Differential Diagnosis • • • • ■ Cardiac tamponade Right ventricular infarction Restrictive cardiomyopathy Cirrhosis with ascites (most common misdiagnosis) Treatment • Acute treatment usually includes gentle diuresis • Definitive therapy is surgical stripping of the pericardium • Evaluation for tuberculosis ■ Pearl Constriction should be excluded in a patient with new onset ascites felt due to cirrhosis.
Clinical features and complications. BMJ;2000;320:236. [PMID: 10642237] Chapter 1 Cardiovascular Diseases 25 Myocarditis ■ Essentials of Diagnosis • Focal or diffuse inflammation of the myocardium due to various infections, toxins, drugs, or immunologic reactions; viral infection, particularly with coxsackieviruses, is the most common cause • Other infectious causes include Rocky mountain spotted fever, Q fever, Chagas’ disease, Lyme disease, AIDS, trichinosis, toxoplasmosis, and acute rheumatic fever • Symptoms include fever, fatigue, palpitations, chest pain, or symptoms of congestive heart failure, often following an upper respiratory tract infection • Electrocardiography may reveal ST–T wave changes, conduction blocks • Echocardiography shows diffusely depressed left ventricular function and enlargement • Routine myocardial biopsy usually not recommended since inflammatory changes are often focal and nonspecific ■ Differential Diagnosis • Acute myocardial ischemia or infarction due to coronary artery disease • Pneumonia • Congestive heart failure due to other causes ■ Treatment • Bed rest • Specific antimicrobial treatment if an infectious agent can be identified • Immunosuppressive therapy is controversial • Appropriate treatment of the systolic dysfunction that may develop: vasodilators (ACE inhibitors or combination of hydralazine and isosorbide dinitrate), beta-blockers, spironolactone, digoxin, lowsodium diet, and diuretics ■ Pearl “Rule of thirds” for patients with viral myocarditis: one-third return to normal, one-third have stable left ventricular dysfunction, and onethird have a rapidly deteriorating course.
Reference Ambrose JA et al: Unstable angina: current concepts of pathogenesis and treatment. Arch Intern Med 2000;160:25. [PMID: 10632302] 1 16 Essentials of Diagnosis & Treatment Acute Myocardial Infarction 1 ■ Essentials of Diagnosis • Prolonged (> 30 minutes) chest pain, associated with shortness of breath, nausea, left arm or neck pain, and diaphoresis; can be painless in diabetics • S4 common; S3, mitral insufficiency on occasion • Cardiogenic shock, ventricular arrhythmias may complicate • Electrocardiography shows ST elevation or depression, T wave inversion, or evolving Q waves; however, can be normal or unchanged in up to 10% • Elevated cardiac enzymes (troponin, CKMB) • Regional wall motion changes by echo • Non-Q wave infarct may mean additional jeopardized myocardium ■ Differential Diagnosis • Stable or unstable angina • Tietze’s syndrome (costochondritis) • Aortic dissection • Cervical radiculopathy • Carpal tunnel syndrome ■ • • • • • • Esophageal spasm or reflux Pulmonary embolism Cholecystitis Pericarditis Pneumothorax Pneumonia Treatment • Monitoring, aspirin, and analgesia for all; heparin for most • Reperfusion by thrombolysis or angioplasty in selected patients with either ST segment elevation or new left bundle branch block on ECG • Glycoprotein IIb/IIIa inhibitors considered in non-Q wave infarcts • Beta-blockers for heart rate and blood pressure control, and survival advantage when given chronically • Nitroglycerin for recurrent ischemic pain; also useful for relieving pulmonary congestion and reducing blood pressure • ACE inhibitor may confer survival benefit ■ Pearl Monitoring for prompt treatment of ventricular fibrillation remains the most cost-effective intervention to prolong life.