inroduction to medicine-approach to dyspnea

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					 INTRODUCTION TO

MEDICINE

Dr.Bilal Natiq Nuaman
C.A.B.M. , F.I.B.M.S. , D.I.M. , M.B.Ch.B.
Lecturer in Ibn-Sina Medical College
2013 -2014
Basic Vs Clinical
         • Basic
         • Examples
         • Cytology ,
           Biochemistry ,
           Microbiology ,
           Histology , Pathology
         Ø deal with samples
           from patients for
           diagnostic purposes
Basic VS Clinical
         • Clinical
         • Examples
         • Internal Medicine ,
           General Surgery ,
           Ophthalmology,
           Orthopedics ,Urosurgery,
           ENT, etc….
         Ø Deal with the patient
           directly for diagnosis ,
           treatment , and
           counseling .
Internal Medicine
  The branch of medicine that deals with the diagnosis and
  nonsurgical treatment of diseases affecting adults within
  its scope .
  is the medical specialty dealing with the prevention,
  diagnosis, and treatment of adult diseases.
  Doctors specializing in internal medicine are called
   internists, or physicians
Scope of Subspecialties of Internal Medicine
 Cardiology, dealing with disorders of the heart and blood
 vessels

 Endocrinology, dealing with disorders of the endocrine system
 and its specific secretions called hormones
 Gastroenterology, concerned with the field of digestive
 diseases

 Hematology, concerned with blood, the blood-forming organs
 and its disorders.

 Infectious Diseases, concerned with disease caused by a
 biological agent such as by a virus, bacterium or parasite
Nephrology, dealing with the study of the function and
diseases of the kidney

 Pulmonology, dealing with diseases of the lungs and
the respiratory tract

Rheumatology, devoted to the diagnosis and therapy of
rheumatic diseases.

Neurology dealing with diseases of nervous system

Medical Oncology, dealing with the chemotherapeutic
(chemical) treatment of cancer

Poisoning and Critical Care
Internal Medicine , Management ,
sequence of roles

     1-DIAGNOSIS
     2-TREATMENT
     3-PREVENTION
              Medical Diagnosis
• Sequence of Diagnosis
• 1-History taking from patient (record patient
  symptoms)


• 2-Examination of the patient (looking for physical
  signs )
• 3-Investigations (done in lab. ,etc..)
Approach to patient = Management of patient
              Symptom vs sign
• A symptom(complaint) is subjective feeling
  from the patient point of view.
• A symptom is what the patient experiences about the
  disease.
• Symptoms can only be experienced, they are not able to
  be observed or measured objectively.
• Pain is a symptom. I do not know you are having pain
  unless you tell me. Nausea is also a symptom, as are:
  chills, numbness, fatigue, vertigo, malaise, itching,
  stomach cramps, burning on urination, etc.
• A sign is an objective physical manifestation of disease.
• It is an objective finding, something one can observe and
  measure.
• A rapid pulse, a high temperature, a low blood pressure,
  an open wound, bruising, etc. are all signs.
• Signs give a more definite indication of the presence of a
  particular disease to the physician.

  So in the simplest form, signs are observations
  of the doctor and symptoms are the experiences
  of the patient.
Dyspnea; Breathlessness; Shortness of
Breath(SOB)
• ‘’Dyspnea’’

Dys: difficult, painful
Pneumea:breath



• Breathlessness or dyspnoea can be defined as the
  feeling of an uncomfortable need to breathe.
DEFINITION OF DYSPNEA

• Clinical : A subjective experience of breathing discomfort that
  consists of qualitatively distinct sensations that vary in
  intensity.
• Physiological: The stimulation of pulmonary and
  extrapulmonary afferent receptors and the transmission of
  afferent information to the serebral kortex,where the sensation
  is perceived as uncomfortable or unpleasant
                    Patients perceptions:
ü Unsatisfied inspiration

ü Chest tightness

ü Sensation of feeling breathless

ü Cannot get enough air

ü Hunger for air

ü Incomplete exhalation
                THE PNEA’S
• DYSPNEA – SOB :

 ACUTE – (PULMONARY EMBOLISM,
 PNEUMOTHORAX, PULMONAR EDEMA)<30 days

 CHRONIC – (COPD, CHF)>30 days

• TACHYPNEA – RR>20 BR/MIN(PNEUMONIA)
•
• BRADYPNEA - RR< 8 BR/MIN (DRUGS, AGONAL)
Stages of Cardiac dyspnea
1-EXERTIONAL DYSPNEA- Dyspnea due to exercise

2-ORTHOPNEA – SOB LYING FLAT AND BETTER
  SITTING UP (CHF, pregnancy, resp.muscle weakness)

3-PND - PAROXYSMAL NOCTURNAL DYSPNEA
characterized by acute shortness of breath almost always
  accompanied by coughing and wheezing. This respiratory
  distress usually occurs when a person is already sleep in
  a reclining position (HEART FAILURE-early night ,
  ASTHMA-late night )

4-Resting dyspnea- dyspnea at rest
• Pathophysiology :
Respiratory diseases can stimulate breathing and
  dyspnoea by: stimulating intrapulmonary sensory nerves
  (e.g. pneumothorax, interstitial inflammation and
  pulmonary embolus)
• increasing the mechanical load on the respiratory
  muscles (e.g. airflow obstruction or pulmonary fibrosis)
Causing hypoxia, hypercapnia or acidosis, stimulating
  chemoreceptors.
• In cardiac failure, pulmonary congestion reduces lung
  compliance and can also obstruct the small airways. In
  addition, during exercise, reduced cardiac output limits
  oxygen supply to the skeletal muscles, causing early
  lactic acidaemia and further stimulating breathing via the
  central chemoreceptors.
Etiologies: Pulmonary Causes
Common Pulmonary Causes
• Obstructive lung disease
  • Asthma/COPD (Chronic Bronchitis ,Emphysema)

• Pneumonia

• Pulmonary embolism

• Pneumothorax
Common Cardiac Causes
• Acute coronary syndromes

• CHF

• Dysrhythmias

• Valvular heart disease
Common Miscellaneous Causes
• Metabolic acidosis

• Severe anemia

• Pregnancy

• Hyperthyroidsm

• Hyperventilation syndrome
ACUTE VE CHRONIC DYSPNEA


• Acute: Dyspnea (AP4) <30 days
that develops over hours or days :
• Asthma
• Pulmonary edema
• Pneumothorax
• Pulmonary embolism
• Pneumonia
•
• Chronic: Dyspnea >30 days
that develops over weeks, months or years.
• COPD
• Left ventricular failure
• Interstitial fibrosis
• Asthma
• Pleural effusion
•
CHARACTERISTICS OF HISTORY


• Persistence and variability
  • Intermittent
  • Persistent
  • Nocturnal
  • Seasonal
  • Occupational ( work,home ...etc.)
History Taking
nature of onset (acute, chronic) , duration ,
  evolution over time
  associated symptoms (cough, sputum ,wheeze, )
  physiologic vs. pathologic

• Exposures
   •   Sick contacts
   •   Tobacco
   •   Occupational
   •   Hobbies
   •   Pets
   •   Drugs
   •   Radiation
Physical signs in dyspnic patient
                     Investigations

Chest radiograph (CXR): weather cardiac or pulmonary




   Cardiac Causes!                Pulmonary causes!
      ECG                   Pulmonary function test(PFT)
(abnormally significant)        (abnormally significant)

      Echo                         CT scan of chest
(abnormally significant)        (abnormally significant)

Coronary angiography                  Lung Biopsy
CXR
Treatment
   ØNon-Drug Treatments
      • Positioning - sitting up
      •Relaxation
      • Humidified air
      • Noninvasive positive pressure mask

   ØOxygen
   ØSpecific treatment according to diagnosis

   Asthma------- Bronchodilators + anti
   inflammatory
   Pneumonia--------Antibiotics
   Pneumothorax ------Chest tube
   Heart failure------- Diuretics + nitrate
THANK YOU

				
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