Clinical Correlation in the Cardiovascular Examination

On last august 25, 2011, I've been posting about Clinical correlation that we can find in the abdominal examination. Now I'll show you some CC that usually found in the cardiovascular examination:

1. Some abnormal heart sounds are loud enough that they can be heard without a stethoscope. Examples include an artificial valve or grade 6 murmur.

2. A JVP of 10 or greater is considered elevated and, among other things, may indicated heart failure, specifically right heart failure.

3. Pitting edema is a result of a transudate, where as non-pitting edema is a common sign in congestive heart failure, hepatic cirrhosis, or nephrotic syndrome.

4. If the point of maximal impulse is lateralized it may be indicated left ventricular hypertrophy.

Jaundice: The History of Disease and Related Things

Some things can be related to the mechanism of occurrence of jaundice. Then as a doctor we should ask questions related to several things, such as:

• Age. The older patient, carcinoma is more often the cause of jaundice, While the hepatitis, less frequent in old age.
• Injection or transfusion within the last 6 months (characterizing viral hepatitis), including drug addiction. You also have to looking for evidence of injection site.
• Contact with the patient's jaundice and a history of living abroad
• Jobs. farm employment and work in sewers at risk of leptospirosis.
• History of dark urine and pale stools in biliary obstruction.
• Drugs taken recently, especially phenothiazines and the contraceptive pill.
• Onset of illness until it becomes the main symptom of jaundice. hepatitis Agenerally lasts 1-3 weeks, carcinoma is 1-2 months, hepatitis B 6 weeks-6months, cirrhosis hepatic are usually very long.
• Alcohol consumption
• Abdominal pain which was recently, or dyspepsia may be a sign of chroniccholecystitis, cholangitis, gallstones, or pancreatic carcinoma.
• Recent surgery, anesthesia (halothane).
• Family history, if suspected of having Gilbert's syndrome.

Jaundice: The Causes and Cases

Jaundice is a yellow color to the skin and sclera. Usually only visible when bilirubun serum levels above 35 mol / L. Sclera is not colored in yellow skin due to hiperkeratonemia. The three basic causes: hemolytic, hepatocellular, obstructive. It's how to remember: H2O --> Hemolytic, Hepatocellular, Obstructive
Some of diseases that jaundice as the clinical sign are:

• Acute viral hepatitis, because the recovery is slow, or there is persistent intrahepatic cholestasis.
• Bile duct obstruction due to gallstones or carcinoma of the head of the pancreas.
• Jaundice due to drugs
• Multiple secondary deposits in liver carcinoma (clinical jaundice is rare but often increased bilirubin)
• intrahepatic cholestasis
• Mononukleus infectious
• Gilbert syndrome

At Kuta Beach, Bali

On 12 September 2011, our last day in Bali, me and my twin sister were having fun at Kuta Beach, Bali.

The beach was so beautiful. The wave was big so you can surfing on it.

I took some pictures of us. That's me with the black shirt and my twin sister wearing red shirt.

Pura Tirta Empul, Tapak Siring, Bali

After we visited Batur Mountain and Batur lake, we went to tapak siring. There is a well-known Pura named Pura Tirta Empul.

Tirta Empul Temple or Tapak Siring Temple is a holy spring water temple located in Tapak Siring Village, about 42 km eastwards from Denpasar town.

People usually refining body&mind at the Holy Water temple in Tapak Siring.

I took some pictures of my oldest sister and her husband at this temple :D




















- Posted using BlogPress from my iPad

Batur Mountain volcano and Batur Lake

After we arrived at our bungalow, we went to Kintamani by a rental car. Along the ways there lots of beautiful scenery. There lots of green and beautiful rice field, and also lots of beautiful Pura.

And finally we arrived at Batur mountain and Batur lake. The mountain volcano is still active. It was very beautiful.


I took some pictures of it :D








- Posted using BlogPress from my iPad

Gatotkaca Statue

On last 10-12 Sept 2011, me, my twin sister, my oldest sister and her husband visited Bali for three days.

Arriving in Bali, we were picked up by Mr. ketut, our rental car driver. Our first destination is ubud (1,5 hours from airport).

Along the way, there are lots of beautiful statues. One of them is Gatotkaca Statue.

Gatotkaca statue was built in 1993. Located at the center of road intersection at the northeast of Bali International airport, Ngurah Rai Airport.

In Mahabrata story, Gatotkaca is depicted as a very brave and powerful knight, the son of Bima, one of the five Pandawa Brothers.

I took some pictures of it. I'm sorry that I took from the back of the statue. But it still beautiful :D








- Posted using BlogPress from my iPad

Medical News: 24-Hour Monitoring Best to Diagnose Hypertension - in Cardiovascular, Hypertension from MedPage Today

Medical News: 24-Hour Monitoring Best to Diagnose Hypertension - in Cardiovascular, Hypertension from MedPage Today

Clinical Correlation in The Abdominal Examination

I've been posting about Abdominal Examination on last June, now I'll show you about some clinical correlation that we usually found in the abdominal examination. I hope this article will be worth,, ^___^

1. Abdominal Bruits. During Auscultation you listen to normal active bowel sound or some normal bruits (like bruits in the epigastric area from abdominal aorta, and the upper quadrants from renal arteries. But in some case you may listen to abnormal bruits. The abdominal bruits may be due to atherosclerotic lession, or masses that may be impinging on the abdominal aorta or renal arteries.
2. Rebound Tenderness. Begin palpating the abdomen very gently in all four quadrants. Look at the patient's face to see any signs of pain or discomfort. if there is abdominal tenderness, look for rebound tenderness by slowly pressing into the tender area then quickly releasing. Rebound tenderness may indicate peritonitis (inflammation of the peritoneum), which is classically seen in appendicitis.

Cardinal Sign of Acute Appendicitis

Cardinal sign of acute appendicitis:
- abdominal pain for less than 72 hours
- vomitting 1-3 times
- facial flush
- tenderness concentrated in the right iliac fossa
- rebound tenderness in the right iliac fossa
- anterior tenderness on rectal examination (9-11 positions)
- fever between 37,3 and 38,5 C
- no evidence of UTI on urine microscopy


- Posted using BlogPress from my iPad

Renal Trauma Classification

Minor Renal Trauma (85%)


Grade I:

• Renal Contusion
• Sub capsular hematoma

Grade II:

• Ruptures/ tears of the renal capsule and parenchyma <1 cm
• Perirenal hematoma

Mayor Renal Trauma (15%)

Grade III:

• Parenchymal laceration > 1 cm into the cortex
• No urinary extravasation

Grade IV:

• Parenchymal laceration --> extend into the collecting system
• Urinary extravasation
• Laceration a segmental vessel

Grade V:

• Thrombosis of the main renal artery
• Multiple renal laceration --> Shattered kidney
• Avulsion of the main renal vessel

My sister's library floorplan

- Posted using BlogPress from my iPad

Other Special Situations of Hypertension

Minorities

BP control rates vary in minority populations and are lowest in Mexican Americans and Native Americans. In general, the treatment of hypertension is similar for all demographic groups, but socioeconomic factors and lifestyle may be important barriers to BP control in some minority patients. The prevalence, severity, and impact of hypertension are increased in African Americans, who also demonstrate somewhat reduced BP responses to monotherapy with BBs, ACEIs, or ARBs compared to diuretics or CCBs.

These differential responses are largely eliminated by drug combinations that include adequate doses of a diuretic. ACEI-induced angioedema occurs 2–4 times more frequently in African American patients with hypertension than in other groups.

Obesity and the metabolic syndrome

Obesity (BMI >30 kg/m2) is an increasingly prevalent risk factor for the development of hypertension and CVD. The Adult Treatment Panel III guideline 17 for cholesterol management defines the metabolic syndrome as the presence of three or more of the following conditions: abdominal obesity (waist circumference >40 inches in men or >35 inches in women), glucose intolerance (fasting glucose >110 mg/dL), BP >130/85 mmHg, high triglycerides (>150 mg/dL), or low HDL (<40 mg/dL in men or <50 mg/dL in women).

Intensive lifestyle modification should be pursued in all individuals with the metabolic syndrome, and appropriate drug therapy should be instituted for each of its components as indicated.

Left ventricular hypertrophy

Left ventricular hypertrophy (LVH) is an independent risk factor that increasesthe risk of subsequent CVD. Regression of LVH occurs with aggressive BP management, including weight loss, sodium restriction, and treatment with all classes of antihypertensive agents except the direct vasodilators hydralazine, and minoxidil.

Peripheral arterial disease

Peripheral arterial disease (PAD) is equivalent in risk to IHD. Any class of antihypertensive drugs can be used in most PAD patients. Other risk factors should be managed aggressively, and aspirin should be used.

Hypertension in older persons

Hypertension occurs in more than two-thirds of individuals after age 65. This is also the population with the lowest rates of BP control. Treatment recommendations for older people with hypertension, including those who have isolated systolic hypertension, should follow the same principles outlined for the general care of hypertension. In many individuals, lower initial drug doses may be indicated to avoid symptoms; however, standard doses and multiple drugs

are needed in the majority of older people to reach appropriate BP targets.

Postural hypotension

A decrease in standing SBP >10 mmHg, when associated with dizziness or fainting, is more frequent in older patients with systolic hypertension, diabetes, and those taking diuretics, venodilators (e.g., nitrates, alpha-blockers, and sildenafillike drugs), and some psychotropic drugs. BP in these individuals should also be monitored in the upright position. Caution should be used to avoid volume depletion and excessively rapid dose titration of antihypertensive drugs.

Dementia

Dementia and cognitive impairment occur more commonly in people with hypertension. Reduced progression of cognitive impairment may occur with effective antihypertensive therapy.

Hypertension in women

Oral contraceptives may increase BP, and the risk of hypertension increases with duration of use. Women taking oral contraceptives should have their BP checked regularly. Development of hypertension is a reason to consider other forms of contraception. In contrast, menopausal hormone therapy does not raise BP.

Women with hypertension who become pregnant should be followed carefully because of increased risks to mother and fetus. Methyldopa, BBs, and vasodilators are preferred medications for the safety of the fetus. ACEI and ARBs should not be used during pregnancy because of the potential for fetal defects and should be avoided in women who are likely to become pregnant.

Preeclampsia, which occurs after the 20th week of pregnancy, is characterized by new-onset or worsening hypertension, albuminuria, and hyperuricemia, sometimes with coagulation abnormalities. In some patients, preeclampsia may develop into a hypertensive urgency or emergency and may require hospitalization, intensive monitoring, early fetal delivery, and parenteral antihypertensive and anticonvulsant therapy.

Hypertension in children and adolescents

In children and adolescents, hypertension is defined as BP that is, on repeated measurement, at the 95th percentile or greater adjusted for age, height, and gender. The fifth Korotkoff sound is used to define DBP. Clinicians should be alert to the possibility of identifiable causes of hypertension in younger children (i.e., kidney disease, coarctation of the aorta). Lifestyle interventions are strongly recommended, with pharmacologic therapy instituted for higher levels of BP or if there is insufficient response to lifestyle modifications.

Choices of antihypertensive drugs are similar in children and adults, but effective doses for children are often smaller and should be adjusted carefully. ACEIs and ARBs should not be used in pregnant or sexually active girls.

Uncomplicated hypertension should not be a reason to restrict children from participating in physical activities, particularly because long-term exercise may lower BP. Use of anabolic steroids should be strongly discouraged. Vigorous interventions also should be conducted for other existing modifiable risk factors (e.g., smoking).

Hypertensive urgencies and emergencies

Patients with marked BP elevations and acute target-organ damage (e.g., encephalopathy, myocardial infarction, unstable angina, pulmonary edema, eclampsia, stroke, head trauma, life-threatening arterial bleeding, or aortic dissection) require hospitalization and parenteral drug therapy. Patients with markedly elevated BP but without acute target organ damage usually do not require hospitalization, but they should receive immediate combination oral antihypertensive therapy. They should be carefully evaluated and monitored for hypertension-induced heart and kidney damage and for identifiable causes of hypertension.

Reference:

NIH Publication No. 03-5233

December 2003

Special Concideration of Hypertension: Cerebrovascular Disease

The risks and benefits of acute lowering of BP during an acute stroke are still unclear; control of BP at intermediate levels (approximately 160/100 mmHg) is appropriate until the condition has stabilized or improved. Recurrent stroke rates are lowered by the combination of an ACEI and thiazide-type diuretic.


Reference:
NIH Publication No. 03-5233
December 2003

A love story

We never know what the future brings, I just know that I love you and I always do



- Posted using BlogPress from my iPad

Special Concideration of Hypertension: Chronic Kidney Disease

In people with chronic kidney disease (CKD), as defined by either reduced excretory function with an estimated GFR below 60 ml/min per 1.73 m2 (corresponding approximately to a creatinine of >1.5 mg/dL in men or >1.3 mg/dL in women),20 or (2) the presence of albuminuria (>300 mg/day or 200 mg albumin/g creatinine), therapeutic goals are to slow deterioration of renal function and prevent CVD. Hypertension appears in the majority of these patients, and they should receive aggressive BP management, often with three or more drugs to reach target BP values of <130/80 mmHg. ACEIs and ARBs have demonstrated favorable effects on the progression of diabetic and nondiabetic renal disease. A limited rise in serum creatinine of as much as 35 percent above baseline with ACEIs or ARBs is acceptable and is not a reason to withhold treatment unless hyperkalemia develops.With advanced renal disease (estimated GFR <30 ml/min 1.73 m2, corresponding to a serum creatinine of 2.5–3 mg/dL), increasing doses of loop diuretics are usually needed in combination with other drug classes.

A Promise

A Promise by Julie Fain



- Posted using BlogPress from my iPad

Tesettur

Tesettur by Seher Aydin



- Posted using BlogPress from my iPad

Updated JNC Guidelines May Address Individualization of BP Goals : Internal Medicine News

Updated JNC Guidelines May Address Individualization of BP Goals : Internal Medicine News

Special Concideration of Hypertension: Diabetic Hypertension

Combinations of two or more drugs are usually needed to achieve the target goal of <130/80 mmHg. Thiazide diuretics, BBs, ACEIs, ARBs, and CCBs are beneficial in reducing CVD and stroke incidence in patients with diabetes. ACEI- or ARB-based treatments favorably affect the progression of diabetic nephropathy and reduce albuminuria and ARBs have been shown to reduce progression to macroalbuminuria.


Reference:

NIH Publication No. 03-5233
December 2003