Aisha is not feeling so good

Shortness of breath - Dyspnea
1. Definition : An intense tightening in the chest, air hunger or a feeling of suffocation.
2. Normally arises when :
  1. Very strenuous exercise
  2. Extreme temperatures
  3. Massive obesity
  4. High altitude
3. Pathological causes
  1. Acute
    1. CO poisoning
    2. Hypotension
    3. Pulmonary embolism
    4. Cardiac tamponade
    5. Heart failure
    6. Pneumothorax
    7. Pneumonia
    8. Hemorrhage
  2. Chronic
    1. Asthma
    2. COPD
    3. Heart dysfunction
    4. Interstitial lung disease
    5. Renal impairment
    6. Obesity
4. Types
  1. Orthopnea
    1. Sensation of breathlessness in the recumbent position, relieved by sitting or standing
    2. Patient will increase the number of pillows at night to avoid becoming dyspnoeic due to the accumulation of fluid & edema
      1. Edema
        What is edema?
        The accumulation of fluid in the interstitial space.
        Types
        Transudate :Filtration (starling forces).
        Exudate: increase in vascular permeability.
        Causes of edema
  2. Paroxysmal nocturnal Dyspnea
    1. Sensation of shortness of breath that awakens the patient, often after 1 or 2 hours of sleep.
Heart Failure
1. Lifestyle risk factors
  1. Smoking
  2. Diabetes
  3. Hypertension
  4. Hyperlipidemia
2. Types of heart failure
  1. Left sided heart failure
    1. Heart failur with reduced ejection fraction: The left venticle loses ability to contract, the heart loses ability to contract normally.
    2. Heart failure with preserved ejection fraction: The left venticle loses its ability to properly fill with blood thus the heart does not pump enough blood into the circulation.
  2. Right sided heart failure
    1. Usually occurs With association of left sided heart hailure.
  3. Congestive heart failure
    1. Covers and used interchangebly with LHF & RHF
3. Prognosis
  1. Poor prognosis
4. History taking
5. Physical examination
  1. General Inspection (signs of shortness of breath)
  2. Blood pressure measurement (High- 168/102)
  3. Hands: Tar stain, peripheral cyanosis.
  4. Assessment of pulse: Rate (tachycardia- 95), rhythm (irregular), character (pulsus alternans),
  5. Face : Mitral facies, xanthelasmata
  6. Eyes: Icterus/ jaundice
  7. Mouth: central cyanosis
  8. Lower limbs: Pitting edema
  9. Auscultation: S3 & S4.
  10. The back:: Percuss (dull), auscultate (crackles, wheezing).
  11. Neck : elevated JVP = High arterial pressure, Hepatojugular reflex (higher level > few seconds).
6. Investigations
  1. Chest X-ray findings
    1. Congestion in the upper lobes
    2. Perihilar congestion
    3. Fluffy alveolar infiltrates
    4. Kerley lines
    5. Air bronchograms
  2. ECG
  3. Echocardiogram
7. Treatment
  1. Frusemide
    1. Loop diuretics that act on the Na+-K+-2Cl− symporter (cotransporter) in the thick ascending limb of the loop of Henle to inhibit sodium, chloride and potassium reabsorption.
  2. Common Side effects
    1. Vomiting, diarrhea, fever, chills, or nausea.
    2. Muscle pain, cramps, or weakness.
    3. Irregular heartbeat.
    4. Ototoxicity
    5. Headache
  3. Enalapril
    1. After hydrolysis to enalaprilat, inhibits angiotensin-converting enzyme (ACE) a peptidyl dipeptidase that catalyzes the conversion of angiotensin I to the vasoconstrictor substance, angiotensin II.
  4. Carvedolil
    1. Carvedilol is used to prevent further worsening of congestive heart failure. It is also used to treat left ventricular dysfunction after a heart attack.
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Aisha is not feeling so good

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