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Case 1

Case 1 . Endo week 1. 1. What are the clinical signs and X-ray features of a pleural effusion?. T rachea and apex beat displacement Decrease lung expansion on affected side S tony dull percussion over effusion D ecrease or absent breath sounds Decrease vocal resonance. CXR.

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Case 1

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  1. Case 1 Endo week 1

  2. 1. What are the clinical signs and X-ray features of a pleural effusion? • Trachea and apex beat displacement • Decrease lung expansion on affected side • Stony dull percussion over effusion • Decrease or absent breath sounds • Decrease vocal resonance

  3. CXR • Meniscus sign • Hemi-diaphragm may not be seen • May show displacement of heart

  4. 2. What are some of the signs and symptoms of hyponatraemia? • Definition: serum sodium concentration < 134 mEq/L and is significant when the concentration is < 130 mEq/L. • Symptoms: nausea or headache, or the development of lethargy, confusion and coma or seizures. • Signs: • Decreased plasma volume: tachycardia, hypotension, oliguria, peripheral circulatory failure • Decreased interstitial fluid: decreased skin turgor, decreased intraocular pressure

  5. >130 mEq/L: asymptomatic • 125 mEq/L to 130 mEq/L: nausea, vomiting, or abdominal symptoms. • < 125 mEq/L: Headache, agitation, and confusion may develop in patients with level • <120 mEq/L: associated with seizures and coma • Roy:  Sodium = 114 mmol/L

  6. 3. What are some causes of hyponatremia and how might you differentiate between them? • Hydration status • hypervolemic = Pulmonary rales, S3 gallop, jugular venous distention, peripheral edema, or ascites • euvolemic = no signs hyper/hypo-volaemia • hypovolemic = Dry mucous membranes, tachycardia, diminished skin turgor, and orthostasis

  7. 4. What is the most likely case of Roy’s hyponatremia? What are some of the causes of this condition? • Considering • Roy is a smoker • Lung mass  carcinoma • Clubbing • Neither dehydrated or edematous • High urine osmolality • Ectopic secretion of vasopressin by the carcinoma, condition known as SIADH (syndrome inappropriate antiduretic hormone secretion)

  8. SIADH • Essentials: • urine osmolality > 200 mmol/kg • urine sodium > 20 mmol/L • low serum sodium • patient not dehydrated • no renal, adrenal, thyroid, cardiac or liver disease or interfering drugs

  9. Other etiologies of SIADH • Cancers (eg, pancreas, lung) • CNS disease (eg, cerebrovascular accident, trauma, infection, hemorrhage, mass) • Pulmonary diseases (eg, infections, respiratory failure) • Drugs  (1)   Thiazides •    (2)   Antidiuretic hormone (ADH) analogues (vasopressin, desmopressin acetate [DDAVP], oxytocin) •    (3)   Chlorpropamide (6–7% of treated patients) •    (4)   Carbamazepine •    (5)   Antidepressants (tricyclics and selective serotonin reuptake inhibitors) and antipsychotics •    (6)   Nonsteroidalantiinflammatory drugs (NSAIDs) •    (7)   Ecstasy (MDMA) •    (8)   Others (cyclophosphamide, vincristine, nicotine, opioids, clofibrate)

  10. 5. How should cases of hyponatremia caused by SIADH be managed • Treat underlying disease! • Water restriction and demeclocycline are the traditional therapies • Demeclocycline causes nephrogenic diabetes insipidus which leads to free water loss (polyuria) and normalization of the serum sodium levels • Aggressive treatment of hyponatremia should always be weighed against the risk of inducing osmotic central pontinemyelionlysis (rare) • Patients with chronic hyponatremia require slow correction and those with acute require more rapid correction. • Emergent care: 3% hypertonic saline

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