(14)Approach in Cardiopulmonary Dz

Approach in Cardiopulmonary disease Te & Chin

Contents 1. Dyspnea 2. Chest pain 3. Heart failure 4. Obstructive Airway disease 5. HT 6. HT with hypokalemia and metabolic alkalosis 7. HT with SPELL or paroxysm 8. Hemoptysis 9. Cough 10.Cyanosis 10.Cyanosis 11.Syncope 11.Syncope 12.Claudication 12.Claudication

1. Dyspnea CVS (Chest pain / HF / FC / Palpitation) Arrthymia Structural Endocardium Congenital : CY / NCY Acquired RHD Infective endocarditis CNT Degenerative Myocardium Ischemic  Non-ischemic DCM Alcohol B1 Pericardium Effusion-Temponade Constrictive pericarditis

RS (Cough / Hemoptysis) (5) Airway disease Parenchyma Alveoli Pulmonary edema  Non-cardiogenic Direct Hematogenous Pneumonia DAH Bronchioloalveolar cell CA Interstitial Interstitial lung disease Always exclude TB / CA Pulmonary vv. Pulmonary embolism Pulmonary HT Chest wall Bone Muscle (Neuro disease or muscle disease) Respiratory m. Diaphragm Abdomen Ascites Obesity Pregnancy Pleura Effusion Empyema thoracis Hemothorax Pneumothorax Mesothelioma Metabolic Anemia Thyroid disease / Adrenal insufficiency Metabolic acidosis Dysglycemia

Neurological disease High cord AHC Pure UMN : PLS / FSP Pure LMN : SMA III / X-linked SMBD / MMNCB / Adult Taysach Mixed : ALS  Nerve Peripheral neuropathy  NMJ Myasthenia gravis Muscle Inflammatory  Non inflammatory Psychiatric disease

2. Chest pain Cardiovascular cause Cardiac cause Ischemic : CAD Congenital stenosis Thromboembolism Spontaneous Dissection Vasculitis Atherosclerosis Transient spasm : Prinzmetal’s  Non Ischemic Endocardium : AS / MVP Myocardium : HCOM Takosubo CM Pericardium : pericarditis Vascular cause Aortic Dissection  Non Cardiovascular cause RS Pneumonia Pleural effusion Pneumothorax / Hemothorax Pulmonary Embolism : TE / Fat / Air / Amniotic F / CA Pulmonary HT GI Esophagitis Esophageal spasm Esophageal rupture (Boerhaave’s syndrome) GERD Peptic ulcer  HB Cholecystitis Pancreatitis Splenic flexure syndrome MS Costochondritis (Tietze’s) Xiphiodalgia Shoulder arthropathy Cervical spondyloarthropathy Thoracic outlet syndrome Skin Herpes zoster  Psychogenic disease

3. Heart failure Congestive Heart failure : Endocardium  VHD / IE Pure Left side HF : Myocardium  MI / CM Pure Right side HF : R/O occult Lt. sided HF Myocardium Hyperkinetic heart TH+ / Beriberi etc. EMF / RCM Rhythmogenic RV dysplasia Pericardium Constrictive pericarditis Cardiac temponade Endocardium Rt. side VHD : PS-TR-IE Lung dz. (Cor pulmonale) Severe obstructive AW dz. Restrictive lung KyphoSc / Obesity Destroy lung Bronchiectasis PHT of any causes 4. Obstructive Airway disease (5) Asthma COPD Bronchiolitis obliterans (BO) in RA Clinical mimic intractable COPD Endobronchial lesion : TB / Tumor  Tracheal stenosis OSA-OHS

5. HT Essential Secondary CVS TK / Coarc K  Renovascular : RAS (Arth-FMD-PAN) Parenchyma : GLOM / TI (PKD) Endocrine Mineralocorticoid Pheochromocytoma Cushing’s syndrome Acromegaly HypoTH / HyperTH Hypercalcemia Others : Drugs / OSA / Polycythemia 6. HT + Hypokalemia + Metabolic alkalosis BP low or normal Low ECV : vomiting / diarrhea / dehydration BP high (Mineralocorticoid effect) High Aldosterone H Renin H Ald (Secondary HyperAld) RAS : Arth / FMD Renin secreting tumor  L Renin H Ald (Primary HyperAld) 2/3 APA and 1/3 BAH ARR  30-50 Saline loading  Imaging > 50 Imaging If positive APA / BAH (IVC-Lt kidney before cut spleen) > 1 cm + Young age  Surgery  Not : AVS lateralization APA : Surgery BAH : Medication Sp / Am / Triam  Normal Aldosterone ( AME) Licorice / Carbenyxolone 11-BHSD deficiency Liddle’ syndrome Cushing’s syndrome Essential HT

7. HT + SPELL or Paroxysm Triad : Headache / Sweating / Palpitation Associated MEN 2 / NF1 / Familial paraganglioma / VHL Best sensitivity : Plasma Metanephrine Best specificity : Urine fractionated Metanephrine Positive  Imaging CT Adrenal gland + Abdomen  Negative repeat imaging with MRI  Negative R/O Paraganglioma  I MIBG Positive if bilateral or R/O familial  I MIBG  Negative  Repeat during symptom If until negative  Medication + F/U 8. Hemoptysis DDX Hematemesis : pH / cough / food particle / frothy Massive / Non massive (200 ml/times or 600 ml/day) Local or systemic bleeding or combined Causes Pulmonary disease Infection TB / Aspergillosis  Necrotizing pneumonia : Staph / P. / N. Lung abscess Infected Bronchiectasis Immune DAH Lupus pneumonitis Anti-GBM : Goodpasture’s Trauma Tumor  Primary / Metastasis Vascular  Pulmonary AVM Cardiac disease Pulmonary edema

9. Cough Acute cough (8wk) o COPD o Bronchiectasis o Bronchogenic CA

 Non-smoker w/ chr cough w/ normal CXR  o ACEI o Postnasal drip o Asthma o GERD

10. Cyanosis Increased quantity of reduced Hb or Hb derivatives in small bl vv  bluish color  Central cyanosis  SaO2 Relative      anemia)  PV        cyanosis      Venous dilataion/ congestion  inc amount of Reduced Hb o Other Hb: MetHb, SulfHb •

    Cause of cyanosis

SaO2      = approach cause of hypoxemia o Altitude o Hypoventilation: central or peripheral o V/Q mismatch o Diffusion abnormalities o shunt  Intracardiac  Cyanotic HD  Intrapulmonary  AVF Abnormal Hb o MetHb o SulfHb o COHb (not true cyanosis) o Hb w/ low affinity Approach True cyanosis  COHb, PV Central cyanosis (exclude peripheral cyanosis) o Look at face & mucous membrane o Pulse oximetry o  Not in low CO state, peripheral vasocons Onset o Since birth or infancy  Congenital heart o            acquired cause      Heart, Lung, or Hb is the cause? Clubbing w/ cyanosis  chronic process o Congenital Heart disease w/ Rt to Lt shunt o IE o Lung dz: lung abscess, Pulm AVF, Bronchiectasis, cystic fibrosis, cirrhosis (HPS), Metas lung cancer, Mesothelioma Clubbing w/ HOA o Metas lung cancer  o Mesothelioma o Bronchiectasis o Cirrhosis

11.Syncope 11.Syncope

transient loss of consciousness and postural tone due to reduced cerebral blood flow o with spontaneous recovery o             = presyncope  lightheadedness, dizziness, a feeling of warmth, diaphoresis, nausea, and visual blurring occasionally  proceeding to transient blindness Causes Vascular tone or Blood volume disorders o Reflex   Neurocardiogenic: Vasovagal  Situational: cough, mic, defe, valsava, deglutition  Caroid sinus hypersensitivity: Hx of neck manipulation, tight collar  o Orthostatic hypotension:  Drug  Autonomic Peripheral = neuropathy, sympatectomy Central = MSA Idiopathic  Decreased blood volume CVS dz o Structural heart dz = obstructive cause  Lt sided Valve o AS, HOCM o MS Myocardium o MI, CM o Atrial myxoma  Rt sided Valve Pericardium o Constrictive pericarditis o Tamponade Lung o PE o PHT • • •

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Arrhythmias  Bradyarrhythmia

Sinus problem AV block   Tachyarrhythmia SVT w/ structural Heart AF w/ WPW AFl 1:1 AV conduction VT Cerebrovascular disease o Vertebrobasilar insuff  o Basilar migraine Syncope mimick (DDx trainsient loss of consciousness w/o reduced cerebral bl flow) o Seizure o Metabolic: hypogly, anemia, hypoxia, hypocarbia (hypervent) o Psychia: anxiety, hysterical Approach Exclude Life-threatening causes Hx  most important diagnostic tool o Events & time course      syncope         syncope      syncope o Supine position syncope  not vasovagal          arrhythmia, seizure o Loss of conscious             , micturition, vol depletion  abn of vascular tone • •

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CVS Cerebrovascular  Reflex syncope  Vasovagal  Carotid sinus hypersensitivity Orthostatic hypotension

12.Claudication 12.Claudication = pain, ache, cramp, numbness, or a sense of fatigue in the muscles; it occurs during exercise and is relieved by rest       Pathology        vascular cause Psuedocluadication = Neurogenic claudication o Lumbar stenosis & Lumbar radiculopathy o

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relieve nerve entrapment Cause of Claudication Venous site o DVT Arterial site (PAD) o Intraluminal  Thrombosis  Emboli Cholesterol Septic o Luminal  Artherosclerosis  FMD (female)  Vasculitis Buerger’s  Pseudoxanthoma elasticum, forme frusta (progressive calcification & degeneration of elastic fiber)  Aortic dissection  Coarctation of aorta o Extraluminal • •

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Arterosclerosis        site Calf pain  Superficial femoral, or Femoro-popliteal a. Thigh & calf pain  Iliofemoral a. Buttock, hip pain +/- ED  Aorto-iliac a. (Leriche’s syndrome) Onset for clues Acute = Thrombosis, Emboli Progressive = Artherosclerosis Age