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So in the morning arrhythmia caffeine order clonidine line, any type of activity may produce pain, but during the day time, this type of activity may not start pain due to progressively increasing threshold of pain as the day progresses. Relieving factors: Anginal pain usually is relieved with rest, or after taking nitroglycerin tablets Other types of presentation of anginal pain: Shortness of breath-discomfort in mid chest Discomfort at any sites-the sites of radiation. Angina is stable, if: occurs only with provocations It has been occurring for last two months It is symptomatically stable. It Unstable angina can be presented in any of the following ways: Rest angina: Occurs, when the patient is at rest is prolonged for more than 20 minutes It Occurs within a week of presentation with anginal symptoms At night it may occur when the diastolic blood pressure decreases to lower levels-nocturnal angina. Cardiovascular System 289 Linked angina It is a type of anginal pain, where there is: Typical history of angina Definite history of coronary artery disease occurs after gastrointestinal factor, such as, stooping after It heavy meals. Walking or climbing stairs after meals, in cold wind, under emotional stress or during after few hours after awakening. Duration: It persists for hours, till treatment is started, although pain is absent in diabetic and elderly individual. Occasionally, site of radiation of chest pain denotes or excludes specific coronary arteries: Left-sided chest pain with radiation to left arm-denotes involvement of left coronary artery Epigastric pain radiating to neck or jaw-excludes left anterior descending artery. Onset: may be very severe from onset It ere may be preceding history of stable or unstable angina Th or both. Associated symptoms: Sweating, palpitation, syncope, dyspnea, vomiting Pain may be absent in: Elderly Diabetic Women. If Relieving factor: Leaning forward Associated symptoms: Fever of myocarditis Congestive cardiac failure. Duration: Persists for hours till intervention Character: Acute sharp, stabbing, ripping in nature Radiation: It migrates according to site of dissection: Chest pain radiates to neck, throat, jaw and face-ascending aorta is involved Pain in back radiates to abdomen or lower limb-descending aorta will be involved. Chest Pain due to Pulmonary Embolism Site: Anterior chest according to site of obstruction of pulmonary vein Character: Pleuritic in nature Radiation: No radiation Onset: Acute in nature Duration: It may persist for minutes to hours Associated symptoms: Dyspnea, tachypnea, hypotension, and hemoptysis History suggestive of pulmonary embolism: Deep vein thrombosis Recent surgery Prolonged immobilization Malignancy Oral contraceptive pill Pregnancy Hypercoaguable state Cardiovascular System 293 Congestive cardiac failure Prolonged travel. Pleuritic chest pain from infection of lung producing pneumonia can be differentiated by high fever, cough with rusty sputum production. Supportive evidence: Chest Pain due to Pleural Disorder Character: Stabbing in nature Radiation: No radiation Duration: Persists for minutes to hours Site: Area of involvement Aggravating factors: Respiration, movement of chest wall Relieving factors: Lying down on the same side Holding breath at the end of deep inspiration to prevent friction between parietal and visceral pleurae. Chest Pain due to Pneumothorax Onset: Acute Intensity: Very severe at the onset Radiation: No radiation Site: At the localized area Aggravating factor: Movement of the chest Associated symptoms: Dyspnea, cough History: Trauma to chest, violent cough, iatrogenic procedure. Chest Pain due to Musculoskeletal System Disorders Site: Area is localized, chest wall, or thoracic spine Character: Pricking in nature Duration: Several hours to several days Radiation: No radiation Aggravating factors: Deep inspiration Postural movements Movement of upper limbs Relieving factor: Pain killer and rest Intensity: Low intensity History: Trauma, injury, strenuous exercise. Pain of Thoracic Inlet Syndrome Pain associated with paresthesia Distribution along the ulnar side of arm and forearm Cardiovascular System 295 Aggravated by: Abduction of the affected arm Lifting heavy weight Elevating the arm above shoulder. Chest Pain due to Herpes Zoster Character: Lancinating or shooting in character Radiation: Along the corresponding dermatome Duration: It persists for more than hours Associated phenomenon: Characteristic vesicles along the affected dermatome. Chest Pain due to Tietze Syndrome Aching pain Anterior chest pain Localized swelling and tenderness over costal cartilage, costochondral joints and costosternal junction No radiation Resolves spontaneously Aggravated by coughing, sneezing No muscle tenderness. Pericardial scratch syndrome Sudden onset Scratch, sharp needle like, jabbing pain Short lasting It may recur. Associated symptoms: Anxiety Dizziness Depression Tingling and numbness in the extremities. Pain Radiates from Back of the Neck to the Left Shoulder and Left Arm: Cervical Spondylosis Pain in the nipple and around the apex radiation to left lower chest Cervical (lower) or cervicodorsal osteoarthritis Acid-peptic disorder. It is not due to forceful contraction of the heart, as in case of aortic stenosis, pulmonary stenosis, severe systemic and pulmonary hypertension. Cardiovascular System 297 Causes of Palpitation Cardiac Causes Valvular heart diseases: Aortic stenosis Mitral regurgitation Aortic regurgitation Mitral valve prolapses Prosthetic heart valves. Ischemic heart diseases: Stable or unstable angina Myocardial infarction Ventricular aneurysm-complication of infarction.

The resulting process of rationing requires a system of justice that does not discriminate on the basis of race, sex, age, gender or religion to administer resources prehypertension caffeine buy clonidine with visa. The focus for the surgeon is more likely to involve individual patients and how their interests should be prioritised, for example, when managing a waiting list for surgery. Resources may be allocated on clinical grounds such as threat to life or degree of pain. These perceptions of clinical need consider the timeliness of intervention to achieve a favourable outcome. This should be assumed for all conscious adults unless there is evidence to the contrary. The surgeon must maximise the opportunity for patients to consent and facilitate the process wherever possible. Informed consent General considerations Informed consent is central to the practice of surgery, and has to be obtained for surgical procedures, other treatment modalities, investigations, screening tests and prior to patient participation in Other important considerations in obtaining consent relate to who should obtain consent and when, and what information should be shared withheld and in what format. All potential serious adverse outcomes, no matter how rare, should be discussed, along with more frequent minor complications. These figures should derive from audited local/personal practice and not simply plucked from the literature. It is acceptable for the surgeon to give the patient advice; but in such circumstance, any conflict of interest must be declared. Lanarkshire) expects that the treating surgeon takes `reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments. Implied consent is considered adequate for routine interventions with negligible risks where patient consent is implied by their cooperation. The majority of interventions require explicit consent; this may be oral or written. Nevertheless, the existence of a written, dated form of consent provides evidence that a consultation covering specific issues was likely to have taken place. Where the surgeon and patient are unable to communicate effectively because of language barriers, the consultation and consent process should not be considered via a family member or friend acting as an informal interpreter. Written information should be available in a range of languages that may be reasonably encountered; if this is not possible the translator should read it out to the patient who then has an opportunity to ask questions back through the translator. The medical records should clearly document that this process has taken place, but patients may require time to reflect on any written information. The surgeon must also be sensitive to, and respect other social and cultural differences. Other challenging situations may arise where close family want to hide unpleasant diagnoses from a patient with the idea of protecting the patient. In children under the age of 16, their mental ability to understand, retain, weigh up and use information, as well as communicate their decision, is more important than their age in determining their capacity to consent. It should be borne in mind that while capacity may exist for simple procedures, this does not necessarily translate into the ability to weigh up more complex treatments. For those that lack capacity, treatment can be provided with the consent of parents or the courts. Where either a competent child or the parents refuse life-saving treatment, or where disagreement exists between parents, legal advice should be sought. In emergency or urgent situations, treatment may be provided with their compliance if the patient lacks capacity to consent. Although treatment may be administered compulsorily for the treatment of mental illness, treatment for other medical disorders must not be imposed even where mental illness means that the patient lacks capacity. If a consensus cannot be reached, then legal advice should be sought or the case referred to the courts to decide.

Mechanism of venous hum: It is produced by compression of internal jugular vein by transverse process of atlas It occurs in patient with high cardiac output and increased venous flow It occurs in young adult (25%) heart attack 6 minutes cheap clonidine 0.1mg with mastercard. Thoracic cavity contains heart and great vessels, lungs, thymus, distal part of trachea and most of the esophagus. Thoracic cavity is bounded: z Anteriorly by sternum and ribs z Laterally by ribs z Posteriorly by ribs and vertebrae z Inferiorly by diaphragm and ribs margins z Superiorly by clavicles and soft tissues of the neck. Thoracic cavity communicates with abdomen through inferior thoracic aperture called thoracic outlet. Manubrium is joined with gladiolus by fibrocartilage, mobility of this joint is slight. Shape: Looking like ancient Greek sword-manubrium is the handle, gladiolus is the blade, xiphoid cartilage is the tip Shape of the xiphoid cartilage: Lance-shaped or bifid, angulates forward. Other joints (2nd to 7th ribs) are arthrodial, these are mobile 2nd rib at its sternal edge joins with interface of manubrium and gladiolus-fibrocartilage. So ribs can be counted from here, since 1st rib is deep to the clavicle, so cannot be counted Trachea bifurcates here It demarcates the division between superior and inferior mediastinum It denotes the beginning of the arch of aorta. This angle is used for cardiopulmonary resuscitation for proper position of the hand on the inferior part of the body of sternum. Muscles of thoracic wall helpful for respiration z Intercostals: Internal intercostals and external intercostals, transversus thoraces (continuous with tranversus abdominis), subcostal, levator costarum, serratus posterior muscles are the muscles of the thoracic wall z Pectoralis major and pectoralis minor, inferior part of serratus anterior-act as accessory muscles of respiration-expands the thoracic cavity during forceful respiration Respiratory System z 151 the scalene muscles of respiration-fix these ribs and help the muscles connected below to be more effective in elevating lower ribs during forceful inspiration. Respiratory passage: It consists of: z Nose z Nasopharynx z Mouth z Oropharynx z Larynx z Trachea z Bronchial tree supplying the alveoli. Aorta arches over the left bronchus from front to back Left recurrent laryngeal nerve descents in front of the aortic arch, hooks under it and ascends besides the trachea to the neck. Dilated aorta may compress the left recurrent laryngeal nerve against left main bronchus Each segmental bronchus ends into 6 to 10 terminal bronchioles Each terminal bronchiole gives rise to several generations (5 to 10) respiratory bronchioles Each respiratory bronchiole gives rise to 2 to 11 alveolar ducts Each alveolar duct gives rise to 8 to 10 alveolar sacs-this is the basic structural unit of gas exchange. Each lobe is separated from the other of the same lung by lobar fissure-infolding of the visceral pleura. Shape of both the lungs are similar, but medial edge of left lung has an inferior indentation-cardiac notch. Visceral pleura: It covers and adheres to lung surfaces including the surfaces of the fissures-horizontal and oblique. Cervical pleura: It extends through the superior thoracic aperture into root of the neck, 2 to 3 cm superior to the level of medial third of clavicle at the level of the neck of the 1st rib. Costodiaphragmatic recess: Pleural-lined gutters surrounding convexity of diaphragm including the thoracic wall 2. Smaller pleural recesses are located posterior to the sternum where the costal pleura are in contact with mediastinal pleura- costomediastinal recess. Root of the lung the root of the lung is formed by the structures entering into and emerging from the lung, consists of: z Pulmonary artery z Superior and inferior pulmonary vein z Bronchus. Mediastinum It occupies center of thorax, bounded laterally by mediastinal pleura and contains all thoracic viscera and structures except the lungs. It extends from superior thoracic inlet to the diaphragm below, anteriorly sternum and costal cartilage to posteriorly thoracic vertebrae. It is arbitrarily divided by an imaginary plane extending anteriorly from the sternal angle to 4th intervertebral disc posteriorly into: z Superior mediastinum: It contains: Superior vena cava Brachiocephalic vein Arch of aorta Thoracic duct Trachea Esophagus Thymus Vagus nerve Left recurrent laryngeal nerve Phrenic nerve.

The syringe is aspirated as the needle is advanced, until it easily fills with blood blood pressure and headaches order cheap clonidine on line. Pericardiocentesis must always be followed by a request for an urgent consultation by a cardiologist or cardiothoracic surgeon. The labia minora are separated with the thumb and fingers of the left hand to expose the urethral meatus on the anterior vaginal wall. Two swabs are used, each being swept once across the pudenda from anterior to posterior and then discarded. In general, the catheter need only be inserted for half its length before the passage of urine confirms correct placement. The balloon is inflated and the catheter withdrawn until the balloon impacts in the bladder neck. It is important to examine the patient beforehand for evidence of raised intracranial pressure, examining the fundi in particular for evidence of papilloedema. Suprapubic catheterisation this procedure is only appropriate when the bladder is distended and urethral catheterisation has failed or is contraindicated. Procedure Patients are placed on one side (usually the left), with their back at the edge of the bed or trolley. They are then asked to curl up as much as possible, to flex the lumbar spine and open up the interspinous spaces. The skin is thoroughly cleansed and drapes are applied to ensure strict aseptic technique. The space between the spinous processes of the third and fourth lumbar vertebrae is identified using the point at which a vertical line dropped from the highest point of the iliac crest crosses the spine. Local anaesthetic is infiltrated into the skin and subcutaneous tissues to a depth of about 2 cm. A small stab incision is made in the midline, midway between the two spinous processes. A 22-gauge spinal needle is inserted through the stab incision and advanced in the midline in a slightly headward direction. If the needle is in the midline, it should be withdrawn and reinserted in a slightly more headward direction. Once the procedure is complete, the needle is withdrawn and a sterile dressing applied. The patient is usually advised to remain Procedure the position of the bladder is determined by percussion. Generally, the point of insertion lies two finger-breadths above the pubic symphysis in the midline. The area is cleansed and draped before local anaesthetic is infiltrated through all layers of the anterior abdominal wall, using an 18-gauge needle. The depth and position of the bladder can be gauged by the free aspiration of urine through this needle. Entry into the bladder is confirmed by the loss of resistance, at which point the catheter is advanced as the trocar is withdrawn. The catheter must be advanced far enough into the bladder so that the balloon, when inflated, is well within the bladder. Contrast studies Radio-opaque contrast media may be used to demonstrate the gastrointestinal, biliary, vascular and urinary tracts. They can either be used to outline anatomical structures directly, or else be concentrated physiologically in an organ (indirect imaging). Barium sulphate is insoluble and is used extensively to investigate the gastrointestinal tract. Gastrograffin is a water-soluble contrast medium used if leakage from the gastrointestinal tract into the peritoneal cavity is likely. A barium swallow is used to assess the oesophagus and a barium meal to investigate the stomach and duodenum. Progress of contrast can be observed by fluoroscopic screening, using an image intensifier.

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