Disease and Treatment: June 2009

Necrotizing Fasciiti

Necrotizing fasciitis is infection of skin and fascia caused by group A streptococci, mixed aerobic-anaerobic bacteria, or Clostridium perfringens. It develops rapidly and has high mortality without emergent treatment.

Signs and Symptoms:

Pain and unexplained fever
Swelling, tenderness, induration, or bullae
Extending of infection to fascia and spreads rapidly
Predisposing factors: DM, peripheral vascular disease, breaches in the skin or mucosa, and surgery
Necrotizing fasciitis of the perineal region is called Fournier's gangrene

Treatments:

Surgery
Antibiotic therapy after gram stain and culture of tissue

Molluscum contagiosum

Molluscum contagiosum is an infection caused by a poxvirus. It is commonly found in young children and AIDS patients

Signs and Symptoms:

Discrete, dome shaped, and shiny papules (2-5 mm) with central umbilication
The lesions are asymptomatic unless inflamed or irritated
In adult: lesions on the perianal and perigenital areas
In child: lesions on the trunk, extremities, and face

Treatments:

The lesions resolve (months to years) spontaneously
Liquid nitrogen cryotherapy
Curettage
Trichloroacetic acid

Lice

Types of Lice:

Pediculus capitis - infection of the scalp
Pediculus corporis - infection of the body
Phthirus pubis - infection of the pubic area

Signs and Symptoms:

Pruritus
Nits fluoresce blue under Wood's lamp

Treatments:

Permethrin shampoo or cream
Sources of reinfection (such as combs, bed sheets, clothing) should be decontaminated

Lyme Disease

Lyme Disease:

"Bull's eye" erytheuma
Occurs in moist and warm areas of the body (axillae, behind the knees, inguinal area) where the tick initially bites
Fatigue
Malaise
Arthralgias
Headache
Lymphadenopathy
Neurologic deficits
History of tick bite

Rocky Mountain Spotted Fever

Rocky Mountain Spotted Fever:

Rash on the palms and soles then spreads to the trunk and face
High fever
Chills
Headache
History of tick bite

Scarlet Fever

Scarlet Fever:

Rash on the trunk as sandpaper-like
Strawberry tongue
Circumoral pallor
Most occurs in untreated streptococcal pharyngitis
Penicillin is drug of choice to prevent rheumatic fever

Chickenpox (varicella)

Chickenpox (varicella):

Macules on the trunk cause papules and vesicles, ruptured and crusting
Crops of lesions
Dewdrop on a rose petal: a clear vesicle on an erythematous base
Fever
Risk for bacterial superinfection of lesions

Fifth Disease

Fifth Disease (Erythema infectiosum):

Caused by parvovirus B19
Slapped-cheek rash over the cheeks
Maculopapular rash on the trunk and extremities 1-2 days later
Malaise
Low-grade fever

Infectious Rashes: Rubella

Rubella (German measles):

Maculopapular rash (spreading from the head downward)
Suboccipital swelling
Postauricular nodes
Low-grade fever
Malaise
Arthralgias

Infectious Rashes: Measles / Rubeola

Measles / Rubeola:

Koplik's spots (white spots on buccal mucosa) usually occurs 3 days after a high fever
Maculopapular rash (spreading from the head downward)
Cough
Coryza
Conjunctivitis

Impetigo

Impetigo is a contagious and autoinoculable skin infection caused by staphylococci or streptococci. It commonly in children than adults

Signs and Symptoms:

Pruritus with honey-colored crusts on the face, neck, and extremities
Nonbullous impetigo: superficial pustules with surrounding erythema
Bullous impetigo: erythematous macules as thin-walled vesicles or bullae on an erythematous base.

Treatments:

Mild soap for washing the lesions
Topical mupirocin
Systemic antibiotics
Patient's towels and washcloths should be segregated

Herpes Simplex

Herpes simplex is a recurrent vesicular eruption of mucocutaneous surfaces due to HSV infections. It is a painful eruption.

Signs and Symptoms:

First outbreaks are longer and more sever than recurrent eruptions
Prodromal tingling, burning, or frank pain with lymphadenopathy
Fever, discomfort, malaise, and edema on involved area
Grouped vesicles on erythematous base
Recurrent infections are limited to mucocutaneous areas

Treatments:

Acyclovir ointments
Oral or IV acyclovir
Daily acyclovir therapy for patient with more than 6 outbreaks per year

Fungal Infections: Tinea Corporis/Capitis

Tinea corporis / capitis is an infection of the body/scalp caused by fungus

Signs and Symptoms:

Pruritus
Ring-shaped (ringworm)
Erythematous
Scaling plaques

Treatments:

Tinea corporis: topical anti-fungal
Tinea capitis and tinea unguium (nail infection): oral anti-fungals

Fungal Infections: Pityriasis versicolor

Pityriasis versicolor is also named by tinea versicolor. It is caused by Malassezia furfur.

Signs and Symptoms:

Small, scaling, hyper or hypopigmented macules
Lesions: asymptomatic or mild itching
Chest and back is the common site of infections

Diagnosed by:

Treatments:

Topical anti-fungal agents
Selenium sulfide shampoo

Cellulitis

Cellulitis or folliculitis is skin infections due to streptococci or staphylococci.

Signs and Symptoms:

Folliculitis: hair follicles infection commonly on facial hair
Cellulitis: red, hot, and swollen skin lesions, fever and chills

Treatments:

Oral antibiotics such as cephalexin or dicloxacillin for mild to moderate cases
In cases of systemic toxicity, comorbid condition, DM, extremes of age, or hand or orbital involvement, patient should be hospitalized and give IV antibiotics

Acne Vulgaris

Acne vulgaris is a condition in which the hair follicles are blocked by sebum and keratinous material. This blockage causes formation of cyst/comedones. Propionibacterium acnes within comedones break down sebum into free fatty acids.

History and Physical Exams:

Acne is associated with changes in androgen levels
Found primarily in puberty
More common in males than in females
Open comedones - blackheads and closed comedones - whiteheads on the face, neck, arms, back, and buttocks
Drugs are related to acne: lithium, steroids, OCPs, androgens

Treatments:

Treatments are according to the severity of acne
Mild case: topical clindamycin or erythromycin, benzoyl peroxide, topical retinoids
Moderate case: treatments in mild case plus oral antibiotics
Severe case: oral isotretinoin (Accutane)

Vitiligo

Vitiligo is a depigmentation due to loss of melanocytes and associates with autoimmune and thyroid disease. It more common in dark-skinned peaople with a family history.

Signs and Symptoms:
Irregular white patches

Treatments:

Topical artificial tanning cream
Steroid/tretinoin creams
Phototherapy

Steven-Johnson Syndrome

Steven-Johnson Syndrome/Toxic Epidermal necrolysis (SJS/TEN) is a life threatening exfoliative mucocutaneous disease. It often caused by a drug induce immunologic reaction such as sulfa drugs, carbamazepine, phenytoin, valproic acid, quinolones, cephalosporins, phenobarbital, allopurinol, aminopenicillins, and corticosteroids.

Signs and Symptoms:

History of new drug exposure within 1-3 weeks
Flu-like prodrome
Skin tenderness
Painful mouth lesions
Nikolsky's sign is positive
Coalescing red macules and flaccid blisters with full-thickness epidermal loss
Sepsis from superimposed bacterial skin infections that leads to death

Treatments:

Eliminate the offending agents
Analgesia and IVIG
Hospitalize in the burn center to manage skin and fluid losses

Seborrheic Dermatitis

Seborrheic dermatitis is a chronic superficial inflammatory. It may be a reaction to Pityrosporum yeast

Signs and Symptoms:

Pruritus during neonatal and postpubertal periods
Yellowish, greasy, and erythematous scaling patches and plaques on the scalp, ear, and face

Treatments:

1% hydrocortisone and topical antifungals
Shampoos contain of selenium sulfide or zinc pyrithione to treat the scalp

Psoriasis

Psoriasis is epidermal hyper-proliferation caused by a T-cell-mediated inflammatory

Signs and Symptoms:

Dark red plaques with silvery-white scales and sharp margins on extensors surface
Nail pitting, oil spots, and lifting of the nail plate
Joint stiffness, tenderness, pain on psoriatic arthritis
Malaise and fever

Treatments:

Mild to moderate cases: topical steroids and topical calcipotriol
Phototherapy and immunosuppressants: methotrexate
Biologic agents: infliximab, etanercept

Lichen Planus

Lichen planus is an inflammatory dermatosis on skin and mucous membranes

Signs and Symptoms:

Flat-topped, purple, polygonal pruritic papules with overlying network of white lines - Wickham's striae
Reticulate white hyperkeratosis on mucosal surface

Treatments:

Antihistamines and topical steroids
Cyclosporine, oral prednisolone, oral retinoids, and PUVa in severe cases

Erythema Nodosum

Erythema nodosum is an inflammation of the subcutaneous fat. It produces tender erythematous nodules most on the anterior tibial areas. It is most commonly found in young women.

Etiology:

Hypersensitivity reaction to drugs (OCP - NSAID)
Infection
Sarcoid
Rheumatic fever
IBD

Signs and Symptoms:

Painful erythematous
Malaise
Arthralgia
Fever

Treatments:

NSAIDs
Potassium iodide
Leg elevation and bed rest
Systemic corticosteroid

Erythema Multiforme

Erythema multiforme is an acute, self-limiting, inflammatory skin eruption.

Etiology:

Drugs (penicillin, sulfonamides, phenytoin)
Infection
Vaccination
Malignancy

Signs and Symptoms:

Malaise and myalgias
Lesions on the extremities
Erythematou s

Treatments:

In mild cases, it resolves spontaneously
Discontinue the inciting agent/drugs
Acyclovir, if it due to HSV

Contact Dermatitis

Contact dermatitis is defined when a skin rash is developed from contact with a substance to which the patient has previously been sensitized. It is a delayed type IV hypersensitivity reaction. The agents include poison ivy, poison oak, nickel, perfumes, soaps, detergents, and cosmetics.

Signs and Symptoms:

Pruritus and rash
Malaise and fever
Edema
Lymphadenopathy
Erythematous, weepy, and crusted patches, plaques, or papulovesicles

Treatments:

Cool compresses or oatmeal preparation, topical steroids for mild cases
Extended course of systemic corticosteroids and antihistamines for severe cases

Pemphigus

Pemphigus is a shallow, painful corrosions and blisters on epidermal and mucosal surfaces. It is caused by autoantibodies against desmocollins and desmogleins in the epidermis. The onset is between 40 and 60 years of age.

Signs and Symptoms:

Shallow croisons on mucous membranes, developing slowly that may involve the skin
Shallow ulceration from blisters that are easily ruptured
Nikolsky's signs
Epistaxis, hoarseness, weakness, malaise and weight loss

Diagnosis:

Immunologic staining of skin biopsy
Acantholysis is seen on biopsy
Increased serum levels of antibodies to desmoglein 1 and 3

Treatments:

Oral steroids - imunosuppressants
Plasmapheresis if the cases are severe
Care the lesions as burns

Bullous pemphigoid

Bullous pemphigoid is a chronic blistering eruptions on an inflamed base. It is more common in > 60 years of age. It is due to autoantibodies to BP1 and BP2 found in the basement membrane of the skin.

Signs and Symptoms:

Prodromal erythematous, pavular lesion that is large, tense and pruritic bullae
Rarely involves the mucous membranes
Pruritic (usually not painful)
No Nikolsky's sign

Treatments:

Topical steroids if mild cases
Oral Steroid if severe

Atopic Dermatitis or Eczema

Atopic dermatitis or eczema is an inflammatory skin disorder characterized by pruritus.

Signs and Symptoms:
Dry, scaly, itchy patches and plaques with excoriations in the flexural areas (elbows, knees, antecubital fossae, buttocks) and neck

Etiology:

Skin irritants such as dry skin, wool clothing and perfume
Stress
Airborne allergens (dust mites, pollens)
Foods (eggs, milk, peanuts, seafood, wheat, soybeans)
Asthma and allergic rhinitis

Treatments:

Mild soaps and emollients
Topical steroids
Topical tacrolimus
PUVA phototherapy
Methotrexate

Erythrasma

ERYTHRASMA

Etiology:

Corynebacterium minutissimun
Diabetics
Warm climates

Physical Examinations:

Enlarging area of pink or brown macular patches on flexor surfaces (axilla, groin)
Typically asymptomatic

Diagnosis:

Wood's light : fluoresce coral pink or red
KOH prep is negative

Treatments:
Topical or oral erythromycin

Acanthosis Nigricans

Acanthosis nigricans is a velvetly hyperpigmentation of the skin. It associates with Insulin resistance, endocrine disorders, obesity, drugs, and malignancy.

Etiology:
The etiology is unclear but may be related to the growth factors on skin

Signs and Symptoms:
Dark, thickened, dirty-appearing, velvety plaques predominantly in the flexural areas such as axillae, neck, and under the breast and groin

Treatments:
Treat the underlying disorder such as weight reduction for obesity and insulin resistance

Peripheral Vascular Disease

Peripheral vascular disease is an occlusion of the blood supply to the extremities by atherosclerotic plaques. It most commonly affect to the lower extremities.

Signs and Symptoms:

Intermittent claudication (leg pain when walking and relieved by rest)
Dorsal foot ulcerations may develope
Painful, cold, and numb on foot
Aortoiliac disease: buttock claudication and femoral pulses are absent, impotence in male
Femoropopliteal disease: calf claudication, pulses below the femoral artery are absent
Small vessel disease: foot pulses are absent
Acute ischemia: caused by embolization from the heart
Severe chronic ischemia: mucle atrophy, pallor, cyanosis, hair loss, and gangrene/necrosis

Diagnostic Procedures:

Palpation of pulses and auscultation for bruits
Measurement of ankle and brachial systolic BP
Droppler ultrasound
Arteriography and digital substraction angiography

Treatments:

Control the underlying causes
Eliminate tobacco
Hygiene and foot care
Exercise
Aspirin, cilostazol, and thromboxane inhibitors
Angioplasty and stenting
Surgery (artery bypass) or amputation

Deep Venous Thrombosis

Deep venous thrombosis is a clot formation in the large veins of the extremities or pelvis. The disease can be diagnosed by doppler ultrasound.

Predisposing Factors:

Venous statis due to immobilization
Incompetent venous valves in the lower extremities
CHF
Traumatic injury to the lower extremities
Hypercoagulable states
Obesity
Indwelling venous catheters

Signs and Symptoms:

Homan's signs: tendernes on calf with passive foot dorsiflexion
Pain, erythema and swelling unilateral lower extremities

Treatments:

Initial anticoagulation with IV heparin or low-molecular-weight heparin, followed by PO walfarin for a total of 3-6 months
IVC filter in patient with contraindication to anticoagulation
Hospitalized patients: DVT prophylaxis consisting of rapid mobilization, antithromboembolic stockings, leg exercises, and SQ heparin

Aortic Dissection

Aortic dissection is a transverse tear in the intima of a vessel. The blood enters the media and creates a false lumen and hematoma that propagates longitudinally. The most common sites of origin are above the aortic valve and distal to the left subclavian artery. It occurs often in age 40-60 years of age and a greater frequency in men than in women.

Etiology:
Hypertension (most)

Signs and Symptoms:

Sudden tearing / stabbing pain in the anterior chest in ascending dissection
Interscapular back pain in descending dissection
Hypertensive
Signs of pericarditis or pericardial tamponade may be seen
A murmur of aortic regurgitation may be heard
Neurologic deficits may be seen

Treatments:

If hypertensive, reduce the BP and heart rate. Do not use thrombolytics
Surgical emergency for ascending aortic dissection
Medical therapy for descending dissection aorta

Aortic Aneurysm

AORTIC ANEURYSM

Etiology:
Atherosclerosis (most are abdominal and more than 90% originate below the renal arteries

Risk Factors:

Hypertension
High cholesterol
Other vascular disease
Family history
Smoking
Age
Gender (males > females)

Signs and Symptoms:

Usually asymptomatic
Pulsatile abdominal mass or abdominal bruits
Ruptured aneurysm
Hypotension
Severe and tearing abdominal pain radiating to the back

Treatments:

If asymptomatic, monitoring is appropiate for lesions less than 5 cm
Surgical repair if lesion is more than 5.5 cm on abdominal or more than 6 cm on thoracic or if enlarges rapidly
Emergency surgery for symptomatic or ruptured aneurysms

Mitral Valve Prolapse

MITRAL VALVE PROLAPSE

Risk Factors:
Young women (found in 7% of the population)

Signs and Symptoms:

Benign and asymptomatic
Murmur: late systolic murmur with mid-systolic click
Can progress to mitral regurgitation

Treatments:
Treatments are unnecessary unless symptomatic

Mitral Regurgitation

MITRAL REGURGITATION

Risk Factors:

Rheumatic heart disease
Myocardial Infarction
Infective endocarditis
Severe mitra valve prolapse

Signs and Symptoms:

Signs of left-sided heart failure that can progress to right-sided heart failure
Murmur: high-pitched, holosystolic murmur at the apex that radiates to the axilla
Laterally displaced PMI with left ventricular heave
Atrial fibrillation
Fatigue

Treatments:

ACEIs
Vasodilators
Diuretic
Digoxins
Anticoagulants
Valve repair or replacement

Mitral Stenosis

MITRAL STENOSIS

Risk Factors:
Rheumatic heart disease

Signs and Symptoms:

Symptoms of CHF (left and right side)
Murmur: mid-diastolic rumble with opening snap at the apex
Atrial fibrillation
Pulmonary rales
Increased intensity of S1 and P2
Right ventricular heave

Treatments:

Avoid inotropic agents
Beta-blocker and diuretics
Digoxins
Anticoagulants
Balloon valvuloplasty

Aortic Regurgitation

AORTIC REGURGITATION

Risk Factors:

Rheumatic heart disease
VSS
Infective endocarditis
Congenital bicuspid valve
Marfan's syndrome
Syphilis

Signs and Symptoms:

LVH symptoms
Angina
CHF
Widened pulse pressure
Laterally displaced PMI
Three murmur: high-pitched (blowing diastolic murmur at the left sternal border); Austin Flint-low-pitched (mid-diastolic rumble); mid-systolic murmur at the base

Treatments:

Aortic valve replacement
Afterload reducers (ACEIs, vasodilators)
Diuretics
Digoxin

Aortic Stenosis

AORTIC STENOSIS

Risk Factors:

Rheumatic heart disease
Congenital aortic stenosis
Bicuspid valve

Signs and Symptoms:

Classic triad of exertional dyspnea, angina, and syncope
Can develops to CHF or even death
Murmur: midsystolic crescendo-decrescendo heard best at the second intercostal space radiating to the neck
Pulsus parvus et tardus: weak, delayed caroid upstroke
Sustained apical beat
Paradoxically split S2

Treatments:

Avoid afterload reducers
Valve replacement

Cardiac Tmponade

Cardiac tamponade is an excess fluid in the pericardial sac. It compromises ventricular filling and decreases output.

Risk Factors:

Pericarditis
Malignancy
SLE
TB
Trauma

Signs and Symptoms:

Fatigue, dyspnea, tachycardia and tachypnea that worsen rapidly and causes shock and death
Beek's triad (hypotension, distant heart sound, and distended neck veins)
Narrow pulse pressure
Pulsus paradoxus
Kussmaul's sign (JVD on inspiration)

Treatments:

Aggressive volume expansion with IV fluids
Pericardiocentesis immediately
Balloon pericardotomy
Pericardial window

Pericarditis

Pericarditis is an inflammation of the pericardial sac. It often with an effusion and can compromise cardiac output via tamponade or constrictive pericarditis. Most commontly idiopathic.

Etiology:

Collagen vascular disease
Aortic dissection
Radiation
Drugs
Infections
Acute renal failure (uremia)
Cardiac (Myocardial Infarction)
Rheumatoid Fever
Injury
Neoplasms
Dressler's syndrome

Signs and Symptoms:

Pleuritis chest pain that worsens in the supine position and with inspiration
Dyspnea
Cough
Fever
Pericardial friction rub
Elevated JVP
Pulsus paradoxus

Treatments:

Treat the underlying causes, eg. steroid/immunosuppressants for SLE, ASA/NSAIDs for viral pericarditis, dialysis for uremia
Pericardiocentesis with continuous drainage for tamponade or large effusion

Hypertension - Urgency and Emergency

Hypertensive urgency is defined as systolic BP > 180 mmHg and diastolic BP > 130 mmHg with asymptomatic or moderately symptomatic such as headache, chest pain, and syncope.

Hypertensive emergency is defined as signs or symptoms of impending end-organ damage such as acute renal failure or hematuria, altered mental status or evidence of neurologic disease, intracranial hemorrhage, ophthalmologic problems (papilledema), unstable angina or MI, or pulmonary edema.

Malignant hypertension is defined as progressive renal failure and/or encephalopathy with papilledema.

Treatments:

Treatment is to decrease blood pressure slowly to prevent cerebral hypoperfusion or coronary insufficiency
Oral drugs: beta-blocker, clonidine, and ACEIs
IV agents: nitroprusside, nitroglycerin, labetalol, necardipine, or hydralazine
Diuretics are used if there are signs of fluid overload

Hypertension

Hypertension is defined as a systole BP > 140 mmHg and/or a diastolic BP > 90 mmHg based on three measurements, each separated by two weeks. It is classified as Stage 1 Hypertension and Stage 2 Hypertension.

Stage 1 (essential) Hypertension

It represent 95% of hypertension cases. Systolic BP 140-139 mmHg, Diastolic BP 90-99 mmHg. Risk factors: family history of hypertension or heart disease, high-sodium diet, smoking, obesity, race (African-American > Caucasians), elderly

Signs and Symptoms:

Asymptomatic until complications develop
Retinal changes
S4 gallop
Systolic click
Loud S2
If untreated will damage to the heart, brain, kidney, vasculature, and eye

Treatments:

Lifestyle management
Diuretics and beta-blocker
Test for end-organ complication periodically; renal and cardiac complications

Stage 2 Hypertension

Stage 2 hypertension is due to an identifiable organic cause. Systolic BP is > 160 mmHg and diastolic BP is > 100 mmHg.

Etiologies and Treatments:
Treatments for stage 2 hypertension are treatment of underlying causes:

Renal disease (stage 1); treatments: ACEIs
Renal artery stenosis; treatments: angioplasty and stenting, ACEIs, and open surgery
OCP use; treatment: discontinue OCPs
Pheochromocytoma; treatment: surgical removal of tumor
Conn's syndrome (hyperaldosteronism); treatment: surgical removal of tumor
Cushing's syndrome; treatment: surgical removal of tumor
Coarctation of the aorta; treatment: surgical repair

Myocardial Infarction (MI)

Myocardial infarction usually caused by occlusive thrombus or prolonged vasospasm in a coronary artery.

History and Physical Exams:

Acute onset substernal chest pain that is described as pressure or tightness and radiate to the left arm, neck, or jaw
Shortness of breath, diaphoresis, light-headedness, nausea, vomiting, anxiety, syncope
Tachycardia, bradycardia, arrhythmias, new mitral regurgitation, hypotension, pulmonary edema, and ventricular fibrillation
Sudden death from a lethal arrhythmia (ventricle fibrillation)
Clinically silent MIs in elderly, diabetic, postmenopausal and postorthopic heart transplant patients

Diagnosis

ST-segment elevation or new LBBB on ECG
ECG changes: peaked T waves, ST-segment elevation, Q wave, T-wave inversion, ST-segment normalization, T-wave normalization
Inferior MI : ST-segment elevation in leads II, III, and aVF
Anterior MI : ST-segment elevation in leads V1-V4
Lateral MI : ST-segment elevation in leads I, aVL, and V5-V6
Serial cardiac enzymes: troponin and CK-MB.

Treatments:

Acute treatments is Morphine, Oxygen, Nitroglyserin sublingualy, Aspirin, and IV beta-blocker.
Glycoprotein
Heparinization, angiography and revascularization
Consider thrombolysis with tPA, urokinase, or streptokinase
PTCA
CABG - Coronary Artery Bypass Graft (for depressed ventricular function, unable to PTCA, stenosis of left main, and triple-vessel disease)
Long term treatments: ASA, beta-blocker, ACEIs, and statins
Dietary changes and exercises

Angina - Unstable Angina

Unstable Angina

The angina is unstable if it is new and accelerating or occurs at rest.

Treatments:

Acute treatments is Morphine, Oxygen, Nitroglyserin sublingualy, Aspirin, and IV beta-blocker.
Glycoprotein
Heparinization, angiography and revascularization

Angina Pectoris

Angina pectoris is substernal chest pain due to myocardial ischemia. Angina pectoris can be distinguished from prinzmetal's (varian) angina by definition that prinzmetal's angina is caused by vasospasm of coronary vessels.

Signs and Symptoms:

Substernal chest pain precipitated by exertion and relieved by rest or nitrates
Pain radiates to the arms, jaw, and neck
Shortness of breath
Nausea or vomiting
Light-headedness
Diaphoresis
Hypertension
Tachycardia
Apical systolic murmur or gallop

Diagnoses:

ST segment depression or T-wave flattening on ECG
Cardiac enzymes to rule out myocardial infarction

Treatments in Acute Case:

Morphine
Oxygen
Nitroglycerin sublingually
Aspirin
IV beta-blocker

Treatments in Chronic Case:

Nitrates
Beta-blockers
Calcium channel blockers
ASA
Risk factor reduction such as smoking, cholesterol, hypertension

Hypercholesterolemia

Hypercholesterolemia is defined as a total cholesterol level more than 200 mg/dL.

Risk Factors:

Increased blood cholesterol
Increased LDL
Increased triglycerides
Decreased HDL

Etiology:

Obesity
Diabetes Mellitus
Alcoholism
Hypothyroidism
Nephrotic syndrome
Hepatic disease
Cushing's disease
OCP use
Diuretic use
Familial hypercholesterolemia

Data Findings:

No specific signs and symptoms for most patients
Xanthomas - eruptive nodules in skin over tendons
Xanthelasma - yellow fatty deposits in skin around eyes
Lipemia retinalis - creamy of retinal vessels

How to diagnosed:

Hypercholesterolemia is diagnosed by:
Fasting lipid profile for patient more than 20 year and repeat ever five years
Total serum cholesterol > 200 mg/dL on two different occation
LDL > 130 mg/dL or HDL <>

Treatments:

Treatments are based on risk stratification
Diet and exercise

CHF - Diastolic Dysfunction

CHF - Diastolic Dysfunction is characterized by decreased ventricular compliance with normal contractile function. the ventricle is unable either to actively relax or to passively fill properly

Physical Examinations:

Stable and unstable angina
Shortness of breath
Dyspnea on exertion
Arrhythmias
Myocardial infarction
Heart failure
Sudden death

Treatments:

Beta-blocker
ACEIs
Diuretics
Rate control drugs
Blood pressure management

CHF - Systolic Dysfunction

CHF - Systolic Dysfunction is determined by an EF < style="font-size:130%;">Physical Examination:

Dyspnea on exertion or at rest if severe
Chronic cough
Fatigue
Lower extremity edema
Orthopnea
Paroxysmal nocturnal dyspnea
Abdominal fullness

Treatments in acute:

Correct underlying causes such as arrhythmia, alcohol-induced failure, thyroid and valvular disease
Diuretics
ACEIs

Treatments in chronic:

Beta-blocker and ACEIs together
Daily aspirin and a statin
Chronic diuretics
Low-dose spironolactone
Treatment of arrhythmias
Limitation of dietary sodium and fluid intake
Warfarin
Mechanical left ventricular assist device or cardiac transplantation

Congestive Heart Failure

Congestive heart failure is the clinical condition in which the heart is unable to pump enough blood to meet the oxygen demand of the heart and other body tissues.

Risk Factors:

CAD
Hypertension
Valvular heart disease
Pericardial disease
Cardiomopathy
Pulmonary hypertension

Classification and Treatments:
According to the AHA/ACC the classification and treatments of CHF are:

CHF stage A

Present of the risk factors
No structural or functional abnormalities
No signs and symptoms of CHF
Treatments: managing the treatable risk factors, ACEIs

CHF stage B

Present of structral heart disease without symptoms of CHF
Treatments: ACEIs and beta blocker

CHF stage C

Present of structural heart disease with prior or current symptoms of CHF (shortness of breath, fatigue, exercise intolerance)
Treatments: diuretic, ACEIs, beta-blocker, digitalis, dietary salt restriction

CHF stage D

Marked symptoms of CHF at rest despite maximal medical therapy
Treatments: mechanical assist devices, heart transplant, continuous IV inotropic drugs, hospice care

Classification CHF according to New York Heart Association:

CHF Class I