java barcode generate code 2 Clinical findings suggesting obstructive airway disease in Objective-C

Draw Quick Response Code in Objective-C 2 Clinical findings suggesting obstructive airway disease

Table 2 2 Clinical findings suggesting obstructive airway disease
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Adjusted Likelihood Ratios Factor Present > 40 pack-years smoking Age 45 years Maximum laryngeal height 4 cm All three factors 116 14 36 585 Factor Absent 09 05 07 03
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Reproduced, with permission, from Straus SE et al The accuracy of patient history, wheezing, and laryngeal measurements in diagnosing obstructive airway disease CARE-COAD1 Group Clinical Assessment of the Reliability of the Examination Chronic Obstructive Airways Disease JAMA 2000 Apr 12;283(14):1853 7
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A focused physical examination should include evaluation of the head and neck, chest, heart, and lower extremities Visual inspection of the patient s respiratory pattern can suggest obstructive airway disease (pursed-lip breathing, use of extra respiratory muscles, barrel-shaped chest), pneumothorax (asymmetric excursion), or metabolic acidosis (Kussmaul respirations) Patients with impending upper airway obstruction (eg, epiglottitis, foreign body), or severe asthma exacerbation, sometimes assume a tripod position Focal wheezing raises the suspicion for a foreign body or other bronchial obstruction Maximum laryngeal height (the distance between the top of the thyroid cartilage and the suprasternal notch at end expiration) is a measure of hyperinflation Obstructive airway disease is virtually nonexistent when a nonsmoking patient younger than 45 years has a maximum laryngeal height 4 cm (Table 2 2) Because arterial blood gas testing is impractical in most outpatient settings, pulse oximetry has assumed a central role in the office evaluation of dyspnea Oxygen saturation values above 96% almost always correspond with a PO2 > 70 mm Hg, and values less than 94% almost always represent clinically significant hypoxemia Important exceptions to this rule
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include carbon monoxide toxicity, which leads to a normal oxygen saturation (due to the similar wavelengths of oxyhemoglobin and carboxyhemoglobin), and methemoglobinemia, which results in an oxygen saturation of about 85% Supplemental oxygen fails to improve desaturation due to methemoglobinemia A normal or mildly abnormal oxygen saturation (< 90%) in a delirious or obtunded patient with obstructive lung disease warrants immediate measurement of arterial blood gases to exclude hypercapnia and the need for intubation When pulse oximetry yields equivocal results, assessment of desaturation with ambulation (eg, a brisk walk around the clinic) can be a useful finding (eg, when Pneumocystis jiroveci [formerly Pneumocystis carinii] pneumonia is suspected) A systematic review has identified several clinical predictors of increased LVEDP useful in the evaluation of dyspneic patients with no prior history of CHF (Table 2 3) When none is present, there is a very low probability (< 10%) of increased LVEDP, and when two or more are present, there is a very high probability (> 90%) of increased LVEDP
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Table 2 3 Clinical findings suggesting increased left ventricular end-diastolic pressure
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Tachycardia Systolic hypotension Jugular venous distention (> 5 7 cm H2O)1 Hepatojugular reflux (> 1 cm)2 Crackles, especially bibasilar Third heart sound3 Lower extremity edema Radiographic pulmonary vascular redistribution or cardiomegaly1 These findings are particularly helpful Proper abdominal compression for evaluating hepatojugular reflux requires > 30 seconds of sustained upper quadrant abdominal compression 3 Cardiac auscultation of the patient at 45-degree angle in left lateral decubitus position doubles the detection rate of third heart sounds Source: Badgett RG et al Can the clinical examination diagnose left-sided heart failure in adults JAMA 1997 Jun 4;277(21):1712 9
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Diagnostic Studies
Causes of dyspnea that can be managed without chest radiography are few: ingestions causing lactic acidosis, methemoglobinemia, and carbon monoxide poisoning The diagnosis of pneumonia should be confirmed by chest radiography in most patients When COPD exacerbation is severe enough to require hospitalization, results of chest radiography influence management decisions in up to 20% of patients Chest radiography (detection of redistribution of pulmonary venous circulation) is fairly sensitive and specific for new-onset CHF and can help guide treatment decisions in patients with dyspnea secondary to cardiac disease End-expiratory chest radiography enhances detection of a small pneumothorax A normal chest radiograph has substantial diagnostic value In the absence of physical examination evidence of COPD or CHF, the major remaining causes of dyspnea include pulmonary embolism, upper airway obstruction, foreign body, and metabolic acidosis If a patient has tachycardia and hypoxemia but a normal chest radiograph and electrocardiogram (ECG), then further tests to exclude pulmonary emboli are warranted (see 9), provided blood tests exclude significant anemia or metabolic acidosis High-resolution chest CT is particularly useful in the evaluation of pulmonary embolism and interstitial lung disease Suspected carbon monoxide poisoning or methemoglobinemia can be confirmed with either arterial or venous carboxyhemoglobin or methemoglobin levels Serum or whole blood brain natriuretic peptide (BNP) testing can be useful in the evaluation of dyspnea in the emergency department, since elevated BNP levels are both sensitive and specific for increased LVEDP in symptomatic persons Clinical examination and routine diagnostic testing will identify the cause of dyspnea in most cases Persistent uncertainty warrants arterial blood gas measurement Spirometry is very helpful in further classifying patients with obstructive airway disease, but is rarely needed in the initial or emergent evaluation of patients with acute dyspnea Episodic dyspnea can be challenging if an evaluation cannot be performed during symptoms Life-threatening causes include recurrent pulmonary embolism, myocardial ischemia, and reactive airway disease When associated with audible wheezing, vocal cord dysfunction should be considered, particularly in a young woman who does not respond to asthma therapy
Jennings AL et al A systematic review of the use of opioids in the management of dyspnea Thorax 2002 Nov;57(11):939 44 [PMID: 12403875] Karnani NG et al Evaluation of chronic dyspnea Am Fam Physician 2005 Apr 15;71(8):1529 37 [PMID: 15864893] Luce JM et al Management of dyspnea in patients with faradvanced lung disease: once I lose it, it s kind of hard to catch it JAMA 2001 Mar 14;285(10):1331 7 [PMID: 11255389] Mahler DA et al Evaluation of dyspnea in the elderly Clin Geriatr Med 2003 Feb;19(1):19 33 [PMID: 12735113] Straus SE et al The accuracy of patient history, wheezing, and laryngeal measurements in diagnosing obstructive airway disease CARE-COAD1 Group Clinical Assessment of the Reliability of the Examination-Chronic Obstructive Airways Disease JAMA 2000 Apr 12;283(14):1853 7 [PMID: 10770147]
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