B4 Dyspnea

APPROACH TO A PATIENT
WITH
DYSPNEA
MPPR CONFERENCE
GROUP 4 2-SEC B
MEDICINE
Kristine Glory Flores
Flores, Kristine Glory
General Data
Date of Admission: November 30, 2010
Date of Interview: December 5, 2010
Name: P.C.
Age: 46 y.o.
Birthday: Nov. 21, 1964
Gender: Female
Marital Status: Single
Nationality: Filipino
Religion: Roman Catholic
General Data
Occupation: Unemployed
(1996-2006 Domestic helper in Hong Kong)
Address: Roxas, Oriental Mindoro
History of Present Illness

2 weeks PTA
Cough
-non-productive, non-paroxysmal
-anytime during the day
-(+)body malaise, (+)anorexia
-(-) fever, (-) chest pain
-relieved by increase in fluid intake
Dyspnea
- Parang hinahabol ang hininga ko
- prefers sitting upright
- Could tolerate moderate actvities
(washing dishes)

2 weeks PTA
Consulted to UST-OPD
-CXR (pleural effusion right hemithorax )
-unrecalled antibiotics: partially
relieved SOB but verbalized parang
nasusuka ako tuwing umiinom nung
antibiotic kahit meron o walang laman
ang tiyan ko
-unrecalled antibiotics shifted to
ciprofloxacin 500mg/tab as BID and coamoxiclav
- Cough unrelieved

3 days PTA
Intermittent Fever ( ave. 38.5 oC)

- Paracetamol 500mg/tab prn
-Ciprofloxacin 500 mg/tab BID
1 day PTA
Increased severity of dyspnea

-anytime during the day (3 pillow
orthopnea)
-para akong nalulunod at kinakapos ng
hininga
-Could not tolerate moderate activities
-Difficulty even on upright
-with R pleuritic chest pain
Consulted nearby hospital
-oxygen supplementation
Few hours PTA
Symptoms persisted hence admission was

done
Past Medical History

Birth and developmental history unremarkable
No significant childhood illness and hospitalizations
(+) CML 2006

(+) AML (4 mons. PTA)
(+) Blood transfusion but no transfusions reaction (4 mons.
PTA)
No allergies to food or drugs
No other surgeries
Current Health/Risk Factors

Environmental Exposures-lives far from any factory; has 1
pet dog at home; no exposure to radiation; exposed to 2 nd
hand smoke (son)
Medication data-Imatinib 100mg/tab 6 tablets OD
Childhood Immunization claims to be complete, with
influenza vaccine
Family History
No family member of DM,HPN, cancer and goiter
No apparent exposure to PTB
Personal and Social History

Single parent, lives with his unemployed 25 year old son,
has good relationship with him, currently unemployed
(used to be a domestic helper for 10 yrs), experiencing
financial constraints due to illness,
Review of Systems
General Survey
(-) dizziness
(-) headache
HEENT
(-) Blurring of Vision
(-) Eye pain
(-) Nasoaural
Discharge
(-) Epistaxis
(-) Sore throat
(-) Sores and Fissures
Review of Systems
Cardiovascular
(-) Chest Heaviness
(-) palpitations
Gastrointestinal
(-) Vomiting
(-) Constipation
(-) Hematemesis
(-) Melena
(-) Hematochezia
Review of Systems
Musculoskeletal
(-) Joint pains of upper
and lower extremities
(-) stiffness
Endocrine
(-) polyuria, polydipsia,
polyphagia
(-) Heat or Cold
intolerance
Review of Systems
Renal
(-)
(-)
(-)
(-)
Dysuria
Urgency
Pollakuria
Frequency
Physical Exam
Physical Exam upon Admission
Present Physical Exam
General Survey:
Conscious, coherent not in cardiorespiratory distress
Ht. 54 Wt: 57kg
General Survey:
Conscious, coherent, in respiratory
distress
BMI: 20.96
Vital Signs:
BP 120/60 PR 92 RR 23 T 37.7
Vital Signs
BP 140/90 PR 80 RR 22 T 35.5
Rechecked after 10 minutes
BP 130/80 PR 85 RR: 25 T: 35.5
Integumentary System:
Cold clammy skin
(+) multiple reddish to bluish
bruises:
Right Arm: 15x12 cm
Left forearm: 4x2 cm
Right knee: 3x1.5 cm
Left knee: 1x1 cm
Right thigh: 2x3 cm
Integumentary System:
Warm moist skin,
(+) multiple 2x2 to 3x4 cm circular
patch over extremities
HEENT:
HEENT:
Pink Palpebral conjunctivae, anicteric

sclerae, 2-3 mm pupils, equally
reactive to light, no nasoaural
discharge
Moist buccal mucosa, no gum

bleeding, non hyperemic posterior
pharyngeal wall and tonsils not
enlarged
Supple neck, neck veins not

distended, no palpable cervical lymph
nodes, no thyroid gland enlargement,
no carotid bruit
Pink Palpebral conjunctivae, anicteric

sclerae, 2-3 mm pupils, equally
reactive to light, no nasoaural
discharge.
Moist buccal mucosa, no gum
bleeding, non hyperemic posterior
pharyngeal wall. Tonsils not enlarged
Supple neck, neck veins not

distended, no palpable cervical lymph
nodes, no thyroid gland enlargement,
no carotid bruit.
Respiratory:
Respiratory:
No chest deformities, No retractions,

Asymmetrical chest expansion,
decreased vocal and tactile fremiti
T4-T5 down on the right, (+)
bibasilar crackles
No chest deformities, No chest

retractions, Asymmetrical chest
expansion.
Trachea at midline, (+) lagging at the

right
decreased tactile fremiti T8 down
on the right
Left lung resonant at all lung fields,

Right lung dull from T8 down,
decreased vocal fremiti T8 down on
the right.
(-) bibasilar crackles
Cardiovascular:
Cardiovascular:
Adynamic precordium, AB 5th LICS

MCL, S1 louder than S2 at apex, S2
louder than S1 at base, no murmurs
Pulses full and equal no cyanosis or

edema
Adynamic precordium, AB 5th LICS

MCL, S1 louder than S2 at apex, S2
louder than S1 at base, no murmurs
Pulses full and equal. No cyanosis. (+)

bilateral pitting leg edema grade 1+
Abdominal
Flat abdomen, no visible pulsations,
normoactive bowel sounds, no
tenderness, no hepatomegaly, no
ascites
Abdominal:
Not done due to respiratory distress
CHIEF COMPLAINT:
DYSPNEA
Dyspnea
-Abnormally uncomfortable awareness of breathing
-Difficult and labored breathing with shortness of breath
-Characterized by an excessive or abnormal activation of the
respiratory system in the brainstem
Source: Mosbys Guide to Physical Examination 7th Edition
MEDICINE
Jan Jorge M. Francisco
EFFERENT AND AFFERENT

SIGNALS THAT CONTRIBUTE TO
THE SENSATION OF DYSPNEA
Francisco, Jan Jorge M.
Source: Harrisons Principle of Internal Medicine, 17 th edition
Organ System Involvement

Gastrointestinal
Neuromuscular
DYSPNEA
Hematologic
Cardiovascular
Respiratory
Salient features: Pertinent

Positives
OBJECTIVE
SUBJECTIVE
Female
46 y/o
Hx:
CXR: pleural effusion (Right)

CML AML
Multiple BT
RESPIRATORY
Shortness of breath
3 pillow orthopnea
Non-paroxysmal, non productive
cough
MUSCULOSKELETAL
Body malaise
RESPIRATORY
Dec vocal and tactile fremiti (Right, T4T5 down)
(+) bibasilar crackles
CARDIOVASCULAR
Apex beat at 5th ICS MCL
INTEGUMENTARY
Multiple reddish to bluish bruises on
extremities
VITAL SIGNS:
T: intermittent fever 37.7oC
PR: 92 RR: 23 BP: 120/60
Salient features: Pertinent Negatives

SUBJECTIVE
No Exposure to PTB
No Known Allergy
No Family History of DM, cancer or HPN
CARDIOVASCULAR:
(-) PND
(-) murmurs, carotid bruits
GASTROINTESTINAL:
No tenderness
No Melena, No Hematochezia
ENDOCRINE:
No Heat or cold intolerance
No Polydipsia, Polyphagia, Polyuria
OBJECTIVE
HEENT:
Pink Palpebral conjunctivae
anicteric sclerae
equally reactive to light
GASTROINTESTINAL
no hepatomegaly
No splenomegaly
Respiratory
Respiratory
Centers
Centers
(Respiratory
(Respiratory Drive)
Drive)
Chemoreceptors
Mechanoreceptors
Mechanoreceptors
Metaboreceptors
Gastrointestinal
System
Sensory
Cortex
On
PE:
No tenderness
Feedback
No Melena,
No Hematochezia
NoFeedforward
hepatomegaly
No splenomegaly
Motor
Cortex
Error Signal
Ventilatory
Muscles
Dyspnea
Dyspnea intensity
intensity
and
and quality
quality
Hepatomegaly
Tumors
Respiratory
Respiratory
Centers
Centers
(Respiratory
(Respiratory Drive)
Drive)
Chemoreceptors
Mechanoreceptors
Mechanoreceptors
Metaboreceptors
Neuromuscular
System
On
PE:
Sensory
Cortex
Fever is present
Generalized
body
Feedback
malaise (not
ascending, or
Feedforward
increasing)
No ptosis
Signal
NoError
dysphagia
Motor
Cortex
Ventilatory
Muscles
Dyspnea
Dyspnea intensity
intensity
and
and quality
quality
Guillain-Barr Syndrome
Respiratory
Respiratory
Centers
Centers
(Respiratory
(Respiratory Drive)
Drive)
Chemoreceptors
Mechanoreceptors
Mechanoreceptors
Metaboreceptors
On
PE:
Sensory
Cortex
Motor
Cortex
Error Signal
Ventilatory
Muscles
Dec vocal and

tactile fremiti
Feedback
(Right, T4-T5
down)
(+) bibasilar
Feedforward
crackles
Dyspnea
Dyspnea intensity
intensity
and
and quality
quality
Hematologic
Anemia
Respiratory
Respiratory
Centers
Centers
(Respiratory
(Respiratory Drive)
Drive)
Chemoreceptors
Mechanoreceptors
Mechanoreceptors
Metaboreceptors
Cardiovascular
System
On
PE:
Sensory
Cortex
No trepopnea
(-) PND
Feedback
(-) murmurs,
carotid bruits
Motor
Cortex
Feedforward
Error Signal
Ventilatory
Muscles
Dyspnea
Dyspnea intensity
intensity
and
and quality
quality
Chronic Heart Failure
Cardiovascular and Respiratory
Source: Harrisons Principle of Internal Medicine, 17 th edition
Organ System Involvement

Gastrointestinal
Neuromuscular
DYSPNEA
Hematologic
Cardiovascular
Respiratory
Time Course of Dyspnea

Acute (Minutes to Days)
Subacute (Days to Weeks)
Chronic (Months to Years)
Source: Harrisons Principles of Internal Medicine, 17th Edition
Time course of Dyspnea

Time Courses
Common causes
Uncommon Causes
Acute
Asthma
Bacterial pneumonia
Cardiogenic Pulmonary edema
Psychogenic dyspnea
Pneumothorax
Acute PE
PCP
Chest wall injury
Foreign body in major airway
Subacute
ARDS
PCP
Cardiogenic Pulmonary edema
Subacute interstitial pneumonia
Pneumonia
Alveolar hemorrhage
Progressive airway obstruction
Foreign Body
Pneumothorax or Pleural Effusion
Tuberculosis
Fungal infection
Recurrent
Asthma
Psychogenic dyspnea
Recurrent PE
pneumothorax
Chest wall problems

Chronic thromboembolic
pulmonary hypertension
Severe Anemia
Chronic Asthma
Chronic
COPD
Chronic interstitial lung disease
Chronic heart disease
General Category
Due to airway narrowing or
loss of elastic recoil of
lung, w/ decreased
expiratory flow rate (FEV1)
Due to expansion of lung
parenchyma, reduced TLC,
normal or proportionaly
reduced FEV1
May be due to a
pulmonary embolism
commonly arising from
deep vein thrombosis
Vascular Disease
Patient
Breathlessness
on exertion
Negative
Negative
Negative
Harrison 17th edition
General Category
Ex. COPD,
Bronchitis,
Emphysema, Asthma
Ex. Pneumonia
Tuberculosis
Pneumothorax
Atelectasis
Ex. Pulmonary
Embolism
Obstructive Disease
Condition
Inspection
Palpation
Percussion
Auscultation
Asthma
Tachypnea, dyspnea
Diminished
fremitus
Hyperresonance
Expiration
wheezing
Bronchitis
Often no deviation
from expected
findings
Fremitus
Resonance
undiminished
Wheezing and
crackles
COPD
Cyanosis, distension
of neck veins,
peripheral edema
Diminished
fremitus
Hyperresonance
Wheezing,
rhonchi,
crackles
Emphysema
Delayed respiratory
movement
Diminished
fremitus
Hyperresonance
Diminished voice
sounds
PATIENT
(+) Lagging on the

Right
DECREASED
tactile
fremitus
DULL NESS on
the right
DIMINISHED
Breath Sounds
(T4-T5
downwards)
Mosby 6th edition
General Category
Ex. COPD,
Bronchitis,
Emphysema, Asthma
Ex. Pneumonia
Tuberculosis
Pneumothorax
Atelectasis
Ex. Pulmonary
Embolism
Restrictive Lung Disease

INSPECTION
PALPATION
PERCUSSION AUSCULTATION TRACHEA
Consolidation
N or minor
lagging
INC
DULL
INC
midline
Pneumothorax
Lagging on
affected
side
DEC
Hyperresonant
DEC
Contralateral
LAGGING
DEC
Dull
DEC
Contralateral?
(+) Lagging
on the Right
DECREASED
tactile
fremitus
DULL NESS on
the right
DIMINISHED
Breath Sounds
(T4-T5
downwards)
Pleural
effusion
PATIENT
Midline
(heart
contra)
Clinical Impression:
Dyspnea due to Pleural Effusion secondary to
Pneumonia
CML AML
43
Medical Pathological Pharmacological Radiological Conference
PATHOPHYSIOLOGY
Flores, Kyla Rei G.
Flores, Kyla Rei G.
44
Chronic Myelogenous
Leukemia
1. Breakage and joining of BCR
and ABL
2. BCR-ABL fusion gene that
encodes a constitutively
active BCR-ABL tyrosine
kinase
3. BCR-ABL activates multiple
downstream pathways
growth factor
independent proliferation
survival of bone marrow
progenitors
Source: Robbins and Cotran Pathologic Basis of Disease, 8th edition
Flores, Kyla Rei G.
4545
Chronic Myelogenous
Leukemia
BCR-ABL does not interfere
with differentiation
NET RESULT= increase in
mature elements in the
peripheral blood
(granulocytes, platelets)
Flores, Kyla Rei G.
4646
46
Flores, Kyla Rei G.
4747
47
Acute Myelogenous Leukemia

tumor of hematopoietic progenitors caused by
acquired oncogenic mutations that impede
differentiation
there is increasing evidence that mutated tyrosine
kinases collaborate with transcription factor
aberrations to produce AML
NET RESULT= accumulation of immature myeloid
blasts in the marrow
Flores, Kyla Rei G.
PNEUMONIA IN THE
IMMUNOCOMPROMISED
HOST
Cytomegalovirus
Pneumocystis jiroveci
Mycobacterium aviumintracellulare
Invasive aspergillosis
Invasive candidiasis
Usual bacterial, viral, and
fungal organisms
4848
48
Flores, Kyla Rei G.
Release of Inflammatory Cytokines
FEVER
Source: Schwartzs Principle of Surgery, 9th edition; Robbins and Cotran Pathologic Basis of Disease, 8th
edition
4949
49
Flores, Kyla Rei G.
5050
50
Increased Vascular
Permeability
(1) alterations in vascular caliber that
lead to an increase in blood flow,
(2) structural changes in the
microvasculature that permit
plasma proteins and leukocytes to
leave the circulation
Flores, Kyla Rei G.
51
Pleural Effusion
Source: Grants Atlas of Anatomy, 12th edition; Harrisons Principles of Internal Medicine, 17th
Flores, Kyla Rei G.
5252
Pleuritic Chest Pain
Source: Grants Atlas of Anatomy, 12th edition; Harrisons Principles of Internal Medicine, 17th
Flores, Kyla Rei G.
Source: Harrisons Principles of Internal Medicine, 17th edition
5353
53
5454
54
Flores, Kyla Rei G.
COUGH REFLEX
Flores, Kyla Rei G.
5555
PATHOLOGY
Ma. Elizabeth F. Fontanilla
Fontanilla, Ma. Elizabeth F.
PERIPHERAL BLOOD SMEAR
Chronic myelogenous leukemia (CML) Acute Myelogenous Leukemia (AML)
Robbin and Cotrans Pathologic Basis of Disease, 8th Edition
Normal Lungs
1-Right lung , 2-Left lung, 3-Aorta ,

4-Oesophagus , 5-Trachea
Pneumonia
Pneumonia
Lobar Pneumonia
If not treated, lobar pneumonia evolves in four stages :
1.
Congestion (first 2 days)
2. Red hepatization (fibrinous alveolitis) (2nd to 4th day)

3. Gray hepatization (leukocytic alveolitis) (4th to 8th day)
4. Resolution (after 8th day)
Microscopic view of Normal Lung
- Alveolar-surface
linedis
byoccupied
continuous layer
of alveolar
I (squamous)
and interspersed
The lung
by air
spacestype
of alveoli
andcells
respiratory
ductsalveolar
type II (septal) cells
th
Robbin and Cotrans Pathologic Basis of Disease, 8 Edition
1. Congestion
- The lung is heavy, boggy, and red. It is characterized by

vascular engorgement, intra-alveolar fluid with few
neutrophils, and often the presence of numerous bacteria
2. Red hepatization
- Affected
- Characterized
lobe is red,
by massive
firm, consolidated.
confluent exudation
Cut surface
with
isred
airless,
cellsred, pink,
dry,
(congestion),
granular and
neutrophils,
has liver like
and
consistency.
fibrin filling the alveolar spaces
3. Gray hepatization
- Affected- it
lobe
is firm
and heavy. disintegration of red cells and a persistence
follows
a progressive
- Cut surface
is dry granular andexudate
gray in appearance with liver like consistency.
of a fibrinosuppurative
- Color change from red to gray begins at hilum and spreads towards periphery.
4. Resolution
Macrophages are the predominant cells in the alveolar space.

Alveolar capillaries are engorged.
Bronchopneumonia
Bronchopneumonia
RADIOLOGY
Joemel D. Francisco
Francisco, Joemel D.
Normal vs abnormal (PA)
Normal vs abnormal (PA)
Pleural effusion (PA)

Presence of homogenous
density with ascending
fluid level
Meniscus sign (+)
Fluid where base is wide
narrowing toward the apex
Heart is deviated to
opposite side of affected
part
presence of possible
consolidation
Blunted costophrenic angle
Lowering of the diaphragm
Pleural effusion (lateral)
Opacity of the retrosternal

space
Narrowing of the
retrocardiac space
Left hemidiaphragm
PROVEN CASE OF
PLEURAL EFFUSION
CHEST X-RAY OF PATIENT
Pleural Effusion
Homogenous density
Meniscus maximum in axilla
Loss of cardiophrenic angle
Loss of diaphragmatic and right cardiac
silhouette
Pleural effusion
Minimal- blunting or obliteration of the costophrenic
sulcus
Moderate- occupying half of the total area of the
affected lung
Massive- occupying more than half of the total area of
the affected lung
RADIOLOGIC IMPRESSION
MODERATE TO MASSIVE PLEURAL EFFUSION , RIGHT
CARDIOMEGALY BY LATERAL VIEW
PROBABLE CONSOLIDATION, RIGHT MIDDLE / LOWER
LOBE
ANCILLARY
PROCEDURES
Harly King Gaddi
Gaddi, Harly King M.
Thoracentesis
Invasive procedure to
remove fluid or air from
the pleural space
Midaxillary line in the 9th
ICS
Transudate or exudate
Fluid analysis
Harrisons Principle of Internal Medicine 17th ed.
Thoracentesis
Transudate vs. Exudate
Main causes
Increased
hydrostatic
pressure,
Decreased colloid osmotic pressure
Inflammation
Appearance
Clear
Cloudy
< 1.012
> 1.020
Specific gravity
< 2 g/dL
> 2.9 g/dL
Protein content
< 0.5
> 0.5
Fluid protein
Serum protein
> 1.2 g/dL
< 1.2 g/dL
< 0.6 or <
> 0.6 or >
< 0.8
> 0.8
< 45 mg/dL
> 45 mg/dL
Difference of
albumin content
with blood albumin
Fluid glucose
Serum glucose
Cholesterol content
Culture and Gram Stain

Pleural fluid
Blood
Check for infecting
microorganism
Bacterial
Fungal
Virus
Assess if G(+) or G(-)
Medical Microbiology by Jawetz, Melnick, and Aldeberg, 21stedition
Cell count and differential

Pleural fluid
Lymphocytes
Increased
TB, Chronic rheumatoid pleurisy,
sarcoidosis and malignancy
Eosinophil
Increased
parasitic diseases, fungal infection,
pulmonary embolism and malignancy
Neutrophils
Increased
Pneumonia, TB, and pulmonary embolism
Robbins and Cotrans Pathologic Basis of Disease, 7thEdition
Additional Pleural fluid tests

Lactate dehydrogenase
>1000IU/L (empyema, malignant effusion, and
rheumatoid effusion)
Glucose and pH
<50 mg/dL (tuberculosis pleuritis and
esophageal rupture) <30 mg/dL (rheumatoid
pleurisy and empyema)
pH < 7.1-7.2 indicates parapneumonic effusions
Other tests
Serologic assays
Polymerase chain reaction test
Specific diagnostic tests for organisms such as
Legionella, M. pneumoniae, and C. pneumoniae
Limitations: Delay in obtaining results and poor

sensitivity and specificity
PHARMACOLOGY
Dominic Josef Figueras
Figueras, Dominic Josef
Therapeutic Goals
Primary
To Relieve the symptoms
To Manage infection
To Manage the AML
87
To relieve the symptoms

Dyspnea DO Thoracentecis
Fever Give Antipyretics
Non-Pharmacologic Approach
Thoracentesis
A needle is inserted through the back of the chest wall
in the sixth, seventh, or eighth intercostal space on the
midaxillary line, into the pleural space
Chest tube drainage followed by Pleurodesis

(sclerosing agent like Doxycycline)
Promotes fibrosis of the pleura to prevent
further fluid accumulation
Bone marrow transplantation preceded by high
dose chemotherapy (cure up to 35-40% patients)
[AML]
Supplemental Oxygen for Dyspnea
Source: Basic and Clinical Pharmacology by Katzung et al. 11th ed.
89
go
Fever
Antipyretic (Paracetamol)
Cox-3
Blocks IL1 (pyrogenic Substance)
Dose : 325 500 mg QID or q4h
90
go
Pleural Effusion
Antibiotics for Infection
91
go
Antibiotics for Pneumonia

Community Acquired Pneumonia
Fluoroquinolones
-Moxifloxacin, Levofloxacin
Beta-lactams + Beta-lactamase inhibitors

-Amoxicillin, Cefotaxime, Ceftriaxone, Ampicillin,
Ertapenem
-Sulbactam, Clavulanic acid (Beta-lactamase inh.)
92
Figueras, Dominic Josef P.
93
Fluoroquinolones
Active against gram (+) and gram (-) bacteria
Block DNA synthesis by inhibiting topoisomerase II (DNA
gyrase) and topoisomerase IV
Fluoroquinolones
MOXIFLOXACIN
Improved gram (+) activity including S pneumoniae and some
staphylococci
Half-life of 8-10 hrs; oral dose of 320 and 400 mg respectively
LEVOFLOXACIN
Superior gram (+) activity including S Pneumoniae
Half-life of 5-7 hrs; oral dose of 500 mg
94
Fluoroquinolones
Adverse Effects
Most common nausea , vomiting and diarrhea
Occasional headache, dizziness, insomnia, skin rash
Rarely occurring tendinitis in adults
95
-Lactam Compounds
Amoxicillin
Inhibits the transpeptidation reaction of bacterial cell wall
synthesis
Kill bacteria only when they are synthesizing cell wall
96
go
Pharmacologic Antibiotics for Pneumonia

Beta-Lactamase Inhibitors
-Binds irreversibly to catalytic site of many betalactamases rendering them inactive
-Ampicillin + Sulbactam for S.aureas and H. influenze

- Amoxicillin + Clavulanic acid for polymicrobial
infections and penicillin ressistant pneumococci
-Piperacillin + Tazobactam for P. aeruginosa
97
go
Acute Myelogenous Leukemia

Intensive supportive care during
Chemotherapy
-Antibiotics
Drug of choice is Cytarabine
98
Standard 1st line therapy drug for AML
Cytarabine
-Drug of choice for AML
-inhibition of DNA polymerase, cessation of DNA replication
-best used in combination with an Anthracycline
-Idarubucin is the preferred Anthracycline
-administered IV
-main adverse effect: myelosupression
Source: Harrisons Principle of Internal Medicine 17th ed.
99
100
THE END

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APPROACH TO A PATIENT

Flores, Kristine Glory

Flores, Kristine Glory

Flores, Kristine Glory

History of Present Illness

Flores, Kristine Glory

History of Present Illness

Flores, Kristine Glory

History of Present Illness

Intermittent Fever ( ave. 38.5 oC)

Increased severity of dyspnea

Few hours PTA

Symptoms persisted hence admission was

Flores, Kristine Glory

Past Medical History

No significant childhood illness and hospitalizations

(+) CML 2006

Flores, Kristine Glory

Current Health/Risk Factors

Flores, Kristine Glory

Flores, Kristine Glory

Personal and Social History

Flores, Kristine Glory

Flores, Kristine Glory

Flores, Kristine Glory

Flores, Kristine Glory

Flores, Kristine Glory

Flores, Kristine Glory

Physical Exam upon Admission

Present Physical Exam

Ht. 54 Wt: 57kg

Flores, Kristine Glory

Physical Exam upon Admission

Present Physical Exam

Pink Palpebral conjunctivae, anicteric

Moist buccal mucosa, no gum

Supple neck, neck veins not

Pink Palpebral conjunctivae, anicteric

Supple neck, neck veins not

Flores, Kristine Glory

Physical Exam upon Admission

Present Physical Exam

No chest deformities, No retractions,

No chest deformities, No chest

Trachea at midline, (+) lagging at the

Left lung resonant at all lung fields,

(-) bibasilar crackles

Flores, Kristine Glory

Physical Exam upon Admission

Present Physical Exam

Adynamic precordium, AB 5th LICS

Pulses full and equal no cyanosis or

Adynamic precordium, AB 5th LICS

Pulses full and equal. No cyanosis. (+)

Flores, Kristine Glory

Source: Mosbys Guide to Physical Examination 7th Edition

EFFERENT AND AFFERENT

Francisco, Jan Jorge M.

Francisco, Jan Jorge M.

Source: Harrisons Principle of Internal Medicine, 17 th edition

Francisco, Jan Jorge M.

Organ System Involvement

Francisco, Jan Jorge M.

Salient features: Pertinent