• Author / Uploaded
• drksahil

• Categories
• Enfermedades y trastornos
• Sistema cardiovascular
• Especialidades Medicas
• Angiología
• Medicina CLINICA

Citation preview

BLACKWELL'S

VIKAS BHUSHAN, MJI llrlivt.r,sityof California, San Francisco, Clws or 1991 Series Editor. Di~~gnostic Radiologicy~usis f.lS identification anrl c hieC colnplain t ID/C:C: ii~.;itIin~lrlr~r~cletii rliahelc-3 rnellitus rDnv itnm i ~ n o g l n h ~ ~ l in IK irls~tlin-likejirowth Cactor rC:T; i13 traml~scul;t~* I hl j~igularT-enouspreqsurr .PT

E131' FCC;

RUE

Iti~lneys/i~r~ter/t~IacLrler

1,DM

Iariale deh~rlrr~genasr lower tsophagewl splliilcler li\.er- li~tlctiontests lumhar p~lnrizll-e left vetr tr-icular Icft 'tvenfric(tl;tr hyperi rt)phy electl-nlytey mean cr>rplisct~f;lr hpnjt~glol>in rnncrntration meail CCEI-~IISCZI~:II~ml~~rnt' rnilltiple endocrinc ncolslxia

LES LIT5 LP I ,I'

LW-l 1,l't

PS

R.IC:IIc MCW MEN

MHC Nl1 h,lOPP

pracarbazine Jprc-dnisone hlK t\TfIl, NIDDM NPO NSATD PA PIP PBS

PE PFTF PMI PMN PT PTCA l'TH TTT PUD KHC: Rl'R RR RS R17

RXW S BFT

SIiZDH SLE STT)

TITS P.4 TSEI TIIIC: TIPS TPO *rsH -rrP LTA LTCl LTS

tnagnelic rcsonancc (imaging) norl-Modgkin's 1~mphorn:i non-in5uTin-clcpc11dent cliabetev mell i t u s nil per os (norhirlg h? ~ 1 1 ~ 1 u t h ) nonste~oiclalanti-inflan~mato~v dri ~g poqteroantei-ior proximal in t erp halangeal peripheral I~loorlsnie;w

pr-othrombin time percliiaileotis transIuminal angioplasy pat-athyt--rightflow Gtr-cliac cathcttrization confir lniltory. The iiiost cniiirliclil (r $r.nl iq i t ) fie midseptum, in the area of the Soramen omle (OSI 1 1 . h S~ I ~ . I , C I U DIM): I tllosr in tllc Tower scptlinl ((n\nrlu P K I M I I Z ~ ) are associatc,d with AV valve iincsnl;~lieu(rnosr cclrnnlurl in D o M ~ ' "11ir1sr ~ ; ill he 11ppts srpltlin ( s r ~ r l sv i . ~ t l s ~ s ) arc. awx-ixterl wirh anomaln~lspulmot~aryvenous return.

Sz~rgicalor intcrrrntionnl angiographic clos~~rc. of'drfect with pros111r.ric patch. Operalive repair i q r.ecotnmenderli r all ~ symp i t m ~ a t i ct>;lti~iitq wirh ostitun secunrlutn rlefeclts re~ardlessof size of'rlcfrct.

Discussion

Oxygerlaterl hlt~urlli-rrin l l ~ el ~ f a1 i rit~rn~ ~ S S Pinto T the right atrium. irlcrcasing r i g h ~ventricular ontput ancl pulrnonasy flow. Acyanotic (Iefi-ro-I-i~hr s h u n t ) ; ~ t l emnqt cotntnotl congenital 11c;lrr rliscasc in aclults. Scquclae r ~untreated f acrial scptal clcfrc t~ inrIudc paradoxic emboli, infective endocarditis, ; ~ n d congestive heart failure.

Atlas Link

LTT-=

PEA-002

A T R I A L SEPTAL DEFECT

ID/CC

HPI

PE

A 25-vearuld male postal worker whn waq stabbed in the chest rh~rit~ga n~tygingis brought to the cmer-getlcy room in a semiconscious shte, gasping for air (DWPKEA). T h c knife penetrated the 1ho1.acicwall at (he luvc.1 of the f o ~ ~ r t h intel-cmtal ?pace alor~g the left sternal borcIcr.

VS: hypotension (BP 'JOJ40) that does not respond to rehydration; ir~spira~ory Io~veringoTq5rolic RP hv > 10 mmHg (~rrr.sris r;la~ncrxrls).PE: increase in venous pressure wi Ih itlspiratory lilling nf rlerk veins during inspiri~tion(Eirrss~.e.ku~'s SIGN); cI(n-ingdrawing of venous hlootl, svl-inge filler1 qpon tat-ieo~~sly (clue to increased venous pt-ess~we f : apical impulse diminished; heart sounds seem distant; paticnc a150 cyanotic.

Labs

ECG: reduced vnl tage.

Imaging

CXR: car-cliomegalv,I N I ( ivitli acute heinopericardi~~m , tlte heart shadnw may not enlarge; thus d i a ~ o s i is s clinical. Echo: pericardial fluid; dias~cdic collapse of right ventricle ailrl atria.

Gross Pathology

BIood rrom sitrs of injury fills pericardial sac, causing conlpression of all l ~ e a rrhamlwrs t anct pl-ruenting vennns i-etril-11,heart filling, and artcrial Q I I ~ ~ O ~ V .

Treatment

Immediate pericardiocentesis ancl subseqllelzt operative thorncotomv and pci-icar-dialcFecornprrssion with rrpair of laceration.

Discussion

7

Unlike this case, the ma-jnrir), oi"pat irrits ~ vt h i penetrating cltest 11-aumawill have a pnrumothorax or hetnothorax. The triad nf Ecck (hypotension,distant heart sounds, and increased venom pressure) is c h a r a c t w i ~ f i cnT cardiac tampolrade.

C A R D I A C TAMPONADE

;o

S

s R
f h i ~ hfever, sore throat, cardchc, swollen gIands. and prodnctive, greenish-~t~hite, bIood-tinged spu turn. His mother statcs that the b q has had recurrent bouts of sore throat several times a year Col-the past 5 F r s . crzch lime trearerl r f f r c t i v r l y w i ~ hant ihiolics.

Mouth parlially open (mvollen pharyngeal tonsil c~l~stri~cls nasophar!-nge;ll isthmus) ; tonsiTs markedly enlarged, hyperemic, and cryptic with spotted area5 of pus; infl:immatioil of I( lrus t 11hal-ius{protech opening of eustachian t111~r:ii~lditrr in ratus is imn~ediatelyanterior a n d inferior to pharsngeal lonsil, and infrction or p h a r ~ n g e dtonsils sprcads up aucli~orvt ~ i l ~ r , causing otitis media). Labs

Imaging

CRC: neu trophilic leukocytosis.Antistreptolysin titer ( A S 0 ) high; throat culture st1 ows Phemolytic streptococcus. XR, lateral neck: thickened retrophww~gealprcvcrtuhl-a1 tissue. CT: pharyngeal or retropharyngeal mass (abscesf) rttav he present.

Treatment

I'enicillin . Re~opharvng-ealabscess is a serious complicalioti that reqriircs drainage. Evaluale for- tonsillectonlv.

Qiscussion

Tonsillrctnniy is performed Iess frrquently now Llun a decarl~ ago: nevertheless, a n maltlation rnrist be done w ~ i g l ing i surgical risks wit11 those of recurrent p-ctreptococcal infrctions and posssihle rheumatic fever. Walduyer's ring consists r>l' the nasopharyngeal tonsils, the palaline tonsils, and tile lingual tonsils.

Atlas Link

IDJCC

A 35-vear-nld woman i s kr-nllght to the enlergency room by amhutance because of the suddcn appearance of'severe retrosternal pain with radiation to the hack and ahrtornen along ~vihdvspnea; the pain i~ppearedafter vigorous vomiting.

HPE

Shc wfkrs frnm episodes or hinge eating and self-ind~tcedvnmiting ( I W I ~ I M I ~ ~ ) .

PE

VS: tachycardia (HR 110); mild hvpotcnsjor~(BP 100/65); n o fever. PE:: i t 1 acute distress; complains of scvert chest pain; no heart murmurs; left lung field hypoaerated (due to pneumotho1-ax); cracklitla sound heard over precordium (HAMVAK'S SIGY OF I ' N F ~ ' M ~ ~ ~ ~ ~ I ) ~ . - L ' ; T ~ N L I ~ ~ ) .

Labs

Imaging

Gross Pathology

CBC: le~lkocylosis.Amvlase elevated.

UGI: extravasation of contrast in to medias~inurn.CXR/CT left pleural effusion and hpdropneitr~~othorax; mediastid emphysema. Esophagoscopy: complete rupture of esophageal wall.

All layers or the esophaps arc tori1 completely in posterior lateral wall of esophagus on left side (vs. Mallory-ZI7c"iss tear of otlll; superficial esophageal lavers; presents as pnstetnetic hl~eding} .

m+

% -+

n

*

Treatment

RI-