1. step one
1.1. difficult words
1.1.1. plump: obese
1.1.2. flustered: confused
1.1.3. dappled: spotted
1.2. cues
1.2.1. male; 4th decade
1.2.2. fat
1.2.3. closed eyes and ehauxted
1.2.4. exahusted
1.2.5. flustered
1.2.6. discolerd dappled ankles
1.2.7. pitting edema
1.2.8. 2 year onset
1.2.9. breathlessness on exertion for few monthes
1.2.10. medical attention not sought inintially
1.2.11. dyspnea worsened
1.2.12. gain weight
1.2.13. swollen ankle
1.2.14. sleep troubled
1.2.15. orhtopnea
2. step2
2.1. problem formulation: an obese man in his forties presented with breathlessness for the last two years which has been worsened recently; associated with ankle swelling and weight gain. he can't sleep flat.
3. step3
3.1. hypothesis generation:
3.1.1. edema is due to undermined hydrostatic pressure or oncotic one
3.1.2. heart problem or failure
3.1.3. renal problem
3.1.4. infection
3.1.5. breathlessness is due to heart failure oe weakness; v\q mismatch
3.1.6. hyperlipedimia: precipitate in heart failure
3.1.7. gaining weight could be the cause. or just a symptom
3.1.8. lung problem
3.1.9. bilatiral edema: kidney, lung, or heart disease.
3.1.10. heart is overwhelmed
3.1.11. dyspnea: obsteructive, distructive or hemoblobin problem.
3.1.12. left sided problem cause pulmunary edema.
3.1.13. CHF causing pulmonary or generalised edema
3.1.14. DVT as underlying cause
3.1.15. OSA as underlying cause
3.1.16. AI good pasture syndrome
3.1.17. Anemia
3.1.18. CHF causing pulmonary or generalised edema
3.2. hypothesis generation:
3.3. hypothesis generation:
4. step4
4.1. hypothesis organisation
4.1.1. Primary problems
4.1.1.1. hypertention
4.1.1.2. Kidney faailure
4.1.1.3. hyperlipidemia
4.1.1.4. lung problems
4.1.1.4.1. COPD
4.1.1.5. OSA
4.1.1.6. Anemia
4.1.1.7. Good Pasture
4.1.2. Secondary manifestations
4.1.2.1. CHF
4.1.2.2. edema
5. step5
5.1. OBJECTIVES
5.1.1. to describe the pathophysiology of developing edema (consider the causes).
5.1.2. to learn about CHF(causes -pathophysiology manifestations- risk factors- infestgations)
6. step6
6.1. revision
6.1.1. EDEMA
6.1.1.1. edema develop from hydrostatic pressure
6.1.1.1.1. volume increase
6.1.1.1.2. venous obstruction
6.1.1.2. types
6.1.1.2.1. transudate
6.1.1.2.2. exudate
6.1.1.3. other cassification
6.1.1.3.1. inflammtory
6.1.1.3.2. non-inflammatory
6.1.2. CHF
6.1.2.1. CAUSES
6.1.2.1.1. left venticular dysfunction
6.1.2.1.2. incresed afterload
6.1.2.1.3. valvular disease
6.1.2.1.4. COPD
6.1.2.1.5. OSA
6.1.2.1.6. IHD
6.1.2.1.7. CARDIOMYOPATHY
6.1.2.1.8. thyroid diseas
6.1.2.1.9. main causees
6.1.2.2. PATHOPHYSIOLOGY
6.1.2.2.1. low stroke volume
6.1.2.2.2. less ejection volume
6.1.2.2.3. franksarling mechanism to compensate
6.1.2.2.4. RAAS to compansate
6.1.2.3. manifestaions
6.1.2.3.1. pulmonary edema
6.1.2.3.2. DYSPNEA
6.1.2.3.3. orthpnea
6.1.2.3.4. fatique
6.1.2.3.5. cardiomegaly
6.1.2.4. risk factors
6.1.2.4.1. hyperlipidemia
6.1.2.4.2. diabetes
6.1.2.4.3. hypertension
6.1.2.4.4. smoking
6.1.2.4.5. family history
6.1.2.5. infestigations
6.1.2.5.1. cbc
6.1.2.5.2. BNP
6.1.2.5.3. CXR
6.1.2.6. definition
6.1.2.6.1. inabilily to pump suffeceint amount of blood
7. step7
7.1. inquiry plan
7.1.1. HISTORY
7.1.1.1. SMOKER 20C\D
7.1.1.2. alchohol 5 cups
7.1.1.3. appendectomy - tosillectomy
7.1.1.4. married
7.1.1.5. chronic cough with grey sputum
7.1.1.6. seasonal infections
7.1.2. examination
7.1.2.1. height 173
7.1.2.2. w: 100 kg
7.1.2.3. 36.7 c
7.1.2.4. 120\70 mmgh laying
7.1.2.5. RR: 30\m
7.1.2.6. can't lay flat
7.1.2.7. JVP=6
7.1.2.8. 100 beats\m
7.1.2.9. 3cm liver below CM
7.1.2.10. 3rd HS
7.1.2.11. systolic murmer
7.1.2.12. basal carackles
7.1.3. D
8. step8
8.1. diagnostic dicision
8.1.1. CHF
8.2. objectives
8.2.1. management of CHF
9. step9
9.1. revision
10. step10
10.1. managmement
10.1.1. pharma
10.1.1.1. diureteics
10.1.1.1.1. furosomide
10.1.1.1.2. metolazone
10.1.1.1.3. SE
10.1.1.1.4. no effect on survival
10.1.1.2. ACEI
10.1.1.2.1. IMPROVE SURVIVAL
10.1.1.2.2. NOT BEFORE DIURETICS
10.1.1.2.3. SMALL DOSES
10.1.1.2.4. SE
10.1.1.3. beta-blocker
10.1.1.3.1. inhibit remodeling
10.1.1.3.2. relive heart mouscle
10.1.1.3.3. beta 1 selective
10.1.1.3.4. improve mortaltity
10.1.1.4. spirolactone
10.1.1.4.1. improve mortality
10.1.1.5. angiotensin II receptor antagonist
10.1.1.5.1. candesartan
10.1.1.5.2. no cough
10.1.1.6. acute setting
10.1.1.6.1. morphin
10.1.1.7. digoxin
10.1.1.7.1. not primary considered
10.1.1.8. evapridin
10.1.1.8.1. block calcium channel
10.1.1.9. nitrates
10.1.2. non pharma
10.1.2.1. dietary restriction
10.1.2.1.1. low salt
10.1.2.2. weight reduction
10.1.2.2.1. our pt
10.1.2.3. alchohol abstenence
10.1.2.3.1. our pt
10.1.2.4. smoking cessation
10.1.2.4.1. our pt
10.1.2.5. education
10.1.2.5.1. weight and dose and diet
10.1.2.6. devises
10.1.2.6.1. AICD
10.1.2.6.2. pacemaker
10.1.2.6.3. remodeling devises
10.1.2.7. heart transplant
10.1.2.7.1. NOT gold standard
10.1.2.7.2. comlication
10.1.2.7.3. usually ypunger pt
10.1.2.7.4. not for our pt
10.1.2.8. valvular repair
10.1.2.9. exercise
10.1.3. classification of severity
10.1.3.1. NYHA
10.1.3.1.1. class 1
10.1.3.1.2. class 2
10.1.3.1.3. class 3
10.1.3.1.4. class4
10.1.4. goals
10.1.4.1. control symptoms
10.1.4.2. prevent complication
10.1.4.3. increase survival