抽胸水的時機

1. loculated effusion
2. >1/2
3. Air-fluid level

3. Pus
4. stain +
5. culture +

6. pH<7.2
7. Glu<60

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Ranson

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CV Note

EXERCISE TREADMILL TESTING INDICATION

當病人出現疑似CAD的symptoms，resting ECG表現為正常，且自身條件足以進行，peak heart rate至少要達(220 − age) x 85%。若原本EKG已有不正常finding，可能sensitivity and specificity會下降。當ST-segment depression (horizontal or downsloping > 0.1 mV and lasting > 0.08 sec) 應強烈懷疑CAD。在女性、atypical 或 no chest pain、anemia的患者可能出現False positives的情形。

MYOCARDIAL PERFUSION IMAGING

注入nuclear medicine(dipyridamole or adenosine) induce coronary vasodilation,增加healthy coronary arteries flow，stenosis的血管flow相對減少，dipyridamole (Persantine) or adenosine會造成bronchoconstriction，COPD是一個重要的contraindicationas。

Functional Classification of Heart Disease

Class I: No limitation of physical activity. (正常人)

Class II: Slight limitation of physical activity. (輕微)

Class III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms. (明顯的症狀)

Class IV: Unable to engage in any physical activity without discomfort. Symptoms may be present even at rest. (連休息也會有症狀)

Hypertension

First-line：diuretics, beta blockers, ACEI, ARB, CCB.

Goal is SBP<135–140 systolic, DBP<80–85 (<130/80 in patients with DM or CKD).

A、ACEI：Side effects include angioedema, hyperkalemia and azotemia (particularly in pts with elevated Cr), nonproductive cough-->substitute an ARB

B、Beta Blockers：Relative contraindi-cations include bronchospasm, CHF, AV block, bradycardia, and insulin-dependent diabetes.

C、CCB

1、DHP：

長效：Amlodipine, Nifedipine-MR

短效：Nifedipine, Nicardipine

降低 afterload, 擴張coronary artery, 減低inotropic(但Amlodipine可能在LVF使用)

2、NDPH：verapamil, diltiazem

減低inotropic更明顯，應避免在急性CHF使用

D、Diuretics：

Major side effects include hypokalemia, hyperglycemia, and hyperuricemia 

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主動脈剝離

胸部主動脈剝離--HTN(看到胸部血壓會高)
腹部主動脈剝離--atherosclerosis(粥喝到肚子)


先使用beta blocker

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DM Medication

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Empyema

leukocytosis,
low pH (<7.20),
low glucose (<60 mg/dL),
high LDH (lactate dehydrogenase),
elevated protein
may contain infectious organisms

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Indications for chest drain insertion

Indications for chest drain insertion

• Pneumothorax
  
  
  • in any ventilated patient
  • tension pneumothorax after initial needle relief
  • persistent or recurrent pneumothorax after simple aspiration
  • large secondary spontaneous pneumothorax in patients over 50 years
• Malignant pleural effusion
• Empyema and complicated parapneumonic pleural effusion
• Traumatic haemopneumothorax
• Postoperative—for example, thoracotomy, oesophagectomy, cardiac surgery

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