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Page 1: L 1.approach to cyanosis

INTRODUCTION TO

MEDICINE

Dr.Bilal Natiq Nuaman,MD

C.A.B.M. , F.I.B.M.S. , D.I.M. , M.B.Ch.B.

Lecturer in Al-Iraqia Medical College

2017

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Doctors specializing in internal medicine are called internists,

Internal MedicineThe branch of medicine that deals with the diagnosis and nonsurgical treatment of diseases affecting adults within its scope .

The medical specialty dealing with the prevention, diagnosis, and treatment of adult diseases.

Doctors specializing in internal medicine are called internistsor physicians

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Scope of Subspecialties of Internal Medicine

Cardiology, dealing with disorders of the heart and blood vessels

Endocrinology, dealing with disorders of the endocrine system and its specific secretions called hormones

Gastroenterology, concerned with the field of digestive diseases

Hematology, concerned with blood, the blood-forming organs and its disorders.

Infectious Diseases, concerned with disease caused by a biological agent such as by a virus, bacterium or parasite

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Nephrology, dealing with the study of the function and diseases of the kidney

Pulmonology, dealing with diseases of the lungs and the respiratory tract

Rheumatology, devoted to the diagnosis and therapy of rheumatic diseases.

Neurology dealing with diseases of nervous system

Medical Oncology, dealing with the chemotherapeutic(chemical) treatment of cancer

Poisoning and Critical Care

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Internal Medicine , Management , sequence of roles

1-DIAGNOSIS

2-TREATMENT

3-PREVENTION

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Medical Diagnosis

• Sequence of Diagnosis

• 1-History taking from patient (record patient

symptoms)

• 2-Examination of the patient (looking for physical

signs )

• 3-Investigations (done in lab. ,etc..)

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Approach to patient = Management of patient

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Symptom vs sign

• A symptom(complaint) is subjective feeling from

the patient point of view.

• A symptom is what the patient experiences about the disease.

• Symptoms can only be experienced, they are not able to be observed or measured objectively.

• Pain is a symptom. I do not know you are having pain unless you tell me. Nausea is also a symptom, as are: chills, numbness, fatigue, vertigo, malaise, itching, stomach cramps, burning on urination, etc.

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• A sign is an objective physical manifestation of

disease.

• It is an objective finding, something one can observe and measure.

• A rapid pulse, a high temperature, a low blood pressure, an open wound, bruising, etc. are all signs.

• Signs give a more definite indication of the presence of a particular disease to the physician.

So in the simplest form, signs are observations of the doctor and symptoms are the experiences of the patient.

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Patients commonly have complaints (symptoms). These symptoms may or may not be accompanied by abnormalities on examination (signs) or on laboratory

testing. Conversely, asymptomatic patients may have signs or laboratory abnormalities, and laboratory abnormalities can occur in the absence of symptoms or signs.

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CYANOSIS

/

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Cyanosis is a blue or purple discolorationof the skinby :

and mucous membranes caused

5 g/dL

methemoglobin

_

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Approximately 5 g/dL of deoxygenated hemoglobin in the capillaries generates the dark blue color appreciated clinically as cyanosis. For this reason, patients who are anemic may be hypoxemic without showing any cyanosis.

Conversely, the higher the total hemoglobin content, the greater the tendency toward cyanosis.

/_ --~

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• Methemoglobin results from the presence of iron in the ferric (oxidized) form instead of the usual ferrous form. This results in a decreased availability of oxygen to the tissues.

• When 15-20% of hemoglobin is methemoglobin , Cyanosis will result , though patients may be relatively asymptomatic

/_ --~

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Types of cyanosis

• 1-central(blue and warm)• This is seen at the lips and tongue .

It corresponds to an arterial oxygen saturation (SpO) of<90% and usually indicates underlying cardiac or pulmonary disease.

• Cardiac causes include pulmonary edema and congenital heart disease.

Congenital defects associated with central cyanosis include Eisenmenger's syndrome and Fallot's tetralogy.

/_ --~

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• 2-peripheral(pink lips, cool peripheries)Peripheral cyanosis may result when cutaneousvasoconstriction(acrocyanosis).

Not affect tongue

It is physiological during cold exposure.

• It occurs in heart failure, when reduced cardiac outputproduces reflex cutaneous vasoconstriction,

and venous obstruction, e.g. deep veinthrombosis. .

slows the blood flow in the limbs

--~

produces refle

vascular disease

/_

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Cyanosis types

Skin & mUC'QUS • Penpheral exposed skin•

• Caused by decreased • Caused by

• Exposed

Clubbing

areas warm

may be

• Exposed areas cold,

massage/warming

helps

·

'-._---Oxygen Cyanosismay disappear

in ri ht to left shunt

in pulmonary case (Except Disappears

Central Peripheral

membranes only

arterial oxygen sat. or vasoconstriction or

abnormal hemoqlobin decreased blood flow

present • No clubbinq

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•Cold

• M@t

•Shuntcardiac output

Perilpheral cyanosis Central eya osis

•Polycythemia

•Altitude

•Obst ructto n

•Lung disease

•lVF and shock

sulfhemoglobinemia

•Decreased

Mnemonic: h'COLD PALMS"

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• Cardiogenic shock with pulmonary edema, there may be a mixture of both central and peripheral cyanosis.

/_ --~

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Approach to Cyanosis

ry

Onset? Is the cyanosis of recent onset or has it been present since birth? A1.

history of cyanosis since birth and "squatting" in childhood suggest

congenital heart disease. Chronic cyanosis caused by methemoglobinemia

can be congenital or acquired. Other causes of chronic cyanosis include

chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, and

pulmonary atrioventricular fistula. Acute and subacute cyanosis can be

caused by acute myocardial

pneumonia, or upper airway

infarction, pneumothorax,

obstruction.

pulmonary embolus,

2. Symptomatic? Asymptomatic patients may have methemoglobinemia

(congeni tal

(prescribed

Intermittent

or drug induced) or sulfhemoglobinemia. Exposures to drugs

and!or illicit) or environmental factors should be reviewed.

cyanosis, skin color changes, and pain with cold exposure

suggest Raynaud's phenomenon. Symptomatic patients, especially with

chest pain and respiratory distress, are more likely to have a cardiac or

pulmonary cause of cyanosis.

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)Y

3. Risk Factors? Does the patient have known risk factors for cardiac or

4. Family History or Past Medical History? Is there a family history of

/

pulmonary disease, including smoking, hyperlipidemia, asthma, drug abuse

(especially methamphetamines), severe obesity (sleep apnea),

neuromuscular disease, or autoimmune disease? Does the patient have

chest pain or intermittent cyanosis with exercise, suggesting angina? Chest

pain can be present with acute pulmonary emboli or pneumothorax. Is there

a cough and fever suggesting pneumonia? Has the patient had any

occupational or environmental exposures that might cause pulmonary

problems?

abnormal hemoglobin or pulmonary disease? Has the patient suffered an

episode of hypotension that could produce adult respiratory distress

syndrome (ARDS), such as sepsis or heart failure?

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B. Physical Examination

1. Initial assessment. Vital signs: tachycardia suggests cardiac arrhythmia,

shock, volume depletion, anemia, or fever. An increased or decreased

respiratory rate and use of accessory musculature suggest hypoxia.

Hypotension can signal vascular collapse.

2. Additional physical examination. Stridor suggests upper airway

obstruction. Examine the pharynx for evidence of obstruction. If epiglottitis

or the presence of a foreign body is suspected, be prepared to intubate the

patient. Check the neck for evidence of jugular venous distention.

Auscultate the chest for rales suggestive of pulmonary edema, wheezing,

and rhonchi consistent with reactive airway disease or absence of breath

sounds, suggestive of pneumonia or pneumothorax. Auscultate the heart for

murmurs, arrhythmias, and abnormal heart sounds. Feel the pulses in the

extremities to assess for arterial embolus or venous thrombosis, especially,.................,_..,....-- .........

if cyanosis is localized to one extremity. Examine the abdomen for

evidence of intra-abdominal catastrophe or aneurysm. Examine the nails

for evidence of clubbing, which is suggestive of chronic pulmonary

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e oximetry estimates oxygen saturation but does not measure it

directly.

necessary

Direct measurements using arterial blood gases (ABGs) are

to assess a patient with cyanosis. Patients with abnormal

hemoglobin types have a normal Pao , but decreased hemoglobin O2

saturation A low Pao , is caused by respiratory or cardiac problems in

most circumstances.

2. A chest radiograph helps assess heart size

suggest pneumonia, ARDS, or pulmonary

and lung parenchyma. Infiltrates

edema. Exclude pneumothorax.

Look for evidence of interstitial lung disease. Pleural effusion can

represent infection, malignancy, or pulmonary edema.

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An electrocardiogram may demonstrate acute myocardial infarction,

ventriculararrhythmia, or pericardial process. P pulmonale, right

hypertrophy, and right axis shift suggest chronic pulmonary disease.

4. An echocardiogram can help diagnose both diastolic and systolic heart

failure, as well as visualize wall motion abnormalities that may be present

in acute or prior myocardial infarction. Evidence of pulmonary

hypertension can also be seen on echocardiogram

5. Chest computed tomography (CT) may identify pulmonary emboli

cardiac

and

andprovide more information than chest x-ray in a variety of

pulmonary dbiseases.~~~~)ocardlOgram

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THANK YOU


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