L ONG C ASES CASE 1: CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) WITH OR WITHOUT COR PULMONALE The patient (Fig. 1.1A) presented with cough with mucoid sputum for the last 8 years. These symptoms intermittently increased during windy or dusty weather . No histor y of hemoptysis, fever , pain chest. The sputum is white, small in amount with no postural r elation. P oints to be Stressed in Histor y Cigarette smoking. Exposure to smoke from cigrar ette or biomass and solid fuel fir es, atmospheric smoke is impor tant factor in pathogenesis as well as in acute e xacerbation of COPD. The smoke has adverse effect on sur factants and lung defence. P r ecipitating factors, e.g. dusty atmos- pher e, air pollution and r epeated upper r espirator y tract infections. They cause acute e xacerbations of the disease. F amily history : Ther e is incr eased susceptibility to develop COPD in family of smokers than non -smokers. H e r editary pr edisposition. Alpha-1- antitr ypsin deficiency can cause emphysema in non -smokers adult patients. Physical Signs (See T able 1.1) General Physical Flexed posture (leaning forward) with pursed-lip br eathing and ar ms suppor ted on their knees or table. Figs 1.1A and B: Chronic obstructive pulmonary disease (COPD): A. P atient of COPD demonstrating central cyanosis. B. Clinical signs of COPD (Diag) Clinical Presentations Initially , the patients complain of r epeated attacks of productive cough, usually after colds and especially during winter months which show a steady Examination Inspection Shape of the chest AP diameter is incr eased r elative to transverse diameter . Bar r el-shaped chest: the ster num becomes more arched, spines become unduly concave, the AP diameter is > transverse diameter , ribs ar e less oblique (more or less horizontal), subcostal angle is wide (may be obtuse), intercostal spaces are widened. Movements of the chest wall Bilaterally diminished R espiratory rate and type of br eathing Pursed-lip br eathing Intercostal r ecession (indrawing of the ribs) Excavation of supraster nal, supra- clavicular and infraclavicular fossae during e xpiration W idening of subcostal angle Respirator y rate is incr eased. It is mainly abdominal. The alae nasi and e xtra-r espirator y muscles ar e in action. All these signs indicate hyperinflation of lung due to advanced air flow obstruction. Cardiac ape x beat may or may not be visible.

L UMBAR PUNCTURE (LP) It is a bedside procedur e done to remove cer ebrospinal fluid (CSF) from the subarachnoid space by puncturing it at or below L 2 -L 3 inter ver tebral space. The spinal cord ends at the level of L 1 ver tebra after which ther e is a cul- de-sac (dilatation of subarachnoid space) from which CSF can be r emoved. The instrument used for the purpose is called lumbar punctur e (LP) needle (F ig. 2.1). Indications I. Diagnostic CSF is r emoved for diagnosis of the following conditions: i. CNS infections/inflammation Encephalitis Meningitis Multiple sclerosis Myelitis Acute post-infective polyneuritis (Guillain - Bar r e syndrome) ii. Subarachnoid haemor r hage (to be done af t e r fundus examination) iii. Infiltrative conditions Car cinomatous meningitis L ymphoma and leucaemic infiltration of meninges iv . T o confirm raised intracranial pr essur e when CT scan ex cludes the danger of brain -stem herniation Benign raised intracranial tension Cer ebral venous sinus thrombosis v. Instillation of contrast media or an isotope Myelography (CT myelography) Cisternography . II. Therapeutic Lumbar puncture is done for tr eatment purpose; i . Administration of intrathecal antibiotics or tetanus immunoglobulin ii. Administration of antileucaemic drugs in ALL iii. Spinal anaesthesia i v . Removal of CSF to lower the pr essur e in benign intracranial hyper tension III. Other uses of LP needle i . Used as aspiration needle for tapping fluids from a cavity , e.g. ascites, pleural effusion. Contraindications i . Thrombocytopenia and coagulation disorders i i . Depr essed consciousness especially if focal neurological signs pr esent. CT scan to be done initially to rule out raised intracranial pressur e or mass lesion. LP should not be per for med in p r esence of raised intracranial pr essur e or a mass lesion iii. P apilloedema F ig. 2.

DRUGS USED IN C ARDIOL OG Y C ARDIO V ASCULAR DRUGS Categorisation of drugs used in disorders of cardiovascular system is: CARDIA C STIMULANT a . Cardiac stimulants, e.g. glycosides, (digo xin, digito xin, anabine) and amrinone (inamrinone). They ar e discussed in T able 3.1. b . Sympathomimetic amines e.g. noradr enaline, adr enaline, isoproter enol (isoprenaline), dopamine and dobutamine. They have been dealt separately . ANTI- ARRHYTHMIC DRUGS ( V aughan W illiam classification (T able 3.2) Class I (Block Na Channels) 1 A : Drugs that r educe V max and pr olong action potential duration Quinidine P rocainamide Disopyramide 1B: Drugs that do not r educe V max but pr olong action potential duration M e xiletine Phenytoin Lidocaine T ocainide 1 C : Drugs that r educe V max , primarily slow conduction and can pr olong r efractoriness Flecainide P ropafenone Moricizine Class II: Betablock ers (block beta-adr energic r eceptors) P ropranolol, metoprolol, alenolol, timolol, o xypre- nolol, sotalol, bisoprolol, mebivolol, car vedilol Class III: Drugs block potassium channels and block multiple phases of the action potential and pr olong repolarisation Amiodarone, sotalol, br etylium and N-acetylpro- cainamide, ibutilide, dofetilide Class IV : Calcium channel blockers Diltiazem, verapamil and others Other antiarr hythmic drugs Adenosine Digitalis Betablock ers Beta r eceptors can be separated into two categories; (i) that affect the hear t (  1 ) and (ii) that affect pr edominantly blood vessels (  2 ) or the bronchi. Ther efor e  1 r eceptors produce cardiac stimulation and  2 r eceptors produce bronchodilation and vasodilation. Cardioselective  1 blockers antagonise the  1 -cardiostimulator y effects and have less effect on  2 -r esponses. Nonselective-beta blockers antagonise the effects of both  1 and  2 r ecep- tors. A t high doses, even selective betablockers also block  2 receptors. Some betablockers (alpr enolol, o xypr enolol, pindolol) possess intrinsic sympathomimetic activity i.e. they slightly activate the  - r eceptors.

X - RA Y CHEST A chest X -ray is the common noninvasive investigation that helps not only in the diagnosis of r espirator y disease but also in cardiovascular disease too , hence, should be per for med routinely in these disorders. An anteroposterior (AP view) X -ray chest is nor mally taken in emergency conditions mostly at the bed side; while the other view is posteroanterior (P A view) which is common in use in routine cases. These views in fact r eflect the dir ection of the rays from the sour ce to the plate. In P A view , the beam of rays falls from behind the patient and the hear t size appears mor e or less nor mal; while in AP view the beam of rays falls from the front and the hear t shadow appears as appar ently enlarged. The X -ray chest is r ead with r espect to the following points; 1. V iew Whether it is P A view or AP view . 2. Centralisation or Centering Look at the clavicles, if they ar e at the same level, then X -ray is centralised; and if not then it is poorly centralised. 3. P enetration/exposure If the bony cage, ribs and ver tebral bodies ar e just visible through the cardiac shadow , then penetration is good. If they ar e too clearly visible, then it is over -penetrated and if not visible, then it is under penetrated (under e xposed). In over -penetrated X -rays you ar e likely to miss low density lesions. 4. Sex If br east shadows ar e visible, then X -ray belongs to the female patient. 5. P osition of Diaphragm The right dome of diaphragm is slightly higher than left due to pr esence of liver on the right. Both the costo- phr enic and cardiophr enic angles ar e clear . 6. P osition of the T rachea This is seen as a dark column r epr esenting the air within the trachea. Note whether trachea is central or displaced. This is seen in refer ence to central bony ver tebral column behind it. The trachea may be deviated to the same side or opposite side in a number of conditions (Read the deviation of trachea in clinical methods). 7. Bony Cage Note the central ver tebral column and the horizontal ribs. Decide whether chest is symmetrical or any scoliosis pr esent. Examine whether the ribs ar e unduly crowded (collapse or fibrosis) or widely separated (pleural effusion, pneumothorax) on one side than the other . Look for any cer vical rib, bony erosion of the ribs. 8. Degree of Inspiration T o judge the degr ee of inspiration, count the number of ribs above the diaphragm. The anterior end of the 6th rib should be above the diaphragm as should be the posterior end of 10th rib. If mor e ribs ar e visible then the lung is hyperinflated.

INTRODUCTION Definition Electrocardiography is a graphic r ecording of the electrical potentials generated and propagated in the hear t on a paper by sur face electrodes. The electrical events ar e r ecorded as wavefor ms. Uses Chamber hyper trophy (atrial or ventricular or both) Myocardial ischaemia/infar ction It is a gold standard for diagnosis of arrhythmias Conduction defects at various levels, e.g. SA blocks, A V blocks, bundle branch blocks, fascicular blocks Myocardial and pericardial diseases T o study the effects of drugs, electrolytes and poison on the heart Evaluation of efficacy of various inter vention procedur es, e.g. angioplasty , bypass surger y Holter s monitoring (dynamic/ambulator y ECG) is used to r elate symptoms with ECG while str e s s (e xercise) ECG is used to diagnose asymptomatic coronary ar ter y disease. The ECG paper is designed with small and large squar es such that in one minute 300 large squar es or 1500 small squar es ar e cover ed. One small squar e is equal to 0.04 sec in duration and 1 mm in height and width. One large squar e is equal to 5 small squares and is 5 × 0.04= 0.2 sec in duration. These dimensions help to calculate the hear t rate in regular sinus rhythm and in an ar rhythmia. The voltage of one small squar e is 0.1 mV . The PQRST and U Complex An ECG comple x depending on the wavefor m is called PQRST -U complex . The P wave signifies atrial depolarisation and r epolarisation. It pr ecedes QRS comple x. The QRS comple x consists of a small negative q wave which, sometimes, may be absent, a large positive R wave and a second small negative S wave. It signifies ventricular depolarisation. The T wave is positive wave which follows QRS after a small inter val (ST segment) and signifies ventricular r epolarisation. The U wave is the second r epolarisation wave, indicates delayed r epolarisation, occurs as a small positive deflection after the T wave. The ECG Inter vals 1. PR inter val is the time taken by the impulse to travel from SA node to the ventricles. 2. QT inter val is the time taken by the ventricular events depolarisation cum r epolarisation. Junctions and Segments 1. J point is the junctional point at which QRS ends with S wave r etur ning to the baseline. This point is an impor tant landmark for evaluation of ST segment deviation (elevation/depr ession). 2. The ST segment. It is the distance between the end of S wave (J point) to the beginning of T wave.