Respiratory Distress in Newborn

Respiratory Distress in Newborn
Presentation lecture by:Leena Mane and Rhea Mane


Case study:

* A male infant weighing 3000 g (6 lb 10 oz) is born at 36 weeks' gestation, with normal Apgar scores and an unremarkable initial examination. At 48 hours of age he is noted to have dusky episodes while feeding, and does not feed well. On repeat examination the child is tachypneic, with subcostal retractions. Lung sounds are clear and there is no heart murmur.

What Next ?
Tests & labs…

* Pulse oximetry on room air is 82%.
* Arterial blood gases on 100% oxygen show a pCO2 of 26 mm Hg (N 27-40), a pO2 of 66 mm Hg (N 83-108),
* blood pH of 7.50 mg/dL (N 7.35-7.45), and a base excess of -2 mmol/L (N -10 to -2).
* Hemoglobin- 22.0g/dl (N13.0- 20.0)
* Hematocrit- 66 % (N 42- 66)
* WBC- 19,000/mm3 (N9000-30,000)
* Blood cultures- Pending.
* Chest X-ray- Increased vascular marking, Large thymus.


Most likely diagnosis
* 1- Transient tachypnea of newborn
* 2- Congenital heart disease
* 3- Hyaline membrane disease
* 4- Neonatal sepsis
* 5- Hyperviscosity syndrome

Transient Tachypnea of Newborn
* Most common cause of respiratory distress.
* 40% cases.
* Residual fluid in fetal lung tissues.
* Risk factors- maternal asthma, c- section, male sex, macrosomia, maternal diabetes

TTN

* Tachypnea immediately after birth or within two hours, with other predictable signs of respiratory distress.
* Symptoms can last few hours to two days.
* Chest radiography shows diffuse parenchymal infiltrates, a “ wet silhouette” around heart, or intralobar fluid accumulation

X-ray
Fluid in the fissure
Respiratory Distress Syndrome
RDS
Meconium Aspiration Syndrome
Infections
Other causes-
Congenital Heart disease
Hyperoxia Test
Treatment
Transient Tachypnea of Newborn
Respiratory distress Syndrome
Meconium Aspiration Syndrome
Algorithm
Evaluation
Treatment

Respiratory Distress in Newborn.ppt

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Tinnitus

Tinnitus
Presenatation by:Lianne Beck, MD
Assistant Professor
Emory Family Medicine

Tinnitus
* Definition
* Classification
* Objective tinnitus
* Subjective tinnitus
* Theories
* Evaluation
* Treatment

Introduction
* Tinnitus -“The perception of sound in the absence of external stimuli.”
* Tinnire – means “ringing” in Latin
* Includes buzzing, hissing, roaring, clicking, pulsatile sounds
* For some, an unbearable sound that drives them to contemplate suicide.
* May be perceived as unilateral or bilateral
* Originating in the ears or around the head
* First or only symptom of a disease process or auditory/psychological annoyance

Classification

* Objective tinnitus – sound produced by paraauditory structures which may be heard by an examiner, often pulsatile
* Subjective tinnitus – sound is only perceived by the patient (most common)
* Pulsatile tinnitus – matches pulse or a rushing sound
o Possible vascular etiology
o Objective or subjective
o Increased or turbulent blood flow through paraauditory structures

Objective tinnitus
* Vascular (pulsatile)
o A/V malformations
o Vascular tumors
o Venous hum (cardiac murmurs, anemia, BIH, thyrotoxicosis, pregnancy, dehiscent jugular bulb)
o Atherosclerosis
o Ectopic carotid artery
o Persistent stapedial artery
o Vascular loops
* Neuromuscular
o Palatomyclonus
o Stapedial muscle spasm
* Patulous eustachian tube

Arteriovenous Malformations
* Congenital lesions
* Occipital artery and transverse sinus, internal carotid and vertebral arteries, middle meningeal and greater superficial petrosal arteries
* Mandible
* Brain parenchyma
* Dura
* Pulsatile tinnitus
* Headache
* Papilledema
* Discoloration of skin or mucosa

Vascular tumors
* Glomus tympanicum
o Paraganglioma of middle ear
o Loud pulsatile tinnitus which may decrease with ipsilateral carotid artery compression
o Reddish mass behind tympanic membrane which blanches with positive pressure
o Conductive hearing loss

Vascular tumors
* Glomus jugulare
o Paraganglioma of jugular fossa
o Loud pulsatile tinnitus
o Conductive hearing loss if into middle ear
o Cranial neuropathies

Venous hum
* Benign intracranial hypertension
* Dehiscent jugular bulb
* Transverse sinus partial obstruction
* Increased cardiac output from
o Pregnancy
o Thyrotoxicosis
o Anemia

Benign Intracranial Hypertension
* Also called pseudotumor cerebri
* Young, obese, female patients
* Hearing loss
* Aural fullness
* Dizziness
* Headaches
* Visual disturbance
* Papilledema, pressure >200mm H20 on LP

Benign Intracranial Hypertension
* Sismanis and Smoker 1994
o 100 patients with pulsatile tinnitus
o 42 found to have BIH syndrome
o 16 glomus tumors
o 15 atherosclerotic carotid artery disease
* Treatment
o Weight loss
o Diuretics
o Subarachnoid-peritoneal shunt
o Gastric bypass for weight reduction

Neuromuscular Causes
* Palatal myoclonus
o Clicking sound
o Rapid (60-200 beats/min), intermittent
o Contracture of tensor palantini, levator palatini, levator veli palatini, tensor tympani, salpingopharyngeal, superior constrictors
o Muscle spasm seen orally or transnasally
o Rhythmic compliance change on tympanogram

Myoclonus
Stapedius Muscle Spasm
Patulous Eustachian Tube
Subjective Tinnitus
Conductive hearing loss
Sensorineural hearing loss
Other subjective tinnitus
CNS Mechanisms
Neurophysiologic Model
Role of Depression
Ototoxic Drugs
Evaluation - History
Evaluation – Physical Exam
Evaluation - Audiometry
Laboratory studies
Imaging
Glomus Tympanicum
Glomus jugulare
Acoustic Neuroma
ENT Referral
Treatments
Treatments - Medicines
Treatments
* Hearing aids – amplification of background noise can decrease tinnitus
* Maskers – produce sound to mask tinnitus
* Tinnitus instrument – combination of hearing aid and masker
Conclusions
References

Tinnitus.ppt

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Hematuria

Hematuria

Gross hematuria:
Suspected if a red or brown color change of urine
Intermittent red or brown color urine a/w variety of clinical setting
Medications (phenazopyridine, microbid, NSAID)
Ingestion of beets or certain dyes
Metabolities
Myoglobinuria or hemoglobinuria

Work up
Centrifuge the specimen, Supernatant be tested for heme (hemoglobin or myoglobin) with a urine dipstick.

Causes of heme-negative red urine
Medications
Food dyes
Metabolities
Doxorubicin
Beets (in selected patients)
Bile pigments
Chloroquine
Blackberries
Homogentisic acid
Deferoxamine
Food coloring
Melanin
Ibuprofen
Methemoglobin
Iron sorbitol
Porphyrin
Nitrofurantoin
Tyrosinosis
Phenazopyridine
Urates
Phenolphthalein
Rifampin

Approach to the patient with red or brown urine
Microscopic hematuria:
Major causes of hematuria by age and duration
The evaluation should address the following three questions

1. Are there any clues from the history or physical examination that suggest a particular diagnosis?
2. Does the hematuria represent glomerular or extraglomerular bleeding?
3. Is the hematuria transient or persistent?

Goal is to quickly identify
* Infection
* Kidney stone
* Malignant

History and Physical
Mechanisms by Which Selected Drugs May Cause Hematuria
Hemorrhagic cystitis
Urolithiasis
Carbonic anhydrase inhibitors
Vital sign: BP, T, HR
Abdomen for masses, tenderness (flank, suprapubics), bruits
CVS: irregular irregular
Edema (especially periorbital)
Joint erythema, swelling, warmth
Paleness, jaundice
Careful inspection of external genitalia
Physical Examination Findings and Associated Causes of Hematuria

Physical examination finding
Cause of hematuria
General (systemic) examination
Severe dehydration
Renal vein thrombosis
Peripheral edema
Nephrotic syndrome, vasculitis
Cardiovascular system
Myocardial infarction
Renal artery embolus or thrombus
Atrial fibrillation
Renal artery embolus or thrombus
Hypertension
Glomerulosclerosis with or without proteinuria
Abdomen
Bruit
Arteriovenous fistula
Genitourinary system
Enlarged prostate
Urinary tract infection
Phimosis
Urinary tract infection
Meatal stenosis
Urinary tract infection
Glomerular or Extra Glomerular bleeding?
Microscopic hematuria DDx
Microscopic hematuria DDx
Rare cause of Microscopic Hematuria
Arteriovenous malformations and fistulas
Nutcracker syndrome
Loin pain-hematuria syndrome
Proteinuria
Extraglomerular vs Glomerular in UA
Findings on Microscopy
Transient or persistent hematuria
Exception:
Persistent hematuria
Laboratory Tests (initial work up)
Further Work up
Renal Biopsy
Radiologic and other tests for the evaluation of hematuria
Initial Evaluation of Asymptomatic Microscopic Hematuria
Reference

Hematuria.ppt

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