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The returns order can be created with reference to an invoice to ensure traceability of the process It may be worthwhile ensuring this is mandatory (settings on the sales document type) when creating the returns order type It may also be worthwhile ensuring the returns order reason was entered on the sales document, thus it may be necessary to add this in an incompletion procedure You may wish to copy the pricing unchanged from the invoice back into the sales order (There is no need to indicate a negative value in the copying control rules; since the system sees the document type as a return it automatically posts the entries in the finance document as opposite entries on the ledger) By using the same pricing values you ensure a complete reversal of the invoice Do not forget to activate the update document flow checkbox on the copy control rules, between billing (invoice) and sales document (return) It is advisable to have a billing block assigned to the return order in the sales document header configuration to initiate a billing block automatically, in order to prevent a credit for returns being created until an authorized person releases the billing block Once the returns delivery is created and goods receipted, the material is receipted back into the plant The material should use a goods movement that receives the stock into blocked stock Once the blocked stock has been inspected, you can either scrap it or rework it if the stock is faulty; or, if the stock is saleable, you can put it into unrestricted use stock The stock is then available for the next sales order It is advisable to indicate a shipping condition that is specifically used for returns; thus, all return deliveries or goods receipts may be done by a specific shipping point (See shipping point determination in 6) This is useful when running the delivery due list You can select only to process the returns deliveries, as well as offer better visibility of stock movements The standard item category used by returns is REN After the creation and goods issue of the delivery, the billing block is removed from the sales order and the invoice is created, with reference to the sales order This way you are able to create a credit for the return in the sales order, which in turn has the order quantity copied from the preceding invoice The credit memo then automatically reduces the customer s accounts receivable balance SAP creates the billing document from the returns order rather than from the delivery so that the customer can receive the credit without waiting for the goods receipt to take place if, for example, it may take a while for the stock to be returned to the plant, but the customer wants the credit immediately.

A variety of medications, illicit drugs, and toxic substances can produce acute or chronic myocardial injury; the clinical presentation varies widely Doxorubicin and other cytotoxic agents, emetine, and catecholamines (especially with pheochromocytoma) can produce a pathologic picture of inflammation and necrosis together with clinical heart failure and arrhythmias; toxicity of the first two is dose related The phenothiazines, lithium, chloroquine, disopyramide, antimony-containing compounds, and arsenicals can also cause ECG changes, arrhythmias, or heart failure Hypersensitivity reactions to sulfonamides, penicillins, and aminosalicylic acid as well as other drugs can result in cardiac dysfunction Radiation can cause an acute inflam-

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Dilated Frequent causes Idiopathic, alcoholic, major catecholamine discharge, myocarditis, postpartum, doxorubicin, endocrinopathies, genetic diseases Left or biventricular congestive heart failure Cardiomegaly, S3, elevated jugular venous pressure, rales ST T changes, conduction abnormalities, ventricular ectopy Enlarged heart, pulmonary congestion Left ventricular dilation and dysfunction Hypertrophic Hereditary syndrome, possibly chronic hypertension Restrictive Amyloidosis, post-radiation, postopen heart surgery, diabetes, endomyocardial fibrosis Dyspnea, fatigue, right-sided congestive heart failure Elevated jugular venous pressure, Kussmaul s sign ST T changes, conduction abnormalities, low voltage Mild to moderate cardiomegaly Small or normal left ventricular size, normal or mildly reduced left ventricular function

Dyspnea, chest pain, syncope Sustained point of maximal impulse, S4, variable systolic murmur, bisferiens carotid pulse Left ventricular hypertrophy, exaggerated septal Q waves Mild cardiomegaly Left ventricular hypertrophy, asymmetric septal hypertrophy, small left ventricular size, normal or supranormal function, systolic anterior mitral motion, diastolic dysfunction Small, hypercontractile left ventricle, dynamic outflow gradient, diastolic dysfunction

abnormalities are being recognized, and these may represent up to 25 30% of cases Often no cause can be identified, but chronic alcohol abuse and unrecognized myocarditis are probably frequent causes Chronic tachycardia may also precipitate a dilated cardiomyopathy Amyloidosis, sarcoidosis, hemochromatosis, and diabetes may rarely present as dilated cardiomyopathies, as well as the more classic restrictive picture The RV may be primarily involved in arrhythmogenic RV dysplasia, an unusual cardiomyopathy with displacement of myocardial cells by adipose tissue, or in Uhl s disease, in which there is extreme thinning of the RV walls Intraventricular thrombus is not uncommon Histologically, the picture is one of extensive fibrosis unless a specific diagnosis is established Myocardial biopsy is rarely useful in establishing the diagnosis, though occasionally the underlying cause (eg, sarcoidosis, hemochromatosis) can be discerned

The major findings are listed in Table 10 12 Sinus tachycardia is common Other common abnormalities include left bundle branch block and ventricular or atrial arrhythmias The chest radiograph reveals cardiomegaly, evidence for left and/or right heart failure, and pleural effusions (right > left)

An echocardiogram is indicated to exclude unsuspected valvular or other lesions and confirm the presence of dilated cardiomyopathy and reduced systolic function (as opposed to diastolic heart failure) Mitral Doppler inflow patterns also help in the diagnosis of associated diastolic dysfunction Color flow Doppler can reveal tricuspid or mitral regurgitation, and continuous Doppler can help define PA pressures Exercise or pharmacologic stress myocardial perfusion imaging may suggest the possibility of underlying coronary disease Radionuclide ventriculography provides a noninvasive measure of the EF and both RV and LV wall motion Cardiac MRI is particularly helpful in infiltrative processes, such as sarcoidosis or hemochromatosis, and is the diagnostic study of choice for RV dysplasia MRI can also help define an ischemic etiology by noting gadolinium enhancement consistent with myocardial scar Cardiac catheterization is seldom of specific value unless myocardial ischemia or LV aneurysm is suspected The serum ferritin is an adequate screening study for hemochromatosis The erythrocyte sedimentation rate may be low due to liver congestion The serum level of BNP or pro-BNP can be used to help quantitate the severity of CHF

In most patients, symptoms of heart failure develop gradually Cardiomyopathy may be recognized because of asymptomatic cardiomegaly or ECG abnormalities, including arrhythmias The initial presentation may be severe left or biventricular failure The physical examination reveals rales, an elevated JVP, cardiomegaly, S3 gallop rhythm, often the murmurs of functional mitral or tricuspid regurgitation, peripheral edema, or ascites In severe CHF, Cheyne-Stokes breathing, pulsus alternans, pallor, and cyanosis may be present

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