Ross C Donehower, M.D.
- Director, Medical Oncology/Hematogy Fellowship Training Program
- Professor of Oncology
https://www.hopkinsmedicine.org/profiles/results/directory/profile/0002087/ross-donehower
Three major types of respiratory system disturbances will be reviewed: ventilatory function gastritis diet 4 you generic motilium 10mg without a prescription, pulmonary circulation gastritis olive oil discount motilium 10 mg amex, and gas exchange gastritis journal pdf purchase motilium 10 mg with mastercard. Expiratory flow rates may be plotted against lung volumes to yield a flow-volume curve gastritis diet motilium 10mg mastercard. Lung volumes and flow rates are typically compared with population-based normal values that adjust for the age, height, sex, and race of the pt. There are two major patterns of abnormal ventilatory function detected by pulmonary function testing: restrictive and obstructive (Tables 135-1 and 135-2). All diseases of the respiratory system causing hypoxemia are capable of causing pulmonary hypertension. Normal tidal volume is approximately 500 mL and normal respiratory rate is approximately 15 breaths/ min, leading to a total minute ventilation of approximately 7. Gas exchange depends on alveolar ventilation rather than total minute ventilation. Other limitations of pulse oximetry include relative insensitivity to oxygenation changes when PaO2 is >60 mmHg, problems with obtaining an adequate signal when cutaneous perfusion is decreased, and inability to distinguish oxyhemoglobin from other forms of hemoglobin, such as carboxyhemoglobin and methemoglobin. A variety of other imaging techniques are used less commonly to assess respiratory disease. Ultrasound is not useful for assessing the pulmonary parenchyma, but it can detect pleural abnormalities and guide thoracentesis of a pleural effusion. Sputum samples induced by hypertonic saline can be stained for the presence of Pneumocystis jiroveci. Invasive Procedures Bronchoscopy Bronchoscopy is a procedure that provides direct visualization of the tracheobronchial tree. Flexible fiberoptic bronchoscopy allows visualization of the airways; identification of endobronchial abnormalities, including tumors and sites of bleeding; and collection of diagnostic specimens by washing, brushing, biopsy, or lavage. Washing involves instilling sterile saline through the bronchoscope channel onto the surface of a lesion; part of the saline is suctioned back through the bronchoscope and processed for cytology and microorganisms. Transbronchial biopsy is particularly useful in diagnosing diffuse infectious processes, lymphangitic spread of cancer, and granulomatous diseases. Percutaneous Needle Aspiration of the Lung A needle can be inserted through the chest wall and into a pulmonary lesion to aspirate material for cytologic and microbiologic studies. Thoracentesis and Pleural Biopsy Thoracentesis should be performed as an early step in the evaluation of a pleural effusion of uncertain etiology. Mediastinoscopy Tissue biopsy is often required to assess mediastinal masses or lymph nodes. Lymph nodes in the left paratracheal or aortopulmonary locations typically require a parasternal mediastinotomy to provide access for biopsy. Although asthmatics typically have periods of normal lung function with intermittent airflow obstruction, a subset of pts develop chronic airflow obstruction. In developed countries, approximately 10% of adults and 15% of children have asthma. A minority of asthmatic pts do not have atopy (negative skin prick tests to common allergens and normal serum total IgE levels). Occupational asthma can result from a variety of chemicals, including toluene diisocyanate and trimellitic anhydride, and also can have an adult onset. Other triggers of increased asthma symptoms include air pollution, occupational exposures, and stress. The severity of their asthmatic symptoms, as well as their need for systemic steroid treatment, hospitalization, and intensive care treatment, are important to ascertain. Types of asthmatic triggers for the particular pt, and their recent exposure to them, should be determined. Physical Exam It is important to assess for signs of respiratory distress, including tachypnea, use of accessory respiratory muscles, and cyanosis. On lung exam, there may be wheezing and rhonchi throughout the chest, typically more prominent in expiration than inspiration.
Diagnostic Strategies the initial decision point is based on whether the pt is hemodynamically stable gastritis diet 4 idiots cheap motilium 10mg otc. Pain localized to the epigastrium may be of cardiac origin gastritis stress effective 10 mg motilium, esophageal inflammation or perforation gastritis causes and symptoms generic motilium 10 mg with visa, gastritis gastritis diet sweet potato discount 10mg motilium with amex, peptic ulcer disease, biliary colic or cholecystitis, and pancreatitis. Pain localized to the right upper quadrant includes those same entities plus pyelonephritis or nephrolithiasis, hepatic abscess, subdiaphragmatic absess, pulmonary embolus, or pneumonia or be of musculoskeletal origin. Left lower quadrant pain may be due to diverticulitis, perforated neoplasm, and other entities previously mentioned. Intestinal water absorption passively follows active transport of Na, Cl, glucose, and bile salts. Propulsion is controlled by neural, myogenic, and hormonal mechanisms; mediated by migrating motor complex, an organized wave of neuromuscular activity that originates in the distal stomach during fasting and migrates slowly down the small intestine. Defecation is effected by relaxation of internal anal sphincter in response to rectal distention, with voluntary control by contraction of external anal sphincter. Mediated by one or more of the following mechanisms: Osmotic Diarrhea Nonabsorbed solutes increase intraluminal oncotic pressure, causing outpouring of water; usually ceases with fasting; stool osmolal gap 40 (see below). A longer (4 weeks), more insidious course suggests malabsorption, inflammatory bowel disease, metabolic or endocrine disturbance, pancreatic insufficiency, laxative abuse, ischemia, neoplasm (hypersecretory state or partial obstruction), or irritable bowel syndrome. Fecal impaction may cause apparent diarrhea because only liquids pass partial obstruction. Several infectious causes of diarrhea are associated with an immunocompromised state (Table 52-1). Certain signs are frequently associated with specific deficiency states secondary to malabsorption. Stool Examination Culture for bacterial pathogens, examination for leukocytes, measurement of C. Measurement of Na and K levels in fecal water helps to distinguish osmotic from other types of diarrhea; osmotic diarrhea is implied by stool osmolal gap 40, where stool osmolal gap osmolserum [2 (Na K)stool]. Serum levels of calcium, albumin, iron, cholesterol, folate, B12, vitamin D, and carotene; serum iron-binding capacity; and prothrombin time can provide evidence of intestinal malabsorption or maldigestion. Other Studies D-Xylose absorption test is a convenient screen for smallbowel absorptive function. Specialized studies include Schilling test (B12 malabsorption), lactose H2 breath test (carbohydrate malabsorption), [14C]xylose and lactulose H2 breath tests (bacterial overgrowth), glycocholic breath test (ileal malabsorption), triolein breath test (fat malabsorption), and bentiromide and secretin tests (pancreatic insufficiency). Acute diarrhea History and physical exam Likely noninfectious Likely infectious Evaluate and treat accordingly Mild (unrestricted) Moderate (activities altered) Severe (incapacitated) Institute fluid and electrolyte replacement Observe Fever 38. Before evaluation, consider empiric Rx with (*) metronidazole and with quinolone. Protein-losing enteropathy may result from several causes of malabsorption; it is associated with hypoalbuminemia and can be detected by measuring stool 1-antitrypsin or radiolabeled albumin levels. For symptomatic relief, magnesium-containing agents or other cathartics are occasionally needed. With severe hypoor dysmotility or in presence of opiates, osmotically active agents. Hematemesis: Vomiting of blood or altered blood ("coffee grounds") indicates bleeding proximal to ligament of Treitz. Melena: Altered (black) blood per rectum (100 mL blood required for one melenic stool) usually indicates bleeding proximal to ligament of Treitz but may be as distal as ascending colon; pseudomelena may be caused by ingestion of iron, bismuth, licorice, beets, blueberries, charcoal. Recommendations on level of care and time of discharge assume patient is stabilized without further bleeding or other concomitant medical problems. Scleral icterus becomes clinically evident at a serum bilirubin level of 51 mol/L (3 mg/dL); yellow skin discoloration also occurs with elevated serum carotene levels but without pigmentation of the sclerae. Initially it is bound to albumin, transported into the liver, conjugated to a water-soluble form (glucuronide) by glucuronosyl transferase, excreted into the bile, and converted to urobilinogen in the colon.
A blood glucose level below 250 mg/dL improves but does not correct white blood cell phagocytic function gastritis y diarrea order 10 mg motilium with mastercard, improves but does not correct granulocyte adherence gastritis diet education buy motilium 10mg with visa, and improves but does not correct leukocyte bacterial killing gastritis workup cheap motilium 10mg on line. Lastly gastritis working out generic motilium 10mg with mastercard, as mentioned earlier, new-onset diabetic patients have a fivefold increase in hospital mortality compared with hospitalized known diabetic patients. Likely the new-onset hyperglycemia is proinflammatory and contributes to more tissue inflammation and injury. Immune-Enhancing Diet the use of an immune-enhancing diet in severe trauma patients can reduce major infectious complications (6% versus 41%) and hospital stay (18 versus 33 days). The use of this specific form of immunonutrition was stopped because of harm to patients with septic shock and severe sepsis. Therefore, these agents should be used only in nonseptic surgical patients until safety can be established. Acute Hepatic Porphyria this rare cause of abdominal pain is treated with dextrose, 500 g/day (2 L of 25% dextrose at a rate of 80 mL/h). This recommendation has been established based on the clinical trials of van den Berghe and others and has increased the need for aggressive administration of insulin. Careful monitoring of the serum phosphorus level over the first 48 hours of insulin therapy is important to prevent hypophosphatemia (refeeding syndrome), which has a mortality of up to 33%. Respiratory failure and cardiac dysfunction can be seen at serum phosphorus levels below 2. A severely reduced serum phosphate concentration of less than 1 mg/dL is often lethal. Critically ill patients without diabetes frequently have elevated blood glucose concentrations owing to metabolic stress syndrome. Some of these patient who also have insulin resistance develop new-onset diabetes, as defined by two random blood glucose values greater than 199 mg/dL on two separate days or a fasting blood glucose concentration of greater than 125 mg/dL on two separate days. The new-onset diabetes is due to insulin resistance and elevations in counterregulatory hormones. The metabolic abnormalities of insulin resistance include glucose intolerance, increased hepatic glucose production, increased whole body amino acid flux, and decreased whole body glucose utilization. Insulin resistance resulting in the metabolic stress syndrome is type 2 diabetic in character because patients are not insulinopenic but are insulin-resistant. The more severe the malnutrition or illness, the greater is the hepatic glucose production. The use of insulin or other agents that reduce hepatic glucose production in critical illness may be helpful in reducing protein breakdown from the lean body mass for amino acid gluconeogenic precursors. Hypoglycemia (blood glucose <40 mg/dL) occurred in 5% of the intensively treated group and fewer than 1% of the conventionally treated patients. While there were small differences in outcome in these studies, the overall benefit of more stringent glycemic control is generally apparent. Additional studies that support the use of growth hormone are needed prior to the use of growth hormone in patients who are seriously ill. Anabolic Steroids Anabolic steroids have been used in several clinical trials of malnourished patients with mixed results. Nitrogen balance has been shown to be improved in some but not all the clinical trials. The improved nitrogen balance generally was seen in patients with benign diseases (eg, hip replacement surgery, vagotomy, or pyloroplasty). In a prospective study of burns, oxandrolone 20 mg/day reduced weight loss (3 versus 8 kg), nitrogen loss (4 versus 13 g/day), and healing time (9 versus 13 days). In fact, recent data suggest that their use is associated with a prolongation of the time on the ventilator (22 versus 16 days).
Syndromes
- Excessive bleeding
- Eyes -- decreased vision or blindness
- When did the symptom first occur?
- You suddenly develop pain in the hernia and the hernia cannot be pushed back into the abdomen using gentle pressure.
- Small, bulging sacs or pouches of the inner lining of the intestine, called diverticulosis
- Cardiomyopathy
- Impaired vision
- Getting too much activity
- Epinephrine: 0.5 - 20 mcg/24 hours
- Whether a previous vaccine helped your immune system protect you against the specific disease
Cutaneous xanthomas are distinctive nhs direct gastritis diet discount 10mg motilium mastercard, in the form of palmar and tuberoeruptive xanthomas gastritis chronic nausea cheap motilium 10 mg online. Therapy begins with a low-fat diet xifaxan gastritis cheap motilium 10 mg otc, but pharmacologic intervention is often required (Table 187-2) gastritis and duodenitis buy discount motilium 10 mg online. The classic clinical constellation of hemochromatosis is a patient presenting with bronze skin, diabetes, cardiac conduction abnormalities, and liver disease. Diagnosis Serum Fe, percent transferrin saturation, and serum ferritin levels are increased. In an otherwise-healthy person, a fasting serum transferrin saturation > 50% is abnormal and suggests homozygosity for hemochromatosis. In most untreated pts with hemochromatosis, the serum ferritin level is also greatly increased. If either the percent transferrin saturation or the serum ferritin level is abnormal, genetic testing for hemochromatosis should be performed. All first-degree relatives of pts with hemochromatosis should be tested for the C282Y and H63D mutations. Liver biopsy may be required in affected individuals to evaluate possible cirrhosis or to quantify tissue iron. Hemochromatosis Therapy involves removal of excess body Fe, usually by intermittent phlebotomy, and supportive treatment of damaged organs. Less frequent phlebotomy is then used to maintain serum Fe at <27 mol/L (<150 g/dL). Chelation therapy is indicated, however, when phlebotomy is inappropriate, such as with anemia or hypoproteinemia. Each disorder causes a unique pattern of overproduction, accumulation, and excretion of intermediates of heme synthesis. It is due to deficiency (inherited or acquired) of hepatic uroporphyrinogen decarboxylase. Porphyria Cutanea Tarda Avoidance of precipitating factors, including abstinence from alcohol, estrogens, iron supplements, and other exacerbating drugs, is the first line of therapy. The skin manifestations differ from those of other porphyrias, in that vesicular lesions are uncommon. Protoporphyrin levels are increased in bone marrow, circulating erythrocytes, plasma, bile, and feces. Cholestyramine or activated charcoal may promote fecal excretion of protoporphyrin. Clinical Features Hepatic disease may present as hepatitis, cirrhosis, or hepatic decompensation. In other pts, neurologic or psychiatric disturbances are the first clinical sign and are always accompanied by Kayser-Fleischer rings (corneal deposits of copper). Dystonia, incoordination, or tremor may be present, and dysarthria and dysphagia are common. In about 5% of pts, the first manifestation may be primary or secondary amenorrhea or repeated spontaneous abortions. Diagnosis Serum ceruloplasmin levels are often low, and urine copper levels are elevated. Recall of historic events or dates of current events can be used to assess knowledge. Segmental Innervation C5,6 C5,6 C5,6 C5,6 C6,7,8 C5,6 C7,8 C7,8 C6,7 C6,7 C7,8,T1 C6,7 C7,8,T1 C6,7 C8,T1 C8,T1 C7,C8,T1 C8,T1 C7,8 C8,T1 C8,T1 C8,T1 L1,2,3 L4,L5,S1,S2 L2,3,4 L2,3,4 L5,S1,S2 S1,S2 L4,5 L5,S1 L4,5 L5,S1 Wrist Hand Thumb Thigh Foot Toes and copy, perform calculations, interpret proverbs or logic problems, identify right vs. Formal perimetry and tangent screen exam are essential to identify and delineate small defects. Optic fundi should be examined with an ophthalmoscope, and the color, size, and degree of swelling or elevation of the optic disc recorded. The retina, including the macula, should be examined for abnormal pigmentation and other lesions. Test taste for sweet (sugar), salt, sour (lemon), and bitter (quinine) using a cotton-tipped applicator moistened in appropriate solution and placed on lateral margin of protruded tongue halfway back from tip.
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