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Professor, Perelman School of Medicine at the University of Pennsylvania
Cervical (Pap) smears are usually avoided in However virus 3030 bactrim 480 mg online, Christmas disease does occur in women treatment for dog's broken toenail buy generic bactrim 960mg on line. If no local cause is detected antimicrobial agent definition purchase bactrim, the patient’s coagulation profle The use of heparin, aspirin, or warfarin during preg- should be evaluated. In all cases, a blood group should be obtained and consideration given to administering anti-D, if the Bleeding from other sites bleeding is excessive or if any operative procedure Bleeding haemorrhoids are ofen confused with vag- needs to be undertaken, e. The embryo may be viable, in which careful history of the amount of bleeding and any case the pregnancy will continue, or it may be non-viable accompanying pain should be elicited. Induced surgical miscarriage: pregnancy terminated by nancies and is a leading cause of maternal mortal- dilatation and curettage or suction evacuation. Any bleeding ing before 20th week of pregnancy: pro- in pregnancy is a cause of anxiety and stress for the spective study from general practice. Threatened Placental causes miscarriage in general practice: diagnostic Placenta praevia value of history-taking and physical exam- Abruption of placenta ination. Risk factors for placenta praevia include previous caesarean section, previous termination of pregnancy, multi- parity, advanced maternal age, multiple pregnancy, defcient endometrium due to a uterine scar, endo- metritis, and a previous history of manual removal of placenta. An ultrasound scan performed at 20 weeks will detect whether the placenta praevia is reaching or covering the internal cervical os. A low-lying pla- centa usually appears to move upwards as the lower Figure 2 Abruption: a large retroplacental clot attached found at emergency caesarean section at 30 weeks’ gestation. If the lead- Abruption is the premature separation of the ing edge of the placenta has completely covered the placenta and occurs in 1 per cent of pregnancies. Tis condition accounts for 20 per cent of cases of In this situation and where there is an overlying scar, bleeding in late pregnancy. The best predictive factor a repeat ultrasound scan at 32 weeks’ gestation would for abruption is a history of a previous abruption, with enable confrmation of the diagnosis, thereby allow- a 4 per cent risk for one to a 20–25 per cent risk for two ing for planning of the mode and timing of delivery. An ante- drug use (amphetamine and cocaine), and abdominal rior placenta praevia in a woman with a previous trauma (both accidental, e. Early diagnosis enables the woman to be transferred to a tertiary facility with Maternal causes a multi-professional team including urologists and A systematic way of looking at local causes of bleeding interventional radiologists who are skilled in uter- in later pregnancy is to consider the anatomy from ine artery embolisation in obstetric cases. Uterine Uterine rupture Traumatic causes Anal (need to be excluded) During pregnancy the genital tract increases in vas- Haemorrhoids cularity, and so trauma to any par of the genital tract Anorectal carcinoma – unusual in this age group can cause signifcant bleeding. It should be considered in all women but the introitus to a tear at the vaginal fornices due to deep especially in those with the following risk factors: penetrative injury; the latter can cause profound bleeding. When these vessels are below obstructed labour in a multiparous woman are causes of the presenting part in the region of the internal os uterine rupture in the absence of a scar. The earliest signs of hypovolaemia are a rise in respiratory rate, a delay in capillary refll time, and an abnormality of the cardiotocograph. If this Hypotension may be a late sign in young healthy occurred over the cervix, it would be a vasa praevia. Women with these signs should be stabilised and immediately transferred to a consultant-led unit or any facility where an emergency delivery and transfusion of the mother can be performed. All units should have a massive obstetric haemorrhage protocol which includes contacting the haematologist on call for advice regarding the use of blood products. In women who are stable, the history should include the nature and amount of bleeding, the pres- ence of pain, contractions, ruptured membranes, placental localisation at the last ultrasound scan, the result of the last cervical smear, and the rhesus sta- Figure 5 Placenta from twin pregnancy with velamentous insertion tus. Bleeding at the time of ruptured membranes may of cord on the right hand placenta. Sudden onset of painless, bright red vaginal bleeding may suggest placenta praevia. Tese vessels may rupture Sudden onset of a severe continuous abdominal pain with either spontaneous or artifcial rupture of mem- associated with darker bleeding may suggest placen- branes, causing signifcant fetal haemorrhage and tal abruption. The symp- thick mucoid plug, this may be a heavy show associ- toms are usually fresh vaginal bleeding at the time ated with the onset of labour. It can be due to mul- abdomen with a high unengaged presenting part tiple mild abruptions (separations) at the periphery or abnormal lie is suggestive of placenta praevia. The uterus may be markedly tender and babies who are more likely to be admitted to neo- all over or localised to where the placental abruption natal intensive care units. It is important that the diagnose local causes of vaginal bleeding as well as massive obstetric haemorrhage protocol is activated, help assess cervical dilatation.
- Speak in a normal tone of voice. Speech apraxia is not a hearing problem.
- Infant test or procedure preparation (birth - 1 year)
- Spinal anesthesia
- Activities that may cause constant, low-level injury to the scrotum, such as riding a motorcycle
- People who are at risk for more dangerous infections (because chronic bowel diseases, kidney disease, cancer, diabetes, or HIV) should talk to their doctor before traveling.
- Plumbing, pipes, and faucets. Lead can be found in drinking water in homes containing pipes that were connected with lead solder. Although new building codes require lead-free solder, lead is still found in some modern faucets.
- Multiple pregnancy (twins, triplets, etc.)
Decreases in renal perfusion pressure also reduce peritubular capillary hydrostatic pressure antibiotic resistance lactic acid bacteria cheap 480 mg bactrim free shipping, + thereby increasing the uptake of reabsorbed fluid and diminishing Na excretion antibiotics over the counter cvs buy bactrim mastercard. When kidney perfusion is threatened antibiotics for dogs online cheap bactrim, the kidneys retain salt and water, a response that tends to improve their perfusion. In a number of important diseases, including heart, liver, and some kidney diseases, abnormal renal + retention of Na contributes to the development of generalized edema, a widespread accumulation of salt and water in the interstitial spaces of the body. The condition is often not clinically evident until a person has accumulated more than 2. Expansion of the interstitial space has two components: (1) an altered balance of Starling forces exerted across capillaries and (2) the retention of extra salt and water by the kidneys. Conservation of salt and water by the kidneys is clearly an important part of the development of generalized edema. Patients with congestive heart failure may accumulate many liters of edema fluid, which is easily detected as weight gain (because 1 L of fluid weighs 1 kg). Because of the effect of gravity, the ankles become swollen and pitting edema develops. As a result of heart failure, venous pressure is elevated, causing fluid to leak out of the capillaries because of their elevated hydrostatic pressure. To minimize the accumulation of edema fluid, patients are + often placed on a reduced Na intake and given diuretic drugs. It plays an important role in the electrophysiology of all nerve and muscle tissues and can + affect acid–base balance in the body as well. When cells lose K (and accompanying anions), they also lose water and shrink; the converse is also true. Disturbances of K balance often produce altered excitability of nerves and + muscles. A low plasma K level leads to membrane hyperpolarization and reduced excitability; muscle + weakness is a common symptom. Excessive plasma K levels lead to membrane depolarization and + increased excitability. High plasma K levels can cause cardiac arrhythmias and ventricular fibrillation, which is usually a lethal event. K depletion, for + example, can lead to metabolic alkalosis, and K excess can lead to metabolic acidosis. A primary + + disturbance in acid–base balance can also lead to abnormal K balance. K also affects the activity of + enzymes involved in carbohydrate metabolism and electron transport. K is needed for tissue growth and + repair, whereas tissue breakdown or increased protein catabolism results in a loss of K from cells. Distribution of potassium between intracellular and extracellular fluid is tightly regulated. About 8% of the + body’s K is in bone, dense connective tissue, and cartilage, and another 1% is in transcellular fluids. Skeletal muscle cells constitute the largest + fraction of the cell mass in the human body and contain about two thirds of the body’s K. One can easily + appreciate that abnormal leakage of K from muscle cells, as a result of trauma for example, may lead to dangerous hyperkalemia. If this enzyme is inhibited-as a result of an inadequate tissue oxygen supply or digitalis overdose, for example-then hyperkalemia may result. This results + + from a passive exchange of extracellular H for intracellular K across the cell membrane. When an organic acid (which can penetrate cell membranes) is + added, the rise in plasma K level for a given fall in blood pH is considerably less. Insulin (administered with glucose) is also used in the emergency treatment of hyperkalemia.
Letterer-Siwe disease • Also known as Multifocal multisystem Langerhans cell histiocytosis • Occurs most frequently before 2 years of age but occasionally affects adults antibiotic quick reference guide buy bactrim from india. Polycythemia is not to be confused with the polycythemia vera for which the following information is asked repeatedly antibiotic resistance mrsa buy bactrim no prescription. Singh 1/e p198) Leukoerythroblastosis is a term used for “an anemia characterized by the presence in the peripheral blood of immature red cells and a few immature white cells of the myeloid series” that is erythroblasts and leukoblasts antibiotic resistance funding generic 960 mg bactrim fast delivery. The common pathogenic feature is the presence of mutated, constitutively activated tyrosine kinases or other acquired mutations result- ing in growth factor independence. The examples include: • Chronic myelogenous leukemia • Chronic neutrophilic leukemia • Polycythemia vera • Primary myelofbrosis • Essential thrombocythemia • Chronic eosinophilic leukemia • Mastocytosis 103. The patient in question has 14% plasma blasts in the peripheral blood and thus does not ft into category of plasma cell leukemia. Plasma cell leukemia • More than 20% plasma cells in the peripheral blood • Absolute plasma cell count of more than 2 X 109/L 2. IgD Myeloma • Presence of Monoclonal IgD in the serum usually indicates IgD myeloma • No evident M– spike on serum protein electrophoresis • Higher incidence of renal insuffciency, amyloidosis and proteinuria than IgG/IgA myeloma. Langerhans cell is a special type of dendritic cell in the skin functioning as antigen presenting cell. In the past, these disorders were called histiocytosis X and were subdivided into three categories: • Letterer-Siwe syndrome • Hand-Schüller-Christian disease, • Eosinophilic granuloma. Under the electron microscope, Birbeck’s granules have a tennis-racket appearance. His bone marrow is infltrated with plasmacytoid lymphocytes having immunoglobulins in the cytoplasm (Russell bodies). These fndings are suggestive of the patient suffering from lymphoplasmacytic lymphoma/ Waldenstrom’s macroglobulinemia. This disorder is characterized by neoplastic B cells producing IgM leading to a mono- clonal IgM spike in the serum. Hypercalcemia occurs with myeloma because of bone destruction, and punched out lytic lesions are typical of multiple myeloma. Light chain in urine (Bence Jones proteins) is also a feature of multiple myeloma. This patient is making a monoclonal population of kappa light chains and excreting them in the urine as Bence-Jones proteins. These patients make decreased levels of normal im- munoglobulins of all isotypes, thus making them susceptible to infections (also the commonest cause of death). Such variants include: • Flame cells: with fery red cytoplasm, • Mott cells: with multiple grapelike cytoplasmic droplets The globular inclusions are referred to as Russell bodies (if cytoplasmic) or Dutcher bodies (if nuclear). Less commonly, unisystem lesions of identical histology arise in the skin, lungs, or stomach. Unifocal disease is indolent and may heal spontaneously or be cured by local excision or irradiation. Hand-Schuller-Christian triad: calvarial bone defects + diabetes insipidus + exophthalmos • Pulmonary Langerhans cell histiocytosis – Seen in adult smokers – Regress spontaneously upon cessation of smoking. Serum β 2 -microglobulin is the single most powerful predictor of survival and can substitute for staging. Clinically, both Glanzmann thrombasthenia and Bernard Soulier syndrome are indistinguishable. However, most of the haematologists agreed on placing Glanzmann thrombasthenia in preference to Bernard Soulier syndrome as the answer. We got an article supporting the increased prevalence of Glanzmann in compari- son to Bernard Soulier in Western India as well. However females are less likely to suffer from hemophilia B because it is an X-linked disease. In remaining the causes are autoimmune disease, malignancies, dermatologic diseases, pregnancy and post partum. Platelet count and bleeding time is normal (matches with the data given in our question). Options ‘a’, ‘b’ and ‘c’ are rare because these would present with some additional symptoms apart from the ones mentioned in the question.
What are the important causes of intesti- described above antibiotic resistance webquest order cheap bactrim on-line, that is antibiotic dental prophylaxis order genuine bactrim on-line, detailed history tak- The likely diagnosis in this case is acute nal obstruction? In a suspected perforated peptic ulcer infection 5 metal militia generic bactrim 480mg with mastercard, a at a diagnosis is detailed history taking, Q. Abdominal movement diminished with acute pain in the right lower abdomen ceed to manage the case? What are the important etiological factors for the development of acute pancreatitis? Causes in the duodenum: investigations which are same as described – Hydronephrosis. Bleeding from ruptured esophageal The answer to this question will be in the Hematemesis varices – about fve percent. For duodenal ulcer with outlet obstruc- electrocoagulation of angiodysplasia is know pathology of the organs. Infusion of plasma expanders to into the stomach so common presentation is (Hematochezia) make up the volume loss. Neoplasms – Colonic polyps and tine – ulcerative colitis, carcinoma and an idea about continuation of bleeding. Bilateral recurrent laryngeal nerve palsy and salmonella infections ofen which may cause respiratory obstruction cause bloody diarrhea. Proper exploration is then made in the sac otherwise fuid enters the perito- operation theater, hemostasis achieved neonatal Intestinal obstruction neal cavity. Collapse or kinking of trachea The common causes are: viable, it is pushed into the abdominal (Tracheomalacia) – Tis condition will a. Intestinal atresia (From duodenum to cavity, if not, resection and anastomo- need immediate endotracheal intubation or colon). Color is greenish or blackish instead of The tetany is due to hypoparathyroidism intestinal obstruction? The fuid in the sac is red in color and impairment of their blood supply during thy- afected, followed by ileum and jejunum. Total absence of gas distal to duodenum Postoperative respiratory indicates atresia rather than stenosis. A 45-year-old female patient has presented distress After total – Duodenojejunostomy. How will you treat meconium ileus and gone total thyroidectomy and developed breast in this age group are: volvulus neonatorum? Duct ectasia and duct papilloma without The management consists of detailed his- otherapy, hormone therapy and radi- lump formation involving a single duct tory, clinical examination, relevant investiga- otherapy to breast and axilla. The important causes of nipple discharge If associated with a lump and invasive in such a patient include: ductal carcinoma treatment is done as in case a. A 40-year-old male patient has come to surface, margin, consistency, fxity to emergency with multiple injuries follow- skin pectoral fascia and chest wall. Tese refer to a priority order and should be done immediately as soon as the patient comes before any history taking or other The treatment is done according to the i. The spleen followed by the liver are the should be done to assess the initial dys- Q. What is damage control surgery in major be covered with worm blankets or a injuries? What are the types of traumatic Genitourinary trauma medical history, Time of last food or drink, pneumothorax? How will you diagnose and treat closed secondary survey in benign once the patient pneumothorax? A 35-year-old male patient sufered blunt is stabilized during the primary survey and Q. The management plan is the same as in always a constant factor and the other case of a polytrauma patient described injuries may or may not be associated earlier that is Q. Blood urea and electrolytes to assess renal ing urine with progressive distension of care? Conservative measures physical examination and relevant emergency with acute retention of urine. The important causes of hematuria are – patient according to Parkland formula in herniated disc or other lesions.
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