Medicine for health care

Polycystic ovarian syndrome

2011-12-21T14:45:00.000-08:00

Polycystic ovarian syndrome :

Polycystic ovarian disease , is a hormonal problem that causes women to have a variety of symptoms. It should be noted that most women with the condition have a number of small cysts in the ovaries. However, women may have cysts in the ovaries for a number of reasons, and it is the characteristic constellation of symptoms, rather than the presence of the cysts themselves, that is important in establishing the diagnosis of PCOS. PCOS occurs in 5% to 10% of women and is the most common cause of infertility in women.

Symptoms of polycystic ovarian syndrome :

The main signs and symptoms of PCOS are related to menstrual irregulatories and elevated levels of male hormones (androgens). Menstrual irregulatories can include delay of normal menstruation (primary amenorrhea), the presence of fewer than normal menstrual periods (oligomenorrhea), or the absence of menstruation for more than three months (secondary amenorrhea). Menstrual cycles may not be associated with ovulation (anovulatory cycles) and may result in heavy bleeding. Symptoms related to elevated androgen levels include acne, excess hair growth on the body (hirsutism), and male-pattern hair loss.
Other signs and symptoms:
Obesity, weight gain, increase insuline level, oily skin, dandruff, infertility, high cholesterol levels.

Causes polycystic ovarian syndrome:

No one is quite sure what causes PCOS, and it is likely to be the result of a number of both genetic (inherited) as well as environmental factors. Women with PCOS often have a mother or sister with the condition, and researchers are examining the role that genetics or gene mutations might play in its development. The ovaries of women with PCOS frequently contain a number of small cysts, hence the name poly=many cystic ovarian syndrome. A similar number of cysts may occur in women without PCOS. Therefore, the cysts themselves do not seem to be the cause of the problem. A malfunction of the body's blood sugar control system (insulin system) is frequent in women with PCOS, who often have insulin resistance and elevated blood insulin levels, and researchers believe that these abnormalities may be related to the development of PCOS. It is also known that the ovaries of women with PCOS produce excess amounts of male hormones known as androgens. This excessive production of male hormones may be a result of or related to the abnormalities in insulin production. Other possible contributing factors in the development of PCOS may include a low level of chronic inflammation in the body and fetal exposure to male hormones.

Diagnosis

The diagnosis of PCOS is generally made on the basis of clinical signs and symptoms as discussed above. The doctor will want to exclude other illnesses that have similar features, such as low thyroid hormone blood levels (hypothyroidism) or elevated levels of a milk-producing hormone (prolactin). Also, tumors of the ovary or adrenal glands can produce elevated male hormone (androgen) blood levels that cause acne or excess hair growth, mimicking symptoms of PCOS. Other laboratory tests can be helpful in making the diagnosis of PCOS. Serum levels of male hormones (DHEA and testosterone) may be elevated. However, levels of testosterone that are highly elevated are not unusual with PCOS and call for additional evaluation. Additionally, levels of a hormone released by the pituitary gland in the brain (LH) that is involved in ovarian hormone production are elevated. The cysts (fluid filled sacs) in the ovaries can be identified with imaging technology. (However, as noted above, women without PCOS can have many cysts as well.) Ultrasound, which passes sound waves through the body to create a picture of the kidneys, is used most often to look for cysts in the ovaries. Ultrasound imaging employs no injected dyes or radiation and is safe for all patients including pregnant women. It can also detect cysts in the kidneys of a fetus. Because women without PCOS can have ovarian cysts, and because ovarian cysts are not part of the definition of PCOS, ultrasound is not routinely ordered to diagnose PCOS. The diagnosis is usually a clinical one based on the patient's history, physical examination, and laboratory testing. More powerful and expensive imaging methods such as computed tomography (CT scan) and magnetic resonance imaging (MRI) also can detect cysts, but they are generally reserved for situations in which other conditions that may cause related symptoms, such as ovarian or adrenal gland tumors are suspected. CT scans require X-rays and sometimes injected dyes, which can be associated with some degree of complications in certain patients.

Complications

The risk of developing prediabetes and type 2 diabetes is increased in women with PCOS, particularly if they have a family history of diabetes. Obesity and insulin resistance, both associated with PCOS, are significant risk factor for the development of type 2 diabetes. Several studies have shown that women with PCOS have abnormal levels of LDL ("bad") cholesterol and lowered levels of HDL ("good") cholesterol in the blood. Elevated levels of blood triglycerides have also been described in women with PCOS. Changes in skin pigmentation can also occur with PCOS. Acanthosis nigricans refers to the presence of velvety, brown to black pigmentation often seen on the neck, under the arms, or in the groin. This condition is associated with obesity and insulin resistance and occurs in some women with PCOS.

Treatments

Treatment of PCOS depends partially on the woman's stage of life. For younger women who desire birth control, the birth control pill, especially those with low androgenic (male hormone-like) side effects can cause regular periods and prevent the risk of uterine cancer. Another option is intermittent therapy with the hormone progesterone. Progesterone therapy will induce menstrual periods and reduce the risk of uterine cancer, but will not provide contraceptive protection. For acne or excess hair growth, a water pill (diuretic) called spironolactone (Aldactone) may be prescribed to help reverse these problems. The use of spironolactone requires occasional monitoring of blood tests because of its potential effect on the blood potassium levels and kidney function. Eflornithine (Vaniqa) is a cream medication that can be used to slow facial hair growth in women. Electrolysis and over-the-counter depilatory creams are other options for controlling excess hair growth. For women who desire pregnancy, a medication called clomiphene (Clomid) can be used to induce ovulation (cause egg production). In addition, weight loss can normalize menstrual cycles and often increases the possibility of pregnancy in women with PCOS. Other, more aggressive, treatments for infertility (including injection of gonadotropin hormones and assisted reproductive technologies) may also be required in women who desire pregnancy and do not become pregnant on Clomid therapy. Metformin (Glucophage) is a medication used to treat type 2 diabetes. This drug affects the action of insulin and is useful in reducing a number of the symptoms and complications of PCOS. Metformin has been shown to be useful in the management of irregular periods, ovulation induction, weight loss, prevention of type 2 diabetes, and prevention of gestational diabetes mellitus in women with PCOS. Obesity that occurs with PCOS needs to be treated because it can cause numerous additional medical problems. The management of obesity in PCOS is similar to the management of obesity in general. Weight loss can help reduce or prevent many of the complications associated with PCOS, including type 2 diabetes and heart disease. Consultation with a dietician on a frequent basis is helpful until just the right individualized program is established for each woman. Finally, a surgical procedure known as ovarian drilling can help induce ovulation in some women who have not responded to other treatments for PCOS. In this procedure a small portion of ovarian tissue is destroyed by an electric current delivered through a needle inserted into the ovary.

Chronic Diarrhea

2011-03-23T13:12:00.000-07:00

Chronic Diarrhea

A 21 year-old male presents with a 6-week history of watery diarrhea

and crampy abdominal pain. He reports that the diarrhea has not been constant and has alternated with periods of constipation. For the past 2 weeks, the diarrhea has been blood-streaked and he has had several weeks of midepigastric pain. He spent the past 6 months in a rural community in Guatemala participating in a community service project sponsored by his college. He returned from Guatemala just 10 days ago. While there, he drank the water and ate the food available in the local community, and he did not routinely boil water for drinking. He denies antibiotic exposure but has taken mefloquine weekly for malaria prophylaxis. Two separate stool specimens taken by student health when he returned were

reported as negative for Salmonella, Shigella, Campylobacter, E. coli O157:H7, Yersinia, Aeromonas, and Pleisiomonas as well as Giardia lamblia. On physical examination he appeared well nourished and well developed but reports an 8–10 lb weight loss.

LABORATORY TESTS

Just as with acute diarrhea, the history of a patient’s illness frequently

provides clues to the etiology of the disease. The length of illness and

travel history of this patient plus abdominal findings and weight loss

are key features. Diarrhea with blood narrows infectious causes to agents such as Shigella, Salmonella, Campylobacter, EHEC, EIEC, and Entamoeba histolytica. An evaluation for chronic diarrhea requires a stool culture (×3), ova and parasite exam of stool (×3), and guaiac test of stool for occult blood. Because of this patient’s abdominal findings, liver function tests such as alkaline phosphatase and serum transaminases should also be ordered. Whenever liver abscess is suspected, abdominal ultrasound or computed tomography (CT scan) should also be performed.

Because both bacteria and parasites can be shed intermittently in stool, multiple stool specimens should be submitted for both bacterial culture and ova and parasite examination. See Case 3 for information on stool collection and transport for bacterial culture. For parasite analysis, specimens should be taken on separate days (every other day if possible) to increase likelihood of detection. Stool specimens collected for parasite analysis should be submitted in preservation vial(s) designed for this purpose.

All forms of parasites (ova, larvae, protozoa, worms) can be

maintained at room temperature for long periods of time (months) using preservation vials. In addition, concentration procedures to recover small numbers of protozoan cysts, eggs, and larvae can be performed using the vials, and permanent stained smears can be prepared as well. If preservation vials are not available, then stool should be collected in clean, dry, wide-mouthed containers with tight-fitting lids. The stool should not be contaminated with urine because the pH of urine can destroy motile parasites. Liquid stool specimens must be examined by the laboratory within 30 min after they were taken from the patient, or some parasitic forms will disintegrate. If this rapid transport time is not possible, then preservation vials should be used. Results of an initial ova and parasite stool examination showed that the specimen was positive for cysts of E. histolytica/E. dispar. With this additional information, a serology test for E. histolytica antibodies and an abdominal CT scan were ordered.

E. histolytica, the cause of intestinal amebiasis and amebic liver abscess, can be diagnosed in the laboratory using a variety of methods:

1. Microscopic exam (stool, liver abscess). Microscopic identification of E. histolytica cysts or trophozoite (ameboid) forms is the most common method used to diagnose the infection; however, it is both insensitive and nonspecific. The test is nonspecific because E. histolytica cysts cannot be morphologically distinguished from those of Entamoeba dispar, a harmless commensal, unless ingested RBCs are present inside the trophozoite. Microscopic examination of liver abscess material is a poor way to attempt the diagnosis of amebiasis. While the abscess material is known to have the appearance of “anchovy paste,” ameba are rarely visualized in the material because they have disintegrated.

2. Antibody detection (serum). Serology studies [indirect hemagglutination, gel diffusion, enzyme-linked immunosorbent assay (ELISA)] to detect antibody to E. histolytica are positive in >90% of patients who have invasive disease. In the vast majority of patients antibodies are detectable after 7–10 days. When patients no longer have detectable parasites in their stools, detection of antibodies is critical for diagnosis of amebic liver abscesses.

TREATMENT AND PREVENTION

Two classes of drugs are used to treat E. histolytica infections. (1) a luminal amebicide, such as iodoquinol, which destroys parasites in the lumen of the intestine but does not kill ameba in tissue; and (2) a tissue amebicide, such as metronidazole or chloroquine, which treats invasive amebiasis but is less effective in the lumen. Amebic dysentery may be treated with iodoquinol and metronidazole. Extraintestinal disease is treated with a combination of

metronidazole and chloroquine. To follow the clinical response of intestinal disease to therapy, a repeat stool exam for parasites should be done 2–4 weeks after treatment, and extraintestinal disease should be monitored by repeat CT scans. Repeat serology tests are of little use since antibody titers remain elevated in spite of response to therapy. Prevention of infection with E. histolytica involves drinking boiled or bottled water when traveling to developing nations, and avoiding uncooked foods that may have been washed in water, such as salad.

Vomiting and Diarrhea after a School Picnic

2011-03-23T07:41:00.000-07:00

Vomiting and Diarrhea after a School Picnic

PATIENT HISTORY

A 14-year-old male presented to his pediatrician for evaluation of vomiting,abdominal discomfort, and nonbloody diarrhea. Three days prior, he attended his school picnic, where he ate everything offered: barbecued chicken, potato salad, baked beans, tossed salad, and ice cream . Within 36 h of the picnic he noted mild abdominal discomfort, intermittent crampy abdominal pain, and three to five loose, watery bowel movements per day. He reported no blood in the stool, rash, pain on urination (dysuria), or blood in the urine (hematuria) and had no travel history, had no pets, and denied taking antibiotics. The school reports that at least 50 other students who attended the picnic are also reporting similar symptoms.

LABORATORY TESTS

There are various interpretations of what is considered medically indicated for evaluating persons with acute diarrhea. Because most diarrheal illness is self-limited, the usefulness of stool cultures is questioned by some; however, early diagnosis can lead to interventions that both alleviate symptoms and prevent secondary transmission, which can have tremendous public health impact. In addition, detection of specific agents aids in the timely detection and control of outbreaks. Some causes of acute diarrhea can result in serious long-term sequelae such as Guillain–Barr´e syndrome (with

Campylobacter) or hemolytic uremic syndrome (HUS) due to EHEC, further justifying the need for performing stool culture. A stool specimen for culture should be obtained as early in the course of the disease as possible from all patients with bloody diarrhea, patients with fever, in persons with diarrhea who are immunosuppressed, from patients in whom the diagnosis of HUS is suspected, and from persons involved in possible outbreaks.

Pathogenic bacteria can be identified by isolating the organism by

culture and/or by identifying a characteristic marker for virulence such

as a toxin. Routine bacterial stool cultures can identify Campylobacter, Salmonella, Shigella,Yersinia enterocolitica, Aeromonas hydrophila, Pleisiomonas shigelloides, and noncholera Vibrio spp. Special media are required to identify E. coli O157:H7 and Vibrio cholera, and laboratory personnel should be notified when such agents are suspected. In addition to culture, E. coli

O157:H7 can also be diagnosed using a toxin assay that detects shiga toxins produced by all EHEC types. Toxin assays rather than culture are routinely used for diagnosing Clostridium difficile diarrhea.

Because an outbreak was suspected from the school picnic our case

patient attended, a stool culture was performed despite the fact that he had a mild self-limited illness. A routine bacterial stool culture would be appropriate in this case since Salmonella, Shigella, or Campylobacter spp. would be the most likely causes. His lack of bloody diarrhea would make EHEC, such as E. coli O157:H7, less likely. His lack of travel history indicates that his specimen does not need to be screened for organisms found outside his geographic area, and the absence of antibiotic use makes testing for toxins of C. difficile less of a priority.

Because there is no specific antiviral treatment available, testing for viral causes of gastroenteritis is not routinely performed except in outbreak situations or hospital settings. Testing for rotavirus, a major cause of fever, vomiting, and watery diarrhea in infants and young children, is routinely performed in hospitals so that patients can be cohorted and infection control practices emphasized. Rotavirus is commonly seen during the winter months (October–March).

Feces should be submitted in a clean, dry, plastic or waxed cardboard container with a tight-fitting or screwcap lid. Once collected, the specimen can be maintained at room temperature during transport. Rectal swabs should be used only with infants and young children fromwhomcollecting feces may be difficult and again should be taken only during acute disease. For an adequate specimen, the swab should be inserted past the anal sphincter into the rectum, and feces should be obvious on the swab when

removed. If the specimen (feces or swab) will not be processed or reach the laboratory within 1 h, an enteric transport medium should be inoculated with the feces and this will be stable for as long as 72 h at room temperature. In addition to stool, blood cultures should also be obtained from patients who have fever and diarrhea.

TREATMENT AND PREVENTION

The first line of therapy is supportive treatment, to return the patient to fluid and electrolyte balance. The patient may drink an oral rehydration solution that contains water, salt, and sugar, or liquids such as Pedialyte, which have the appropriate electrolytes and fluids to replace those being lost. Most cases of gastroenteritis are self-limited and require no antibiotic therapy. In fact, antibiotics are contraindicated in some cases. Giving antibiotics for Salmonella gastroenteritis prolongs the carriage of the organism in the GI tract and can lead to the person retaining the organism for months. Treatment of E. coli O157:H7 may increase the risk of hemolytic

uremic syndrome (HUS) in children and should be avoided. Likewise, one should avoid using antimotility agents in cases with bloody diarrhea or proven EHEC infection.

Patients who are very young or immunosuppressed may require antibiotics to recover from their disease. Patients with Shigella gastroenteritis are more likely to be sicker and require antibiotic therapy than are patients with Salmonella or Campylobacter gastroenteritis. Ampicillin, SXT, or ciprofloxacin are common choices for antimicrobial therapy because they can be administered orally if the patient can tolerate drinking liquids. Since the organism may be resistant to one or more of these antimicrobials, susceptibility results for the patient’s organism should guide the physician’s choice.

According to surveillance by the Centers for Disease Control and Prevention (CDC), Campylobacter jejuni is the most common enteric pathogen seen in adult patients with diarrhea, whereas Salmonella is the most common in children. Campylobacter spp. are not susceptible to penicillins or cephalosporins. Ciprofloxacin and erythromycin are the drugs of choice.

If a patient is hospitalized with enteric fever (S. typhi), a thirdgeneration cephalosporin is usually given intravenously. Our case patient has an infection with Salmonella susceptible to ampicillin, SXT, and ciprofloxacin. Because he is a healthy young adult, only supportive treatment

was given.

Student with Dysuria

2011-03-21T02:10:00.000-07:00

Student with Dysuria

PATIENT HISTORY

A 20-year-old college student complained of burning when urinating and a strong desire to void frequently although she had little urine to void. She was not experiencing any pelvic pain or discharge. Her symptoms beganshortly after she returned from a weekend visit to her boyfriend’s school.

She went to her university health service for diagnosis and treatment. On exam she was without fever and had moderate suprapubic tenderness, but

no flank tenderness.

LABORATORY TESTS

Urine Dipstick

A urine specimen was collected from this patient by a noninvasive technique,a midstream clean catch. Screening tests can predict which urine specimens contain a high colony count of bacteria. The most frequently used screening test with urine is called a “dipstick test”. A dipstick consists of plastic strips that contain multiple pads with chemical indicators. Normal urine is sterile, without protein, white cells, blood, or nitrites. A positive test for nitrites indicates the presence of bacteria that produce nitrate reductase, changing nitrate to nitrite. A positive test for leukocyte esterase indicates the presence of polymorphonuclear neutrophils (PMNs) in the urine that produce the enzyme. Inflammatory cells are the host’s response to infection. The strip is dipped into the urine, and the indicator

pads turn colors that are read immediately and compared to a scale of +1 to +4 . A dipstick test performed at the university health center on the urine from our college student showed positive reactions for both nitrate and leukocyte esterase, so her urine was sent to the lab for culture. A urine culture should be performed in patients with suspected cystitis regardless of dipstick results.

TREATMENT AND PREVENTION

Factors to consider when treating UTI include:

■ Patient’s age and sex

■ Symptomatic versus asymptomatic infection

■ Upper (pyelonephritis) versus lower (cystitis) urinary tract involvement

■ Community- versus hospital-acquired infection

■ Single event versus recurrent events

■ Patient’s underlying illness

For uncomplicated cystitis a 3-day course of treatment is recommended. Symptoms usually resolve over 1–3 days. Many antibiotics with a broad range of activity against gram-negative rods and/or gram-positive cocci are suitable for the treatment of UTI, whether they are bacteriostatic or bacteriocidal drugs because they are concentrated 10–30-fold in the urine. Choices for initial empiric treatment of uncomplicated UTI in women include trimethoprim–sulfamethoxazole, a fluoroquinolone, or nitrofurantoin. The choice of an empiric antibiotic should always be based on the local prevalence of resistance in one’s geographic area, and this should be

periodically reevaluated. Ampicillin, amoxicillin, and sulfonamides are no longer considered good empiric choices because of the higher resistance rates seen in Enterobacteriaceae and Enterococcus spp. isolated from adults. Follow-up urine cultures are not necessary for patients with uncomplicated cystitis who respond clinically to treatment. Pregnant women should receive a follow-up culture 1–2 weeks after treatment. Complicated UTIs are more often caused by bacteria that may be resistant to the antibiotics used to treat uncomplicated UTI, particularly in hospitalized patients. Until the results of urine cultures are available in these patients, a fluoroquinolone is an excellent antibiotic choice in adult patients. In

these patients, treatment should be continued for 7–14 days. If symptoms resolve, a follow-up urine culture is not generally recommended.

Liver blood test

2011-03-17T04:17:00.000-07:00

Liver blood test

An initial step in detecting liver damage is a simple blood test to determine the presence of certain liver enzymes (proteins) in the blood. Under normal circumstances, these enzymes reside within the cells of the liver. But when the liver is injured for any reason, these enzymes are spilled into the blood stream. Enzymes are proteins that are present throughout the body, each with a unique function. Enzymes help to speed up (catalyze) routine and necessary chemical reactions in the body.

Among the most sensitive and widely used liver enzymes are the aminotransferases. They include aspartate aminotransferase (AST or SGOT) and alanine aminotransferase (ALT or SGPT). These enzymes are normally contained within liver cells. If the liver is injured or damaged, the liver cells spill these enzymes into the blood, raising the enzyme levels in the blood and signaling the liver disease.

Aminotransferases

The aminotransferases catalyze chemical reactions in which an amino group (amino acids are building blocks of proteins) is transferred from a donor molecule to a recipient molecule. Hence, the names "aminotransferases."

Medical terms can sometimes be confusing, as is the case with these enzymes.

· Another name for aminotransferase is transaminase.

· The enzyme aspartate aminotransferase (AST) is also known as serum glutamic oxaloacetic transaminase (SGOT); and

· alanine aminotransferase (ALT) is also known as serum glutamic pyruvic transaminase (SGPT).

To put matters briefly, AST = SGOT and ALT = SGPT.

Normal levels of AST and ALT

The normal range of values for AST (SGOT) is from 5 to 40 units per liter of serum (the liquid part of the blood).

The normal range of values for ALT (SGPT) is from 7 to 56 units per liter of serum.

The ranges of AST and ALT numbers may differ slightly depending on the technique and protocols used by different laboratories. However, normal reference ranges are routinely provided by each laboratory and printed in the report.

Medications cause abnormal aminotransferase levels

A host of medications can cause abnormal liver enzymes levels.

Examples include:

Pain relief medications such as:

· aspirin,

· acetaminophen (Tylenol),

· naproxen (Narcosis, Nap élan, Anaprox, Aleve),

· diclofenac (Voltaren, Cataflam, Voltaren-XR), and

· phenylbutazone (Butazolidine)

Anti-seizure medications such as:

· phenytoin (Dilantin),

· valproic acid (Depakote, Depakote ER, Depakene, Depacon),

· carbamazepine (Tegretol, Tegretol XR, Equertro), and

· phenobarbital

Antibiotics such as:

· tetracyclines, [for example, tetracycline (Achromycin)]

· sulfonamides,

· isoniazid (INH) (Nydrazid, Laniazid)

· sulfamethoxazole (Gantanol),

· trimethoprim (Trimpex; Proloprim, Primsol)

· nitrofurantoin (Macrodantin; Furadantin; Macrobid),

· fluconazole (Diflucan ) and some other anti-fungals, etc.

Cholesterol lowering drugs such as:

· the statins:

o lovastatin (Mevacor, Altocor),

o pravastatin (Pravachol),

o atorvastatin (Lipitor),

o fluvastatin (Lescol),

o rosuvastatin (Crestor),

o simvastatin (Zocor), and

· niacin

Cardiovascular drugs such as:

· amiodarone (Cordarone),

· hydralazine (Apresoline)

· quinidine (Quinaglute, Quinidex), etc.

Other drugs

· Antidepressant drugs of the tricyclic type

With drug-induced liver enzyme abnormalities, the enzymes usually normalize weeks to months after stopping the medications.

Acute Pharyngitis

2011-03-16T09:28:00.000-07:00

Acute Pharyngitis

PATIENT HISTORY

The patient was a 6 year-old male who had been in good health with no significant medical problems. In late September he presented to his pediatrician’s office with a complaint of sore throat, fever, headache, and swollen glands in his neck for the past 36 h. On physical examination

(PE), he had a fever of 38◦C (100.4◦F), a red posterior pharynx, yellowish exudate on his tonsils, and multiple, enlarged, tender cervical lymph nodes.

There were no other pertinent symptoms.

LABORATORY TESTS

pain on swallowing, as well as erythema with or without exudate on the

tonsils and tender cervical lymph nodes. There are no clinical indicators

that would make it possible to accurately predict the cause of this child’s

pharyngitis. Laboratory tests are required to make a diagnosis.

When deciding whether to perform a laboratory test, clinical and epidemiological

features as well as the availability and usefulness of treatment

must be considered. While viruses are the most common cause

of acute pharyngitis in both adults and children, lab testing for viruses

is not warranted because antiviral agents are not used to treat acute

pharyngitis. Given the age of this patient, the absence of travel, and the

lack of suspicion of child abuse, GAS is the most likely etiologic agent.

Since GAS pharyngitis is the most commonly occurring form of pharyngitis

for which antibiotic therapy is indicated, lab testing should be directed

at ruling out GAS. Appropriate laboratory tests for this would

include:

Rapid strep test. This is not a culture; the test detects a unique carbohydrate

on the cell wall of GAS.

Throat culture. This test will grow the GAS organism from a throat

specimen taken from the patient and will require overnight incubation

at the minimum. Most labs offer a specific “rule out GAS”

throat culture.

The specimen required for each of these tests is a throat swab. Use of a

double-swab format allows one to obtain sufficient specimen to perform

both tests if necessary. As with any microbiology test, the quality of the

results is contigent on whether the laboratory receives a well-taken specimen.

The double swab should be firmly rubbed over much of the surface

of both tonsils and the posterior pharyngeal area and rolled to ensure

that there is ample specimen is on each swab tip. If exudate is present, it

should also be sampled on the same swabs. Care should be taken to avoid

touching other areas of the oropharynx, mouth, and tongue.

DirectGramstains fromthroat swabs are not at all useful becausemany

bacteria normally reside in the throat, including nonpathogenic streptococci

that have Gram stain appearance identical to that of GAS.

TREATMENT AND PREVENTION

Treatment of group A streptococcal pharyngitis is important in order to

relieve the patient’s symptoms and to prevent the transmission to others.

Prompt treatment will also prevent complications such as peritonsillar abscess

and acute rheumatic fever. Symptoms will often disappear within

3–4 days even without antibiotics, but early antibiotics can shorten the

duration of symptoms. Pharyngitis caused by S. pyogenes can be effectively

treated with a penicillin. In children, like this patient, amoxicillin

is routinely prescribed. Patients must complete the course of antibiotic to

eradicate the organisms from the pharynx. For patients who are allergic

to penicillin, erythromycin would be an acceptable alternative. If left untreated,

patients with GAS infection may develop the sequellae of heart

valve damage (RF) or kidney damage (GN).

Susceptibility tests on GAS would not be performed since resistance

to penicillin has not been documented in these organisms to date. Carriers

maintain S. pyogenes in their throats despite appropriate antibiotic therapy;

it is not because the organisms are resistant to penicillin. Carriers are not

symptomatic but can spread the organism to others who may develop an

infection.

Alcoholism

2011-03-14T06:07:00.000-07:00

Alcoholism

Definition

• Alcoholism and alcohol abuse

o Regular and excessive use of alcohol with concomitant social, interpersonal, legal, occupational, and/or physical problems or

o Repeated use in hazardous situations such as driving

• Alcohol dependence

o Repeated alcohol-related difficulties in at least 3 areas of functioning that cluster together over any 12-month period

o Regular use of alcohol has resulted in a state of physiologic tolerance.

Symptoms & Signs

• Most patients with alcoholism do not have dramatic physical symptoms.

o Instead present with psychosocial difficulties

Marital difficulties

Job problems (tardiness, absenteeism)

Legal problems resulting from driving while intoxicated

o Patients may describe a host of difficulties but may deny that they have a problem with alcohol abuse.

o Denial is a characteristic symptom of alcoholism.

• "CAGE" questionnaire: any positive answer indicates a high probability of alcoholism

o Blackouts

Episode of temporary anterograde amnesia associated with alcohol use

Occurs in ~35% of drinkers

o Sleep disturbances

Deficiency in rapid eye movement and deep sleep results in prominent and sometimes disturbing dreams later in the night.

o Sleep apnea

75% of alcoholic men over age 60

Relaxes muscles in the pharynx

o Impairment in judgment and coordination

At least half of patients with physical trauma have evidence of substance-related impairment.

In the U.S., 40% of drinkers have at some time driven while intoxicated.

o Peripheral neuropathy

Chronic high doses of alcohol; occurs in 5–15% of alcoholics

o Cerebellar degeneration

1% of alcoholics

Syndrome of progressive unsteady stance and gait often accompanied by mild nystagmus

2 Alcoholism

o Alcohol-induced mood disorder

Intense sadness lasting for days to weeks in the midst of heavy drinking in 40% of alcoholics

o Alcohol-induced anxiety disorder

Temporary severe anxiety in 10–30% of alcoholics

Often begins during alcohol withdrawal

Can persist for many months after cessation of drinking

o Alcohol-induced psychotic disorder

Auditory hallucinations and/or paranoid delusions with a clear sensorium

• GI findings

o Esophagus and stomach

Inflammation of the esophagus and stomach

Epigastric distress

GI bleeding

o Pancreas and liver

Incidence of acute pancreatitis (~25 per 1000 per year) almost 3-fold higher than in the general population

Repeated exposure to ethanol leads to:

Fatty accumulation in the liver

Alcohol-induced hepatitis

Perivenular sclerosis

Cirrhosis (15–20%)

Chronic pancreatitis

• Cardiovascular findings

o Chronic heavy drinking

Mild to moderate hypertension

Cardiomyopathy

One-third of cases of cardiomyopathy are alcohol induced.

Atrial or ventricular arrhythmias, especially paroxysmal tachycardia

Occurs after a drinking binge in individuals showing no other evidence of heart disease: "holiday heart"

• Genitourinary system changes; sexual function

o Acutely (modest alcohol dose: blood alcohol concentrations of ≤100 mg/dL)

Increases sexual drive and decreases erectile capacity in men

o Chronic alcoholism in men

Irreversible testicular atrophy with concomitant shrinkage of the seminiferous tubules, decreases in ejaculate volume, lower sperm count

o Repeated ingestion of high doses of ethanol by women

Amenorrhea

Decrease in ovarian size

Absence of corpora lutea with associated infertility

Spontaneous abortions

• Musculoskeletal findings

o Acute alcoholic myopathy

Condition improves, but might not disappear with abstinence.

o Effects of repeated heavy drinking

Alteration in calcium metabolism

Lower bone density

Increased risk for fractures and osteonecrosis of the femoral head

Alcoholism 3

• Alcohol-withdrawal syndrome

o Withdrawal symptoms generally begin within 5–10 hours of decreasing ethanol intake, peak in intensity on day 2 or 3, and improve by day 4 or 5.

o Anxiety, insomnia, and mild levels of autonomic dysfunction may persist to some degree for ≥6 months; may contribute to the tendency to return to drinking.

Cough and Sputum Production

2011-03-14T03:29:00.000-07:00

Cough and Sputum Production

Definition

A cough is a sudden, usually involuntary, expulsion of air from the lungs with a characteristic and easily recognizable sound. Although it is known as the most common symptom of respiratory disorders, it serves the functions of defending the respiratory tract against noxious substances and maintaining airway patency by removing excessive secretions from the air passages. Expectoration or sputum production is the act of coughing up and spitting out the material produced in the respiratory tract.

Clinical Significance

As a cardinal manifestation of respiratory diseases, coughing is one of the most common symptoms encountered in clinical medicine. Being a physiologic reflex, the cough also occurs without any demonstrable evidence of disease when triggered by the stimulation of the irritant receptors. Moreover, it may be a voluntary act or may result from nervous habit. Although the clinical significance of coughing in many instances is trivial, it may be an indication of a serious intrathoracic disease. Pathologic conditions causing the cough are usually the ones that irritate the airways, increase their irritability, result in their deformation, or increase the tracheobronchial secretions. These factors may operate singly or in various combinations. Sputum production with coughing occurs when the respiratory tract secretions are beyond the ability of the mucociliary mechanism to deal with them.

The most common cause of the acute cough of clinical significance is viral tracheobronchitis. The cough in this transient and self-limited condition is, at the beginning, nonproductive and quite annoying; later it becomes productive of mucous or mucopurulent sputum before it begins to subside. Inflammation of the respiratory tract mucosa, from infectious or noninfectious causes, results in hyper-reactivity of the cough receptors. This results from the alteration of the surface epithelium, making them more sensitive to the cough-producing effect of commonly occurring mild irritants such as cold air, respiratory pollutants, deep or fast respiration, and excessive use of the larynx. At times, the mechanical irritation of coughing itself brings about more coughing. Inflammation, in addition, increases the secretions. In acute viral respiratory tract infection, post-nasal drip may be another cause for triggering the cough. Other infectious, as well as noninfectious, diseases of upper or lower respiratory tract are known for their propensity in causing the cough as a part of their clinical

Anatomic Classification of Causes of Cough.

A chronic cough, defined as a cough lasting for a minimum duration of 3 weeks, is usually indicative of structural changes in the respiratory tract or the persistence of other cough-stimulating factors. By far the most common cause of a chronic cough in developed nations is tobacco smoking, which is the most important factor in the etiology of chronic bronchitis. In this disease, the cough is productive of a fairly large amount of sputum that varies from mucous to mucopurulent. Patients with chronic bronchitis, well accustomed and often oblivious to their symptoms, become concerned when the characteristics of their cough and sputum production change. The most frequent cause for the change is the intercurrence of an infection; however, it may indicate the occurrence of a neoplasm.

Since the decline of tuberculosis in developed nations, lung cancer has become most feared among the people with a chronic cough. The cough in lung cancer may develop de novo when there is no underlying chronic bronchitis and may be its only manifestation. As chronic bronchitis and lung cancer are very uncommon among nonsmokers, a chronic persistent cough has a different significance in this population. Airway hyperreactivity, the hallmark of bronchial asthma, is a rather common condition in which the cough may be the predominant or even the sole manifestation. Patients with hyperreactive airways, without other manifestations of asthma, may have a chronic cough for as long as several years until the condition is suspected, accurately diagnosed, and properly treated. Chronic postnasal drip, a frequent symptom of allergic or nonallergic rhinitis and/or sinusitis, is implicated in many instances of a chronic cough. A sensation of secretions dripping down into the throat and the feeling of a need to clear the throat are very suggestive of this disorder.

The chronic cough may be a manifestation of many other pathologic conditions involving the intra- and extrathoracic organs . Left-sided heart failure not only results in a cough with acute pulmonary edema but also may be a cause of a chronic nocturnal cough. Recurrent aspiration is another condition in which the cough characteristically occurs in a supine position. Foreign-body aspiration should always be considered in the differential diagnosis of the chronic cough. After the initial coughing or choking episode at the time of its aspiration, the cough may restart and continue long after the incident. Other, less common intraluminal or compressing lesions of the tracheobronchial tree, chronic inflammatory or fibrosing lung diseases, and extrapulmonary lesions may have cough as their predominant symptom. Tumors of the mediastinum, enlarged heart chambers, and pleural disease may manifest with cough. A psychogenic or intentional cough for personal gain should be seriously considered only when other causes are properly excluded. The angiotensin-converting enzyme inhibitors such as captopril and enalapril, used for the treatment of hypertension and congestive heart failure, are being increasingly recognized as a cause of a dry, annoying, and often incessant cough, which disappears only after the discontinuation of these agents.

Characteristics of expectorated sputum often suggest the diagnosis of its cause. Chronic expectoration of large amounts of purulent and foul-smelling sputum is strongly suggestive of bronchiectasis. Sudden production of such a sputum in a febrile patient indicates a lung abscess. Rust-colored purulent sputum in pneumococcal pneumonia, currant jelly and sticky sputum in klebsiella pneumonia, and blood-tinged foamy sputum in pulmonary edema are other examples in which the diagnosis of the underlying disease is strongly suggested.

Types of Healthy Exercises

2011-03-14T03:04:00.000-07:00

Types of Healthy Exercises

Considering exercise as a part of our routine is surely a well known fact. But in fact the fundamentals of the exercise also need to be understood. There can be several types of physical exercises broadly characterized into four main types that is, endurance, balance, strength and flexibility. Endurance is something that put up stress on the major organs of the body like heart, lungs and the circulatory system. Activities like walking, jogging, swimming, biking and walking uphill can all be counted as endurance exercises provided they are conducted in the right spirit. Certain sports activities can also be regarded as the endurance exercises like tennis and basketball etc. Strength exercises on the other hand are in fact to strengthen the body muscles. This can be achieved by lifting weights and putting up stress on the muscles involved in that particular exercise. Balance exercises are in order to help us achieve the balance in our body, heel to toe exercise and standing on one foot are few of such exercises. There are exercises resorting to which we can easily improve upon the flexibility in our body fiber. Stretching exercises can lead to improving upon the flexibility. Shoulder and upper arm stretch, calf stretch and certain yoga exercises can be regarded as the stretching exercises. In order to be able to find a sound health and body it is necessary to carry out a number of different exercises or physical activities, encompassing all the above mentioned types of exercises. This can be achieved by planning out the daily routine and finding out time for such essential exercises. Though, all kinds of exercises can not be undergone on daily basis. But still there is a possibility to strike a balance between exercises and plan them as part of the routine. It is obvious that exercises that fulfil the above mentioned aspects would really help us lead a healthy body and healthy mind.

Exercise and Weight Control

2011-03-14T03:00:00.000-07:00

Exercise and Weight Control

We all know that the weight our bodies gain is directly related to food we consume and ultimately to the amount of our calories intake. It is very obvious that we all require lot of calories to be able to carry out our daily activities. But there is certainly a limit to that beyond which any calories consumed are in fact going to gain us nothing more than additional weight to our bodies. It is just because the extra amount of calories that we could not utilize in our daily routine is added to our bodies in the form of fats. Fats can accumulate inside our bodies under our skin at a number of areas.

We need to understand the basic requirement in order to have a controlled weight. The excess of fats in our bodies can lead to quite a lot of diseases like heart diseases, diabetes, high blood pressure and so many other harmful diseases. We have a solution available in order to avoid the accumulation of such extra weight to our bodies. Exercise is the recommended solution. It can help kill the obesity, which is a cause of health problems. We need to eat according to our daily energy requirements. If weight reduction or weight control is sought, the best way is to increase the physical activities and exercise and reduce the calorie intake. This will help us gain a good required balance which can give us a balanced health. A check is also need to be kept on the leisure activities we indulge in because it causes us to be idle most of the times and wasting a lot of our time.

Health related problems can always be overcome by properly adhering to the prevention measures and the recommended steps necessary. An idea of keeping an eye on our routine can make us find the weaker aspects which we can be addressed for a positive outcome.

How to Control Diabetes

2011-03-14T02:58:00.000-07:00

How to Control Diabetes

Any kind of disease is highly undesired by the human body. It makes our healthy body suffer. It prevents us from performing our day to day activities. One of such disease is Diabetes. There can be a lot of ways various diseases can be cured if prevention is adhered to whenever it is required. Same is the case with diabetes. We can always try to gain control on this disease if we happen to know the necessary tips that can help prevent it. Given below are certain tips that can be an aid to our control on diabetes.

1. Keep a check on meat poultry and fish content in food.

2. Do not snack while cleaning or cooking

3. Try to eat meals at regular timings

4. Have breakfast daily

5. Share a single dessert

6. Eat large chunks of vegetable salad

7. Cook with less oil and butter

8. Take a glass of water 10 minutes before meal

9. Avoid watching TV while eating

10. Eat smaller meals

11. Use smaller utensils and spoons

12. Cut down portions of food you eat

13. Make less food look like more by serving in different ways

14. Do some physical activity regularly

15. Go out for walk very often

16. March while you watch TV

17. Go for lots of vegetables

18. Have low fat macaroni and cheese

19. Drink lots of water

20. Consume food with less sugar quantity

There can be a lot more different ways we can have reasonable control on diabetes. But it must be remembered that prevention is always better than cure and if we are able to stick to the above mentioned simple tips, there is no doubt that we can soon come over this disease and start living a healthier normal life. After all it requires just a little bit of commitment and dedication from our side

Stress Relief Technique

2011-03-14T02:55:00.000-07:00

Stress Relief Techniques

In the busy world of today, an individual come across a number of activities simultaneously. Lot of actions occurs to create tension and stress. Stress cause to unnecessarily overburden the mind thereby, reducing the overall efficiency of an individual. It is always encouraged to live a life that is simple and relaxed, free of tension. Because it helps us do better and live longer. If at all we are suffering from the problem of stress, we need to assess the issues we are confronting. Like we should see that are we prioritizing ourjobs, if not then we must give it a due consideration. We should see why we get angry. May be that it’s because of jumping into conclusions, we needs to avoid that. An analysis should be made as to determine whether we are sure of our abilities or not? If we are not we need to be certain of our abilities and sure we would do it.

Overburdening itself could also be the cause of a lot of stress and tension. Duties and responsibility needs to be disseminated appropriately to the concerned and taken a back seat comfortable enough to relax our mind. We must take out times in bits and pieces for minor relaxations. Hot bath, walking and running all of this helps us get relieved and feel relaxed. Avoiding pessimism is always recommended in order to have a positive overview of the life. If one is upset by conflict with others, it is preferable for him to exercise assertiveness training. Eating healthy food, good exercise and productive and leisure activities can pay rich dividends. If feeling lonely it is better to socialize or contact friends and fellows, start sharing certain experiences. Acquaintances projects positive reflections upon the soul. There are so many other ways which can help us control stress.

Successful Approach to Physical Exercise

2011-03-14T02:52:00.000-07:00

Successful Approach to Physical Exercise

Physical exercise is essentially part of our daily life. It is always mandatory to understand the due importance of exercise as part of our daily life. At times in spite of an adequate understanding of the importance of physical exercise, there remains a lack of practical application aspect into it. Physical activity should be given a due priority. A habit of remaining active always leads us to have a positive bearing on our life. Exercise daily should be made as special appointment. We are all well familiar with the four main types of exercises like endurance, strength, balance and flexibility. The tip is to try mixing up all the types of exercises, to have a dynamic approach. This will aid to avoid injuries and boredom. A sequential routine is bound to become boring. We must incorporate reasonable pauses in between the routine. Breaks due certain natural causes can possibly result in breaks in our physical activities. A degree of motivation is required to remain active and again commence the physical activity. There can be a few recommendations made in this aspect. It can be getting help form friends and doctor. Must be started at comfortable levels again and creativity involved in thinking process once it comes to exercising. Being flexible and believing in ones abilities is also quite helpful. There is some thing towards the exercise that is rather more important than the exercise itself. It can be rightly termed as the approach towards the exercise. A constant vision of what the requisite health condition can always give us further motivation to be more focused. Innovations and improvisations can all aid to creating interest in the physical activity and exercise. Keeping a serious attitude towards exercise can cause us concentrate more effectively. The right approach is certainly the key to good exercising habits.

Abdominal Pain

2011-03-12T06:15:00.000-08:00

Abdominal Pain

Definition n

• Pain in the abdomen ranging from acute, life-threatening emergencies to chronic

functional disease and disorders of several organ systems

• Evaluation of acute pain requires rapid assessment of likely causes and early

initiation of appropriate therapy.

• A more detailed and time-consuming approach to diagnosis may be followed in

less-acute situations.

Symptoms & Signs n

Abdominal origin

• Inflammation of parietal peritoneum: pain characteristics

o Quality: steady and aching

o Location: directly over inflamed area with exact reference possible

o Intensity: dependent on type and amount of material to which peritoneal

surfaces are exposed in a given time period

Sudden release into peritoneal cavity of small quantity of sterile acid

gastric juice causes much more pain than same amount of grossly

contaminated neutral feces.

Enzymatically active pancreatic juice causes more pain and

inflammation than same amount of sterile bile containing no potent

enzymes.

Blood and urine are often so bland they are detected only if contact

with peritoneum is sudden or massive.

In bacterial contamination (e.g., pelvic inflammatory disease), pain is

frequently of low intensity until bacterial multiplication has caused

elaboration of irritating substances.

o Rate at which irritating material is applied to peritoneum is important.

Perforated peptic ulcer: clinical picture dependent only on rapidity with

which gastric juice enters peritoneal cavity

o Pain is accentuated by pressure or changes in tension of peritoneum.

Produced by palpation or movement (e.g., coughing, sneezing)

Patient with peritonitis lies quietly in bed to avoid painful motion.

Patient with colic may writhe incessantly.

o Tonic reflex spasm of abdominal musculature

Localized to involved body segment

Intensity of spasm is dependent on location and rate of development

of inflammatory process and integrity of nervous system.

Spasm over perforated retrocecal appendix or perforated ulcer into

lesser peritoneal sac may be minimal or absent because of protective

effect of overlying viscera.

Slowly developing process often greatly attenuates degree of spasm.

o Obstruction of urinary bladder

Dull suprapubic pain, usually low in intensity

Restlessness without specific complaint of pain may be only sign of

distended bladder in obtunded patient.

o Acute obstruction of intravesicular portion of ureter

Severe suprapubic and flank pain that radiates to penis, scrotum, or

inner aspect of upper thigh

o Obstruction of ureteropelvic junction

Pain in costovertebral angle

o Obstruction of remainder of ureter

Flank pain that often extends into same side of abdomen

• Vascular disturbances

o Pain not always sudden or catastrophic

o Embolism or thrombosis of superior mesenteric artery or impending rupture

of abdominal aortic aneurysm

Pain may be severe and diffuse.

o Occlusion of superior mesenteric artery

Pain may be mild, continuous, and diffuse for 2 or 3 days before

vascular collapse or findings of peritoneal inflammation appear or may

be severe and diffuse.

Early, insignificant discomfort is caused by hyperperistalsis rather than

peritoneal inflammation.

Absence of tenderness and rigidity in presence of continuous, diffuse

pain are characteristic of vascular disease.

o Rupturing abdominal aortic aneurysm

Abdominal pain with radiation to sacral region, flank, or genitalia

Pain may persist over several days before rupture and collapse occur.

• Abdominal wall

o Usually constant and aching

o Movement, prolonged standing, and pressure accentuate discomfort and

muscle spasm.

o Hematoma of rectus sheath

Most frequently with anticoagulant therapy

Mass may be present in lower quadrants of abdomen.

Simultaneous involvement of muscles in other parts of body usually

differentiates myositis of abdominal wall from intra-abdominal process

that might cause pain in same region.

Treatment Approach n

• Stabilize patient.

• Ascertain if urgent surgical intervention is required.

o If so, establish venous access for fluid replacement and begin surgery

immediately.

• Provide pain relief.

o Narcotics or analgesics should not be withheld until definitive diagnosis or

definitive plan is formulated.

o Obfuscation of diagnosis by adequate analgesia is unlikely.

• Prescribe empiric antibiotic therapy if intra-abdominal infection suspected.

Abdominal Pain 9

• Provide other symptomatic relief (e.g., antiemetics, antispasmodics).

• Definitive treatment is dependent on etiology of pain.

Cough

2011-03-12T05:56:00.000-08:00

Cough

Definition

• An explosive expiration that provides a normal protective mechanism for clearing the

tracheobronchial tree of secretions and foreign material

• Acute cough: <3 weeks

• Chronic cough: >3 weeks

Symptoms & Signs

History

• Valuable clues for etiology

o Acute or chronic?

o Symptoms of respiratory infection at onset?

o Seasonal? Wheezing?

o Symptoms of postnasal drip?

Nasal discharge

Frequent throat clearing

"Tickle in the throat"

o Symptoms of gastroesophageal reflux?

Heartburn or sensation of regurgitation

o Fever or sputum? If sputum present, what is its volume, character?

o Hemoptysis?

o Associated diseases or risk factors?

Cigarette smoking

HIV

Environmental exposures (e.g., asbestos)

o Angiotensin-converting enzyme (ACE) inhibitor?

Physical examination

• Signs of postnasal drip may be present.

o Oropharyngeal mucus or erythema

o "Cobblestone" appearance to mucosa

• Auscultation of the chest may demonstrate:

o Inspiratory stridor (upper airway disease)

o Rhonchi or expiratory wheezing (lower airway disease)

o Inspiratory crackles (process involving pulmonary parenchyma—e.g., interstitial lung

disease, pneumonia, or pulmonary edema)

• Temperature

o Fever suggests infection (bronchitis, pneumonia).

• Check for systemic or nonpulmonary causes.

o Heart failure

o Primary nonpulmonary neoplasm

o AIDS

Treatment Approach

• Definitive treatment

o Dependent on determining underlying cause

• Specific considerations

o Elimination of exogenous inciting agent (cigarette smoke, ACE inhibitor) or

endogenous trigger (postnasal drip, gastroesophageal reflux)

Usually effective if precipitant can be identified

o Treat specific respiratory tract infections.

o Bronchodilators for potentially reversible airflow obstruction

o Inhaled glucocorticoids for eosinophilic bronchitis

o Chest physiotherapy and other methods to clear secretions in bronchiectasis

o Treatment of endobronchial tumors or interstitial lung disease if therapy availableand appropriate.

HISTORY TAKING

2011-03-11T07:17:00.000-08:00

HISTORY TAKING

HISTORY IDENTIFYING DATA
Patients name, age, race, sex; referring physician or clinic.

SOURCE AND RELIABILITY:
Name and reliability of informant (patient, old chart, relative).

HISTORY OF PRESENT ILLNESS (HPI)
Describe the course of the patients illness, including when it began, character of the symptoms; location where the symptoms began; aggravating or alleviating factors; pertinent positives and negatives, other related diseases; past illnesses or surgeries, past diagnostic testing.

PAST MEDICAL HISTORY (PMH): Past diseases, surgeries, hospitalizations; significant medical problems; history of diabetes, hypertension, peptic ulcer disease, asthma, COPD, MI, Cancer, TB. In children include birth history, prenatal history, immunizations, type of feedings.

MEDICATIONS

ALLERGIES
Penicillin?

FAMILY HISTORY
Medical problems in relatives; specifically ask about problems similar to patients illness. Asthma, MI, heart failure, hypertension, CA, TB, diabetes, kidney diseases, hemophilia.

SOCIAL HISTORY
Alcohol, smoking, drug usage. Marital status and children; employment and home situations; exposure to carcinogens or environmental agents. In children include: Sleep, play habits, grade in school.

REVIEW OF SYSTEMS (ROS)
General:
Weight gain or loss, appetite loss, fever, chills, fatigue, night sweats.

Skin
Rashes, bruising, skin discolorations.

Head
Headaches, dizziness, tenderness, lumps or masses; history of seizures, head trauma.

Eyes
Visual changes, visual acuity, visual field deficits, diplopia, inflammation.

Ears
Tinnitus, vertigo, pain, discharge.

Nose
Nose bleeds, discharge, sinus diseases.

Mouth & Throat
Dental diseases, hoarseness, sore throat, pain.

Respiratory
Cough, shortness of breath, sputum (color, amount), chest pain; history of PTB; vaccination for influenza or pneumococcus. Positive Purified Protein Derivative (PPD Testing).

Cardiovascular
Chest pain, orthopnea, paroxysmal nocturnal dysonea; dyspnea on exertion, claudication, extremity edema.

Gastrointestinal
Odynophagia, dysphagia, abdominal pain, nausea, vomiting, hematemesis, diarrhea, melena, hematochezia, constipation, bloody stool, change in bowel habits, jaundice.

Genitourinary
Dysuria, frequency, hesitancy, hematuria, polyuria, discharge, impotence, testicular masses, penile discharge.

Gynecological
Gravida/para, abortions, LMP (frequency, duration), age of menarche, menopause; dysmenorrhea, contraception, vaginal bleeding; last pelvic exam and pap smear, breast masses, self-examination, mammography.

Endocrine
Polyuria, polydipsia, polyphagia, skin or hair changes, cold or heat intolerance, hormonal therapy.

Musculoskeletal
Joint pain or swelling, arthritis, myalgias.

Skin
Easy bruising, bleeding tendencies.

Lymphatics
Lymphadenopathy.

Neuropsychiatric:
Weakness, seizures, paresthesias, memory changes, emotional depression disturbances.

Leishmaniasis

2011-02-28T03:14:00.000-08:00

Leishmaniasis

Causes, incidence, and risk factors

There are different forms of leishmaniasis.

· Cutaneous leishmaniasis affects the skin and mucus membranes. Skin sores usually start at the site of the sandfly bite. They can last for months or years before healing on their own. In a few people, sores may develop on mucus membranes.

· Systemic, or visceral leishmaniasis affects the entire body. This form occurs 2 - 8 months after a person is bitten by the sandfly. Most people do not remember having a skin sore. This form can lead to deadly complications. The parasites damage the immune system by decreasing the numbers of disease-fighting cells.

Cases of leishmaniasis have been reported on all continents except Australia and Antarctica. In the Americas, leishmaniasis can be found in Mexico and South America. Leishmaniasis has been reported in military personnel returning from the Persian Gulf.

Symptoms

Cutaneous leishmaniasis affects the skin and sometimes the mucus membranes. Symptoms may include:

· Skin sores, which may become a skin ulcer that heals very slowly

· Ulcers and wearing away (erosion) in the mouth, tongue, gums, lips, nose, and inner nose

· Stuffy nose, runny nose, and nosebleeds

· Breathing difficulty

· Swallowing difficulty

Systemic visceral infection in children usually begins suddenly with vomiting, diarrhea, fever, and cough. Adults usually have a fever for 2 weeks to 2 months, along with symptoms such as fatigue, weakness, and appetite loss. Weakness increases as the disease gets worse.

Other symptoms of systemic visceral leishmaniasis may include:

· Belly area (abdominal) discomfort

· Cough (children)

· Diarrhea (children)

· Fever that lasts for weeks; may come and go in cycles

· Night sweats

· Scaly, gray, dark, ashen skin

· Thinning hair

· Vomiting (children)

· Weight loss

Signs and tests

A physical exam may show signs of an enlarged spleen, liver, and lymph nodes. The patient may have been bitten by sandflies, or was in an area known for leishmaniasis.

Tests that may be done to diagnose the condition include:

· Biopsy of the spleen and culture

· Bone marrow biopsy and culture

· Direct agglutination assay

· Indirect immunofluorescent antibody test

· Lymph node biopsy and culture

Montenegro

skin test

· Skin biopsy

Other tests that may be done include:

· Complete blood count

· Serum immunoglobulin levels

· Serum protein

· Serum albumin

· Serologic testing

Treatment

Medicines called antimony-containing compounds are the main drugs used to treat leishmaniasis. These include:

· Meglumine antimonate

· Sodium stibogluconate

Other drugs that may be used include:

· Amphotericin B

· Fluconazole

· Pentamidine

Plastic surgery may be needed to correct the disfigurement caused by sores on the face (cutaneous leishmaniasis). Patients with drug-resistant viral leishmaniasis may need to have their spleen removed (splenectomy).

Measles

2011-02-17T04:15:00.000-08:00

Measles

Measles is best known for causing a rash in childhood, but measles can affect other parts of the body and sometimes occurs in adults. Vaccination has significantly reduced the number of cases in the United States, although isolated outbreaks continue to occur.

There are two types of measles, each caused by a different virus. Although both produce a rash and fever, they are really different diseases:

· The rubeola virus causes "red measles," also known as "hard measles" or just "measles." Although most people recover without problems, rubeola can lead to pneumonia or inflammation of the brain (encephalitis).

· The rubella virus causes "German measles," also known as "three-day measles." This is usually a milder disease than red measles. However, this virus can cause significant birth defects if an infected pregnant woman passes the virus to her unborn child.

Measles Symptoms

Rubeola ("red measles" or "hard measles")

Symptoms appear about 10-14 days after a person is infected with the rubeola virus. This is called the incubation period. During this period, the virus is multiplying. Symptoms occur in two phases.

· The early phase begins with these symptoms:

o Fever

o A run-down feeling

o Cough

o Red eyes

o Runny nose

o Loss of appetite

· The red measles rash develops from two to four days later.

o The rash usually starts on the face, spreading to the trunk and then to the arms and legs.

o The rash is initially small red bumps that may blend into each other as more appear. From a distance, the rash often looks uniformly red.

o People with measles may develop small grayish spots on the inside of the cheek, called "Koplik spots."

o The rash is usually not itchy, but as it clears up, the skin may shed (this looks like skin that is peeling after sunburn).

o Although red measles is usually a mild disease, a few serious complications may occur. Red measles makes patients more vulnerable to pneumonia and bacterial ear infections. Pneumonia as a complication of measles is especially serious in infants and is responsible for most deaths in this age group. Inflammation of the brain (encephalitis) occurs about once in every thousand cases and is a serious complication that can be fatal.

o Red measles is particularly severe in patients with weakened immune systems, including people who are malnourished or have HIV.

Rubella ("German measles")

German measles causes milder symptoms than red measles. The incubation period between getting the virus and getting sick is 10 days to two weeks.

· Initially, some people experience fatigue, low-grade fever, headache, or red eyes several days before the rash appears. These symptoms are more common in adults than in children.

· Swollen, tender lymph nodes may occur in the back of the neck.

· The rash is light red to pink. It starts as individual spots which may merge together over time. The rash usually starts on the face and moves down to the trunk.

· The rash does not usually itch, but as it clears up, the skin may shed.

· Adult women who get rubella may get painful joints for days to weeks after the infection. This affects the hands, wrists, and knees.

· Symptoms may be so mild that they are not even noticed, especially in children. Most symptoms resolve in a few days, but swollen lymph nodes may persist for a few weeks.

· The most feared complication of rubella is "congenital rubella," which occurs when an infected pregnant woman passes the virus to her unborn child. Among other problems and birth defects, affected infants may have cataracts, heart defects, hearing impairment, and learning disabilities. The risk of transmission is highest early in pregnancy. The virus may also causemiscarriage or stillbirth.

Measles Treatment

Self-Care at Home

Although there is no cure for measles, there are steps that can make the disease more tolerable. These include the following:

· Get plenty of rest.

· Sponge baths with lukewarm water may reduce discomfort due to fever.

· Drink plenty of fluids to help avoiddehydration.

· A humidifier or vaporizer may ease the cough.

· Pain relievers and fever reducers such as acetaminophen (Tylenol, Liquiprin Drops, and other brands) and ibuprofen (Advil, Motrin and other brands) can help with symptoms when used according to directions. Remember never to give aspirin to children or teenagers because it may cause a disease known as Reye syndrome.

Medical Treatment

There is no specific treatment or cure for measles. Children should stay at home and out of school until they are cleared to return by their health-care provider.

Mumps

2011-02-17T01:19:00.000-08:00

Mumps

It is an infection caused by the mumps virus.

Symptoms of mumps

The most common symptoms are fever, headache, muscle aches, tiredness andloss of appetite followed by onset of parotitis (swollen and tender salivary glands under the ears -- on one or both sides).

Symptoms

Symptoms typically appear 16-18 days after infection, but this period can range from 12-25 after infection.

Mumps spread

Mumps is spread by mucus or droplets from the nose or throat of an infected person, usually when a person coughs or sneezes. Surfaces of items (e.g. toys) can also spread the virus if someone who is sick touches them without washing their hands, and someone else then touches the same surface and then rubs their eyes, mouth, nose etc. (this is called fomite transmission).

Treatment

There is no specific treatment. Supportive care should be given as needed. If someone becomes very ill, they should seek medical attention. If someone seeks medical attention, they should call their doctor in advance so that they don't have to sit in the waiting room for a long time and possibly infect other patients.

Sore throat

2011-02-17T01:06:00.000-08:00

Sore throat

A sore throat can have many causes including:

Common viruses, and even the viruses that causemononucleosis (mono) and the flu, can cause a sore throat. Some viruses can also produce blisters in the mouth and throat ("aphthous stomatitis").
Breathing through the mouth can produce throat dryness and soreness.
Sinus drainage (post nasal drip) may cause a sore throat.
A sore throat can also be caused by bacteria. The two most common bacteria to cause a sore throat areStreptococcus (which causesstrep throat) andArcanobacterium haemolyticum.Arcanobacterium causes sore throats mainly in young adults and is sometimes associated with a fine redrash.
Sore throat appearing after treatment with antibiotics,chemotherapy, or other immune-compromising medications may be due toCandida, commonly known as "thrush."
A sore throat lasting for more than two weeks can be a sign of a serious illness, such as throat cancer or AIDS.

What can I do at home for a sore throat?

Generally, sore throats must run their course (exception, strep throat will be addressed below.)

· Salt water gargles, hard candies, sprays for example, Chloraseptic) and lozenges can provide temporary pain relief. (Caution: Lozenges and hard candy are a choking hazard for children. Avoid their use in young children.)

· A humidifier may be helpful in relieving symptoms, especially in sore throats caused by mouth breathing and dry air.

· Acetaminophen or ibuprofen may help control the pain.

· For adults, if your nose is plugged, nasal sprays such as Afrin may be used for two to three days to prevent mouth breathing. It is NOT a good idea to use these products for more than a couple of days; you may become dependent on them.

· Other decongestant products, such as Sudafed, may be helpful.

Medical care

Seek medical care:

If you have been in contact with someone with strep throat and you have a sore throat, it is reasonable to have a strep test done.
If your sore throat is associated with a fever, swollen "glands" (lymph nodes), or white patches on the back of your throat.
If your sore throat is not associated with other cold symptoms (runny nose, watery eyes, sinus congestion).
Any sore throat that has a sudden onset and is associated with a fever.
If you are having trouble swallowing liquids (pain with swallowing is to be expected with a sore throat).
If your sore throat persists for more than a week.
If you have a sore throat and the front of your neck is sore and stiff.

Kidney Structure

2011-02-16T11:29:00.000-08:00

The Human Kidney Structure and Function
One of the most complex, beautifully “engineered” organs of the human body, the kidneys perform several essential tasks including the excretion of waste products, the maintenance of homeostatic balance in the body and the release of important hormones. To achieve this, human kidneys have a highly developed, superbly refined anatomy and physiology.
Location and Basic Structure of the Kidneys
The kidneys are located near the vertebral column at the small of the back; the left kidney lying a little higher than the right. Each is identical in structure and function. They are bean-shaped, about 10 cm long and 6.5 cm wide. Each kidney comprises an outer cortex and an inner medulla. The kidney is supplied with oxygenated blood via the renal artery and drained of deoxygenated blood by the renal vein. In addition, urine produced by the kidney as part of its excretory function, drains out via narrow “tubules” and the ureter, in turn connected to the bladder.
The Nephron
The main functional unit of the kidney is the nephron. There are approximately one million nephrons per kidney. The role of nephrons is to make urine by:
Filtering blood of small molecules and ions such as water, salt, glucose and other solutes including urea. Large “macromolecules” like proteins are untouched.

Recycling the required quantities of useful solutes which then re-enter the bloodstream. (A process called reabsorption)

Allowing surplus or waste molecules/ions to flow from the tubules/ureter as urine.

Filtration and Reabsorbtion in the Kidneys
During progress through the nephron, some solutes like sodium chloride, potassium and glucose are reabsorbed, along with water, back into the bloodstream. This maintains a correct balance of these chemicals within the blood, assisting blood pressure regulation, for example. The filtration and reabsorbtion of glucose within the kidneys also helps to maintain correct levels of vital blood sugars. When this regulation breaks down very serious health consequences can follow.
Urea and uric acid are nitrogen containing waste products from metabolic processes in the body. These substances are potentially toxic and are partially excreted by the kidneys to maintain good health. Interestingly, of the filtrate which enters each nephron from the blood, only about 1% actually leaves the body as urine because of the various reabsorbtion mechanisms driven by osmosis, diffusion, and active transport.
Tubular Secretion in the Kidneys
Another, less familiar, mechanism for urine production in the kidneys is tubular secretion. Specialised cells move solutes directly from the blood into the tubular fluid. For example, hydrogen and potassium ions are secreted directly into the tubular fluid. This process is “coupled” or balanced by the re-uptake of sodium ions back into the blood.
n
Tubular secretion of hydrogen ions, augmented by control of bicarbonate levels, is important in maintaining correct blood pH. When the blood is too acidic (acidosis) more hydrogen ions are secreted. If the blood becomes too alkaline (alkalosis), hydrogen secretion is reduced. In maintaining blood pH within normal limits (about 7.35–7.45) the kidney can produce urine with pH as low as that of acid rain or as alkaline as baking soda!
The Kidney as an Endocrine Gland
In addition to its excretory and homeostatic roles, the kidneys also release two important hormones into the blood. These are:
Erythropoietin which acts on bone marrow to increase the production of red blood cells

Calcitriol which promotes the absorption of calcium from food in the intestine and acts directly on bones to shift calcium into the bloodstream.

Finally the kidney produces the enzyme renin, an important regulator of blood pressure.

Kidney stone

2011-02-16T04:51:00.000-08:00

Kidney stone
A kidney stone is a solid mass made up of tiny crystals. One or more stones can be in the kidney or ureter at the same time.

Causes, incidence, and risk factors

Kidney stones can form when urine contains too much of certain substances. These substances can create small crystals that become stones.

The biggest risk factor for kidney stones is dehydration.

Kidney stones may not produce symptoms until they begin to move down the tubes (ureters) through which urine empties into the bladder. When this happens, the stones can block the flow of urine out of the kidneys. This causes swelling of the kidney or kidneys, causing pain. The pain is usually severe.

Kidney stones are common. A person who has had kidney stones often gets them again in the future. Kidney stones often occur in premature infants.

Some types of stones tend to run in families. Certain kinds of stones can occur with bowel disease, ileal bypass for obesity, or renal tubule defects.

There are different types of kidney stones. The exact cause depends on the type of stone.

· Calcium stones are most common. They occur more often in men than in women, and usually appear between ages 20 - 30. They are likely to come back. Calcium can combine with other substances, such as oxalate (the most common substance), phosphate, or carbonate to form the stone. Oxalate is present in certain foods. Diseases of the small intestine increase the risk of forming calcium oxalate stones.

· Cystine stones can form in people who have cystinuria. This disorder runs in families and affects both men and women.

· Struvite stones are mostly found in women who have a urinary tract infection. These stones can grow very large and can block the kidney, ureter, or bladder.

· Uric acid stones are more common in men than in women. They can occur with goutor chemotherapy.

Other substances also can form stones.

Symptoms

The main symptom is severe pain that starts suddenly and may go away suddenly:

· Pain may be felt in the belly area or side of the back

· Pain may move to groin area (groin pain) or testicles (testicle pain)

Other symptoms can include:

· Abnormal urine color

· Blood in the urine

· Chills

· Fever

· Nausea

· Vomiting

Treatment

The goal of treatment is to relieve symptoms and prevent further symptoms. (Kidney stones that are small enough usually pass on their own.) Treatment varies depending on the type of stone and how severe the symptoms are. People with severe symptoms might need to be hospitalized.

When the stone passes, the urine should be strained and the stone saved and tested to determine the type.

Drink at least 6 - 8 glasses of water per day to produce a large amount of urine. Some people might need to get fluids through a vein (intravenous).

Pain relievers can help control the pain of passing the stones (renal colic). For severe pain, you may need to take narcotic pain killers or nonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen.

Depending on the type of stone, your doctor may prescribe medicine to decrease stone formation or help break down and remove the material that is causing the stone. Medications can include:

· Allopurinol (for uric acid stones)

· Antibiotics (for struvite stones)

· Diuretics

· Phosphate solutions

· Sodium bicarbonate or sodium citrate (which make the urine more alkaline)

Surgery is usually needed if:

· The stone is too large to pass on its own

· The stone is growing

· The stone is blocking urine flow and causing an infection or kidney damage

Today, most treatments are much less invasive than in the past.

· Extracorporeal shock-wave lithotripsy is used to remove stones slightly smaller than a half an inch that are located near the kidney. This method uses ultrasonic waves or shock waves to break up stones. Then, the stones leave the body in the urine.

· Percutaneous nephrolithotomy is used for large stones in or near the kidney, or when the kidneys or surrounding areas are incorrectly formed. The stone is removed with an endoscope that is inserted into the kidney through a small opening.

· Ureteroscopy may be used for stones in the lower urinary tract.

· Standard open surgery (nephrolithotomy) may be needed if other methods do not work or are not possible.

Carcinoid tumor and Carcinoid syndrome

2010-12-27T15:23:00.000-08:00

Carcinoid tumor
A carcinoid tumor is a tumor that develops from enterochromaffin cells. Enterochromaffin cells are hormone-producing cells that normally are found in the small intestine, appendix, colon, rectum, bronchi, pancreas, ovaries, testes, bile ducts, liver, as well as other organs. Enterochromaffin cells produce many types of hormones for example, histamine, serotonin, dopamine, tachykinins, and other substances that have profound effects on the circulatory system (heart and blood vessels), the gastrointestinal tract, and the lungs. For example, serotonin can cause diarrhea, histamine wheezing, and tachykinins flushing due to dilation of blood vessels.
Since carcinoid tumors develop from enterochromaffin cells, they frequently retain the capability of producing the same hormones, often in large quantities. When these hormones circulate in the blood, they can cause symptoms of carcinoid syndrome, which is discussed later.
The important characteristic of carcinoid tumors that sets them apart from other gastrointestinal tract tumors is their potential to cause the carcinoid syndrome. Most other gastrointestinal tract tumors (such as colon cancers or small bowel lymphomas) cause symptoms primarily due to their local effects on the intestines such as abdominal pain, intestinal bleeding, and intestinal obstruction. Although carcinoid tumors may also cause these local symptoms, they may also produce and release hormones that cause the carcinoid syndrome. Often, symptoms of the carcinoid syndrome can be more devastating than the local symptoms.

Carcinoid syndrome
The carcinoid syndrome is a combination of symptoms caused by the hormones released by the tumors into the blood stream. The symptoms of the carcinoid syndrome vary depending on which hormones are released by the tumors. The common hormones released are serotonin, bradykinin (a molecule produced by enzymes at the site of an injury and then binds to receptors to cause pain), histamine, and chromogranin A (a general marker for neuroendocrine tumors). Typical carcinoid symptoms include:
• flushing
• diarrhea
• abdominal pain
• and wheezing due to bronchospasm (airway narrowing)
• valvular heart disease
• surgery can provoke a complication known as carcinoid crisis.
Flushing
Flushing is the most common symptom of carcinoid syndrome. An estimated 90% of the patients have flushing some time during their illness. Flushing is characterized by redness or purple discoloration of face and neck (or upper body) accompanied by a warm sensation. Episodes of flushing typically occur suddenly, either spontaneously or brought on by emotional stress, physical stress, or drinking alcohol. Episodes of flushing can last minutes to hours. Flushing can be accompanied by palpitations, low blood pressure, or fainting if blood pressure becomes too low to supply blood to the brain. Rarely, flushing can be accompanied by high blood pressure. Hormones responsible for flushing have not been clearly identified; possible candidates include serotonin, bradykinin, and substance P.
Diarrhea
Diarrhea is the second most common symptom of carcinoid syndrome. An estimated 75% of patients with carcinoid syndrome have diarrhea. Diarrhea often occurs with flushing but also can occur alone. Diarrhea in the carcinoid syndrome is most likely caused by the hormone serotonin. Medications that block the action of serotonin such as ondansetron (Zofran) often alleviates the diarrhea. Sometimes diarrhea in the carcinoid syndrome can be due to a local effect of the tumor obstructing the small intestine.
Heart disease
Heart disease occurs in an estimated 50% of patients with the carcinoid syndrome. Carcinoid syndrome typically causes scarring and stiffness of the tricuspid and pulmonic valves of the right side of the heart. Stiffness of these two valves decreases the ability of the heart to pump blood from the right ventricle to the lungs and to the rest of the body and leads to heart failure. Typical symptoms of heart failure include an enlarged liver (due to the backup of blood returning to the failing heart which is unable to pump all of the blood returning to it), swelling of the feet and ankles (edema), and swelling of the abdomen due to fluid accumulation (ascites). The damage to the tricuspid and pulmonic valves of the heart in the carcinoid syndrome is most likely caused by prolonged exposure to high levels of serotonin in the blood.
Carcinoid crisis
Carcinoid crisis is a dangerous condition that can occur at the time of surgery. It is characterized by a sudden and profound drop in blood pressure causing shock, sometimes accompanied by an abnormally fast heart rate, high blood glucose, and severe bronchospasm. Carcinoid crisis can be fatal. The best way to prevent carcinoid crisis is to treat patients undergoing surgery with somatostatin (see below) before surgery begins.
Wheezing
Wheezing occurs in approximately 10% of the patients with carcinoid syndrome. It is a result of bronchospasm (constriction of the bronchial airways) caused by hormones released by the carcinoid tumors.
Abdominal pain
Abdominal pain is common in patients with carcinoid syndrome. The pain may be due to tumor metastases in the liver, tumor invading neighboring tissues and organs.

Adenoma

2010-12-27T15:09:00.000-08:00

An adenoma is a benign tumor that has a glandular origin. Adenomas typically originate from cells used for secretion. Called epithelial cells, these cells are located throughout the body. However, only a portion of such cells is used for secretion. An adenoma forms when normal epithelial cells grow excessively.
Epithelial cells that are used for secretion make up specific parts of the body referred to as glands. Glands have the job of forming a number of substances in the body including, but not limited to, sweat, saliva, breast milk, mucous, and hormones. An adenoma can form from just about any glandular cell in the body.
An adenoma may form in a similar way to a malignant or cancerous tumor. A major difference between malignant tumors and adenomas is that adenomas do not metastasize or spread to other organs or tissues. Sometimes, however, adenomas develop into malignancies. When this happens, the newly malignant adenoma is called an adenocarcinoma.
Though it is possible for some adenomas to develop into cancerous tumors, having an adenoma is not usually predictive of the development of a malignancy. Most adenomas remain benign and do not form carcinomas. However, colon and rectal cancers may begin as adenomas. Additionally, bronchial adenomas can develop into lung cancer.
Frequently, adenomas have a noticeable affect on the organs or gland tissue in which they develop. Often, adenomas secrete hormones. When this occurs, the effects can be quite uncomfortable for the affected individual. In certain situations, the effects can even be deadly. However, some adenomas develop without any demonstrable effects.
There are certain types of adenomas that are more common in women, such as adenomas of the liver. Others, such as colon adenomas, are most common in adults of advancing age. The cause of adenomas is not yet known.
There are some things that seem to make developing adenomas more likely. For example, women who use oral contraceptives may be at increased risk of developing liver adenomas. Furthermore, certain types of adenomas may be inheritable. This is true of colon adenomas.
Symptoms related to adenomas vary widely. For example, a breast adenoma, called a fibroadenoma, typically causes no symptoms and may be so small that the affected individual is unable to detect it. Other breast adenomas, however, may be large enough to be noticeable by touch. By contrast, a lung adenoma can cause fever, chills, shortness of breath, and a bloody cough.
Pituitary Adenoma
• Patients tend to recover more quickly, and experience fewer complications than with conventional methods. During endoscopic pituitary adenoma surgery, access to the tumor is created via a small cut made at the rear of the nasal cavity.
• People may want to get second or third opinions prior to determining what to do if they’re diagnosed with a pituitary adenoma. It’s also challenging to discuss treatment and survival rate. A high percentage of people with an adenoma will receive excellent care and live to a ripe age.
Adenoma Tumors
• Unfortunately, the risk of the tumor becoming malignant is not reduced even if the use of steroids or contraceptives is stopped. Hepatic adenoma tumors that cause symptoms and tumors larger than 2 inches (5 cm) in size are almost always removed via surgery.
• Occasionally, adenomas begin to bleed spontaneously, and this might prove life-threatening without surgery. In the main, though, an adenoma is benign and won’t cause cancerous tumors to develop elsewhere, so outlook with treatment is good.
Kidney Adenoma
• The condition cannot be cured, and treatment measures are generally aimed at reducing symptoms and the chances of dangerous medical complications. Adenoma sebaceum tends to emerge around the age of two and worsen until a child reaches puberty.
• What type of kidney mass a patient has is generally determined by doing a biopsy and each tumor is classified by the location and nature of the mass. Renal adenoma is the most common form of benign kidney mass. Renal adenomas generally present themselves as small growths on either kidney and are mostly asymptomatic.
Adenoma Symptoms
• Another factor that might influence the development of these tumors is an imbalance in insulin and glucagons, the hormones that balance blood sugar levels and blood sugar uptake by cells. The most common hepatic adenoma symptom is pain in the upper right portion of the abdomen. As much as 50 percent of people with this tumor will experience pain in this region.
• People may want to get second or third opinions prior to determining what to do if they’re diagnosed with a pituitary adenoma. It’s also challenging to discuss treatment and survival rate. A high percentage of people with an adenoma will receive excellent care and live to a ripe age.

Crohn's disease

2010-12-27T14:59:00.000-08:00

Crohn's disease
Crohn's disease (also spelled Crohn disease) is a chronic inflammatory disease of the intestines. It primarily causes ulcerations (breaks in the lining) of the small and large intestines, but can affect the digestive system anywhere from the mouth to the anus. It is named after the physician who described the disease in 1932. It also is called granulomatous enteritis or colitis, regional enteritis, ileitis, or terminal ileitis.
Crohn's disease is related closely to another chronic inflammatory condition that involves only the colon called ulcerative colitis. Together, Crohn's disease and ulcerative colitis are frequently referred to as inflammatory bowel disease (IBD). Ulcerative colitis and Crohn's disease have no medical cure. Once the diseases begin, they tend to fluctuate between periods of inactivity (remission) and activity (relapse).
Inflammatory bowel disease affects approximately 500,000 to two million people in the United States. Men and women are affected equally. Americans of Jewish European descent are 4 to 5 times more likely to develop IBD than the general population. IBD has historically been considered predominately disease of Caucasians, but there has been an increase in reported cases in African Americans suffering from IBD. The prevalence appears to be lower among Hispanic and Asian populations. IBD most commonly begins during adolescence and early adulthood (usually between the ages of 15 and 35). There is a small second peak of newly-diagnosed cases after age 50. The number of new cases (incidence) and number of cases (prevalence) of Crohn's disease in the United States are rising, although the reason for this is not completely understood.
Crohn's disease tends to be more common in relatives of patients with Crohn's disease. If a person has a relative with the disease, his/her risk of developing the disease is estimated to be at least 10 times that of the general population and 30 times greater if the relative with Crohn's disease is a sibling. It also is more common among relatives of patients with ulcerative colitis.

Symptoms
Common symptoms of Crohn's disease include abdominal pain, diarrhea, and weight loss. Less common symptoms include poor appetite, fever, night sweats, rectal pain, and occasionally rectal bleeding. The symptoms of Crohn's disease are dependent on the location, the extent, and the severity of the inflammation. The different subtypes of Crohn's disease and their symptoms are:
1. Crohn's colitis is inflammation that is confined to the colon. Abdominal pain and bloody diarrhea are the common symptoms. Anal fistulae and peri-rectal abscesses also can occur.
2. Crohn's enteritis refers to inflammation confined to the small intestine (the first part, called the jejunum or the second part, called the ileum). Involvement of the ileum alone is referred to as Crohn's ileitis. Abdominal pain and diarrhea are the common symptoms. Obstruction of the small intestine also can occur.
3. Crohn's terminal ileitis is inflammation that affects only the very end of the small intestine (terminal ileum), the part of the small intestine closest to the colon. Abdominal pain and diarrhea are the common symptoms. Small intestinal obstruction also can occur.
4. Crohn's entero-colitis and ileo-colitis are terms to describe inflammation that involve both the small intestine and the colon. Bloody diarrhea and abdominal pain are the common symptoms. Small intestinal obstruction also can occur.
Crohn's terminal ileitis and ileo-colitis are the most common types of Crohn's disease. (Ulcerative colitis frequently involves only the rectum or rectum and sigmoid colon at the distal end of the colon. These are called ulcerative proctitis and procto-sigmoiditis, respectively.)
Up to one-third of patients with Crohn's disease may have one or more of the following conditions involving the anal area:
1. Swelling of the tissue of the anal sphincter, the muscle at the end of the colon that controls defecation.
2. Development of ulcers and fissures (long ulcers) within the anal sphincter. These ulcers and fissures can cause bleeding and pain with defecation.
3. Development of anal fistulae (abnormal tunnels) between the anus or rectum and the skin surrounding the anus). Mucous and pus may drain from the openings of the fistulae on the skin.

4. Development of peri-rectal abscesses (collections of pus in the anal and rectal area). Peri-rectal abscesses can cause fever, pain and tenderness around the anus.
Treatment
The symptoms and severity of Crohn's disease vary among patients. Patients with mild or no symptoms may not need treatment. Patients whose disease is in remission (where symptoms are absent) also may not need treatment.
Crohn's disease medications
There is no medication that can cure Crohn's disease. Patients with Crohn's disease typically will experience periods of relapse (worsening of inflammation) followed by periods of remission (lessening of inflammation) lasting months to years. During relapses, symptoms of abdominal pain, diarrhea, and rectal bleeding worsen. During remissions, these symptoms improve. Remissions usually occur because of treatment with medications or surgery, but occasionally they occur spontaneously without any treatment.
Since there is no cure for Crohn's disease, the goals of treatment are to 1) induce remissions, 2) maintain remissions, 3) minimize side effects of treatment, and 4) improve the quality of life. Treatment of Crohn's disease and ulcerative colitis with medications is similar though not always identical.
Medications for treating Crohn's disease include
1. anti-inflammatory agents such as 5-ASA compounds and corticosteroids,
2. topical antibiotics, and
3. immuno-modulators.
Selection of treatment regimens depends on disease severity, disease location, and disease-associated complications. Various guidelines recommend that approaches be sequential - initially to induce clinical remission, and then to maintain remissions. Initial evidence of improvement should be seen within 2 to 4 weeks and maximal improvement should be seen in 12 to 16 weeks3. The classic approach to therapy in Crohn's disease has been a "step-up" approach starting with the least toxic agents for mild disease, and increasingly more aggressive treatment for more severe disease, or patients who have not responded to less toxic agents. More recently the field has been moving toward a "top-down" approach (early aggressive management) which might decrease exposure to anti-inflammatory agents and increase exposure to agents that enhance mucosal healing that might prevent future complications.