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By N. Tyler. American InterContinental University. 2018.

The history should establish the du- Constipation ration and severity of weight loss buy cheap promethazine 25mg on-line allergy medicine mixing. Hard promethazine 25 mg otc allergy symptoms loss of voice, dif- The acute abdomen introduction ficulttopassstoolsarealsoconsideredconstipation,even if frequent. The patient is often generally unwell and may be shocked due to dehydration and loss of fluid into extravascular Management spaces such as the lumen of the bowel and the abdominal Patients may require resuscitation, and general manage- cavity. Investigations r If shocked, a fluid balance chart should be started and r Full blood count (often normal, but leucocytosis may where appropriate urinary catheterisation to monitor be present). Gallbladder Acute cholecystitis Colon Diverticulitis Fallopian tube Pelvic inflammatory disease Prevalence Pancreas Acute pancreatitis Dyspepsia has a prevalence of between 23 and 41% in Obstruction Western populations. Intestine Intestinal obstruction Biliary system Biliary colic Aetiology/pathophysiology Urinary system Ureteric obstruction/colic. Acute urinary retention Diagnosesmadeatendoscopyincludegastritis,duodeni- Ischaemia tis or hiatus hernia (30%); oesophagitis (10–17%); duo- Small/large bowel Strangulated hernia denal ulcers (10–15%); gastric ulcers (5–10%) and oe- Volvulus sophageal or gastric cancer (2%); however, in 30% the Mesenteric ischaemia endoscopy is normal. Functional dyspepsia describes the Perforation/rupture Duodenum/ Perforation of peptic ulcer or presence of symptoms in the absence of mucosal abnor- stomach eroding tumour mality, hiatus hernia, erosive duodenitis or gastritis. Colon Perforated diverticulum or tumour Fallopian tube Ruptured ectopic pregnancy Clinical features Abdominal aorta Ruptured aneurysm Patients may complain of upper abdominal discomfort, Ruptured spleen Trauma retrosternal burning pain, anorexia, nausea, vomiting, Nonsurgical causes Myocardial infarction, gastroenteritis (inc. Epigastric mass Suspicious barium meal Previous gastric ulcer Clinical features Peritonitis presents with pain, tenderness, rebound ten- derness and excessive guarding. Antise- the pain, so patients often lie very still and have a rigid cretorydrugs(i. At endoscopy, biopsy and urease tests should be Infection may spread to the blood stream (septicaemia) performed. In patients under the age of 55 years with significant symptoms but without any ‘alarm symptoms or signs’ antisecretory agents may be commenced. It is recom- Microscopy mended that such patients should undergo Helicobac- An acute inflammatory exudate is seen with cellular in- ter pylori testing and where appropriate, eradication filtration of the peritoneum. Investigations The diagnosis is clinical, further investigation depends on the possible underlying cause. Peritonitis Definition Management Peritonitis is inflammation of the peritoneal lining of the Managementinsecondaryperitonitisisaimedatprompt abdomen. Peritonitis may be acute or chronic, primary surgical treatment of the underlying cause (after ag- or secondary. Primary or postoperative peri- tonitis, which is non-surgical in origin, is managed medically. Patients undergo- Intestinal obstruction ing peritoneal dialysis are at particular risk of recur- Definition rent acute peritonitis, which may result in fibrosis and Intestinal obstruction results from any disease or process scarring preventing further use of this type of dialysis. It may be Chronic liver disease patients with ascites are at risk acute, subacute, chronic or acute on chronic. Aetiology r Chronic infective peritonitis occurs from tuberculous The common causes vary according to age. Childrendevelopintestinalobstructionfromex- lae conniventes) whereas large bowel markings (haus- ternal hernia, intussusception or surgical adhesions. Erect adults external hernia, large bowel cancer, adhesions, di- abdominal X-ray may demonstrate fluid levels and any verticular disease and Crohn’s disease may all cause ob- co-existent perforation. Management Pathophysiology Following resuscitation, prompt diagnosis and opera- r The bowel may obstruct from an intraluminal mass, tion are essential to avoid strangulation. Theremaybecompressionofblood r Hernias are reduced and repaired, adhesions and vessels and a consequent ischaemia. As the ex- r Gallstones or food bolus causing intraluminal ob- tracellular pressure rises arteries become obstructed struction are milked into the colon. Clinical features Right colonic obstruction: Patients present with pain, vomiting and a failure to pass r Obstructive lesions of the right colon are managed by faeces or flatus. The site of pain is dependent on the righthemicolectomy and end-to-end ileocolic anas- embryological gut: tomosis. Left colonic obstruction:Surgery is often a two-stage r Hind gut (down to the dentate line of the rectum). Auscultation reveals exaggerated with closure of the distal stump, which is returned to bowel sounds and high pitched tinkling sounds when the abdominal cavity).

Clinical features Osteoporosis is not itself painful buy 25mg promethazine mastercard allergy forecast pearland tx; however cheap 25mg promethazine visa allergy or bug bite, the fractures that result are. Typical sites include the vertebrae, distal Clinical features radius(Colles’fracture)andtheneckofthefemur. Other Onset is insidious with bone pain, backache and weak- symptomsofvertebralinvolvementarelossofheightand ness that may be present for years before the diagnosis is increasing kyphosis. Vertebral compression and pathological fractures may occur; a biochemical diagnosis may be made prior Investigations to onset of clinical disease. Investigations r X-rayinvestigationshowsfractures,abonescancanbe r X-ray investigation shows generalised bone rarefac- used to demonstrate recent fractures. Looser’s zones bone density is difficult to assess as the appearance is may be seen in which there is a band of severe rarefac- dependent on the X-ray penetration. Maleswith A disorder of bone remodelling with accelerated rate of gonadal failure benefit from androgens. Chapter 8: Genetic musculoskeletal disorders 375 Prevalence calcium level may rise dramatically. Asymptomatic Paget’s disease requires no treatment, patients with persistent bone pain, repeated fractures, Sex neurological complications or high cardiac output are M = F treated with calcitonin and/or bisphosphonates, which suppress bone turnover. Viral infections may also be involved in the aetiology, including canine dis- Genetic musculoskeletal temper virus and measles. Paget’s disease may be due to disorders a latent infection in a genetically susceptible individual. Achondroplasia Pathophysiology Osteoclastic overactivity causes excessive bone resorp- Definition tion. There follows osteoblast activation in an attempt Achondroplasiaisaformofosteochondroplasiainwhich to repairthelesion. Clinical features Incidence Most patients are asymptomatic and the disease is dis- Commonest form of true dwarfism. On examina- Age tion the bone may be bent and thickened, most obvious Congenital, usually obvious by age 1. With widespread bone involvement there may be a bowing of the legs and con- siderable kyphosis. Disproportionate shortening of the long bones of the limbs with a normal trunk length. The head is large Investigations with a prominent forehead and a depressed bridge of Characteristically there is a very high serum alkaline the nose causing a saddle shaped nose. There is a large lumbar lordosis, which causes phate reflecting the high bone turnover. A tri- ing periods of immobilisation in active disease the serum dent deformity of the hands may be present. Patients may develop neurological problems due to r Correction of deformities if necessary by surgical in- stenosis of the spinal canal; this may require surgical in- tervention. Definition Aheterogenous disorder with brittle bones and involve- ment of other collagen containing connective tissue. Definition Metastatic cancer is much more common than primary Aetiology bone cancer. Bluescleraresultfrom Two thirds of bone secondaries arise from adenocarci- a thinning of the sclera, which allows the colour of the nomas of the breast or prostate. Metastases usually appear in the Clinical features marrow cavity, damaging bone both directly through Features and classification are given in Table 8. Thetriadofotosclerosis, Patients may present with bone pain or a pathological blue sclera and brittle bones is termed van der Hoeve’s fracture. May arise growth, streaks in Paget’s of soft tissue disease calcification (sun-ray appearance) Ewing’s tumour Malignant Child/adolescent Pain and swelling Bone destruction Surgery often tumour M > F with warm with overlying requires arising from tender lump ‘onion skin’ amputation the vascular with ill defined layers of followed by endothelium edges periosteal new chemotherapy bone Chondroma Benign tumour 40+ age M > F Pain, swelling or a Low density area in Excised and replaced of cartilage fracture often in medulla of the with bone graft hands bone often with specks of calcification Chondrosarcoma Malignant 30–60 yrs M > F Pain, fracture or Destructive Surgery or tumour growing medullary chemotherapy, arising from exostosis tumour metastasises early chondrocytes containing flecks of calcification anaemia due to marrow replacement, hypercalcaemia fractures and spinal decompression in vertebral collapse and nerve or spinal cord compression. Investigations TheX-raytypicallydemonstratesadestructivelyticbone Primary bone tumours lesion, although some metastases appear sclerotic (e. Vasculitis Management Symptomatic treatments include analgesia, local ra- Vasculitis is an inflammatory infiltration of the wall of diotherapy and chemotherapy, internal fixation of any blood vessels with associated tissue damage. The underlying Investigations mechanisms of the disorders are not fully understood.

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According to the justification principle 25 mg promethazine with visa allergy symptoms heart rate, if a diagnostic imaging examination is indicated and justified quality promethazine 25mg allergy testing accuracy, this implies that the risk to the patient of not performing the examination is greater than the risk of potential radiation induced harm to the patient. The implementation of quality criteria and regular audits should be instituted as part of the radiological protection culture in the institution. Imaging techniques that do not employ the use of ionizing radiation should always be considered as a possible alternative. For the purpose of minimizing radiation exposure, the criteria for the image quality necessary to achieve the diagnostic task in paediatric radiology may differ from adults, and noisier images, if sufficient for radiological diagnosis, should be accepted. The advice of medical physicists should be sought, if possible, to assist with installation, setting imaging protocols and optimization. Exposure parameters that control radiation dose should be carefully tailored for children and every examination should be optimized with regard to radiological protection. Apart from image quality, attention should also be paid to optimizing study quality. Acceptable quality also depends on the structure and organ being examined and the clinical indication for the study. Additional training in radiation protection is recommended for paediatric interventional procedures, which should be performed by experienced paediatric interventional staff due to the potential for high patient radiation dose exposure. Public protection: Release of patients after therapy with unsealed radionuclides A major concern for public protection related to medicine is the release of patients after therapy with unsealed radionuclides. After some therapeutic nuclear medicine procedures with unsealed radionuclides, precautions may be needed to limit doses to other people. Iodine-131 results in the largest dose to medical staff, the public, caregivers and relatives. Young children and infants, as well as visitors not engaged in direct care or comforting, should be treated as members of the public (i. The modes of exposure to other people are external exposure, internal exposure due to contamination, and environmental pathways. Contamination of infants and children with saliva from a patient could result in significant doses to the child’s thyroid. Many types of therapy with unsealed radionuclides are contraindicated in pregnant females. The second largest 131 discharges, I, can be detected in the environment after medical uses. Radionuclides released into modern sewage systems are likely to result in doses to sewer workers and the public that are well below public dose limits. The decision to hospitalize or release a patient should be determined on an individual basis. In addition to residual activity in the patient, the decision should take many other factors into account. Hospitalization will reduce exposure to the public and relatives, but will increase exposure to hospital staff. Hospitalization often involves a significant psychological burden as well as monetary and other costs that should be analysed and justified. Patients travelling after radioiodine therapy rarely present a hazard to other passengers if travel times are limited to a few hours. Environmental or other radiation detection devices are able to detect patients who have had radioiodine therapy for several weeks after treatment. Personnel operating such detectors may need specific training to identify and deal with nuclear medicine patients. Records of the specifics of therapy with unsealed radionuclides should be maintained at the hospital and given to the patient along with written precautionary instructions. In the case of death of a patient who has had radiotherapy with unsealed radionuclides in the last few months, special precautions may be required. Primum non nocere, the old Latin motto meaning ‘first, do no harm’ should be prevalent in the medical uses of radiation.

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