Cambridge University Hospitals NHS Foundation Trust
Addenbrookes Hospital
Cambridge, UK
Increasing the length of the preoperative hospital stay to prophylactically treat the asthma with steroids b medicine and health solian 50 mg generic. A 72-year-old man undergoes a subtotal colectomy for a cecal perforation due to a sigmoid colon obstruction treatment yellow fever cheap solian 50mg amex. A 12-year-old boy with a femur fracture after a motor vehicle collision undergoes operative repair treatment lyme disease solian 100mg generic. Alkalinization of the urine medicine urinary tract infection solian 100mg without a prescription, administration of mannitol, and continuation with the procedure b. Administration of intravenous steroids and an antihistamine agent with continuation of the procedure. Administration of intravenous steroids and an antihistamine agent with termination of the procedure 37. Synthetic colloids should be administered as the primary resuscitation fluid in a 3:1 ratio to replace the volume of blood lost. Lactated Ringer solution should be administered in a ratio of 3:1 to replace the blood lost. A 60-kg, 53-year-old man with no significant medical problems undergoes lysis of adhesions for a small-bowel obstruction. Replacement of nasogastric tube losses with lactated Ringer in addition to maintenance fluids. Four days after surgical evacuation of an acute subdural hematoma, a 44-year-old man becomes mildly lethargic and develops asterixis. He has received 2400 mL of 5% dextrose in water intravenously each day since surgery, and he appears well hydrated. Pertinent laboratory values are as follows: Serum electrolytes (mEq/L): Na+ 118, K+ 3. A 43-year-old woman develops acute renal failure following an emergency resection of a leaking abdominal aortic aneurysm. One week after surgery, the following laboratory values are obtained: Serum electrolytes (mEq/L): Na+ 127, K+ 5. Eight hours after these values are reported, the following electrocardiogram is obtained. Which of the following is the most appropriate initial treatment in the management of this patient A 63-year-old man with a 40-pack per year smoking history undergoes a low anterior resection for rectal cancer and on postoperative day 5 develops a fever, new infiltrate on chest x-ray, and leukocytosis. A 60-year-old woman with no previous medical problems undergoes a total colectomy with diverting ileostomy for a cecal perforation secondary to a sigmoid stricture. Her other laboratory values on postoperative day 6 are as follows: Na+: 128 K+: 3. She should be intubated to correct her tachypnea and prevent respiratory alkalosis. A 45-year-old woman undergoes an uneventful laparoscopic cholecystectomy for which she receives 1 dose of cephalosporin. One week later, she returns to the emergency room with fever, nausea, and copious diarrhea and is suspected of having pseudomembranous colitis. Multiple units of packed red blood cells are transfused in an effort to resuscitate him. Intravenous parathyroid hormone Questions 46 to 49 A patient has a calculated basal energy expenditure of 2000 kcal/day. Match the following clinical situations with the appropriate daily energy requirement. States of magnesium excess are characterized by generalized neuromuscular depression. Clinically, severe hypermagnesemia is rarely seen except in those patients with advanced renal failure treated with magnesium-containing antacids. Greater elevations of magnesium produce progressive weakness, which culminates in flaccid quadriplegia and in some cases respiratory arrest due to paralysis of the chest bellows mechanism. Hypotension may occur because of the direct arteriolar relaxing effect of magnesium. Changes in mental status occur in the late stages of the syndrome and are characterized by somnolence that progresses to coma. Symptomatic hyponatremia, which occurs at serum sodium levels less than or equal to 120 mEq/L, can result in headache, seizures, coma, and signs of increased intracranial pressure and may require infusion of hypertonic saline. Rapid correction should be avoided so as not to cause central pontine myelinolysis, manifested by neurologic symptoms ranging from seizures to brain damage and death. Additionally, a search for the underlying etiology of the hyponatremia should be undertaken. Acute severe hyponatremia sometimes occurs following elective surgical procedures due to a combination of appropriate stimulation of antidiuretic hormone and injudicious administration of excess free water in the first few postoperative days. Calcium oxalate stones can subsequently develop due to excessive absorption of oxalate from the colon. Normally, fatty acids are absorbed by the terminal ileum, and calcium and oxalate combine to form an insoluble compound that is not absorbed. In the absence of the terminal ileum, unabsorbed fatty acids reach the colon, where they combine with calcium, leaving free oxalate to be absorbed. Unabsorbed fatty acids and bile acids in the colon also promote oxalate uptake by the colon. Subsequently, the excess oxalate is excreted by the kidneys, promoting calcium oxalate stone formation. Hungry bone syndrome refers to rapid remineralization of bones leading to hypocalcemia and can be seen postoperatively in patients with secondary or tertiary hyperparathyroidism. Pseudohyperparathyroidism refers to hypercalcemia associated with the production of parathyroidrelated peptide. When oliguria occurs postoperatively, it is important to differentiate between low output caused by the physiologic response to intravascular hypovolemia and that caused by acute tubular necrosis. Values above this suggest a tubular injury such that Na cannot be appropriately reclaimed. The neuromuscular effects resemble those of calcium deficiency-namely, paresthesia, hyperreflexia, muscle spasm, and, ultimately, tetany. Many hospital patients with refractory hypocalcemia will be found to be magnesium deficient. Often this deficiency becomes manifest during the response to parenteral nutrition when normal cellular ionic gradients are restored. The serum calcium in this patient is normal when adjusted for the low albumin (add 0. Hypomagnesemia causes functional hypoparathyroidism, which can lower serum calcium and thus result in a combined defect. Additionally, most textbooks recommend use of an oral, nonabsorbable antibiotic regimen effective against aerobes and anaerobes in combination with a mechanical bowel preparation before elective colon resections. There is no evidence to support the continuation of antibiotics for more than 24 hours after an elective operation has been completed, and this practice should be avoided to prevent increasing microbial drug resistance. Broad-spectrum antibiotic coverage, including against anaerobic organisms, is required only in cases where such flora are anticipated, such as during colon resections. The development of a clinically significant metabolic alkalosis is secondary not only to the loss of acid or addition of alkali but also to renal responses that maintain the alkalosis (paradoxical aciduria). The normal kidney can tremendously augment its excretion of acid or alkali in response to changes in ingested load. However, in the presence of significant volume depletion and consequent excessive salt and water retention, the tubular maximum for bicarbonate reabsorption is increased. Correction of volume depletion alone is usually sufficient to correct the alkalosis, since the kidney will then excrete the excess bicarbonate. Acetazolamide can be utilized to increase renal excretion of bicarbonate but should be avoided in volume-depleted individuals. Moreover, to the extent that acetazolamide causes natriuresis, it will exacerbate the volume depletion. Salicylates directly stimulate the respiratory center and produce respiratory alkalosis. By building up an accumulation of organic acids, salicylates also produce a concomitant metabolic acidosis. The patient is in a state of metabolic acidosis as shown by a markedly increased anion gap of 28 mEq unmeasured anions per liter of plasma.
Recent pseudo-outbreaks involving contaminated water supplies have been described (108 symptoms 4dp5dt discount solian 100mg with visa, 422) medications medicaid covers purchase solian 50 mg amex. The newer 8-methoxy fluoroquinolone symptoms dengue fever 50 mg solian sale, moxifloxacin treatment lupus buy discount solian 100mg online, seems to have activity against M. Recent reports suggest a regimen including clarithromycin, moxifloxacin, and trimethoprim/sulfamethoxazole may be successful. Recent studies have shown this resistance to relate to the presence of a chromosomal erythromycin (macrolide) methylase gene. Antituberculous medications are not active, with the exception of ethambutol, to which M. They exhibit variable susceptibility to cefoxitin and the older fluoroquinolones and are usually resistant to the macrolides (423). For severe infections, amikacin or imipenem are the parenteral agents most often used. In previously reported cases, chemotherapy was successful when combinations of more than two drugs were used (425). Although the optimal duration of treatment has not been established, a three- to fourdrug regimen that includes 12 months of negative sputum cultures while on therapy is probably adequate. Therapy with combination antituberculous medication based on in vitro susceptibilities for 4 to 6 months should be successful for extrapulmonary M. Differentiation of the species usually requires molecular techniques so that most clinical laboratories still refer to the collective designation, M. Moreover, most of the isolates of this complex have previously been presumed to be nonpathogenic so that little attention has been focused on this group of organisms (429). Of the cases cited, 59% involved tenosynovitis, and 26% were associated with pulmonary disease. One-half of the patients with tenosynovitis were treated with local or systemic corticosteroid and only onehalf of the patients who were followed for 6 months showed clinical improvement. The other half of the patients required extensive debridement, and surgical intervention or amputation (431). Some reports have also indicated potential pathogenicity of this organism for the lung. In 1983, a case of localized cavitary disease in the lung with multiple isolations of M. In one report, all six of the isolates from a single center and 90% or more of an additional 22 isolates of M. Infection is believed to occur through abraded or compromised skin after contact with contaminated water or soil. The lesions occur most commonly in children and young adults and often result in severe scarring and deformities of the extremities (88). Preulcerative lesions are often painless and can be treated effectively by excision and primary closure, rifampin monotherapy, or heat therapy. Postsurgical antimycobacterial treatment may prevent relapse or metastasis of infections. Clarithromyicn and rifampin may be the best choice for controlling complications of the ulcer. Drug treatment of the disease has been disappointing; surgical debridement combined with skin grafting is the usual treatment of choice (436). Supplementation of media with egg yolk or reduction of oxygen tension enhances the recovery of this species. Molecular techniques have been developed that may lead to more rapid identification of the organism. Clusters of hospital isolates have been reported from the United States, the United Kingdom, and in other areas in Europe. It has been speculated that the organism enters the hospital from municipal water mains, then multiplies in the hospital heating tanks where the temperature is 43 to 45 C, the optimal temperature for growth of this organism (442). In addition, the response of this organism to therapy is variable and does not always correlate well with the results of in vitro susceptibility. Therapy should be continued until the patient has maintained negative sputum cultures while on therapy for 12 months. It has been observed that sputum conversion occurs readily, but relapse rates are high even with macrolidecontaining regimens. Surgical resection of the affected lung may be appropriate in selected patients who have sufficient lung function and fail to respond to chemotherapy. A quinolone, preferably the 8-methoxy quinolone moxifloxacin, could be substituted for one of the antituberculous drugs. Therapy for extrapulmonary disease would include the same agents as for pulmonary disease. Important issues to be answered include prevalence and incidence rates, including geographic differences in those rates, and potential risk factors. However, greater awareness of factors at the molecular level, such as mutations and polymorphisms, and at the morphologic level, such as the roles of sex and chest shape, will gradually improve our understanding of susceptibility to mycobacterial diseases of individual patients. Nevertheless, multicenter, controlled trials are desperately needed for answering the many important questions about optimal therapy that remain unanswered. There is a need for a disease treatment model that will allow agents to be tested without significantly long monotherapy exposure. New antimicrobial agents are urgently needed to shorten or simplify therapy, provide more effective therapy, and diminish drug side effects. The identification of specific immune defect(s) might prove the essential element for the development of new therapeutic approaches. Interest in developing new drugs with mycobacterial disease activity is limited by the lack of economic return for these relatively rare diseases. The rating system includes a letter indicating the strength of the recommendation, and a roman numeral indicating the quality of the evidence supporting the recommendation (3) (Table 1). Laboratory Procedures Collection, digestion, staining, decontamination, and culturing of specimens. Clarithromycin is recommended as the "class agent" for testing of the newer macrolides because clarithromycin and azithromycin share cross-resistance and susceptibility. The clinician should use in vitro susceptibility data with an appreciation for its limitations. Fiberoptic endoscopes: the use of tap water should be avoided in automated endoscopic washing machines as well as in manual cleaning. Acknowledgment: the committee thanks Elisha Malanga, Monica Simeonova, and Judy Corn of the American Thoracic Society for patient and excellent administrative support. American Thoracic Society statement: diagnosis and treatment of disease caused by nontuberculous mycobacteria. Assessment of partial sequencing of the 65-kilodalton heat shock protein gene (hsp65) for routine identification of mycobacterium species isolated from clinical sources. Isolation of Mycobacterium avium complex from water in the United States, Finland, Zaire, and Kenya. Tanaka E, Kimoto T, Matsumoto H, Tsuyuguchi K, Suzuki K, Nagai S, Shimadzu M, Ishibatake H, Murayama T, Amitani R. Periodic administration of multidrug therapy, including a macrolide and one or more parenteral agents (amikacin, cefoxitin, or imipenem) or a combination of parenteral agents over several months may help control symptoms and progression of M. Skin test reactions to Mycobacterium tuberculosis purified protein derivative and Mycobacterium avium sensitin among health care workers and medical students in the United States. The epidemiology of nontuberculous mycobacterial diseases in the United States: results from a national survey. Mycobacterial species and drug resistance patterns reported by state laboratories. Joint Position Paper of the American Thoracic Society and the Centers for Disease Control. Pectus excavatum and scoliosis: thoracic anomalies associated with pulmonary disease caused by Mycobacterium avium complex. Interleukin12 production by human monocytes infected with Mycobacterium tuberculosis: role of phagocytosis. Rapidly growing mycobacterial lung infection in association with esophageal disorders.
A 35-year-old woman presents with frequent and multiple areas of cutaneous ecchymosis symptoms panic attack cheap solian 100mg on-line. Workup demonstrates a platelet count of 15 symptoms tonsillitis order 50mg solian amex,000/L medicine clip art generic solian 100 mg with mastercard, evaluation of the bone marrow reveals a normal number of megakaryocytes medications similar to lyrica 100mg solian with mastercard, and ultrasound examination demonstrates a normal-sized spleen. Immediate platelet transfusion to increase platelet counts to greater than 50,000/L c. A 59-year-old woman presents with right lower quadrant pain, nausea, and vomiting. Manometry shows a hypertensive lower esophageal sphincter with failure to relax with deglutition. Which of the following is the safest and most effective treatment of this condition Medical treatment with sublingual nitroglycerin, nitrates, or calcium-channel blockers b. Which of the following is the most appropriate elective operation for this patient Total proctocolectomy with ileal pouch-anal anastomosis and diverting ileostomy c. Total proctocolectomy with ileal pouch-anal anastomosis, anal mucosectomy, and diverting ileostomy d. A 39-year-old previously healthy male is hospitalized for 2 weeks with epigastric pain radiating to his back, nausea, and vomiting. Initial laboratory values revealed an elevated amylase level consistent with acute pancreatitis. Five weeks following discharge, he complains of early satiety, epigastric pain, and fevers. Which of the following would be the most definitive management of the fluid collection Surgical internal drainage of the fluid collection with a cyst-gastrostomy or Roux-en-Y cystjejunostomy 297. A previously healthy 79-year-old woman presents with early satiety and abdominal fullness. A 56-year-old woman is referred to you about 3 months after a colostomy subsequent to a sigmoid resection for cancer. Which of the following is the most common serious complication of an end colostomy A 56-year-old previously healthy physician notices that his eyes are yellow and he has been losing weight. On physical examination the patient has jaundice and scleral icterus with a benign abdomen. Transcutaneous ultrasound of the abdomen demonstrates biliary ductal dilation without gallstones. Which of the following is the most appropriate next step in the workup of this patient A 45-year-old woman with history of heavy nonsteroidal anti-inflammatory drug ingestion presents with acute abdominal pain. She undergoes exploratory laparotomy 30 hours after onset of symptoms and is found to have a perforated duodenal ulcer. Six weeks after surgery, he returns, complaining of postprandial weakness, sweating, light-headedness, crampy abdominal pain, and diarrhea. Dietary advice and counseling that symptoms will probably abate within 3 months of surgery c. Dietary advice and counseling that symptoms will probably not abate but are not dangerous d. A 60-year-old male patient with hepatitis C with a previous history of variceal bleeding is admitted to the hospital with hematemesis. His blood pressure is 80/60 mm Hg, physical examination reveals splenomegaly and ascites, and initial hematocrit is 25%. Prior to endoscopy, which of the following is the best initial management of the patient A 32-year-old alcoholic with end-stage liver disease has been admitted to the hospital 3 times for bleeding esophageal varices. A 45-year-old man was discovered to have a hepatic flexure colon cancer during a colonoscopy for anemia requiring transfusions. Upon exploration of his abdomen in the operating room, an unexpected discontinuous 3-cm metastasis is discovered in the edge of the right lobe of the liver. Preoperatively, the patient was counseled of this possibility and the surgical options. Which of the following tests provides the least invasive method to document eradication of the infection Which of the following hernias follows the path of the spermatic cord within the cremaster muscle An 80-year-old man with history of symptomatic cholelithiasis presents with signs and symptoms of a small-bowel obstruction. Which of the following findings would provide the most help in ascertaining the diagnosis A 42-year-old man has bouts of intermittent crampy abdominal pain and rectal bleeding. The patient is successfully treated by removing as many polyps as possible with the aid of intraoperative endoscopy and polypectomy. A 70-year-old woman has nausea, vomiting, abdominal distention, and episodic crampy midabdominal pain. She has no history of previous surgery but has a long history of cholelithiasis for which she has refused surgery. A 53-year-old man presents to the emergency room with left lower quadrant pain, fever, and vomiting. After percutaneous drainage and treatment with antibiotics, the pain and fluid collection resolve. He undergoes a colonoscopy, which demonstrates only diverticula in the sigmoid colon. A 29-year-old woman complains of postprandial right upper quadrant pain and fatty food intolerance. Upper endoscopy is normal, and all of her liver function tests are within normal limits. Ultrasound examination should be repeated immediately, since the falsenegative rate for ultrasound in detecting gallstones is 10% to 15%. A 47-year-old asymptomatic woman is incidentally found to have a 5-mm polyp and no stones in her gallbladder on ultrasound examination. Observation with repeat ultrasound examinations to evaluate for increase in polyp size c. En bloc resection of the gallbladder, wedge resection of the liver, and portal lymphadenectomy 314. A 48-year-old woman develops pain in the right lower quadrant while playing tennis. On examination, she is tender in the right lower quadrant with muscular spasm, and there is a suggestion of a mass effect. A 32-year-old alcoholic man, recently emigrated from Mexico, presents with right upper quadrant pain and fevers for 2 weeks. A 45-year-old executive experiences increasingly painful retrosternal heartburn, especially at night. In determining the proper treatment for a sliding hiatal hernia, which of the following is the most useful modality She denies pain and is able to make the bulge disappear by lying down and putting steady pressure on the bulge. Observation for now and follow-up in surgery clinic if she develops further symptoms c. Emergent surgical repair of hernia with exploratory laparotomy to evaluate the small bowel 318. A 22-year-old woman presents with a painful fluctuant mass in the midline between the gluteal folds. Colonoscopy reveals patches of dusky-appearing mucosa at the splenic flexure without active bleeding. A 62-year-old man has been diagnosed by endoscopic biopsy as having a sigmoid colon cancer.
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Diseases
Esophageal varices
Pemphigus
Xeroderma pigmentosum, type 1
Peutz Jeghers syndrome
Pseudo-Turner syndrome
Disaccharide intolerance iii
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