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Clinical Director, Rutgers New Jersey Medical School
Clinical abdominal examination may be unreliable as the enlarged uterus displaces the abdominal content acne during pregnancy boy or girl order bactroban online from canada. The evaluation of possible injury to the abdomen is different because of the presence of the gravid uterus acne at 30 generic 5 gm bactroban amex. In addition acne studios scarf buy 5 gm bactroban with amex, stretching of the abdominal wall modifies the normal response to peritoneal irritation acne and pregnancy cheap 5gm bactroban with visa. Guarding and rebound can be blunted despite significant intraabdominal bleeding or organ injury, leading to an underestimation of the extent and gravity of maternal trauma. The basis of hypotensive resuscitation in trauma is to prevent increased arterial blood loss from uncontrolled bleeding sites due to overly aggressive fluid resuscitation until surgical control of bleeding is achieved. End-organ damage may be seen as myocardial ischaemia, renal failure or cerebral ischaemia and in these situations adequate end-organ perfusion should be maintained with fluid resuscitation and emergent surgical control of bleeding. Hypotensive resuscitation is contraindicated in a head-injured patient where maintenance of cerebral perfusion pressure is dependent on the blood pressure. The standard haemodynamic measurements do not measure the physiologic derangements of a patient in haemorrhagic shock. The initial lactate level and base deficit seem to be useful in quantifying the degree of ongoing fluid resuscitation requirements and one of the targets of resuscitation is to normalise this during the first 24 hours. Additionally, the time taken to normalise the same is considered as circulatory predictors of survival of a trauma patient. It should not be used for younger children because their head is larger and their extremities are smaller in proportion compared with adults. This rule divides the body into segments that are approximately 9% or multiples of nine and puts the percentages allocated for the head at 9%, the front of the trunk at 18%, the back of the trunk at 18%, the upper limbs at 9% and the lower limb at 18%, with the perineum forming the remaining 1%. These charts are age adjusted and allows for changes in children at different ages. Answer: C the Parkland formula is the most commonly used resuscitation fluid prediction formula in both adults and children with moderate-severe burns. It calculates the 24-hour fluid requirement, of which half should be infused in the first 8 hours (counted from the time of the burn injury) and the other half over the following 16 hours. Once the coagulopathy, hypothermia and metabolic acidosis are subsequently corrected in a critical care facility, the definitive surgical procedure can be carried out as necessary. The aetiology of high mortality associated with massive transfusion is usually multifactorial. The factors that could contribute to high mortality include hypotension, acidosis, coagulopathy, shock and the underlying pathologies in the patient. The triad associated with highest mortality are acidosis, hypothermia and coagulopathy. A massive transfusion may be required in the clinical situation of severe trauma, surgery, ruptured aortic aneurysm, gastrointestinal haemorrhage and during obstetric complications. It is recommended that individual institutions should develop a massive transfusion protocol to be used in patients who potentially require massive transfusions. In trauma patients, a ratio of 2: 1: 1 seems to be associated with improved survival. In non-trauma patients currently there is insufficient evidence to support or refute the use of a defined ration of blood components. Answer: C In Salter-Harris type I injuries the fracture goes through the growth plate, completely separating the epiphysis from the metaphysis. However, the epiphysis is not always displaced, hence there may not be any abnormalities visible on X-ray. Usually the displaced epiphysis is easily reduced as the two surfaces are covered with cartilage. It may be associated with a long bone fracture away from the growth plate injury such as a midshaft femur fracture. Consequently, growth arrest at the growth plate may occur, resulting in limb length discrepancy or angular deformity at the joint. Type l and V injuries are difficult to differentiate clinically and there may not be any X-ray changes. The history might give a clue where a type I injury is due to shearing or avulsion forces and a type V injury is due to axial compression. In displaced supracondylar fractures the rate of nerve injury is reported to be 15%. The most commonly affected nerve is the anterior interosseous branch of the median nerve, but median, radial and ulnar nerve injuries may occur. The following screening tests can be used in a young child to check the motor function of the individual nerves.
Nephrotic syndrome is characterized by the massive loss of protein causing In extreme cases acne fulminans purchase bactroban canada, oliguria results skin care khobar purchase bactroban no prescription. No significant renal changes are seen under the light microscope (hence the name) acne xia generic 5 gm bactroban with visa. The cause is unknown skin care quotes bactroban 5gm discount, but potential mechanisms include a post-allergic reaction, circulating immune complexes, or altered T-cell immunity. Treatment involves corticosteroid therapy and ciclosporin or cyclophosphamide (if resistant). The prognosis is good in children and variable in adults, but usually good with it only very rarely causing end-stage renal failure. Focal segmental glomerulosclerosis this accounts for 10% of childhood and up to 30% of cases of adult nephrotic syndrome. It is more common in males and its causes are: Altered cellular immunity Intravenous heroin use Acquired immune deficiency syndrome Reaction to chronic proteinuria Idiopathic. Histological examination reveals focal collapse and sclerosis, with hyaline deposits in glomerular segments. Presentation is with proteinuria or nephrotic syndrome, later developing haematuria and hypertension. Treatment of the idiopathic form might involve steroids, cyclophosphamide, ciclosporin, dialysis and renal transplantation. Membranous glomerulonephropathy this is a chronic disease characterized by: Subepithelial deposition of immune complexes Basement membrane thickening. Histological examination reveals widespread glomerular basement thickening caused by immunoglobulin deposition. Over time, the abnormal excess mesangial matrix causes hyalinization of the glomerulus and death of individual nephrons. In secondary membranous glomerulonephropathy, treatment of underlying disease causes disease remission. Rapidly progressive (crescentic) glomerulonephritis this results in severe glomerular injury. As the name suggests, the disease progresses rapidly 20 Diseases of the glomerulus and there is a loss of renal function within days to weeks. Prompt diagnosis and treatment is therefore required to prevent hypertension, kidney scarring and renal failure. Treatment is usually conservative, with antibiotics to treat any remaining infection. The prognosis is excellent in children but only 60% of adults recover completely; the rest develop hypertension or renal impairment. Membranoproliferative glomerulonephropathy Also known as mesangiocapillary glomerulonephritis, this is rare. It is characterized histologically by diffuse global basement membrane thickening and mesangial proliferation. It can present with asymptomatic haematuria or combined nephrotic/nephritic syndrome. It is more common Focal Diffuse Secondary glomerulonephritis Systemic disorders can cause glomerular disease. It is a relapsing and remitting condition, usually diagnosed between 30 and 40 years of age. It affects many systems and organs in the body; for example, the joints, skin, heart, lungs and the kidneys (75% of cases). Glomerular changes vary from minimal involvement to diffuse proliferative disease with: Immune complex deposition in glomerulus (frequently all classes of immunoglobulin and complement) Basement membrane thickening Endothelial proliferation. Presentation is with microscopic haematuria, fluid retention and renal impairment. Diabetic glomerulosclerosis Diabetes mellitus affects several organs including the kidneys, which are the most commonly and severely damaged organs in diabetes. Renal manifestations include nodular glomerulosclerosis and arteriosclerosis, including benign nephrosclerosis with hypertension. It is an immune-mediated systemic vasculitis that affects many parts of the body including: Skin: a purpuric rash is seen over on the extensor surface of the legs, arms and buttocks Joints: resulting in pain Intestine: resulting in abdominal pain, vomiting, bleeding. Papillary necrosis is a recognized complication, especially in the presence of infection. Diabetic nephropathy presents with microalbuminuria, which increases progressively to nephrotic range proteinuria. Chronic renal damage as a result of diabetes is associated and accelerated by hypertension. Histological examination reveals extensive necrosis, fibrin deposition and epithelial crescents. Amyloidosis this disorder involves deposition of amyloid (an extracellular fibrillar protein) in the glomeruli, usually within the mesangium and subendothelium, and sometimes in the subepithelial space. Deposits can also be found in the walls of the blood vessels and in the interstitium. Autosomal dominant and autosomal recessive patterns of inheritance have also been described. Presentation is with glomerulonephritis and haematuria, ocular abnormalities and sensorineural deafness. Females might have microscopic haematuria, but rarely develop end-stage renal failure. Prognosis is poor without treatment, which involves: Plasma exchange (to remove the antibodies) Corticosteroids (to reduce inflammation).
It is inherited in an autosomal dominant manner and is associated with defects in the sodium channel acne keloidalis nuchae home treatment buy bactroban now. Patients with syncope who are suspected of having Brugada syndrome should be admitted to a monitored bed acne video bactroban 5 gm with visa. Answer: C Isoprenaline causes beta-adrenergic receptor stimulation and has a potential antiarrythmic effect in patients with Brugada syndrome skin care chanel discount bactroban 5gm without a prescription. All other drugs have the potential to block sodium channels and precipitate arrhythmias acne around nose purchase bactroban from india. It has also been shown that efficacy of adenosine increases with faster heart rates. Answer: B Recurrent torsades de pointes, refractory to magnesium therapy, can be effectively managed with overdrive pacing. This can be achieved electrically, or pharmacologically with an agent such as isoprenaline. Dihydropyridine calcium channel blockers do not reduce heart rate (indeed, they may result in reflex tachycardia). Cardioversion is not recommended after 48 hours due to the increased risk of thromboembolism. Digoxin and nondihydropyridine sodium-channel blockers are contraindicated in preexcitation syndromes, where ventricular rate may be paradoxically accelerated. About 20% have reentry involving a bypass tract (accessory pathway) and the remainder have reentry elsewhere. When the patient is unstable due to rapid ventricular rate, immediate cardioversion should be attempted. It is important to exclude underlying illness, such as haemorrhage or sepsis, as the cause of the rapid ventricular rate prior to attempting cardioversion. Indeed, these patients carry a significant risk of embolic events if cardioverted without the necessary period of anticoagulation before and after cardioversion. The resultant increase in the impulse transmission through the accessory pathway causes a rapid ventricular rate. Answer: D In a patient with a pacemaker, failure to pace may be due to a lack of pacemaker output or failure to capture. If the energy in the pacemaker is insufficient to generate an adequate impulse to successfully depolarise the myocardium this may lead to failure to capture myocardium electrically and mechanically. A local inflammatory reaction in the initial few weeks following the insertion of pacemaker, can cause a local fibrosis in the myocardium to occur. Lead problems such as lead fracture or dislodgement, cardiac perforation and faulty connections of leads can cause failure to capture. As expected, a prolonged refractory period of the myocardium causes failure to capture. Electrolyte abnormalities may be a cause for a prolonged refractory period of myocardium. The rate of the atrial complexes are between 215 and 350/min and in adults it will not exceed >350/min. There is absolutely no flat or isoelectric segment between atrial complexes (flutter waves) and therefore they have a saw-tooth appearance. Answer: C Oversensing, therefore inappropriate inhibition of the pacemaker, may cause failure of pacemaker output. Oversensing of P and T waves and skeletal muscle activity by the pacemaker can occur, causing failure of output. The depolarising muscle relaxant suxamethonium causes muscular fasciculation during rapid sequence induction, hence it may cause pacemaker failure during this time. When pacemaker output fails, a pacemakerdependent patient should exhibit signs of hypoperfusion. Answer: B Tetralogy of Fallot results in right heart outflow obstruction, causing right to left shunting and cyanosis. Crying will increase pulmonary pressures and hence increase right to left shunting. Answer: C Paroxysmal supraventricular tachycardia represents 90% of tachyarrhythmias in children. In this age group the vagal manoeuvre commonly used is intermittent placement of a bag filled with ice and some water. If this fails other options such as beta-blockers and amiodarone should only be used with caution. Verapamil can cause cardiovascular collapse and death in this age group and therefore should be avoided. Acyanotic lesions that may be ductal dependent are pulmonary stenosis and severe coarctation of the aorta. Neonates may present with signs of congestive cardiac failure, however, this is not common.
Approximately 10% of adults 65 years of age or older presenting to primary care settings have clinically significant depression acne 3 dpo generic 5 gm bactroban fast delivery. It is often masked by other chronic medical conditions and if not proactively sought it could be missed and left untreated acneorg order 5 gm bactroban mastercard. One reason for this is that depressive symptoms are considered as a normal part of ageing skin care vitamin e order bactroban with visa. Answer: B Evidence shows that one in four females suffers from depression at some time in their lives and most fall Depression is common in women acne wallet order bactroban, in patients with chronic medical conditions, patients reporting insomnia, and in patients who have experienced stressful life events such as loss of a spouse, functional decline or social isolation. These patients often present with other problems including worsening of their existing medical illnesses. In a scenario such as that described, it is important to differentiate depression from grief. Persistence of major depressive symptoms in a patient who experienced a loss of a loved one more than 2 months previously should increase the suspicion for this diagnosis. If untreated, late-life depression is associated with a poor quality of life, with poor social and physical functioning, poor adherence to treatment regimes, and worsening of the medical problems. This also increases morbidity and mortality in older people including from completed suicide. These patients should be appropriately referred to psychiatry services for management and follow-up. In schizophrenia, completed suicide is especially associated with the time of their first diagnosis, as well as after recovery from an exacerbation. When a patient first becomes aware of having this severe mental illness they tend to be highly vulnerable to take their life. This comprises: Sex (males have a higher risk of completing suicide) Age (<19 or >45) Depression and hopelessness Previous attempt or psychiatric care Excessive alcohol or drug use Rational thinking loss Separated, divorced or widowed Organised or serious attempt No social supports Stated future intent. This rough guideline covers many of the high-risk issues and can be easily used in a busy setting. One of the important factors for an emergency clinician to consider is that suicidal ideation is commonly associated with mental illness, and can successfully be treated with appropriate psychiatric interventions. In addition, many suicide attempts occur during an acute situational crisis, such as a personal loss. Assessing or estimating the suicidal risk of a patient is one of the most challenging clinical judgement situations. The risk factors are generally cumulative and worsen the overall risk; however, they should be evaluated against the presence of any protective factors (factors that mitigate the risk). Two of the most important predictors of suicide are current suicidal ideation and severity of previous suicidal attempts. In primary care situations the prevalence is four times higher than in general population. Recurrent suicidal threats or acts and self-injury with a combination of strong preoccupation with expected rejection and abandonment are the strongest indicators. These patients feel they need to be connected to someone who they believe really cares. This preoccupation sets unrealistic expectations and the need for continuous validation by others. The unrealistic expectations and perceived rejections or abandonments by others lead to breakdown of positive relationships. The self-injurious behaviour (cutting or self-poisoning) is a way of coping through their perceived sense of despair and their inability to gain control of this perceived despair. However, front-line emergency medicine staff see this more as a wilful and manipulative behaviour than signs of an illness. In reality the majority of these patients are lowfunctioning individuals due to their illness. Psychotherapy is a main form of treatment along with dialectical behaviour therapy and mentalisation therapy. With respect to comorbid mental disorders, there are differences between female and male patients, with disorders associated with substance misuse being more common in men and eating disorders more common in women. Patients with this condition have poor sleep, hypervigilance and severe anxiety at night, which often leads them to seek help during this time. Patients from certain cultures may present with somatic problems when they are psychologically distressed. Answer: D Rapid tranquilisation (neurolepting) is an important aspect of emergency psychiatry. Rapid tranquilisation must be done in a non-punitive manner with established norms of preserving patient respect and dignity. A confident show of strength with several staff members and security staff may settle patients at times. However, once the decision has been made to use rapid tranquilisation, the initiation of such treatment has to be rapid so as to help prevent potential risks to the patient and the staff. Current options in sedation include both antipsychotics (droperidol, olanzapine) and anxiolytics (benzodiazepines). Rapidly dissolving oral formulations are available for some of the newer antipsychotics (olanzapine). They may be as effective as parenteral formulations if patient cooperation can be obtained. Answer: D Anorexia nervosa is an eating disorder that usually begins in adolescence but can occur in adulthood.
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