approach to the patient with heart murmurs

... that the erosion is the primary lesion and the redness and scale are secondary, while the correct interpretation would be that the patient has a pruritic eczematous dermatitis with erosions caused ... (Table 52-4) For instance, the finding of scaling papules (present in patients with psoriasis or atopic dermatitis) places the patient in a different diagnostic category than would hemorrhagic papules, ... important to differentiate primary from secondary skin lesions If the examiner focuses on linear erosions overlying an area of erythema and scaling, he or she may incorrectly assume that the erosion...

Ngày tải lên: 06/07/2014, 20:20

... elicits the desire to scratch Pruritus is often the predominant symptom of inflammatory skin diseases (e.g., atopic dermatitis, allergic contact dermatitis); it is also commonly associated with ... epidermal atrophy) Scar: A change in the skin secondary to trauma or inflammation Sites may be erythematous, hypopigmented, or hyperpigmented depending on their age or character Sites on hair-bearing ... Lichenoid: Violaceous to purple, polygonal lesions that resemble those seen in lichen planus Milia: Small, firm, white papules filled with keratin Morbilliform: Generalized, small erythematous macules...

Ngày tải lên: 06/07/2014, 20:20

... highly with diagnosis (Fig 52-6) For example, a hospitalized patient with a generalized erythematous exanthem is more likely to have a drug eruption than is a patient with a similar rash limited to ... possible to assess the distribution of the eruption accurately The patient should first be viewed from a distance of about 1.5–2 m (4–6 ft) so that the general character of the skin and the distribution ... patient with cutaneous small vessel vasculitis (Courtesy of Robert Swerlick, MD; with permission.)[newpage] APPROACH TO THE PATIENT: SKIN DISORDER In examining the skin it is usually advisable to...

Ngày tải lên: 06/07/2014, 20:20

... The distribution of some common dermatologic diseases and lesions Figure 52-7 Psoriasis This papulosquamous skin disease is characterized by small and large erythematous papules and plaques with...

Ngày tải lên: 06/07/2014, 20:20

... contrast, lesions with a generalized arrangement are common and suggest a systemic etiology Figure 52-9 Erythema multiforme This eruption is characterized by multiple erythematous plaques with a target ... usually represents a hypersensitivity reaction to drugs (e.g., sulfonylamides) or infections (e.g., HSV) (Courtesy of the Yale Resident's Slide Collection; with permission.) Figure 52-10 ...

Ngày tải lên: 06/07/2014, 20:20

... against the surface of the skin and rotated with downward pressure until it penetrates to the subcutaneous tissue The circular biopsy is then lifted with forceps, and the bottom is cut with iris ... area of skin is anesthetized with 1% lidocaine with or without epinephrine The skin lesion in question can be excised or saucerized with a scalpel or removed by punch biopsy In the latter technique, ... History of allergies Presence of photosensitivity Review of systems Family history (particularly relevant for patients with melanoma, atopy, psoriasis, or acne) 10 Social, sexual, or travel history...

Ngày tải lên: 06/07/2014, 20:20

... to document sensitivity to a specific antigen In this procedure, a battery of suspected allergens is applied to the patient' s back under occlusive dressings and allowed to remain in contact with ... best performed by physicians with special expertise in patch testing and is often helpful in the evaluation of patients with chronic dermatitis FURTHER READINGS Dermatology Lexicon Project: www.futurehealth.rochester.edu/dlp2/ ... designed to assess whether a skin lesion will blanch with pressure as, for example, in determining whether a red lesion is hemorrhagic or simply blood-filled Urticaria (Fig 52-11) will blanch with...

Ngày tải lên: 06/07/2014, 20:20

... same as the prognosis of the person with aortic stenosis who develops the first symptoms of congestive heart failure (median survival, ~8 months) However, the patient with heart disease ... malfunction one step further Not only is there a failure of the cancer cell to maintain its specialized function, but it also strikes out on its own; the cancer cell competes to survive using natural ... selection to seek advantage over normal cells in a recapitulation of evolution One consequence of the traitorous behavior of cancer cells is that the patient feels betrayed by his or her body The cancer...

Ngày tải lên: 07/07/2014, 01:20

... The past medical history may alert the physician to the presence of underlying diseases that may affect the choice of therapy or the side effects of treatment The social history may reveal occupational ... predisposition and point out the need to begin surveillance or other preventive therapy for unaffected siblings of the patient The review of systems may suggest early symptoms of metastatic disease ... 77-3 Patient Management Important information is obtained from every portion of the routine history and physical examination The duration of symptoms may reveal the chronicity of disease The past...

Ngày tải lên: 07/07/2014, 01:20

... Against Cancer and the American Joint Committee on Cancer (AJCC) The TNM classification is an anatomically based system that categorizes the tumor on the basis of the size of the primary tumor ... other prognostic factors have been identified (Chaps 104, 105, and 106) In addition to tumor burden, a second major determinant of treatment outcome is the physiologic reserve of the patient Patients ... are likely to fare worse, stage for stage, than fully active patients Physiologic reserve is a determinant of how a patient is likely to cope with the physiologic stresses imposed by the cancer...

Ngày tải lên: 07/07/2014, 01:20

... physician also has much to offer the patient for whom curative therapy is no longer an option Often a combination of guilt and frustration over the inability to cure the patient and the pressure of a ... schedule greatly limit the time a physician spends with a patient who is receiving only palliative care Resist these forces In addition to the medicines administered to alleviate symptoms (see below), ... 81) Tools are now available to minimize the acute toxicity of cancer treatment New symptoms developing in the course of cancer treatment should always be assumed to be reversible until proven otherwise...

Ngày tải lên: 07/07/2014, 01:20

... Pregnancy disease, gonadal germ cell tumor Calcitonin Medullary cancer of the thyroid Catecholamines Pheochromocytoma Oncofetal Antigens Alphafetoprotein Hepatocellular carcinoma, gonadal germ Cirrhosis, ... Neuron-specific enolase Lactate dehydrogenase Small cell cancer of the lung,neuroblastoma Lymphoma, Ewing's sarcoma Hepatitis, hemolytic many others Tumor-Associated Proteins anemia, Prostate-specific ... Carcinoembryonic antigen Adenocarcinomas hepatitis Pancreatitis, of the colon, pancreas, hepatitis, lung, breast, ovary inflammatory bowel disease, smoking Enzymes Prostatic acid Prostate cancer...

Ngày tải lên: 07/07/2014, 01:20

... most patients who are cured of cancer return to normal lives Supportive Care In many ways, the success of cancer therapy depends on the success of the supportive care Failure to control the symptoms ... nonjudgmental, so that patients are more likely to discuss with the physician what they are actually doing The appearance of unexpected toxicity may be an indication that a supplemental therapy is being ... in the course of their disease Unsound approaches are usually hawked on the basis of unsubstantiated anecdotes and not only cannot help the patient but may be harmful Physicians should strive to...

Ngày tải lên: 07/07/2014, 01:20

... on which to indicate the severity of the pain The clinical condition is often dynamic, making it necessary to reassess the patient frequently Pain therapy should not be withheld while the cause ... signals in the chemoreceptor trigger zone in the medulla, the cerebral cortex, and peripherally in the intestinal tract lead to stimulation of the vomiting center in the medulla, the motor center ... caused by chemotherapy (Chap 81) Its severity can be predicted from the drugs used to treat the cancer Three forms of emesis are recognized on the basis of their timing with regard to the noxious...

Ngày tải lên: 07/07/2014, 01:20

... Sexual dysfunction is highly prevalent and needs to be discussed openly with the patient An empathetic health care team is sensitive to the individual patient' s needs and permits negotiation where ... adversely affect the course of treatment Cancer survivors have other sets of difficulties Patients may have fears associated with the termination of a treatment they associate with their continued ... that cancer therapy is substantially more toxic and less effective in the face of malnutrition Nevertheless, it remains unclear whether nutritional intervention can alter the natural history Unless...

Ngày tải lên: 07/07/2014, 01:20

... affected by the diagnosis and is coping with it is an important goal of patient management It is best to speak frankly with the patient and the family regarding the likely course of disease These discussions ... and the goal of palliative therapy is embraced in the hope of being able to live with disease; finally, at the disclosure of imminent death, another adjustment in outlook takes place The patient ... difficult for the physician as well as for the patient and family The critical features of the interaction are to reassure the patient and family that everything that can be done to provide comfort...

Ngày tải lên: 07/07/2014, 01:20

... Approach to the Patient: Acute Febrile Illness A physician must have a consistent approach to acutely ill patients Even before the history is elicited and a physical ... infection, diabetes, malignancy, and chemotherapy all predispose to specific infections and frequently to increased severity The patient should be questioned about factors that might help identify a nidus ... Assessment of the patient' s general appearance and vital signs, skin and soft tissue examination, and the neurologic evaluation are of particular importance The patient may appear either anxious...

Ngày tải lên: 07/07/2014, 04:20

... (U.S.), Either: Atovaqu one and 01, 204 with fewer side or effects Treatmen Atovaquone t (750 mg q12h) plus with doxycycline c Azithromycin (100 mg bid ) (500-mg loading for potential dose, then 250 ... fludrocortisoneb or may improve outcome in Cefepime (2 g patients with q12h) septic shock Overwhel ming Streptoc post- occus g q12h) plus splenectomy pneumoniae, sepsis Haemophilus influenzae, If a ... be antagonistic in action to β-lactam agents Adjust treatment as soon as the diagnosis is confirmed d The optimal dose of IV immunoglobulin has not been determined, but the median dose in observational...

Ngày tải lên: 07/07/2014, 04:20

... initiated empirically on the basis of the presentation (Table 265-3) Adjunctive therapy with either drotrecogin alfa (activated) or glucocorticoids should be considered for patients with severe sepsis ... Asplenic Patients (See also Chap 265) Patients without splenic function are at risk for overwhelming bacterial sepsis Asplenic adult patients succumb to sepsis at 58 times the rate of the general ... cases occur within the first years after splenectomy, with a mortality rate of up to 80%, but the increased risk persists throughout life In asplenia, encapsulated bacteria cause the majority...

Ngày tải lên: 07/07/2014, 04:20

... petechial The rash spreads to palms and soles later in the course The centripetal spread is a classic feature of RMSF However, 10–15% of patients with RMSF never develop a rash The patient can be hypotensive ... Asia, and southern Europe Patients have fever, flu-like symptoms, and an inoculation eschar at the site of the tick bite A maculopapular rash develops within 1–7 days, involving the palms and ... of patients have skin findings Blanching macules develop initially on the wrists and ankles and then spread over the legs and trunk The lesions become hemorrhagic and are frequently petechial The...

Ngày tải lên: 07/07/2014, 04:20