Severe acute pancreatitis

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History
33-year-old male
Alcohol binge: vodka
Awake and conversant
Severe abdominal pain, vomiting, dyspnoea

Physical and laboratory examinations
Temperature 38.1°C
Pulse 96 bpm, respirations 20/min
Blood pressure 110/70 mmHg
Abdomen tender, distended, quiet
Amylase 3500 IU/L
Lipase 1100 IU/L
AST >250 IU/L
LDH >350 IU/L
WBC count 16 000/mm3
Arterial blood gases:
pH 7.30, PaCO2 32, PaO2 58, BE -5

Which evaluations would you perform to determine if the patient has severe pancreatitis?
C-reactive protein
Computed tomography (CT) scan
Severity scores
Ranson score
Glasgow (Imrie) score
APACHE II or III score
Balthazar score


Molar Pregnancy

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Molar pregnancies are an uncommon and very serious complication of pregnancy. The formal medical term for a molar pregnancy is “hydatidiform mole.” Simply put, a molar pregnancy is an abnormality of the placenta,caused by a problem when the egg and sperm join together at fertilization.

There are two types of molar pregnancy, complete and partial. Complete molar pregnancies have only placental parts, and form when the sperm fertilizes an empty egg. Because the egg is empty, no baby is formed. The placenta grows and produces the pregnancy hormone, called HCG, so the patient thinks she is pregnant. Unfortunately, an ultrasound (sometimes called a sonogram) will show that there is no baby, only placenta. A partial mole occurs when 2 sperm fertilize an egg. Instead of forming twins, something goes wrong, leading to a pregnancy with an abnormal fetus and an abnormal placenta. The baby has too many chromosomes and almost always dies in the uterus.
The incidence of molar pregnancy varies depending on where one lives. For example, in the US about 1 out of every 1000 pregnancies is a molar pregnancy. In Southeast Asia the incidence is 8 times higher. Age over 40 is a risk factor for molar pregnancy, as is having a prior molar pregnancy.
Women with a molar pregnancy usually feel pregnant and complain of vaginal spotting or bleeding. Many women with molar pregnancies develop nausea and vomiting. Some even develop rare complications like thyroid disease or very early preeclampsia (toxemia). Preeclampsia occurring earlier than 20 weeks is very worrisome for a molar pregnancy. The ultrasound will often show a “cluster of grapes” appearance or a “snowstorm” appearance, signifying an abnormal placenta. If a baby is present it’s a possible partial mole, while if the baby is absent it’s probably a complete mole. Treatment consists of a D&C (dilation and curettage) of the uterus, where a small vacuum device is inserted into the uterus, under anesthesia, to remove the molar pregnancy. This must be done very carefully or excessive bleeding and blood clots to the lungs can occur.


Rhabdomyolysis

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Rhabdomyolysis is a condition in which injury to skeletal muscle tissue causes it to quickly break down. This results in the release of myoglobin and other breakdown products into the bloodstream. Acute kidney failure (acute renal failure) may result from such a situation.
Rhabdomyolysis may be caused by any one of a variety of means. Essentially, any situation causing muscle tissue destruction has the potential to be a rhabdomyolysis cause. These are considered to be either physical or non-physical causes. Rhabdomyolysis brought on by physical causes tends to be restricted to one region of the patient's body, whereas non-physical rhabdomyolysis typically harms all of the body's muscles at once.

Physical rhabdomyolysis causes
Traumatic muscle compression - car accident, crush syndrome,physical abuse, etc.
Blood supply to muscle obstruction - arterial thrombosis, artery clamping, embolism, reduced blood supply (in shock or sepsis), etc.
Excessive activity in muscles - Alcohol withdrawal (delirium tremens), extreme physical exercise,persistent seizures (status epilepticus, SE), tetanus, etc.
Electrical shock - high voltage electric shock

Non-physical rhabdomyolysis causes
Autimmune muscle damage - dermatomyositis, polymyositis, etc.
Disturbances of electrolytes or metabolism - hypernatremia and hyponatremia, hypocalcemia , hypokalemia, hypophosphatemia, hypothyroidism, increased plasma osmolality, ketoacidosis, etc.
Infections - Coxsackie virus, herpes virus, Legionella pneumophila, malaria (Plasmodium falciparum), Salmonella, tularemia (Francisella tularensis), etc.
Muscle energy supply disorders - carnitine palmitoyltransferase I deficiency or carnitine palmitoyltransferase I deficiencyprimary carnitine deficiency (CPT type I or II), McArdle's disease, mitochondrial respiratory chain defects, phosphofructokinase deficiency, primary carnitine deficiency, VLCAD deficiency, etc.


Status Epilepticus in Children

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Status epilepticus is defined as recurrent or continuous seizure activity lasting longer than 30 minutes in which the patient does not regain consciousness.It results from rapid abnormal electrical discharges from cerebral neurons. This presents clinically as involuntary alterations of consciousness or motor activity. Consumption of oxygen, glucose, and energy substrates is significantly increased in cerebral tissue during seizures. Optimal delivery of these metabolic substrates to cerebral tissue requires adequate cardiac output and intravascular fluid volume.
Prolonged seizures are associated with cerebral hypoxia, hypoglycemia, and hypercarbia and with concurrent and progressive lactic and respiratory acidosis. When cerebral metabolic needs exceed available oxygen, glucose, and metabolic substrates (especially during status epilepticus), neuronal destruction can occur and may be irreversible.
Causes of Status epilepticus in Children
Neonates
    * Birth injury (eg, anoxia, hemorrhage) and congenital abnormalities
    * Metabolic disorders (eg, hypoglycemia, hypocalcemia, hyponatremia) and inborn errors of metabolism (eg, lipidoses, amino acidurias)
    * Infection (eg, meningitis)

Early childhood
    * Birth injury
    * Febrile convulsions (3 mo to 6 y)
    * Infection
    * Metabolic disorders
    * Trauma
    * Neurocutaneous syndromes
    * Cerebral degenerative diseases
    * Tumors
    * Idiopathic



Arterial Blood Gas Analysis

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An arterial blood gas (ABG) is a blood test that is performed using blood from an artery. It involves puncturing an artery with a thin needle and syringe and drawing a small volume of blood. The most common puncture site is the radial artery at the wrist, but sometimes the femoral artery in the groin or other sites are used. The blood can also be drawn from an arterial catheter.
The test is used to determine the pH of the blood, the partial pressure of carbon dioxide and oxygen, and the bicarbonate level. Many blood gas analyzers will also report concentrations of lactate, hemoglobin, several electrolytes, oxyhemoglobin, carboxyhemoglobin and methemoglobin. ABG testing is mainly used in pulmonology, to determine gas exchange levels in the blood related to lung function, but has a variety of applications in other areas of medicine.
Arterial blood for blood gas analysis is usually extracted by a phlebotomist, nurse, or respiratory therapist.Blood is most commonly drawn from the radial artery because it is easily accessible, can be compressed to control bleeding, and has less risk for occlusion. The femoral artery (or less often, the brachial artery) is also used, especially during emergency situations or with children. Blood can also be taken from an arterial catheter already placed in one of these arteries.
The syringe is pre-packaged and contains a small amount of heparin, to prevent coagulation or needs to be heparinised, by drawing up a small amount of heparin and squirting it out again. Once the sample is obtained, care is taken to eliminate visible gas bubbles, as these bubbles can dissolve into the sample and cause inaccurate results. The sealed syringe is taken to a blood gas analyzer.


Hyperparathyroidism

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Hyperparathyroidism is overactivity of the parathyroid glands resulting in excess production of parathyroid hormone.The parathyroid hormone regulates calcium and phosphate levels and helps to maintain these levels.
Primary hyperparathyroidism results from a hyperfunction of the parathyroid glands themselves. There is oversecretion of PTH due to adenoma, hyperplasia or, rarely, carcinoma of the parathyroid glands.
Secondary hyperparathyroidism is the reaction of the parathyroid glands to a hypocalcemia caused by something other than a parathyroid pathology, e.g. chronic renal failure.
Tertiary hyperparathyroidism result from hyperplasia of the parathyroid glands and a loss of response to serum calcium levels. This disorder is most often seen in patients with chronic renal failure and is an autonomous activity.
Most of the symptoms of parathyroid disease are "neurological" in origin. Common manifestations of hyperparathyroidism include weakness and fatigue, depression, bone pain, muscle soreness (myalgias), decreased appetite, feelings of nausea and vomiting, constipation, polyuria, polydipsia, cognitive impairment, kidney stones and osteoporosis.
Osteomalacia associated with hyperparathyroidism is caused by the high parathyroid hormone secreted by overactive parathyroid gland.


Upper gastrointestinal bleeding

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Upper gastrointestinal bleeding refers to hemorrhage in the upper gastrointestinal tract. The anatomic cut-off for upper GI bleeding is the ligament of Treitz, which connects the fourth portion of the duodenum to the diaphragm near the splenic flexure of the colon.Upper GI bleeds are considered medical emergencies, and require admission to hospital for urgent diagnosis and management. Due to advances in medications and endoscopy, upper GI hemorrhage is now usually treated without surgery.Patients with upper GI hemorrhage often present with hematemesis, coffee ground vomiting and melena,.he presentation of bleeding depends on the amount and location of hemorrhage.Patients may also present with complications of anemia, including chest pain, syncope, fatigue and shortness of breath.

The causes for upper GI hemorrhage include the following:
* Esophageal causes:Esophageal varices,Esophagitis,Esophageal cancer,Mallory-Weiss tear
* Gastric causes:Gastric ulcer,Gastric cancer,Gastric varices,Gastric antral vascular ectasia,Dieulafoy's lesions
*Duodenal ulcer
*Vascular malformation, including aorto-enteric fistulae.
*Severe superior mesenteric artery syndrome
Emergency treatment for upper GI bleeds includes aggressive replacement of volume with intravenous solutions, and blood products if required. As patients with esophageal varices typically have coagulopathy, plasma products may have to be administered. Vital signs are continuously monitored.Early endoscopy is recommended, both as a diagnostic and therapeutic approach, as endoscopic treatment can be performed through the endoscope.


Osteogenesis Imperfecta

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Osteogenesis imperfecta is a genetic bone disorder.People with Osteogenesis imperfecta are born with defective connective tissue, or without the ability to make it, usually because of a deficiency of Type-I collagen.This deficiency arises from an amino acid substitution of glycine to bulkier amino acids in the collagen triple helix structure. As a result, the body may respond by hydrolyzing the improper collagen structure. If the body does not destroy the improper collagen, the relationship between the collagen fibrils and hydroxyapatite crystals to form bone is altered, causing brittleness.
Type I - Collagen is of normal quality but is produced in insufficient quantities:
* Bones fracture easily
* Slight spinal curvature
* Loose joints
* Poor muscle tone
* Discoloration of the sclera (whites of the eyes), usually giving them a blue-gray color
Type II - Collagen is not of a sufficient quality or quantity
* Most cases die within the first year of life due to respiratory failure or intracerebral hemorrhage
Type III- Collagen improperly formed. Enough collagen is made but it is defective
* Bones fracture easily, sometimes even before birth
* Bone deformity, often severe
* Respiratory problems possible
* Short stature, spinal curvature and sometimes barrel-shaped rib cage
Type IV - Collagen quantity is sufficient but is not of a high enough quality
Type V - Same clinical features as Type IV
There have been many clinical trials performed with Fosamax (Alendronate), a drug used to treat those experiencing brittleness of bones due to osteoporosis. Higher levels of effectiveness apparently are to be seen in the pill form versus the IV form, but results seem inconclusive.Bone infections are treated as and when they occur with the appropriate antibiotics and antiseptics.


Colorectal Cancer

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Colorectal cancer includes cancerous growths in the colon, rectum and appendix.It is the fourth most common form of cancer in the United States and the third leading cause of cancer-related death in the Western world.Colorectal cancers arise from adenomatous polyps in the colon. These mushroom-shaped growths are usually benign, but some develop into cancer over time. Localized colon cancer is usually diagnosed through colonoscopy.
Invasive cancers that are confined within the wall of the colon (TNM stages I and II) are curable with surgery. If untreated, they spread to regional lymph nodes (stage III), where up to 73% are curable by surgery and chemotherapy. Cancer that metastasizes to distant sites (stage IV) is usually not curable, although chemotherapy can extend survival, and in rare cases, surgery and chemotherapy together have seen patients through to a cure.Radiation is used with rectal cancer.
The symptoms of colorectal cancer depend on the location of tumor in the bowel, and whether it has spread elsewhere in the body.Most of the symptoms may occur in other diseases as well, and hence none of the symptoms mentioned here is diagnostic of colorectal cancer.Symptoms and signs are divided into local, constitutional and metastasizes.
Local symptoms are more likely if the tumor is located closer to the anus. There may be a change in bowel habit and a feeling of incomplete defecation (rectal tenesmus) and change in stool shape is characteristic of rectal cancer.Lower gastrointestinal bleeding, including the passage of bright red blood in the stool, may indicate colorectal cancer, as may the increased presence of mucus. Melena, black stool with a tarry appearance, normally occurs in upper gastrointestinal bleeding,but is sometimes encountered in colorectal cancer when the disease is located in the beginning of the large bowel.
A tumor that is large enough to fill the entire lumen of the bowel may cause bowel obstruction. This situation is characterized by constipation, abdominal pain, abdominal distension and vomiting. This occasionally leads to the obstructed and distended bowel perforating and causing peritonitis. A large left colonic tumor may compress the left ureter and cause hydronephrosis.
Certain local effects of colorectal cancer occur when the disease has become more advanced. A large tumor is more likely to be noticed on feeling the abdomen, and it may be noticed by a doctor on physical examination. The disease may invade other organs, and may cause blood or air in the urine (invasion of the bladder) or vaginal discharge (invasion of the female reproductive tract).If a tumor has caused chronic occult bleeding, iron deficiency anemia may occur; this may be experienced as fatigue, palpitations and noticed as pallor (pale appearance of the skin). Colorectal cancer may also lead to weight loss, generally due to a decreased appetite.More unusual constitutional symptoms are an unexplained fever and one of several paraneoplastic syndromes.


The 2010 AHA Guidelines for CPR and ECC once again emphasize the need for high-quality CPR, including
• A compression rate of at least 100/min (a change from “approximately” 100/min)
• A compression depth of at least 2 inches (5 cm) in adults and a compression depth of at least one third of the anteriorposterior diameter of the chest in infants and children(approximately 1.5 inches [4 cm] in infants and 2 inches[5 cm] in children). Note that the range of 1½ to 2 inches is no longer used for adults, and the absolute depth specified for children and infants is deeper than in previous versions of the AHA Guidelines for CPR and ECC
Allowing for complete chest recoil after each compression
• Minimizing interruptions in chest compressions
• Avoiding excessive ventilation
There has been no change in the recommendation for a compression-to-ventilation ratio of 30:2 for single rescuers of adults, children, and infants (excluding newly born infants). The 2010 AHA Guidelines for CPR and ECC continue to recommend
that rescue breaths be given in approximately 1 second. Once an advanced airway is in place, chest compressions can be continuous (at a rate of at least 100/min) and no longer cycled with ventilations. Rescue breaths can then be provided at about 1 breath every 6 to 8 seconds (about 8 to 10 breaths per minute). Excessive ventilation should be avoided.


Hyponatremia

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Hyponatremia is an electrolyte disturbance in which the sodium concentration in the serum is lower than normal.Normal serum sodium levels are between 135-145 mEq/L. Hyponatremia is defined as a serum level of less than 135 mEq/L and is considered severe when the serum level is below 125 mEq/L. Sodium is the dominant extracellular cation and cannot freely cross the cell membrane. Its homeostasis is vital to the normal physiologic function of cells.

Hyponatremia is most often a complication of other medical illnesses in which either fluids rich in sodium are lost  or excess water accumulates in the body at a higher rate than can be excreted (for example in congestive heart failure, syndrome of inappropriate antidiuretic hormone, SIADH, or polydipsia).Regarding sodium loss as a cause of hyponatremia, it is important to note that such losses promote hyponatremia in only an indirect manner. In particular, hyponatremia occurring in association with sodium loss does not reflect inadequate sodium availability as a result of the losses. Rather, the sodium loss leads to a state of volume depletion, with volume depletion serving as signal for the release of ADH (anti-diuretic hormone). As a result of ADH-stimulated water retention, blood sodium becomes diluted and hyponatremia results.
The imbalance between sodium and water in blood may occur in three primary ways:
    * Hypervolemic hyponatremia, excess water dilutes the sodium concentration, causing low sodium levels. Hypervolemic hyponatremia is commonly the result of kidney failure, heart failure or liver failure.
    * Euvolemic hyponatremia, normal water levels are combined with low sodium levels. This condition is commonly due to chronic health conditions, cancer or certain medications.
    * Hypovolemic hyponatremia, water and sodium levels are both low. This may occur, for example, when exercising in the heat without replenishing fluid electrolytes or with marked blood loss.
Symptoms of hyponatremia include nausea and vomiting, headache, confusion, lethargy, fatigue, appetite loss, restlessness and irritability, muscle weakness, spasms, or cramps, seizures, and decreased consciousness or coma. The presence and severity of symptoms are associated with the level of serum sodium, with the lowest levels of serum sodium associated with the more prominent and serious symptoms. However, emerging data suggest that mild hyponatremia (serum sodium levels at 131 mEq/L or above) is associated with numerous complications and undiagnosed symptoms.


Paget's disease of the bone is a chronic disorder that typically results in enlarged and deformed bones.The pathogenesis of Paget's disease is described in 3 stages, which are:Osteoclastic activity,Mixed osteoclastic-osteoblastic activity
and Exhaustive (burnt out) stage.
Paget's disease is rarely diagnosed in people less than 40 years of age. Men are more commonly affected than women. Prevalence of Paget's disease ranges from 1.5 to 8.0 percent, depending on age and country of residence. Prevalence of familial Paget's disease ranges from 10 to 40 percent in different parts of the world.Because early diagnosis and treatment is important, after age 40, siblings and children of someone with Paget's disease may wish to have an alkaline phosphatase blood test every two or three years. If the alkaline phosphatase level is above normal, other tests such as a bone-specific alkaline phosphatase test, bone scan, or X-ray can be performed.
Many patients do not know they have Paget's disease because they have a mild case with no symptoms.Symptoms can include:
    * Bone pain is the most common symptom. It can occur in any bone affected by Paget's disease. It often localizes to areas adjacent to the joints.
    * Headaches and hearing loss may occur when Paget's disease affects the skull.
    * Pressure on nerves may occur when Paget's disease affects the skull or spine.
    * Paralysis may be due to vascular steal syndrome of the vertebrae.
    * Increased head size, bowing of limb, or curvature of spine may occur in advanced cases.
    * Hip pain may occur when Paget's disease affects the pelvis or thighbone.
    * Chalkstick fractures can occur.
    * Mosaic bone pattern is symptomatic.
    * Hypercementosis in teeth may occur.


SIRS is a serious condition related to systemic inflammation, organ dysfunction, and organ failure.
Criteria for SIRS were established as part of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference.The conference concluded that the manifestations of SIRS include, but are not limited to:
    * Body temperature less than 36°C or greater than 38°C
    * Heart rate greater than 100 beats per minute
    * Tachypnea with greater than 20 breaths per minute; or, an arterial partial pressure of carbon dioxide less than 32 mmHg
    * White blood cell count less than 4000 cells/mm³ (4 x 109 cells/L) or greater than 12,000 cells/mm³ (12 x 109 cells/L); or the presence of greater than 10% immature neutrophils (band forms)

SIRS can be diagnosed when two or more of these criteria are present.
Fever and leukocytosis are features of the acute-phase reaction, while tachycardia is often the initial sign of hemodynamic compromise. Tachypnea may be related to the increased metabolic stress due to infection and inflammation.SIRS is frequently complicated by failure of one or more organs or organ systems.The complications of SIRS include:
    * Acute lung injury
    * Acute kidney injury
    * Shock
    * Multiple organ dysfunction syndrome


Acute and Chronic Pancreatitis

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Pancreatitis is inflammation of the pancreas that can occur in two very different forms. Acute pancreatitis is sudden while chronic pancreatitis "is characterized by recurring or persistent abdominal pain with or without steatorrhea or diabetes mellitus.Severe upper abdominal pain, with radiation through to the back, is the hallmark of pancreatitis. Nausea and vomiting (emesis) are prominent symptoms.The most common cause of acute pancreatitis is the presence of gallstones that cause inflammation in the pancreas as they pass through the common bile duct.
Excessive alcohol use is the most common cause of chronic pancreatitis and can also be a contributing factor in acute pancreatitis.
Less common causes are
* hypertriglyceridemia
* hypercalcemia,
* viral infection (e.g. mumps),
* trauma (to the abdomen or elsewhere in the body) including post-ERCP
* vasculitis
* autoimmune pancreatitis.
* Pancreas divisum, a common congenital malformation of the pancreas
The diagnostic criteria for pancreatitis are "two of the following three features: abdominal pain characteristic of acute pancreatitis, serum amylase and/or lipase ≥3 times the upper limit of normal and characteristic findings of acute pancreatitis on CT scan.
Several scoring systems are used to help predict the severity of an attack of pancreatitis. The Apache II system has the advantage of being available at the time of admission as opposed to 48 hours later as is the case for the Glasgow criteria and Ranson criteria systems .


Hepatocellular carcinoma

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Hepatocellular carcinoma is a primary malignancy of the liver. Most cases of HCC are secondary to either a chronic viral hepatitis (hepatitis B or C) or cirrhosis.In countries where hepatitis is not endemic, most malignant cancers in the liver are not primary HCC but metastasis of cancer from elsewhere in the body, .HCC may present with jaundice, bloating from ascites, easy bruising from blood clotting abnormalities or as loss of appetite, unintentional weight loss, abdominal pain,especially in the upper -right part, nausea, emesis, or fatigue. Treatment options of HCC and prognosis are dependent on many factors but especially on tumor size and staging. Tumor grade is also important. High-grade tumors will have a poor prognosis, while low-grade tumors may go unnoticed for many years, as is the case in many other organs, such as the breast, where a ductal carcinoma in situ may be present without any clinical signs and without correlate on routine imaging tests, although in some occasions it may be detected on more specialized imaging studies like MR mammography.

The usual outcome is poor, because only 10 - 20% of hepatocellular carcinomas can be removed completely using surgery. If the cancer cannot be completely removed, the disease is usually deadly within 3 to 6 months.This is partially due to late presentation with large tumours, but also the lack of medical expertise and facilities. This is a rare tumor in the United States.


Complications in Long-Term Hypoxia

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Hypoxia is a pathological condition in which the body is deprived of adequate oxygen supply. Variations in arterial oxygen concentrations can be part of the normal physiology, for example, during strenuous physical exercise. A mismatch between oxygen supply and its demand at the cellular level may result in a hypoxic condition. Hypoxia in which there is complete deprivation of oxygen supply is referred to as anoxia.
Generalized hypoxia occurs in healthy people when they ascend to high altitude, where it causes altitude sickness leading to potentially fatal complications: high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE).Hypoxia also occurs in healthy individuals when breathing mixtures of gases with a low oxygen content, e.g. while diving underwater especially when using closed-circuit rebreather systems that control the amount of oxygen in the supplied air. A mild and non-damaging intermittent hypoxia is used intentionally during altitude trainings to develop an athletic performance adaptation at both the systemic and cellular level.
The symptoms of generalized hypoxia depend on its severity and acceleration of onset. In the case of altitude sickness, where hypoxia develops gradually, the symptoms include headaches, fatigue, shortness of breath, a feeling of euphoria and nausea. In severe hypoxia, or hypoxia of very rapid onset, changes in levels of consciousness, seizures, coma, priapism, and death occur. Severe hypoxia induces a blue discolouration of the skin, called cyanosis.

Obstructive jaundice

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Obstructive jaundice caused by obstruction of the bile ducts, as with gallstones. The liver normally produces about 1 litre of bile each day, which is secreted into the bile duct system and stored in the gallbladder. The bile duct empties into the upper intestine to help in digestion. Obstruction anywhere in this drainage system causes the blood levels of bilirubin to increase, resulting in "obstructive jaundice." Common causes of obstructive jaundice include gallstones and tumors of the pancreas or bile duct. With gallstones, jaundice may be intermittent if the stone is not firmly stuck. Rarer causes of obstructive jaundice include parasites such as worms, scarring from previous surgical procedures, bile duct inflammations, and, in infancy, congenital malformations of the bile duct system. Additional symptoms of obstructive jaundice include dark urine, pale feces, and itching, although there is no pain. Sometimes the cause of obstructive jaundice is cancer (malignant obstructive jaundice), in which case treatment is by chemotherapy, radiation, and/or biliary drainage.Obstructive jaundice is often accompanied by severe irritation of the skin ('pruritus'), due to a buildup of other bile constituents (salts) in the blood. In addition, because the bile is not entering the intestine, the stools will be unusually pale in colour and may be bulky and smelly(steatorrhea)


Overactive bladder (OAB) is defined as: “urgency, with or without urge incontinence, usually with frequency and nocturia” where:
Frequency = voiding too often
Urgency = sudden compelling desire to pass urine which is difficult to defer
Incontinence = involuntary urine leakage accompanied by or immediately preceded by urgency, and
Nocturia = wake at night one or more times to void

Urge Urinary Incontinence
Unwanted urine leakage after sudden, intense desire to urinate.
Caused by involuntary detrusor contractions as bladder fills.
Unable to prevent urine flow with the “urge” sensation.

Stress Urinary Incontinence
Increased abdominal pressure (eg lifting, coughing) causing involuntary urine leakage.
Poor urethral support.
Predominately in women after child birth.

Detrusor Hyperreflexia
Failure to store urine due to increased detrusor contractility.
Usually neurological component although can be non-neurological.
Urodynamically defined condition.


Cardiac Auscultation 01

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The heart sounds are the sounds generated by the beating heart and the resultant flow of blood through it. This is also called a heartbeat. In cardiac auscultation, an examiner uses a stethoscope to listen for these sounds, which provide important information about the condition of the heart.
In healthy adults, there are two normal heart sounds often described as a lub and a dub,that occur in sequence with each heart beat. These are the first heart sound (S1) and second heart sound (S2), produced by the closing of the AV valves and semilunar valves respectively. In addition to these normal sounds, a variety of other sounds may be present including heart murmurs, adventitious sounds, and gallop rhythms S3 and S4.
Heart murmurs are generated by turbulent flow of blood, which may occur inside or outside the heart. Murmurs may be physiological or pathological.Abnormal murmurs can be caused by stenosis restricting the opening of a heart valve, resulting in turbulence as blood flows through it. Abnormal murmurs may also occur with valvular insufficiency (or regurgitation), which allows backflow of blood when the incompetent valve closes with only partial effectiveness. Different murmurs are audible in different parts of the cardiac cycle, depending on the cause of the murmur.
Regurgitation through the mitral valve is by far the most commonly heard murmur, producing a pansystolic murmur which is sometimes fairly loud to a practiced ear, even though the volume of regurgitant blood flow may be quite small.
Stenosis of the aortic valve is typically the next most common heart murmur, a systolic ejection murmur. This is more common in older adults or in those individuals having a two, not a three leaflet aortic valve.


Injectable contraceptives

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Depo-Provera (medroxyprogesterone acetate) is an injectable medicine  that prevents pregnancy for up to 3 months with each injection. Depo-Provera prevents pregnancy by preventing ovulation . If your ovaries do not release an egg, you are unlikely to get pregnant. Depo-Provera is given as 1 shot in the buttock or upper arm. The first shot should be given within 5 days after the beginning of a normal menstrual period, and shots should be repeated every 3 months.Depo-Provera is as effective as tubal ligation  and more effective at preventing pregnancy than several other methods, including birth control pills, condoms and diaphragms.
Most women have some changes in their menstrual periods while using Depo-Provera, including irregular and unpredictable bleeding or spotting, an increase or decrease in menstrual bleeding, or no bleeding at all. After 1 year of use, about 50% of women have no bleeding at all. Other possible side effects include weight gain, headaches, nervousness, abdominal discomfort, dizziness and weakness or fatigue.


Systolic Heart Failure

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Causes of a Systolic Heart Failure
Systolic heart failure can result when there is a defect or abnormality in the systolic function during the expulsion of blood to the rest of the body.Congestive heart failure is a result of the weakening of the cardiac muscles due to which the heart is unable to suffice the requirements of the body. Here are some of  the causes of left ventricular failure.
* Unhealthy lifestyle is one of the reasons why some individuals may suffer from heart attacks. Smoking and drinking may lead to the accumulation of toxins in the blood stream, which can affect the heart and result in the organ failure. Heart attacks may also be caused due to aging.
* Chronic systolic heart failure is mainly caused due to the presence of congenital heart defects like a faulty valve.
* The inflammation of the heart muscles, myocarditis, due to an infection,damage to the heart muscles or cardiomyopathy, etc., can be a causative factor for acute systolic heart failure.
* Abnormality in the heart rate, which can cause heart arrhythmias is also one of the causes of systolic heart failure.
* Some other causes are hypertension, diabetes, blood clots, side effects and allergic reactions of certain medications, etc.
Systolic Heart Failure Symptoms
The symptoms are similar to the right sided heart failure symptoms.
* Dyspnea, or shortness of breath, which may worsen when you lie down or due heavy work.
* Sharp chest pain, which may radiate to the arm. Sometimes a heaviness in the chest region is also felt.
* Palpitations of the heart.
* Generalized body weakness.
* Persistent cough and wheezing, which does not go away.


Acute Acalculous Cholecystitis

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Acalculous cholecystitis is cholecystitis without stones. It accounts for 5 to 10% of cholecystectomies done for acute cholecystitis. Risk factors include the following:
    *Critical illness (eg, major surgery, burns, sepsis, or trauma)
    *Prolonged fasting or TPN (both predispose to bile stasis)
    *Shock
    *Immune deficiency
    *Vasculitis (eg, SLE, polyarteritis nodosa)
The mechanism probably involves inflammatory mediators released because of ischemia, infection, or bile stasis. Sometimes an infecting organism can be identified (eg, Salmonella sp or cytomegalovirus in immunodeficient patients). In young children, acute acalculous cholecystitis tends to follow a febrile illness without an identifiable infecting organism.
The symptoms are similar to those of acute cholecystitis with gallstones but may be difficult to identify because patients tend to be severely ill (eg, ICU setting) and may be unable to communicate clearly. Abdominal distention or unexplained fever may be the only clue. Untreated, the disease can rapidly progress to gallbladder gangrene and perforation, leading to sepsis, shock, and peritonitis; mortality approaches 65%.
Acute acalculous cholecystitis is suggested if a patient has no gallstones but has ultrasonographic Murphy's sign or a thickened gallbladder wall and pericholecystic fluid. A distended gallbladder, biliary sludge, and a thickened gallbladder wall without pericholecystic fluid (due to low albumin or ascites) may result simply from a critical illness. CT identifies extrabiliary abnormalities. Cholescintigraphy is more helpful; failure of a radionuclide to fill may indicate edematous cystic duct obstruction.


Anticonvulsants

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The anticonvulsants are a diverse group of pharmaceuticals used in the treatment of epileptic seizures. Anticonvulsants are also increasingly being used in the treatment of bipolar disorder, since many seem to act as mood stabilizers. The goal of an anticonvulsant is to suppress the rapid and excessive firing of neurons that start a seizure. Failing this, an effective anticonvulsant would prevent the spread of the seizure within the brain and offer protection against possible excitotoxic effects that may result in brain damage.Convulsive non-epileptic seizures are quite common and these types of seizures will not have any response to an antiepileptic drug. In epilepsy an area of the cortex is typically hyperirritable that can often be confirmed by completing an EEG. Antiepileptic drugs function to help reduce this area of irritability and thus prevent epileptiform seizures.
The major molecular targets of marketed anticonvulsant drugs are voltage-gated sodium channels and components of the GABA system, including GABAA receptors, the GAT-1 GABA transporter, and GABA transaminase.Additional targets include voltage-gated calcium channels.
During pregnancy, the metabolism of several anticonvulsants is affected. There may be an increase in the clearance an resultant decrease in the blood concentration of lamotrigine, phenytoin, and to a lesser extent carbamazepine, and possibly decreases the level of levetiracetam and the active oxcarbazepine metabolite, the monohydroxy derivative.Therefore, these drugs should be monitored during use in pregnancy.


Nosocomial Pneumonia

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Nosocomial pneumonia refers to any pneumonia contracted by a patient in a hospital at least 48–72 after being admitted. It is usually caused by a bacterial infection, rather than a virus.It is the second most common nosocomial infection (urinary tract infection is the most common) and accounts for 15–20% of the total.It is the most common cause of death among nosocomial infections and is the primary cause of death in intensive care units.Among the factors contributing to contracting
Nosocomial pneumonia are mechanical ventilation (ventilator-associated pneumonia), old age, decreased filtration of inspired air, intrinsic respiratory, neurologic, or other disease states that result in respiratory tract obstruction, trauma, (abdominal) surgery, medications, diminished lung volumes, or decreased clearance of secretions may diminish the defenses of the lung.
In hospitalised patients who develop respiratory symptoms and fever one should consider the diagnosis. The likelihood increases when upon investigation symptoms are found of respiratory insufficiency, purulent secretions, newly developed infiltrate on the chest X-Ray, and increasing leucocyte count. If pneumonia is suspected material from sputum or tracheal aspirates are sent to the microbiology department for cultures. In case of pleural effusion thoracentesis is performed for examination of pleural fluid. In suspected ventilator-associated pneumonia it has been suggested that bronchoscopy(BAL) is necessary because of the known risks surrounding clinical diagnoses.


Status Epilepticus

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Status epilepticus is a life-threatening condition in which the brain is in a state of persistent seizure.It is defined as one continuous unremitting seizure lasting longer than 30 minutes, or recurrent seizures without regaining consciousness between seizures for greater than 30 minutes.It is always considered a medical emergency. There is some evidence that 5 minutes is sufficient to damage neurons and that seizures are unlikely to self-terminate by that time. First aid guidelines for seizures state that, as a rule, an ambulance should be called for seizures lasting longer than 5 minutes (if this is the patient's first seizure episode and there were no known precipitating factors, or if SE happens to an epileptic whose seizures were previously absent or well-controlled for a considerable time period, then that step can be taken before that point).The mortality rate of status epilepticus is very high (at least 20%), especially if treatment is not initiated quickly. However, with optimal neurological care and a good prognosis, the patient in otherwise good health can survive with minimal or no brain damage, and can even avoid future seizures.
Status epilepticus can be divided into two categories—convulsive and nonconvulsive, the latter of which is underdiagnosed.

Convulsive
Epilepsia partialis continua is a variant involving hour, day, or even week-long jerking. It is a consequence of vascular disease, tumours, or encephalitis, and is drug-resistant.
Generalized myoclonus is commonly seen in comatose patients following CPR and is seen by some as an indication of catastrophic damage to the neocortex.

Nonconvulsive
Complex partial status epilepticus, or CPSE, and absence status epilepticus are rare forms of the condition which are marked by nonconvulsive seizures. In the case of CPSE, the seizure is confined to a small area of the brain, normally the temporal lobe. But the latter, absence status epilepticus, is marked by a generalised seizure affecting the whole brain, and an EEG is needed to differentiate between the two conditions. This results in episodes characterized by a long-lasting stupor, staring and unresponsiveness.


Neuroleptic Malignant Syndrome

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Neuroleptic malignant syndrome (NMS) is a life- threatening neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs. Incidence of the disease has declined since its discovery, but it is still a potential danger to patients being treated with antipsychotics. Because of its unpredictability, there is no one set course of action to treat the syndrome, but generally, removal of the antipsychotic drug treatment, along with supportive medical management, lead to a positive outcome.
The first symptom to develop is usually muscular cramps, fever, symptoms of instability of the autonomic nervous system such as unstable blood pressure, and changes in cognition, including agitation, delirium and coma. Other symptoms may include muscle tremors.A raised white blood cell count and creatine phosphokinase (CPK) plasma concentration will be reported due to increased muscular activity and rhabdomyolysis .The patient may suffer hypertensive crisis and metabolic acidosis.
Differentiating NMS from other neurological disorders can be very difficult.Some of the most commonly mistaken diseases are: encephalitis, toxic encephalopathy, status epilepticus, heat stroke, and malignant hyperthermia.NMS is usually caused by neuroleptic drug use, and a wide range of drug potencies can result in NMS.It has been reported that individuals using haloperidol and chlorpromazine are at greatest risk.
NMS is an emergency, and can lead to death if untreated. The first step is to stop neuroleptic drugs and to treat the hyperthermia aggressively, such as with cooling blankets or ice packs to the axillae and groin. Many cases require intensive care and circulatory and ventilatory support. Medications such as dantrolene sodium and bromocriptine may be used. Apomorphine may be used however its use is supported by little evidence. Benzodiazepines may be used to control agitation. Highly elevated CPK can damage the kidneys, therefore aggressive hydration may be required.


Proximal muscle weakness

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Proximal muscle weakness with it's inability to comb the hair, inabilit to rise from sitting, ...etc.It would be a good idea to keep a high yield list of the most common causes of proximal muscle weakness.Causes are
    * Inflammatory myopathies, such as dermatomyositis
    * Thyroid disorders (specially hypothyroidism)
    * Steroids, cushing's disease for example
    * Statins therapy
    * Cyclosporin
    * Hypokalemia
    * Myasthenia gravis



Hormone replacement therapy (HRT) is a system of medical treatment for surgically menopausal, perimenopausal and to a lesser extent postmenopausal women. It is based on the idea that the treatment may prevent discomfort caused by diminished circulating estrogen and progesterone hormones.The main types of hormones involved are estrogens, progesterone or progestins, and sometimes testosterone. HRT is available in various forms. It generally provides low dosages of one or more estrogens, and often also provides either progesterone or a chemical analogue, called a progestin. Testosterone may also be included. In women who have had a hysterectomy, an estrogen compound is usually given without any progesterone, a therapy referred to as "unopposed estrogen therapy". HRT may be delivered to the body via patches, tablets, creams, troches, IUDs, vaginal rings, gels or, more rarely, by injection. Dosage is often varied cyclically, with estrogens taken daily and progesterone or progestins taken for about two weeks every month or two; a method called "sequentially combined HRT" or scHRT. An alternate method, a constant dosage with both types of hormones taken daily, is called "continuous combined HRT" or ccHRT, and is a more recent innovation. Sometimes an androgen, generally testosterone, is added to treat diminished libido. It may also treat reduced energy and help reduce osteoporosis after menopause.
HRT is often given as a short-term relief (often one or two years, usually less than five) from menopausal symptoms (hot flashes, irregular menstruation, fat redistribution etc.). Younger women with premature ovarian failure or surgical menopause may use hormone replacement therapy for many years, until the age that natural menopause would be expected to occur.


Atrial Fibrillation,Pacing and ICDs

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Atrial Fibrillation is the Most common arrhythmia
Accounts for 3- 10% of medical admissions
Is associated with a 6 fold increase in stroke rate
Is associated with a 2 fold increase in mortality from IHD
Prevalence increases as population ages
An ECG should be performed in all patients
Rate control and rhythm control should not be considered mutually exclusive and appropriate anti thrombotic therapy should be used
In pts with permanent AF Beta blockers/Ca Antagonists should be the preferred initial monotherapy, digoxin should be reserved for those predominantly sedentary
Anti-thrombotic therapy should be initiated with minimal delay
Stroke risk algorithm should be used in pts and app thromboprophylaxis given

Persistent AF
Either rhythm or rate control strategy
If decision taken to go for rhythm control treat precipitants first
Electrical vs. pharmacological Cardioversion
No difference between these if duration less 48hrs
If combination used then PCV+ECV more successful than ECV+PCV
If AF of <48hrs Pharmacological Cardioversion If AF of >48hrs then electrical Cardioversion

Pharmacological Cardioversion
In the absence of structural heart disease (IHD or LVSD) a class 1c drug such as Flecainide or Propafenone should be drug of choice
In the presence of structural heart disease Amiodarone should be drug of choice
When pts with AF undergo ECV and there is a cause for heightened concern about success of restoring SR (prev failure or early recurrence) then concomitant Amiodarone or Sotolol for 4 weeks should be given...


Noninvasive ventilation (NIV) refers to the administration of ventilatory support without using an invasive artificial airway (endotracheal tube or tracheostomy tube). The use of noninvasive ventilation has markedly increased over the past two decades, and noninvasive ventilation has now become an integral tool in the management of both acute and chronic respiratory failure, in both the home setting and in the critical care unit.
The key to the successful application of noninvasive ventilation is in recognizing its capabilities and limitations. This also requires identification of the appropriate patient for the application of noninvasive ventilation (NIV). Patient selection is crucial for the successful application of noninvasive ventilation.

Suitable clinical conditions for noninvasive ventilation (most patients)
Chronic obstructive pulmonary disease
Cardiogenic pulmonary edema


Absolute contraindications are
    * Coma
    * Cardiac arrest
    * Respiratory arrest
    * Any condition requiring immediate intubation


Back pain

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Back pain is pain felt in the back that usually originates from the muscles, nerves, bones, joints or other structures in the spine.
The pain can often be divided into neck pain, upper back pain, lower back  pain. It may have a sudden onset or can be a chronic pain; it can be constant or intermittent, stay in one place or radiate to other areas. It may be a dull ache, or a sharp or piercing or burning sensation. The pain may radiate into the arm and hand), in the upper back, or in the low back, (and might radiate into the leg or foot), and may include symptoms other than pain, such as weakness, numbness or tingling.
The spine is a complex interconnecting network of nerves, joints, muscles, tendons and ligaments, and all are capable of producing pain. Large nerves that originate in the spine and go to the legs and arms can make pain radiate to the extremities.
The management goals when treating back pain are to achieve maximal reduction in pain intensity as rapidly as possible; to restore the individual's ability to function in everyday activities; to help the patient cope with residual pain; to assess for side-effects of therapy; and to facilitate the patient's passage through the legal and socioeconomic impediments to recovery. For many, the goal is to keep the pain to a manageable level to progress with rehabilitation, which then can lead to long term pain relief. Also, for some people the goal is to use non-surgical therapies to manage the pain and avoid major surgery, while for others surgery may be the quickest way to feel better.


Acute renal failure often is preventable. Risk factors for this condition include diabetes mellitus, chronic renal insufficiency, heart failure, and advanced age.
Many medications can injure the kidneys. Dosing schedules can help prevent acute renal failure. For example, acute renal failure is less likely to develop with a once-daily dose of an aminoglycoside than with multiple daily doses.When acute renal failure is diagnosed, the causes must be identified and treated.Critical measures include maintaining adequate intravascular volume and mean arterial pressure, discontinuing all nephrotoxic drugs, and eliminating exposure to any other nephrotoxins.Electrolyte abnormalities must be corrected, and urine output should be monitored closely.
Hyperkalemia is a common complication of acute renal failure.Potassium levels below 6 mEq per L (6 mmol per L) usually can be managed with dietary restriction and resin binders. Sodium bicarbonate therapy should be reserved for the treatment of severe metabolic acidosis with or without associated hyperkalemia.When hyperkalemia is severe and unresponsive to treatment, kidney replacement therapy may be indicated.


Nephrolithiasis

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Ureterolithiasis is the condition of having a calculus in the ureter, the tube connecting the kidneys and the bladder.Nephrolithiasis  refers to the condition of having kidney stones. Urolithiasis refers to the condition of having calculi in the urinary tract (which also includes the kidneys), which may form or pass into the urinary bladder.

Symptoms of kidney stones include:
Localization of kidney stone pain
    * Colicky pain: "loin to groin". Often described as "the worst pain ever experienced." This can also occur in the lower back.The pain is elicited by contractions of the ureter in response to the stone, causing severe, crampy pain in the flank or lower back, often radiating to the groin or, in men, to the testes.The pain typically comes in waves, with a typical wave lasting 20 to 60 minutes
    * Nausea/vomiting: embryological link with intestine– stimulates the vomiting center.
    * Hematuria: blood in the urine, due to minor damage to inside wall of kidney, ureter and/or urethra.

There are several types of kidney stones based on the type of crystals of which they consist. The majority are calcium oxalate stones, followed by calcium phosphate stones. More rarely, struvite stones are produced by urea-splitting bacteria in people with urinary tract infections, and people with certain metabolic abnormalities may produce uric acid stones or cystine stones.
The diagnosis of a kidney stone can be confirmed by radiological studies and/or ultrasound examination; urine tests and blood tests are also commonly performed. When a stone causes no symptoms, watchful waiting is a valid option. In other cases, pain control is the first measure, using for example non-steroidal anti-inflammatory drugs or opioids. Using soundwaves, some stones can be shattered into smaller fragments (this is called extracorporeal shock wave lithotripsy). Sometimes a procedure is required, which can be through a tube into the urethra, bladder and ureter (ureteroscopy), or a keyhole or open surgical approach from the kidney's side. Sometimes, a tube may be left in the ureter (a ureteric stent) to prevent the recurrence of pain. Preventive and structive measures are often advised such as drinking sufficient amounts of water and milk although the effect of many dietary interventions has not been rigorously studied.


In the United States, 55,000 patients are cared for daily in 6000 ICUs.
The most common reason for admission is respiratory failure and the need for mechanical ventilator.
The vast majority of patients on ventilators require sedation
60-80% of ventilated patients develop delirium at some point during their hospital course

Sedation in Ventilated Patients
Mechanical ventilation is uncomfortable and anxiety provoking
Sedation is often necessary for comfort and airway, line, foley, nursing protection
More than 85% of ventilated patients receive sedation
“Standard” sedation
Benzodiazepines - midazolam, lorazepam, diazepam
Anesthetics - propofol

Special circumstance sedation
Central alpha-agonists - clonidine, dexmedetomidine
High-dose opioids
Haloperidol

Sedative Dependence
Patients exposed to more than one week of high dose opioid or sedative may develop tolerance and/or dependence.
Opioid withdrawal:-Pupillary dilation, sweating, lacrimation, rhinorrhea, yawning, tachycardia, irritability, anxiety
Benzodiazepine withdrawal:-Dysphoria, tremor, headache, nausea, sweating, agitation, anxiety, sleep disturbances, myoclonus, delirium, seizures
Propofol withdrawal not well-described but reported to resemble BZD withdrawal


Community-acquired pneumonia (CAP)

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Community-acquired pneumonia (CAP) is a term used to describe one of several diseases in which individuals who have not recently been hospitalized develop an infection of the lungs.CAP is a common illness and can affect people of all ages. CAP often causes problems like difficulty in breathing, fever, chest pains, and a cough. CAP occurs alveoli become filled with fluid and cannot work effectively.
CAP occurs throughout the world and is a leading cause of illness and death. Causes of CAP include bacteria, viruses, fungi, and parasites. CAP can be diagnosed by symptoms and physical examination alone, though x-rays, examination of the sputum, and other tests are often used. Individuals with CAP sometimes require treatment in a hospital. CAP is primarily treated with antibiotic medication. Some forms of CAP can be prevented by vaccination.
Symptoms of CAP commonly include:
    * problems breathing
    * coughing that produces greenish or yellow sputum
    * a high fever that may be accompanied with sweating, chills, and uncontrollable shaking
    * sharp or stabbing chest pain
    * rapid, shallow breathing that is often painful
X-rays of the chest, examination of the blood and sputum for infectious microorganisms, and blood tests are commonly used to diagnose individuals with suspected CAP based upon symptoms and physical examination.Chest x-rays and chest computed tomography can reveal areas of opacity which represent consolidation.Blood cultures can be drawn to isolate any bacteria or fungi in the blood stream. Sputum Gram's stain and culture can also reveal the causative microorganism.


Empyema thoracis

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Empyema thoracis: This develops as frank pus accumulates in the pleural space. Laboratory studies indicate that preexisting pleural fluid is required for the development of an empyema because empyema is not seen after direct inoculation into a "dry" pleural space. The pus is seen after thoracentesis or any drainage procedure of the pleural space and is generally characterized as thick, viscous, and opaque.

Causative organisms
Staphylococcus aureus, Streptococcus pneumoniae and Streptococcus pyogenes
Pneumococcal pneumonia presents with effusion in 40% patients, empyema occurs only in 5%
Anaerobes and enterobacter are common in mixed infections. Anaerobes are more common after 6 years of age. For anaerobes, aspiration pneumonia is the most common cause followed by lung abscess, sub diaphrag-matic abscess and spreading infection from adjacent sites, e.g. periodontal, retropharyn-geal, peritonsillar and neck abscesses.
Tuberculous

Stages of Empyema
Exudative stage (1-3 days)
  • Immediate response with outpouring of the fluid.
  • Low cellular content
  • It is simple parapneumonic effusion with normal pH and glucose levels.
  • pH more than 7.30
  • glucose more than 60 mg/dl
  • pleural fluid/serum glucose ratio more than 0.5
  • LDH less than 1000 IU/L
  • Gram stain and culture is negative for micro-organism.

Fibrino purulent stage (4 to 14 days)
  • Large number of poly-morphonuclear leukocytes and fibrin accumulates
  • Fluid pH and glucose level fall while LDH rises.
  • Acumulation of neutro-phils and fibrin, effusion becomes purulent and viscous leading to development of empyema.
  • There is progressive tendency towards loculations and formation of a limiting membranes.
  • Pleural fluid analysis
  • Purulent fluid or pH less than 7.10, glucose less than 40 mg/dl and LDH more than 1000 IU/L. Gram stain and culture reports show microorganism.

Organizing stage (after 14 days)
  • Fibro-blasts grow into exudates on both the visceral and parietal pleural surfaces
  • Development of an inelastic membrane "the peel".
  • Thickened pleural peel may prevent the entry of anti-microbial drugs in the pleural space and in some cases can lead to drug resistance.
  • Most common in S. aureus infection.
  • Thickened pleural peel can restrict lung movement and it is commonly termed as trapped lung


Massive Hemoptysis

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Hemoptysisis coughing up blood from the respiratory tract. Hemoptysis refers specifically to blood that comes from the respiratory tract. Blood also may come from the nose, the back of the throat, or part of the gastrointestinal tract. When blood originates outside of the respiratory tract, the condition is known as "pseudohemoptysis." Vomiting up blood, medically known as hematemesis, is one type of pseudohemoptysis. Differentiating between hemoptysis and hematemesis is an integral part of diagnosis. Since they involve different parts of the body, treatments and prognose (prospect of recovery) are not the same.
There are many underlying disorders that can cause hemoptysis, ranging from heart problems to trauma to infections to lung disease. Worldwide, tuberculosis is the most common cause of hemoptysis. In industrialized countries, the most common causes are bronchitis, bronchiectasis, and bronchogenic carcinoma.
In patients with AIDS, the most common cause of hemoptysis is pneumonia. In about 15% to 30% of cases, the underlying problem is never found—undiagnosed hemoptysis is commonly referred to as idiopathic hemoptysis.
Classifying hemoptysis as mild or massive (some practitioners classify it as trivial, moderate, or massive) is difficult because the amount of blood is often hard to accurately quantify. Life-threatening, "massive" hemoptysis, which requires immediate medical attention, is differentiated from less severe cases.
Hemoptysis is considered massive, or major, when there is so much blood that it interrupts breathing (generally more than about 200-240 mL, or about 1 cup, in 24 hours). Massive hemoptysis is a medical emergency: the mortality rate for patients with massive hemoptysis can be as high as 75%. Most patients who die from hemoptysis suffer from asphyxiation (lack of oxygen) due to too much blood in the airways.


Thrombotic Thrombocytopenic Purpura

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Thrombotic thrombocytopenic purpura (TTP) is a rare disorder of the blood-coagulation system, causing extensive microscopic thromboses to form in small blood vessels throughout the body.Most cases of TTP arise from inhibition of the enzyme ADAMTS13, a metalloprotease responsible for cleaving large multimers of von Willebrand factor (vWF) into smaller units. A rarer form of TTP, called Upshaw-Schülman syndrome, is genetically inherited as a dysfunction of ADAMTS13. If large vWF multimers persist there is tendency for increased coagulation.
Red blood cells passing the microscopic clots are subjected to shear stress which damages their membranes, leading to intravascular hemolysis and schistocyte formation. Reduced blood flow due to thrombosis and cellular injury results in end organ damage.
Classically, the following five features are indicative of TTP in most cases, some of these are absent.
    * Neurologic symptoms (fluctuating), such as hallucinations, bizarre behavior, altered mental status, stroke or headaches
    * Kidney failure
    * Fever
    * Thrombocytopenia leading to bruising or purpura
    * Microangiopathic hemolytic anemia
Since the early 1990s, plasmapheresis has become the treatment of choice for TTP.[13] This is an exchange transfusion involving removal of the patient's blood plasma through apheresis and replacement with donor plasma (fresh frozen plasma or cryosupernatant); the procedure has to be repeated daily to eliminate the inhibitor and abate the symptoms. If pheresis is not available, fresh frozen plasma can be infused, but the volume able to be given safely is limited due to the danger of fluid overload. Lactate dehydrogenase levels are generally used to monitor disease activity. 


HIV Infection in Adults

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Human immunodeficiency virus is the causative organism of acquired immunodeficiency syndrome (AIDS) a condition in humans in which the immune system begins to fail, leading to life-threatening opportunistic infections. Infection with HIV occurs by the transfer of blood, semen, vaginal fluid, pre-ejaculate, or breast milk. Within these bodily fluids, HIV is present as both free virus particles and virus within infected immune cells. The four major routes of transmission are unsafe sex, contaminated needles, breast milk, and transmission from an infected mother to her baby at birth.
HIV infection in humans is considered pandemic by the World Health Organization.From its discovery in 1981,AIDS killed more than 25 million people.In 2005, AIDS claimed an estimated 2.4–3.3 million lives, of which more than 570,000 were children. A third of these deaths occurred in Sub-Saharan Africa, retarding economic growth and increasing poverty. At that time, it was estimated that HIV would infect 90 million people in Africa, resulting in a minimum estimate of 18 million orphans.Antiretroviral treatment reduces both the mortality and the morbidity of HIV infection, but routine access to antiretroviral medication is not available in all countries.
HIV infects primarily vital cells in the human immune system such as helper T cells , macrophages, and dendritic cells.HIV infection leads to low levels of CD4+ T cells.When CD4+ T cell numbers decline below a critical level, cell-mediated immunity is lost, and the body becomes progressively more susceptible to opportunistic infections.
Most untreated people infected with HIV-1 eventually develop AIDS.These individuals mostly die from opportunistic infections or malignancies associated with the progressive failure of the immune system.HIV progresses to AIDS at a variable rate affected by viral, host, and environmental factors; most will progress to AIDS within 10 years of HIV infection: some will have progressed much sooner, and some will take much longer.Treatment with anti-retrovirals increases the life expectancy of people infected with HIV.


Pneumothorax During Anesthesia

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Pneumothorax is a collection of air or gas in the pleural cavity of the chest between the lung and the chest wall. It may occur spontaneously in people without chronic lung conditions  as well as in those with lung disease and many pneumothoraces occur after physical trauma to the chest, blast injury, or as a complication of medical treatment.
Primary spontaneous pneumothorax (PSP), which tends to occur in young people without underlying lung problems, usually causes limited symptoms. Chest pain and sometimes mild breathlessness are the predominant symptoms.Secondary spontaneous pneumothorax (SSP) occurs by definition in those with underlying lung diseases. The symptoms tend to be more severe, as the unaffected lung is generally not capable of replacing the loss of function from the affected side. Hypoxia is usually present and may be observed as cyanosis .Hypercapnia is sometimes encountered.Traumatic pneumothorax occurs either because a hole in the chest wall, such as a stab wound or gunshot wound, allows air to enter the pleural space, or because of injury to the lung. It has been found to occur in half of all cases of injury to the chest, coming second after rib fracture in the complications after chest trauma. Tension pneumothorax is characterized by rapid breathing, cyanosis, falling blood pressure (hypotension) and confusion. The affected side of the chest may be hyperexpanded and show decreased movement, with increased movement on the other side. In very severe cases, the respiratory rate falls sharply, with shock and coma.
Small spontaneous pneumothoraces typically resolve by themselves and require no treatment, especially in those with no underlying lung disease. In larger pneumothoraces or when there are severe symptoms, the air may be aspirated with a syringe, or a one-way chest tube is inserted to allow the air to escape. Occasionally, surgical measures are required, especially if tube drainage is unsuccessful or someone has repeated episodes. Various treatments, usually involving pleurodesis,may be used if there is a significant risk of repeated episodes of pneumothorax.


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