APPROACH TO THE ED PATIENT WITH LOWRISK CHEST PAIN

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Chapter 012. Pain: Pathophysiology and Management (Part 6) pptx

CHAPTER 012. PAIN: PATHOPHYSIOLOGY AND MANAGEMENT (PART 6) PPTX

Chapter 012. Pain: Pathophysiology and Management (Part 6) aAntidepressants, anticonvulsants, and antiarrhythmics have not been approved by the U.S. Food and Drug Administration (FDA) for the treatment of pain.bGabapentin in doses up to 1800 mg/d is FDA approved for postherpetic neuralgia.Note: 5-HT, serotonin; NE, norepinephrine.Since they are effective for these common types of pain and are available without prescription, COX inhibitors are by far the most commonly used analgesics. They are absorbed well from the gastrointestinal tract and, with occasional use, have only minimal side effects. With chronic use, gastric irritation is a common side effect of aspirin and NSAIDs and is the problem that most frequently limits the dose that can be given. Gastric irritation is most severe with aspirin, which may cause erosion and ulceration of the gastric mucosa leading to bleeding or perforation. Because aspirin irreversibly acetylates platelets and thereby interferes with coagulation of the blood, gastrointestinal bleeding is a particular risk. Increased age and history of gastrointestinal disease increase the risks of aspirin and NSAIDs. In addition to NSAIDs' well-known gastrointestinal toxicity, nephrotoxicity is a significant problem for patients using them on a chronic basis, and patients at risk for renal insufficiency should be monitored closely. NSAIDs also cause an increase in blood pressure in a significant number of individuals. Long-term treatment with NSAIDs requires regular blood pressure monitoring and treatment if necessary. Although toxic to the liver when taken in a high dose, acetaminophen rarely produces gastric irritation and does not interfere with platelet function.The introduction of a parenteral form of NSAID, ketorolac, extends the usefulness of this class of compounds in the management of acute severe pain. Ketorolac is sufficiently potent and rapid in onset to supplant opioids for many patients with
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báo cáo hóa học: " Respiratory distress and chest pain: a perforated peptic ulcer with an unusual presentation" pdf

BÁO CÁO HÓA HỌC: " RESPIRATORY DISTRESS AND CHEST PAIN: A PERFORATED PEPTIC ULCER WITH AN UNUSUAL PRESENTATION" PDF

Laparoendoscopic Surgeons 2002, 6:359-368.13. Krobot K, Yin D, Zhang Q, Sen S, Altendorf-Hofmann A, Scheele J, Sendt W:“Effect of inappropriate initial empiric antibiotic therapy on the outcomeof patient with community-acquired intra-abdominal infections requiringsurgery,”. Eur J Microbiol Infect Dis 2004, 23(9):682-7.14. Young GP: “Abdominal catastrophes,”. Emergency Medicine Clinics of NorthAmerica 1989, 7(3):699-720.15. Stapakis JC, Thickman D: “Diagnosis of pneumoperitoneum: abdominalCT vs. upright chest film,”. J Comput Assist Tomogr 1992, 16(5):713-6.16. Grassi R, Roman S, Pinto A, Romano L: “Gastro-duodenal perforations:conventional plain film, US and CT findings in 166 consecutivepatients,”. European Journal of Radiology 2004, 50(1):30-6.17. Thomas SH, Silen W, Cheema F, Reisner A, Aman S, Goldstein JN,Kumar AM, Stair TO: “Effects of morphine analgesia on diagnosticaccuracy in emergency department patients with abdominal pain: aprospective, randomized trial,”. Journal of the American College of Surgery2003, 196:18-31.18. Gallagher EJ, Esses D, Lee C, Lahn M, Bijur PE: “Randomized clinical trial ofmorphine in acute abdominal pain,”. Annals of Emergency Medicine 2006,48:150-160.19. Manterola C, Astudillo P, Losada H, Pineda V, Sanhueza A, Vial M:“Analgesia in patient with acute abdominal pain,”. Cocharane DatabaseSyst Rev 2007, , 3: CD005660.20. Ranji SR, Goldman LE, Simel DL, Shojania KG: “Do opiates affect the clinicalevaluation of patients with acute abdominal pain?”. JAMA 2006,296(14):1764-74.21. Crofts TJ, Park KG, Steele RJ, Chung SS, Li AK: “A randomized trial ofnonoperative treatment of perforated peptic ulcer,”.New England Journalof Medicine 1989, 320(15):970-3.
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PRINCIPLES OF INTERNAL MEDICINE - PART 7 pptx

PRINCIPLES OF INTERNAL MEDICINE PART 7 PPTX

detergent properties, which allow them to form molecular aggregates with cholesterol thatare termed micelles. Cholesterol is poorly soluble in water; its solubility in bile is dependenton both the lipid concentration and the relevant amount of bile acids and lecithin. Bileacids also are required for the normal intestinal absorption of dietary fats by a similarmicellar transport mechanism. Finally, bile acids are important in facilitating water andelectrolyte transport in the intestine. To maintain the reusable pool of bile acids, the mol-ecules are actively reabsorbed in the distal ileum, taken up in the portal bloodstream, andreturned to hepatocytes for reconjugation and resecretion. Compared with a normal-sizebile acid pool of 2 to 4 g, the daily fecal loss of bile acids is only in the range of 0.5 g.X-25. The answer is E. (Chap. 304) Purtscher’s retinopathy is a relatively rare but devas-tating complication of acute pancreatitis. It is characterized by sudden loss of vision andthe presence of cotton-wool spots and hemorrhages in the area of the optic disc and macula.The cause is thought to be occlusion of the posterior retinal artery by aggregated granu-locytes.X-26. The answer is D. (Chap. 302. Johnston, N Engl J Med 328:412, 1993.) Selected pa-tients with gallstones may respond well to treatment with oral chenodeoxycholic acid, itsrelated molecule ursodeoxycholic acid, or both. Patients who are candidates for such ther-apy must have either cholesterol (rather than pigment, as in thalassemia) or mixed radio-lucent gallstones. Second, gallstones Ͼ1.5 cm in diameter and those in gallbladders thatfail to opacify after oral cholecystography will be very unlikely to respond to dissolutiontherapy. Chenodeoxycholic acid is thought to work by decreasing HMG-CoA reductaseactivity and thus hepatically secreted cholesterol. Deoxycholic acid works by a similarmechanism as well as by retarding cholesterol crystal nucleation. Up to 2 years of therapywith these agents often is required to dissolve a gallstone; after withdrawal, there is arecurrence rate of up to 30 to 50%. The same group of patients who are candidates formedical therapy to dissolve gallstones are also generally the patients who are candidatesfor gallstone lithotripsy, a method of fragmenting stones by extracorporeal shock waves.X-27. The answer is A. (Chaps. 303, 304) Serum amylase is an effective screening test foracute pancreatitis. Levels Ͼ300 U/dL make the diagnosis extremely likely, especially ifintestinal perforation and infarction are excluded (both of these conditions can raise serum
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Tension pneumothorax ppsx

TENSION PNEUMOTHORAX PPSX

pneumothorax is crucial for diagnosing and treating the condition. * Early findings o Chest pain o Dyspnea o Anxiety o Tachypnea o Tachycardia o Hyperresonance of the chest wall on the affected side o Diminished breath sounds on the affected side * Late findings o Decreased level of consciousness o Tracheal deviation toward the contralateral side o Hypotension o Distention of neck veins (may not be present if hypotension is severe) o Cyanosis These findings may be affected by the volume status of the patient. In hypovolemic trauma patients with ongoing hemorrhage, the physical findings may lag behind the presentation of shock and cardiopulmonary collapse. In nonventilated patients, the diagnosis of tension pneumothorax often requires a high level of suspicion and the presence of decreased or absent breath sounds on the affected side. In ventilated patients, the physician may begin to suspect tension pneumothorax when increased pleural pressures necessitate an increase in peak airway pressure in order to deliver the same tidal volume. Decreased expiratory volumes secondary to air leakage into the pleural space and increased end-expiratory pressure, even after discontinuation of PEEP, are 2 other signs of tension pneumothorax in these patients. Occasionally, the development of tension pneumothorax may be delayed for hours to days after the initial insult, and the diagnosis may become evident only if the patient is receiving positive-pressure ventilation. Tension pneumothorax has been reported during surgery with both single and double
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UNITTEST 07

UNITTEST 07

Name _______________________________________Class _______________________Gold Pre-First Unit 7 TestVOCABULARY1Complete the gaps with ONE word.James regularly works (1) _________ at a gym in town. He loves to (2) _________ fit as he knows it willhave a positive effect (3) _________ his general well-being. He doesn’t catch colds very often or go(4) _________ with other illnesses and believes that it is because of his healthy diet and exercise routine. Infact, you only have to look at him to see that he is in very (5) _________ shape./52Use the word given at the end of some of the lines to form a word that fits in the gap in the sameline.I have always been a(n) (1)__________ person wanting everything to happenPATIENTimmediately. I also don’t like facing (2)__________ problems and I have alwaysEXPECTEDmanaged to avoid (3)__________ situations – I guess I’ve been lucky most of my life.PAIN
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EVALUATION OF DIFFERENT TYPES OF CHEST SYMPTOMS FOR DIAGNOSING PULMONARY TUBERCULOSIS CASES IN COMMUNITY SURVEYS pot

EVALUATION OF DIFFERENT TYPES OF CHEST SYMPTOMS FOR DIAGNOSING PULMONARY TUBERCULOSIS CASES IN COMMUNITY SURVEYS POT

chest X-ray (CXR). These X-rays are read byindependent readers who classify all persons ashaving shadows suggestive of TB, non- TBconditions or normal. Sometimes both methods areTuberculosis Research Centre, ChennaiCorrespondence: Dr. P.R. Narayanan, Director, Tuberculosis Research Centre, Mayor V.R. Ramanathan Road, Chennai-600 031, (India). Tel (91) 44-28362525, Fax (91) 44-28362528, E-mail: prnarayanan@trcchennai.in[Indian J Tuberc 2008; 55: 116-121]Original ArticleIndian Journal of Tuberculosis117employed for the detection of TB. A case wasdefined as a person with a positive smear (>3 AFB)or culture irrespective of colonies or both.Several TB surveys have been conductedin different pockets of the country. Some of thesesurveys6,7 used mainly two screening methodsnamely, symptom inquiry and CXR. These toolsconsiderably reduce the number of specimens to becollected and processed. A study8 on the yield ofcases by different screening methods showed thatsymptom screening picked up about two-third ofthe cases whereas CXR alone picked up more thanthree-fourth of the cases. With either method theprevalence was underestimated by one-third in theformer method and about one-fifth in the latter
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Chapter 034. Cough and Hemoptysis (Part 5) ppt

CHAPTER 034 COUGH AND HEMOPTYSIS PART 5

Keeping the patient at rest and partially suppressing cough may help the bleeding to subside. If the origin of the blood is known and is limited to one lung, the bleeding lung should be placed in the dependent position, so that blood is not aspirated into the unaffected lung. With massive bleeding, the need to control the airway and maintain adequate gas exchange may necessitate endotracheal intubation and mechanical ventilation. In patients in danger of flooding the lung contralateral to the side of hemorrhage despite proper positioning, isolation of the right and left mainstem bronchi from each other can be achieved by selectively intubating the nonbleeding lung (often with bronchoscopic guidance) or by using specially designed double-lumen endotracheal tubes. Another option involves inserting a balloon catheter through a bronchoscope by direct visualization and inflating the balloon to occlude the bronchus leading to the bleeding site. This technique not only prevents aspiration of blood into unaffected areas but also may promote tamponade of the bleeding site and cessation of bleeding. Other available techniques for control of significant bleeding include laser phototherapy, electrocautery, bronchial artery embolization, and surgical resection of the involved area of lung. With bleeding from an endobronchial tumor, argon plasma coagulation or the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser can often achieve at least temporary hemostasis by coagulating the bleeding site. Electrocautery, which uses an electric current for thermal destruction of tissue, can be used similarly for management of bleeding from an endobronchial tumor. Bronchial artery embolization involves an arteriographic procedure in which a vessel proximal to the bleeding site is cannulated, and a material such as Gelfoam is injected to occlude the bleeding vessel. Surgical resection is a therapeutic option either for the emergent therapy of life-threatening hemoptysis that fails to respond to other measures or for the elective but definitive management of localized disease subject to recurrent bleeding. FURTHER READINGS American College of Chest Physicians: Diagnosis and management of
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Chapter 077. Approach to the Patient with Cancer (Part 11) pot

CHAPTER 077 APPROACH TO THE PATIENT WITH CANCER PART 11

natural history. Unless some pathology is affecting the absorptive function of the gastrointestinal tract, enteral nutrition provided orally or by tube feeding is preferred over parenteral supplementation. However, the risks associated with the tube may outweigh the benefits. Megestrol acetate, a progestational agent, has been advocated as a pharmacologic intervention to improve nutritional status. Research in this area may provide more tools in the future as cytokine-mediated mechanisms are further elucidated. Psychosocial Support The psychosocial needs of patients vary with their situation. Patients undergoing treatment experience fear, anxiety, and depression. Self-image is often seriously compromised by deforming surgery and loss of hair. Women who receive cosmetic advice that enables them to look better also feel better. Loss of control over how one spends time can contribute to the sense of vulnerability. Juggling the demands of work and family with the demands of treatment may create enormous stresses. 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 such flexibility will not 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 survival. Adjustments are required to physical losses and handicaps, real and perceived. Patients may be preoccupied with minor physical problems. They perceive a decline in their job mobility and view themselves as less desirable workers. They may be victims of job and/or insurance discrimination. Patients may experience difficulty reentering their normal past life. They may feel guilty for having survived and may carry a sense of vulnerability to colds and other illnesses. Perhaps the most pervasive and threatening concern is the ever-present fear of relapse (the Damocles syndrome). Patients in whom therapy has been unsuccessful have other problems related to the end of life.
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Chapter 077. Approach to the Patient with Cancer (Part 8) potx

CHAPTER 077. APPROACH TO THE PATIENT WITH CANCER (PART 8) POTX

of therapy, plus dexamethasone, 20 mg IV before treatment, is an effective regimen. Addition of oral aprepitant (a substance P/neurokinin 1 receptor antagonist) to this regimen (125 mg on day 1, 80 mg on days 2 and 3) further decreases the risk of both acute and delayed vomiting. Like pain, emesis is easier to prevent than to alleviate. Delayed emesis may be related to bowel inflammation from the therapy and can be controlled with oral dexamethasone and oral metoclopramide, a dopamine receptor antagonist that also blocks serotonin receptors at high dosages. The best strategy for preventing anticipatory emesis is to control emesis in the early cycles of therapy to prevent the conditioning from taking place. If this is unsuccessful, prophylactic antiemetics the day before treatment may help. Experimental studies are evaluating behavior modification.
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Chapter 077. Approach to the Patient with Cancer (Part 7) ppt

CHAPTER 077 APPROACH TO THE PATIENT WITH CANCER PART 7

consequence of the disease and some as a consequence of the treatment. An understanding of these disease- and treatment-related problems may help in their detection and management. Despite these concerns, 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 of cancer and its treatment may lead patients to abandon curative therapy. Of equal importance, supportive care is a major determinant of quality of life. Even when life cannot be prolonged, the physician must strive to preserve its quality. Quality-of-life measurements have become common endpoints of clinical research studies. Furthermore, palliative care has been shown to be cost-effective when approached in an organized fashion. A credo for oncology could be to cure sometimes, to extend life often, and to comfort always.
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Chapter 077. Approach to the Patient with Cancer (Part 5) doc

CHAPTER 077 APPROACH TO THE PATIENT WITH CANCER PART 5

cancer or its complications (e.g., nausea) may produce central nervous system symptoms that look like metastatic disease or may mimic paraneoplastic syndromes such as the syndrome of inappropriate antidiuretic hormone. A definitive diagnosis should be pursued and may even require a repeat biopsy. A critical component of cancer management is assessing the response to treatment. In addition to a careful physical examination in which all sites of disease are physically measured and recorded in a flow chart by date, response assessment usually requires periodic repeating of imaging tests that were abnormal at the time of staging. If imaging tests have become normal, repeat biopsy of previously involved tissue is performed to document complete response by pathologic criteria. Biopsies are not usually required if there is macroscopic residual disease. A complete response is defined as disappearance of all evidence of disease, and a partial response as >50% reduction in the sum of the products of the perpendicular diameters of all measurable lesions. The determination of partial response may also be based on a 30% decrease in the sums of the longest diameters of lesions (Response Evaluation Criteria in Solid Tumors, or RECIST, criteria). Progressive disease is defined as the appearance of any new lesion or an increase of >25% in the sum of the products of the perpendicular diameters of all measurable lesions (or an increase of 20% in the sums of the longest diameters by RECIST). Tumor shrinkage or growth that does not meet any of these criteria is considered stable disease. Some sites of involvement (e.g., bone) or patterns of involvement (e.g., lymphangitic lung or diffuse pulmonary infiltrates) are considered unmeasurable. No response is complete without biopsy documentation of their resolution, but partial responses may exclude their assessment unless clear objective progression has occurred.
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Chapter 015. Headache (Part 20) docx

CHAPTER 015. HEADACHE (PART 20) DOCX

Chapter 015. Headache (Part 20) Clinical Presentation The patient with NDPH presents with headache on most if not all days; the onset is recent and clearly recalled by the patient. The headache usually begins abruptly, but onset may be more gradual; evolution over 3 days has been proposed as the upper limit for this syndrome. Patients typically recall the exact day and circumstances of the onset of headache; the new, persistent head pain does not remit. The first priority is to distinguish between a primary and a secondary cause of this syndrome. Subarachnoid hemorrhage is the most serious of the secondary causes and must be excluded either by history or appropriate investigation (Chap. 269). Secondary NDPH Low CSF Volume Headache In these syndromes, head pain is positional: it begins when the patient sits or stands upright and resolves upon reclining. The pain, which is occipitofrontal, is usually a dull ache but may be throbbing. Patients with chronic low CSF volume headache typically present with a history of headache from one day to the next that is generally not present on waking but worsens during the day. Recumbency usually improves the headache within minutes, but it takes only minutes to an hour for the pain to return when the patient resumes an upright position. The most common cause of headache due to persistent low CSF volume is CSF leak following lumbar puncture (LP). Post-LP headache usually begins within 48 h but may be delayed for up to 12 days. Its incidence is between 10 and 30%. Beverages with caffeine may provide temporary relief. Besides LP, index events may include epidural injection or a vigorous Valsalva maneuver, such as from lifting, straining, coughing, clearing the eustachian tubes in an airplane, or multiple orgasms. Spontaneous CSF leaks are well recognized, and the diagnosis should be considered whenever the headache history is typical, even when there is no obvious index event. As time passes from the index event, the postural nature
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Chapter 077. Approach to the Patient with Cancer (Part 4) pps

CHAPTER 077 APPROACH TO THE PATIENT WITH CANCER PART 4

Increasingly, biologic features of the tumor are being related to prognosis. The expression of particular oncogenes, drug-resistance genes, apoptosis-related genes, and genes involved in metastasis are being found to influence response to therapy and prognosis. The presence of selected cytogenetic abnormalities may influence survival. Tumors with higher growth fractions, as assessed by expression of proliferation-related markers such as proliferating cell nuclear antigen (PCNA), behave more aggressively than tumors with lower growth fractions. Information obtained from studying the tumor itself will increasingly be used to influence treatment decisions. Host genes involved in drug metabolism can influence the safety and efficacy of particular treatments. 1The AJCC Manual for Staging Cancer, 5th edition, can be obtained from the AJCC at 55 East Erie Street, Chicago, IL, 60611.
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Chapter 052. Approach to the Patient with a Skin Disorder (Part 2) potx

CHAPTER 052. APPROACH TO THE PATIENT WITH A SKIN DISORDER (PART 2) POTX

seen in lichen planus. Milia: Small, firm, white papules filled with keratin. Morbilliform: Generalized, small erythematous macules and/or papules that resemble lesions seen in measles. Nummular: Coin-shaped lesions. Poikiloderma: Skin that displays variegated pigmentation, atrophy, and telangiectases. Polycyclic: A configuration of skin lesions formed from coalescing rings or incomplete rings. Pruritus: A sensation that 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 xerosis and aged skin. Systemic conditions that can be associated with pruritus include chronic renal disease, cholestasis, pregnancy, malignancy, thyroid disease, polycythemia vera, and delusions of parasitosis. Figure 52-3 A schematic representation of several common primary skin lesions (see Table 52-1).
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Báo cáo hóa học: " An international evaluation of ultrasound vs. computed tomography in the diagnosis of appendicitis" doc

BÁO CÁO HÓA HỌC AN INTERNATIONAL EVALUATION OF ULTRASOUND VS COMPUTED TOMOGRAPHY IN THE DIAGNOSIS OF APPENDICITIS DOC

34:7-11.13. Gwynn LK: The diagnosis of acute appendicitis: clinical assessmentversus computed tomography evaluation. J Emerg Med 2001, 21:119-23.14. Brenner DJ, Hall EJ: Computed tomography- an increasing source ofradiation exposure. N Engl J Med 2007, 357:2277-84.15. Broder JS, Hollingsworth CL, Miller CM, Meyer JL, Paulson EK: Prospectivedouble-blinded study of abdominal-pelvic computed tomographyguided by the region of tenderness: estimation of detection of acutepathology and radiation exposure reduction. Ann Emerg Med 2010.16. Broder J, Warshauer DM: Increasing utilization of computed tomographyin the adult emergency department, 2000-2005. Emerg Radiol 2006,13:25-30.17. Howell JM, Eddy OL, Lukens TW, Thiessen MEW, Weingart SD, Decker WW:Clinical policy: critical issues in the evaluation and management ofemergency department patients with suspected appendicitis. Ann EmergMed 2010, 55:71-116.18. Berg ER, Mehta SD, Mitchell P, Soto J, Oyama L, Ulrich A: Length of stay byroute of contrast administration for diagnosis of appendicitis bycomputed-tomography scan. Acad Emerg Med 2006, 13:1040-5.19. Gaitini D, Beck-Razi N, Mor-Yosef D, Fischer D, Ben Itzhak O, Krausz MM,Engel A: Diagnosing acute appendicitis in adults: accuracy of colorDoppler sonography and MDCT compared with surgery and clinicalfollow-up. AJR Am J Roentgenol 2008, 190:1300-6.20. Paulson EK, Kalady MF, Pappas TN: Clinical practice. Suspectedappendicitis. N Engl J Med 2003, 348:236-42.21. Morrow SE, Newman KD: Current management of appendicitis. SeminPediatr Surg 2007, 16:34-40.22. Berrington de González A, Mahesh M, Kim KP, Bhargavan M, Lewis R,Mettler F, Land C: Projected cancer risks from computed tomographicscans performed in the United States in 2007. Arch Intern Med 2009,
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Chapter 052. Approach to the Patient with a Skin Disorder (Part 8) pptx

CHAPTER 052. APPROACH TO THE PATIENT WITH A SKIN DISORDER (PART 8) PPTX

certain dermatophytes such as Microsporum canis or M. audouini exhibits a yellow fluorescence. Pigmented lesions of the epidermis such as freckles are accentuated, while dermal pigment such as postinflammatory hyperpigmentation fades under a Wood's light. Vitiligo (Fig. 52-12) appears totally white under a Wood's lamp, and previously unsuspected areas of involvement often become apparent. A Wood's lamp may also aid in the demonstration of tinea versicolor and in recognition of ash leaf spots in patients with tuberous sclerosis. Figure 52-12 Vitiligo. Characteristic lesions display an acral distribution and striking depigmentation as a result of loss of melanocytes. Patch Tests Patch testing is designed 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 the skin for 48 h. The dressings are removed, and the area is examined for evidence of delayed hypersensitivity reactions (e.g., erythema, edema, or papulovesicles). This test is 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/ James WD et al: Andrews' Diseases of the Skin: Clinical Dermatology, 10th ed. Philadelphia, Elsevier, 2006 Wolff K et al (eds): Fitzpatrick's Dermatology in General Medicine, 7th ed. New York, McGraw-Hill, 2008
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Chapter 052. Approach to the Patient with a Skin Disorder (Part 7) ppt

CHAPTER 052 APPROACH TO THE PATIENT WITH A SKIN DISORDER PART 7

viewed under the microscope, the refractile hyphae will be seen more easily when the light intensity is reduced and the condenser is lowered. This technique can be utilized to identify hyphae in dermatophyte infections, pseudohyphae and budding yeast in Candida infections (see Fig. 196-1), and "spaghetti and meatballs" yeast forms in tinea versicolor. The same sampling technique can be used to obtain scale for culture of selected pathogenic organisms.

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Chapter 052. Approach to the Patient with a Skin Disorder (Part 6) pdf

CHAPTER 052 APPROACH TO THE PATIENT WITH A SKIN DISORDER PART 6

Chapter 052. Approach to the Patient with a Skin Disorder (Part 6) Dermatitis herpetiformis. This disorder typically displays pruritic, grouped papulovesicles on elbows, knees, buttocks, and posterior scalp. Vesicles are often excoriated due to associated pruritus. The shape of lesions is also an important feature. Flat, round, erythematous papules and plaques are common in many cutaneous diseases. However, target-shaped lesions that consist in part of erythematous plaques are specific for erythema multiforme (Fig. 52-9). In the same way, the arrangement of individual lesions is important. Erythematous papules and vesicles can occur in many conditions, but their arrangement in a specific linear array suggests an external etiology such as allergic contact (Fig. 52-10) or primary irritant dermatitis. In 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 or iris morphology. It 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
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Chapter 052. Approach to the Patient with a Skin Disorder (Part 5) pptx

CHAPTER 052. APPROACH TO THE PATIENT WITH A SKIN DISORDER (PART 5) PPTX

Chapter 052. Approach to the Patient with a Skin Disorder (Part 5) Figure 52-6 A–D. 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 overlying adherent silvery scale. Figure 52-8

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Chapter 052. Approach to the Patient with a Skin Disorder (Part 4) doc

CHAPTER 052 APPROACH TO THE PATIENT WITH A SKIN DISORDER PART 4

disrobed as completely as possible. This will minimize chances of missing important individual skin lesions and make it 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 of lesions can be evaluated. Indeed, distribution of lesions often correlates 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 the sun-exposed portions of the face. Once the distribution of the lesions has been established, the nature of the primary lesion must be determined. Thus, when lesions are distributed on elbows, knees, and scalp, the most likely possibility based solely on distribution is psoriasis or dermatitis herpetiformis (Figs. 52-7 and 52-8, respectively). The primary lesion in psoriasis is a scaly papule that soon forms erythematous plaques covered with a white scale, whereas that of dermatitis herpetiformis is an urticarial papule that quickly becomes a small vesicle. In this manner, identification of the primary lesion directs the examiner toward the proper diagnosis. Secondary changes in skin can also be quite helpful. For example, scale represents excessive epidermis, while crust is the result of a discontinuous epithelial cell layer. Palpation of skin lesions can also yield insight into the character of an eruption. Thus, red papules on the lower extremities that blanch with pressure can be a manifestation of many different diseases, but hemorrhagic red papules that do not blanch with pressure indicate palpable purpura characteristic of necrotizing vasculitis (Fig. 52-4).
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