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By L. Yugul. Hebrew College. 2018.

Complications Peritonitis buy cheap v-gel 30gm on-line, perforated viscus cheap 30gm v-gel mastercard, hemorrhage generic v-gel 30gm otc, precipitation of hepatic coma if patient has se- vere liver disease discount 30gm v-gel free shipping, oliguria, hypotension Diagnosis of Ascitic Fluid A complete listing is found in Chapter 3, page 43. Exudative ascites is found with tumors, peritonitis (TB, perfo- rated viscus), hypoalbuminemia. Pleural fluid glucose is much lower than serum glucose in effusions due to rheumatoid arthritis (0–16 mg/100 mL); low 40 mg/100 mL in empyema. Abbreviations: LDH = lactate dehydrogenase; WBC = white blood cells; RBC = red blood cells; PMNs = polymorphonuclear neutrophils; TB = tuberculosis. Background Pulsus paradoxus is an exaggeration of the normal inspiratory drop in arterial pressure. The result is increased right atrial and right ventricu- lar filling with an increase in right ventricular output. Because the pulmonary vascular bed also distends, these changes lead to a delay in left ventricular filling and subsequently a de- creased left ventricular output. In the case of cardiac compression (eg, acute asthma or pericardial tamponade), the right side of the heart fills more with inspiration and decreases the left ventricular volume to even greater degree as a result of compression of the pericardial sac. A simple, qualitative method involves palpating the radial pulse, which “disappears” on normal inspiration. A more precise quantitative method requiring that the patient take a breath, let it out, and hold it. Once the patient is breathing normally, drop the pres- sure in the cuff slowly until you hear the pulse during inspiration. Differential diagnosis includes pericardial effusion, cardiac tamponade, pericarditis, COPD, bronchial asthma, restrictive cardiomyopathies, hemorrhagic shock SIGMOIDOSCOPY (RIGID) Indications • Diagnosis and treatment of lower gastrointestinal problems • Part of the standard work-up of blood in the stool Materials • Examination gloves, lubricant, tissues • Occult blood stool test kit (Hemoccult paper and developer) • Sigmoidoscope with obturator and light source 13 • Insufflation bag • Long (rectal) swabs and suction catheter • Proctologic examination table (helpful but not essential) Procedure 1. These include rigid sigmoidoscopy (endoscopic examination of the last 25 cm of the GI tract), flexible sig- moidoscopy (examination up to 40 cm from the end of the GI tract), proctoscopy (roughly synonymous to sigmoidoscopy, but technically means examination of the last 12 cm), and anoscopy (examination of the anus and most distal rectum). Sigmoidoscopy can be performed with the patient in bed lying on side in the knee–chest position, but the best results are obtained with the patient in the “jackknife” position on the procto table. Do not position the patient until all materials are at hand and you are ready to start. Do a careful rectal exam with a gloved finger and plenty of lubricant, and check for fecal occult blood (Hemoccult test) on the stool recovered on the glove. Lubricate the sigmoidoscope well with water-soluble jelly, and insert it with the obtura- tor in place. Always advance under direct vision and make sure that the lumen is always visible (Fig. Insufflation (introducing air) may be used to help visualize the lumen, but remember this may be painful. It is necessary to follow the curve of the sigmoid to- ward the sacrum by directing the scope more posteriorly toward the back. A change from a smooth mucosa to concentric rings signifies entry into the sigmoid colon. After advancing as far as possible, slowly remove the scope; use a small rotary motion to view all surfaces. Inform the patient that he or she may experience mild cramping after the procedure. Sacrum Sigmoid colon Rectum A 13 B Umbilicus FIGURE 13–19 The sigmoidoscope is advanced under direct vision as shown. Materials • 2-, 3-, 4-, or 5-mm skin punch • Minor procedure tray (page 240) • Curved iris scissors and fine-toothed forceps (Ordinary forceps may distort a small biopsy specimen and should not be used. If more than one lesion is present, choose one that is well developed and representative of the dermatosis. For patients with vesiculobullous disease, an early edematous lesion should be chosen rather than a vesicle.

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Increasing attention is being growth is a well-known side effect of long-term systemic given to the use of lower doses of glucocorticoids in glucocorticoid therapy in children with bronchial combination with other drugs that can have a synergis- asthma buy v-gel 30gm lowest price, even in those receiving alternate-day therapy buy cheap v-gel 30 gm on-line. Moreover buy v-gel 30gm on-line, the lowered Glucocorticoids can also augment bone loss best v-gel 30gm, decreasing dose levels of steroid will minimize the side effects. Thus, patients taking glucocorti- decreased responsiveness to insulin, and even glyco- coids can also develop hypogonadism. Pharmacological mended that all patients who receive long-term concentrations of steroids may precipitate frank dia- glucocorticoid treatment should have measurements of betes in individuals who cannot produce the necessary bone density, gonadal steroids, vitamin D, and 24-hour additional insulin. The effects of estradiol increase bone loss and should be corrected if glucocorticoids on hyperglycemia are usually reversed possible. Bisphosphonates (etidronate, alendronate, or within 48 hours following discontinuation of steroid risedronate) and calcitonin, which inhibit bone resorp- therapy. If glucocorticoid therapy is continued for an tion, have become increasingly popular for treating os- extended period, the alterations of glucose metabolism teoporosis. The Infectious Process Ophthalmic Effects Steroids can alter host–parasite interactions, suppress fever, decrease inflammation, and change the usual Glucocorticoids induce cataract formation, particularly in character of the symptoms produced by most infectious patients with rheumatoid arthritis. There is a heightened susceptibility to seri- ular pressure related to a decreased outflow of aqueous ous bacterial, viral, and fungal infections. Local infec- humor is also a frequent side effect of periocular, topical, tions may reactivate and spread, and infections ac- or systemic administration. Induction of ocular hyperten- quired during the course of therapy may become more sion, which occurs in about 35% of the general population severe and even more difficult to recognize. By interfer- after glucocorticoid administration, depends on the spe- ing with fibroblast proliferation and collagen synthesis, cific drug, the dose, the frequency of administration, and glucocorticoids cause dehiscence of surgical incisions, the glucocorticoid responsiveness of the patient. This untoward effect of steroids may Central Nervous System Effects make it mandatory to administer antibiotics with the steroids, especially when there is a history of a chronic Treatment with steroids may initially evoke euphoria. On the other This reaction can be a consequence of the salutary ef- hand, individuals with normal defenses who are treated fects of the steroids on the inflammatory process or a di- with low to moderate doses of glucocorticoids are not at rect effect on the psyche. While the incidence of infections dictable and often profound effects exerted by steroids has probably decreased with the increased use of in- on mental processes generally reflects the personality of haled steroids and combination therapy, inhaled the individual. Psychiatric side effects induced by gluco- steroids carry an increase in the incidence of oral can- corticoids may include mania, depression, or mood dis- didiasis that can be reduced by using proper doses. Restlessness and early-morning insomnia Nevertheless, glucocorticoids are used to treat herpes may be forerunners of severe psychotic reactions. In addition, patients may become psychically Effects on Gastric Mucosa dependent on steroids as a result of their euphoric ef- Steroid administration was once thought to lead to the fect, and withdrawal of the treatment may precipitate formation of peptic ulcers, with hemorrhage or perfora- an emotional crisis, with suicide or psychosis as a conse- tion or reactivation of a healed ulcer. Since there is a minimal increase in the The hippocampus is a principal neural target for glu- incidence of ulcers in patients receiving glucocorticoid cocorticoids. It contains high concentrations of gluco- treatment alone, prophylactic antiulcer regimens are corticoid and mineralocorticoid receptors and has usually not necessary. Hyperglycemic Action Fluid and Electrolyte Disturbances In about one-fourth to one-third of the patients receiv- The normal subject may retain sodium and water during ing prolonged steroid therapy, the hyperglycemic effects steroid therapy, although the synthetic steroid ana- 60 Adrenocortical Hormones and Drugs Affecting the Adrenal Cortex 695 logues represent a lesser risk in this regard. The functional state of the hypo- nisolone produces some edema in doses greater than 30 thalamic–pituitary axis can be evaluated by tests involv- mg; triamcinolone and dexamethasone are much less li- ing basal plasma cortisol determinations, low and high able to elicit this effect. Glucocorticoids may also pro- doses of cosyntropin (peptide fragment of corti- duce an increase in potassium excretion. Muscle weak- cotrophin), insulin hypoglycemia, metyrapone, and ness and wasting of skeletal muscle mass frequently corticotrophin-releasing hormone. The expan- Glucocorticoids are not withdrawn abruptly but sion of the extracellular fluid volume produced by are tapered. Tapering vascular smooth muscle suggests that glucocorticoids the dose may reduce the potential for the development are also more directly involved in the regulation of of Addison-like symptoms associated with steroid with- blood pressure. Alternate-day therapy will relieve the clinical coids on the cardiovascular system include dyslipidemia manifestations of the inflammatory diseases while allow- and hypertension, which may predispose patients to ing a day for reactivation of endogenous corticosteroid coronary artery disease. A separate entity, steroid my- output, thereby causing less severe and less sustained opathy, is also improved by decreasing steroid dosage.

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