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Pericardial effusion can be an acute complication or can resemble chronic constric- tive pericarditis buy protonix 40 mg mastercard. Non-respiratory disease Non-respiratory disease implies the dissemination of the bacilli through the circu- latory and lymphatic systems generic 40mg protonix. In the majority of these cases discount protonix 40 mg amex, the localization is intrathoracic affecting mainly the mediastinal lymph nodes cheap 40mg protonix mastercard. Close to 25-35 % of these forms have extrathoracic localizations, such as on the neck lymph nodes called scrofula. It has been estimated that 65 % to 80 % of children under 12 years old may be infected with Mycobacterium 534 Tuberculosis in Children avium complex; 10 % to 20 % with Mycobacterium scrofulaceum; and 10 % with M. In contrast, more than 90 % of culture-proven mycobacterial lymphadenitis in adults and children older than 12 years are caused by M. The infected lymph nodes are typically firm, non-tender, and pain- less, with non-erythematous overlying skin. Lymph node suppuration and spontaneous drainage may occur after caseation and necrosis development (Freixinet 1995, Starke 1995). Infants are particularly prone to the bacilli spreading throughout their body and development of the miliary form of the disease. Both pulmonary and extrapulmonary miliary forms are particularly severe diseases (Correa 1997, Rodrigues 1993). Because of the frequent insidious onset of the disease, a very high index of suspi- cion is required to make a timely diagnosis. The clinical presentation com- prises a variety of signs and symptoms with an insidious or acute start. The signs and symptoms include low-grade persistent fever, malaise, anorexia, weight loss, fatigue, hepatomegaly, splenomegaly and generalized lymphadenopathy, alteration in consciousness and sensorium, stupor and the emergence of focal neurological signs. As the disease progresses, a deterioration of mental status is accompanied by head- ache and neck stiffness, photophobia, seizures, coma, and death may occur if a proper diagnosis and early intervention are not promptly started. Typical cerebrospinal fluid findings include a moderate lymphocytic pleocytosis, low glucose level and an elevated protein concentration. Three stages of tubercular meningitis have been identified: • in the first stage, no focal or generalized neurological signs are present. This is due to the pressure of the thick basilar inflammatory exudates on the cranial nerves or to hydrocephalus. Fundoscopic changes may include papil- ledema and the presence of choroid tubercles, which should be carefully sought. Spinal cord disease may result in the acute development of spinal block or a transverse myelitis-like syndrome. Clinical and radiographic presentations vary widely and depend upon the stage of the disease at the time of diagnosis. Sites commonly involved are the large weight-bearing bones or joints including the vertebrae (50 %), hips (15 %), and knees (15 %). Manifestations may include angulation of the spine or “gibbus deformity” and/or the severe ky- phosis with destruction of the vertebral bodies or “Pott’s disease”. Cervical spine involvement may result in atlantoaxial subluxation, which may lead to paraplegia or quadriplegia. This infection is caused by lymphohematogenous spread during pregnancy from an infected placenta or aspiration of contaminated amniotic fluid. Symptoms typically develop during the second or third week of life and include poor feeding, poor weight gain, cough, lethargy, and irritability. Other symptoms include fever, ear discharge, and skin lesions, failure to thrive, icterus, hepatosple- nomegaly, tachypnea, and lymphadenopathy. This evaluation is also indicated for children with fever of unknown origin, failure to thrive, significant weight loss (more than 10 % of normal weight), or unexplained lymphadenopathy.

Divided transversely into triangles 20mg protonix fast delivery, the anterior is the urogenital triangle discount protonix 20 mg online, which includes the external genitals 40 mg protonix with visa. The perineum is also divided into superficial and deep layers with some of the muscles common to men and women (Figure 11 protonix 40 mg on-line. Women also have the compressor urethrae and the sphincter urethrovaginalis, which function to close the vagina. The pectoral girdle, or shoulder girdle, consists of the lateral ends of the clavicle and scapula, along with the proximal end of the humerus, and the muscles covering these three bones to stabilize the shoulder joint. The girdle creates a base from which the head of the humerus, in its ball-and-socket joint with the glenoid fossa of the scapula, can move the arm in multiple directions. Muscles That Position the Pectoral Girdle Muscles that position the pectoral girdle are located either on the anterior thorax or on the posterior thorax (Figure 11. When the rhomboids are contracted, your scapula moves medially, which can pull the shoulder and upper limb posteriorly. Note that the pectoralis major and deltoid, which move the humerus, are cut here to show the deeper positioning muscles. Muscles that Position the Pectoral Girdle Position Target motion Prime in the Movement Target Origin Insertion direction mover thorax Stabilizes clavicle Inferior Anterior during movement by Clavicle Depression Subclavius First rib surface of thorax depressing it clavicle Anterior Rotates shoulder Scapula: surfaces of Coracoid Anterior anteriorly (throwing Scapula; Pectoralis depresses; ribs: certain ribs process of thorax motion); assists with ribs minor elevates (2–4 or scapula inhalation 3–5) Muscle Anterior Moves arm from side slips from surface of Anterior of body to front of Scapula; Scapula: protracts; Serratus certain ribs vertebral thorax body; assists with ribs ribs: elevates anterior (1–8 or border of inhalation 1–9) scapula Elevates shoulders Scapula: rotests Acromion (shrugging); pulls Scapula; inferiorly, retracts, Skull; Posterior and spine of shoulder blades cervical elevates, and Trapezius vertebral thorax scapula; together; tilts head spine depresses; spine: column clavicle backwards extends Stabilizes scapula Thoracic Medial Posterior Retracts; rotates Rhomboid during pectoral girdle Scapula vertebrae border of thorax inferiorly major movement (T2–T5) scapula Table 11. The pectoralis major is thick and fan-shaped, covering much of the superior portion of the anterior thorax. The broad, triangular latissimus dorsi is located on the inferior part of the back, where it inserts into a thick connective tissue shealth called an aponeurosis. The anatomical and ligamental structure of the shoulder joint and the arrangements of the muscles covering it, allows the arm to carry out different types of movements. The deltoid, the thick muscle that creates the rounded lines of the shoulder is the major abductor of the arm, but it also facilitates flexing and medial rotation, as well as extension and lateral rotation. Named for their locations, the supraspinatus (superior to the spine of the scapula) and the infraspinatus (inferior to the spine of the scapula) abduct the arm, and laterally rotate the arm, respectively. The thick and flat teres major is inferior to the teres minor and extends the arm, and assists in adduction and medial rotation of it. The tendons of the deep subscapularis, supraspinatus, infraspinatus, and teres minor connect the scapula to the humerus, forming the rotator cuff (musculotendinous cuff), the circle of tendons around the shoulder joint. When baseball pitchers undergo shoulder surgery it is usually on the rotator cuff, which becomes pinched and inflamed, and may tear away from the bone due to the repetitive motion of bring the arm overhead to throw a fast pitch. Muscles That Move the Forearm The forearm, made of the radius and ulna bones, has four main types of action at the hinge of the elbow joint: flexion, extension, pronation, and supination. The pronators are the pronator teres and the pronator quadratus, and the supinator is the only one that turns the forearm anteriorly. The two-headed biceps brachii crosses the shoulder and elbow joints to flex the forearm, also taking part in supinating the forearm at the radioulnar joints and flexing the arm at the shoulder joint. These muscles and their associated blood vessels and nerves form the anterior compartment of the arm (anterior flexor compartment of the arm) (Figure 11. Muscles of the Arm That Move the Wrists, Hands, and Fingers The muscles in the anterior compartment of the forearm (anterior flexor compartment of the forearm) originate on the humerus and insert onto different parts of the hand. From lateral to medial, the superficial anterior compartment of the forearm includes the flexor carpi radialis, palmaris longus, flexor carpi ulnaris, and flexor digitorum superficialis. The flexor digitorum superficialis flexes the hand as well as the digits at the knuckles, which allows for rapid finger movements, as in typing or playing a musical instrument (see Figure 11. However, poor ergonomics can irritate the tendons of these muscles as they slide back and forth with the carpal tunnel of the anterior wrist and pinch the median nerve, which also travels through the tunnel, causing Carpal Tunnel Syndrome. The muscles in the superficial posterior compartment of the forearm (superficial posterior extensor compartment of the forearm) originate on the humerus. These are the extensor radialis longus, extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, and the extensor carpi ulnaris. The muscles of the deep posterior compartment of the forearm (deep posterior extensor compartment of the forearm) originate on the radius and ulna. These include the abductor pollicis longus, extensor pollicis brevis, extensor pollicis This OpenStax book is available for free at http://cnx. The flexor retinaculum extends over the palmar surface of the hand while the extensor retinaculum extends over the dorsal surface of the hand. Intrinsic Muscles of the Hand The intrinsic muscles of the hand both originate and insert within it (Figure 11.

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Chronic stress purchase 20 mg protonix mastercard, unlike short-term stress generic protonix 40mg on line, may inhibit immune responses even in otherwise healthy adults generic 20mg protonix with amex. The suppression of both innate and adaptive immune responses is clearly associated with increases in some diseases generic 20mg protonix otc, as seen when individuals lose a spouse or have other long-term stresses, such as taking care of a spouse with a fatal disease or dementia. The new science of psychoneuroimmunology, while still in its relative infancy, has great potential to make exciting advances in our understanding of how the nervous, endocrine, and immune systems have evolved together and communicate with each other. Primary lymphoid organs, the bone marrow and thymus gland, are the locations where lymphocytes of the adaptive immune system proliferate and mature. Many immune system cells use the lymphatic and circulatory systems for transport throughout the body to search for and then protect against pathogens. Whereas barrier defenses are the body’s first line of physical defense against pathogens, innate immune responses are the first line of physiological defense. Innate responses occur rapidly, but with less specificity and effectiveness than the adaptive immune response. Innate responses can be caused by a variety of cells, mediators, and antibacterial proteins such as complement. Within the first few days of an infection, another series of antibacterial proteins are induced, each with activities against certain bacteria, including opsonization of certain species. They do not recognize self-antigens, however, but only processed antigen presented on their surfaces in a binding groove of a major histocompatibility complex molecule. There are several functional types of T lymphocytes, the major ones being helper, regulatory, and cytotoxic T cells. B cells have their own mechanisms for tolerance, but in peripheral tolerance, the B cells that leave the bone marrow remain inactive due to T cell tolerance. Some B cells do not need T cell cytokines to make antibody, and they bypass this need by the crosslinking of their surface immunoglobulin by repeated carbohydrate residues found in the cell walls of many bacterial species. The components of the immune response that have the maximum effectiveness against a pathogen are often associated with the class of pathogen involved. Bacteria and fungi are especially susceptible to damage by complement proteins, whereas viruses are taken care of by interferons and cytotoxic T cells. Pathogens have shown the ability, however, to evade the body’s immune responses, some leading to chronic infections or even death. Over-reactive immune responses include the hypersensitivities: B cell- and T cell-mediated immune responses designed to control pathogens, but that lead to symptoms or medical complications. The worst cases of over- reactive immune responses are autoimmune diseases, where an individual’s immune system attacks his or her own body because of the breakdown of immunological tolerance. These diseases are more common in the aged, so treating them will be a challenge in the future as the aged population in the world increases. Blood needs to be typed so that natural antibodies against mismatched blood will not destroy it, causing more harm than good to the recipient. Although this has been shown to occur with some rare cancers and those caused by known viruses, the normal immune response to most cancers is not sufficient to control cancer growth. Thus, cancer vaccines designed to enhance these immune responses show promise for certain types of cancer. What are the three main components of the lymphatic Phagocyte chemotaxis is the movement of phagocytes system? Removing functionality from a B cell without killing it cytotoxic T cells against virally infected cells? Describe how secondary B cell responses are interstitial fluid to its emptying into the venous developed. A typical human cannot survive without breathing for more than 3 minutes, and even if you wanted to hold your breath longer, your autonomic nervous system would take control. For oxidative phosphorylation to occur, oxygen is used as a reactant and carbon dioxide is released as a waste product.

They are also usually really tired so they definitely appreciate your help in any way (tracking down lab values order protonix 20 mg, calling primary care docs protonix 40mg amex, etc cheap protonix 40 mg line. Other people you will interact with: rd • Teaching senior: a 3 year resident whose entire role is to teach the med students on the team generic 40 mg protonix free shipping. He/she will lead special weekly didactic sessions during the inpatient rotation, as well as grade your write-ups. Even though it is “your patient”, the intern is ultimately responsible, so never do anything behind his/her back. As a 200 student, you will rarely call the attending directly with patient issues, but during rounds you should feel free to discuss your ideas with the attending. You should be there when your intern gets his/her sign-out so you know what happened with your patients overnight. This means getting their vital signs from overnight and finding out if there were any acute events by talking to the on-call resident and the nurses. Write a progress note on all of your patients, including an assessment 39 and plan so that you are prepared for rounds (standard progress note sheets are available on all floors so you just fill in the blanks—and the format of these sheets often varies between teams, so it’s best to get them on your own floor). The most important part of your presentation is the assessment and plan where you will summarize the patient and give your differential diagnosis and plan for further management (you will get much better at this as the year progresses, but make sure that you double check the A/P with your intern or resident before attending rounds). When time allows, your attending or resident will often give a lecture on a pertinent topic or bring in articles for review. What to wear: Females: nice pants and a top/sweater, closed toe shoes Males: nice pants, shirt and tie Some people do not like to wear a white coat on peds b/c they feel less approachable to the kids. Some people need it for all of the pocket space while others carry a small bag with their books and tools. What to put in your white coat (or carry with you): - Stethoscope - Pocket pharmacopeia/Epocrates - Pocket antibiotic guide - Pocket medicine (less applicable to Peds than Medicine, but you will still use it) - Otoscope and tips (Otoscopes are often hard to come by on the floor, so if you have one, make sure to bring it. However, if you are there on a slow night, your resident may send you home early, and you can instead pick up a new patient on a non-call day during the day. How to “pick up” patients: On pediatrics, all interns admit new patients on all days (on other rotations, like medicine, interns only admit when they are on call). Generally you will carry around 3 patients on peds (and you may start with 1-2 for the first few days if you take peds early in the year). However, if you don’t feel like you have enough patients, ask the resident if there are other interesting patients you can follow—residents like students who take initiative and don’t wait for work to be given to them. Whenever possible, it’s a good idea to make sure to pick up a mix of general peds and specialty patients, with an emphasis on the general peds patients. This way, you will get exposure to more of the “bread-and-butter” peds cases—and, sometimes, you end up being graded only by the general peds attendings (and not the specialty attendings). Assignments: You will have to write 2 detailed history and physical write-ups during your inpatient rotation. Students also have to do an Evidence Based Medicine exercise, give case presentations to their classmates, and participate in simulation sessions focusing on pediatric emergencies. Your final grade will be a combination of your shelf score, evaluations from your inpatient and outpatient rotations, your write-ups, and a case conference presentation. Tips for the Pediatric Presentation: • Don’t forget about birth history and developmental history (especially for younger children) • Don’t forget about feeding and voiding (pediatricians are more interested in diet and stooling than the average physician! The shelf exams usually test detailed knowledge, especially in peds, so it is usually not enough to only know general principles or basics. The majority of your energy should be focused on the rotation itself as your course evaluations from both inpatient and outpatient make up a substantial portion of your peds grade. Nonetheless, peds is one of the rotations that has a cut-off shelf score to be eligible for an honors grade. Help out others when you can and take initiative by taking on new patients or bringing in a presentation for rounds. Being friendly with your patients, family members, and all team members goes a long way on this rotation. You don’t need to give a detailed neurologic exam every day you present a patient who is admitted for asthma. Always inform your fellow students the day before about what you will be talking about so they can read up on the subject. An attending (or sometimes a resident) may assign or suggest topics and/or days for you to present, but sometimes you can pick your own topics/days.

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