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Signs Hepatomegaly Signs of chronic liver disease Hepatomegaly is the term used to describe an enlarged There are many signs of chronic liver disease purchase cialis 2.5 mg visa, but in liver order 20mg cialis overnight delivery. Normally, the liver edge may be just palpable below some cases examination can be entirely normal, despite the right costal margin on deep inspiration, particularly advanced disease (see Fig. It may also be palpable without being The hands: enlarged due to downward displacement, e. The chest and upper arms: r Dupuytren’s contracture is a thickening of the palmar r Spider naevi are telangiectases that consist of a central fascia which may be palpable as thickening or cords arteriole with radiating small vessels. They blanch if and as it progresses flexes the fingers (most commonly pressure is applied to the centre, then refill outwards. Raised central venous Hepatic vein obstruction r Slate-grey pigmentation of the skin occurs in pressure (Budd–Chiari syndrome) haemochromatosis. Chronic liver disease Pancreatitis r There may be a hepatic flap, which is a flapping tremor Portal vein obstruction Inflammatory bowel disease of the outstretched hands. Congestive cardiac failure The abdomen and lower limbs: r Hepatomegaly and/or splenomegaly (see page 463). A In early cirrhosis liver function is adequate, so that pa- transudate is suggested by a protein of ≥11 g/L below tients are asymptomatic and do not have complications. In more severe disease portal hypertension, low serum r Clear fluid is seen in liver disease and hypoalbu- albumin and other complications occur. Signsofdecompensated cirrhosis: r Ascitic fluid amylase is raised in pancreatic ascites. The progress of ascites can be monitored using repeated Ascites weight and girth measurements. Sodium intake should be restricted but protein and calorie intake should be Definition maintained. Water restriction is only necessary if the Ascites is the accumulation of fluid within the peritoneal serum sodium concentration drops below 128 mmol/L. The combination of spironolactone and furosemide is effective in the majority of patients. Patients who not Aetiology/pathophysiology respond to this treatment may require Ascites may be a transudate or an exudate dependent on r therapeutic paracentesis, the removal of fluid over a the protein content (see Table 5. If more than1Loffluid is removed then intravenous albumin or plasma expander is re- Clinical features quired to prevent hypovolaemia. Chapter 5: Clinical 189 Investigations and procedures Obstruction r Bilirubin: Raised bilirubin levels indicate abnor- Liver function testing malities in its synthesis, metabolism or excretion. It often rises in causes of obstructive (cholestatic) Liver function testing includes blood tests to look for ev- jaundice, but it is not specific for obstruction or idence of hepatocyte necrosis, as well as assessing the even for liver disease (see Table 5. For assessing the synthetic function surement is also raised as it shares a similar pathway of the liver, two other blood tests are needed, the pro- of excretion. Alternatively, it is possible to r Aminotransferases: Two are measured, aspartate differentiate the bone and liver isoenzymes. These are raised by most causes of this enzyme even when there is no liver damage. It liver disease, but paradoxically, in severe necrosis may be used to detect if patients continue to drink or in late cirrhosis levels may fall to normal in- alcohol,butitdoeshavealonghalf-life. It falls Haemolysis in both acute and chronic liver disease, although Bilirubin Haemolysis levels may be normal early in the disease. Other osteomalacia, metastases, causes of hypoalbuminaemia include gastroin- hyperparathyroidism) testinal losses or heavy proteinuria. IgM is Albumin Malnutrition Nephrotic syndrome particularly raised in primary biliary cirrhosis, Congestive cardiac failure whereas IgG is raised in autoimmune hepatitis. Parenteral gallbladder, or may be seen after endoscopic or surgical replacementofvitaminKshouldleadtoimprovementof instrumentation. It is partic- Pancreatic function tests ularly useful in patients who have r jaundice or abnormal liver function tests where it is Exocrine function r Serum amylase is a marker for pancreatic damage. Ultrasound may also be the more complex triglyceride is not, then the steator- used for liver biopsy, and doppler ultrasound is used to rhea is caused by pancreatic disease. Tests for endocrine function in this context taken in case of allergy or risk of contrast nephrotoxicity. Pancreatic polypeptide is raised in all of useful for assessing focal lesions of the liver, staging of these types of tumour and see page 222 for specific malignancy, and it is more sensitive for pancreatic le- tests. Pancreaticcalcificationmay times used as a non-invasive alternative to endoscopic be seen in chronic pancreatitis.

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Recently 10mg cialis otc, thalidomide has been demonstrated to produce a significant response Management in 30% of patients whose disease progressed following Chemotherapy produces a variable response buy cialis 2.5 mg low price. Supportive care includes blood transfu- pheresis is used for symptomatic hyperviscosity. Unlike multiple myeloma there are preserved levels of 492 Chapter 12: Haematology and clinical immunology normal immunoglobulins, no lytic bone lesions and no Age renal failure. Investigations Sex Electropheresis of serum protein demonstrates a raised X linked; males only affected. Aetiology Mutations on the X chromosome including deletions, Management frame shifts and insertions. One third of cases are new Aproportionofpatients will go on to develop multi- mutations. Clinical features Type 1 and 2 causes mild disease with bleeding following Investigations injury, menorrhagia and epistaxis. Type 3 causes spon- r Activated partial thromboplastin time is raised, but taneous bleeding from early life. Clinical features Investigations Similar to haemophilia A with mild deficiency causing r Coagulation studies reveal prolonged clotting times only bleeding post surgery and trauma. Activated partial thromboplastin time is raised, but correctablewith50%normalserum(i. Patients re- quire supportive care and normally are managed in in- Management tensive care units. Definition Deficiency of vitamin K, a fat-soluble vitamin, leads to a Disseminated intravascular bleeding tendency. Deficiency occurs in obstructive jaundice and cer- widespread generation of fibrin within blood vessels and tain malabsorption syndromes. Aetiology Causes include Gram −ve and meningococcal sep- Pathophysiology ticaemia, disseminated malignant disease, haemolytic Vitamin K is a co factor in the synthesis of clotting fac- transfusion reactions, trauma, burns, surgery and P. Vitamin K is also involved in Pathophysiology producing proteins required for bone calcification. Widespread activation of intrinsic, extrinsic pathways and platelet aggregation causes consumption of platelets Clinical features and clotting factors (a consumptive coagulopathy) re- Patients present with bruising, mucosal bleeding and sulting in a severe bleeding risk. Red cells are fragmented during Investigations passage through occluded vessels causing a micro angio- The prothrombin time and the partial thromboplastin pathic haemolytic picture. Chapter 12: Bleeding disorders 495 Management ceptors within the spleen) shorten the course of the con- Vitamin K (phytomenadione) can be given as iv. If given orally in malabsorption syndromes it must be performed to exclude leukaemia. Pre- vious response to intravenous immunoglobulin is sug- Acute immune thrombocytopenia gestive of a favourable outcome of splenectomy. Chronic idiopathic thrombocytopenia purpura Age Definition More common in childhood, peak onset 2–10 years. The cause is largely not understood but it may arise 1–4 weeks after a viral infection. Clinical problems only ders such as systemic lupus erythematosus and thyroid become apparent when the platelet count falls below disease. Clinical features Clinical features Children present with petechiae and superficial bruis- Patients present with easy bruising, purpura, epistaxis ing, however in severe cases mucosal bleeds occur such and menorrhagia. Investigations Full blood count and blood film identify the low platelet Investigations count, a bone marrow aspirate demonstrates normal or Full blood count shows the level of platelets. Intravenous immunoglobulin works by blocking Management the Fc receptors in the spleen. Steroids and intra- but is useful in severe bleeding and predicts the poten- venous immunoglobulin (acts by saturating the Fc re- tial success of splenectomy. Other drugs used include 496 Chapter 12: Haematology and clinical immunology azathioprine, vincristine and danzol. Platelet transfu- Clinical features sions are only used in life threatening haemorrhage. Dilation of small arteries and capillaries result in charac- teristic small red spots that blanch on pressure (telang- iectasia) in the skin and mucous membranes particularly Thrombotic thrombocytopenia the nose and gastrointestinal tract. Patients suffer from purpura recurrent epistaxis and chronic gastrointestinal bleeds.

An 82-year-old man is admitted to the hospital because nursing staff in his skilled nursing care facility report that he has appeared sad and depressed during the past 2 months cialis 2.5mg generic. It is reported that he has a history of psychiatric illness purchase cialis 10mg fast delivery, but details are not provided. Which of the following is the most likely cause of this patient’s current symptoms? A 25-year-old butcher has had severe episodic pain in his right thumb and right second and third digits for 2 months. He has decreased sensation over the palmar surface of the thumb and index and long fingers of the right hand and atrophy of the thenar muscle mass. A 27-year-old woman comes to the physician because of a 3-week history of fatigue and blurred vision. For the past year, she has had 3- to 4-day episodes of numbness and tingling of her arms and legs. Sensation to light touch is decreased over the hands and feet; sensation to pinprick is increased over the fingers and toes bilaterally. A 57-year-old woman comes to the physician because of a 2-year history of difficulty sleeping. After she gets into bed at night, her legs feel cold and crampy, and she cannot settle into a comfortable position. A 77-year-old man comes to the emergency department 1 hour after a 15-minute episode of right arm weakness and an inability to speak in sentences; the symptoms have now resolved. Examination, including cardiopulmonary and neurologic examinations, shows no other abnormalities. Which of the following is the most appropriate next step to prevent cerebral infarction in this patient? A 62-year-old man with alcoholism is admitted to the hospital because of somnolence and hepatic failure. Hypertonic saline is administered, and the next day his serum sodium concentration is 138 mEq/L. Three days after admission, he has severe weakness; neurologic examination shows flaccid paresis of both the upper and lower extremities. Which of the following is the most likely cause of this patient’s acute neurologic symptoms? A 32-year-old woman comes to the emergency department 3 hours after the sudden onset of a severe headache. A previously healthy 4-year-old boy is brought to the emergency department 8 hours after the onset of fever and a diffuse, constant headache. Laboratory studies show: Serum glucose 120 mg/dL Cerebrospinal fluid Opening pressure 250 mm H2O Glucose 10 mg/dL Protein 85 mg/dL Leukocyte count 750/mm3 Segmented neutrophils 95% Lymphocytes 5% Erythrocyte count 0/mm3 A Gram stain of cerebrospinal fluid shows gram-negative diplococci. C - 83 - Family Medicine Modular Systems General Principles, Including Normal Age-Related Findings and Care of the Well Patient 5%–10% Immune System 1%–5% Blood & Lymphoreticular System 1%–5% Behavioral Health 5%–10% Nervous System & Special Senses 1%–5% Skin & Subcutaneous Tissue 3%–7% Musculoskeletal System (% increases with the addition of the Musculoskeletal module) 5%–10% Cardiovascular System 5%–10% Respiratory System 5%–10% Gastrointestinal System 5%–10% Renal & Urinary System 1%–5% Pregnancy, Childbirth, & the Puerperium 1%–5% Female Reproductive System & Breast 1%–5% Male Reproductive System 1%–5% Endocrine System 5%–10% Multisystem Processes & Disorders 1%–5% Biostatistics, Epidemiology/Population Health, & Interpretation of the Medical Lit. A 22-year-old college student comes to the physician because of a 2-month history of palpitations. She is a single mother and notes that her boyfriend has not helped with their infant daughter as much as he had promised. A 62-year-old man comes to the physician because of pain and swelling of the right foot for 24 hours. One month ago, he was diagnosed with hypertension and started treatment with hydrochlorothiazide. Examination shows tenderness, swelling, erythema, and warmth of the right first metatarsophalangeal joint; range of motion is decreased. X-rays of the right foot show mild joint space narrowing and periarticular bony erosions of the metatarsophalangeal joint. A 23-year-old man comes to the physician because of a 1-week history of painful urination and a clear urethral discharge. One month ago, he had similar symptoms and completed a course of doxycycline therapy for a chlamydial infection. He has been sexually active with one female partner for 2 years, and she takes an oral contraceptive. Which of the following is the most likely explanation for this patient’s current infection?

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Use in connection with any form of information storage and retrieval order 5 mg cialis visa, electronic adaptation buy 5mg cialis otc, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid free paper Springer is part of Springer ScienceþBusiness Media (www. Readers should consult other resources before applying information in this manual for direct patient care. The author, editors, and publisher of Approach to Internal Medicine cannot be held responsible for any harm, direct or indirect, caused as a result of application of information con tained within this manual. Confessio Medici, Stephen Paget, 1909 The third edition of Approach to Internal Medicine builds upon previous efforts to create a practical, evidence based, and concise educational resource for everyday clinical use and examination preparation. Approach to Internal Medicine now has an expanded repertoire of over 250 internal medicine topics, classified under 17 subspecialties. With the input of a new editor and publisher, we were able to significantly expand and update the content and substantially improve the layout, while maintaining the same conciseness and practicality found in previous editions. Under each topic, the sections on differential diagnoses, investigations, and treatments are designed for the rapid retrieval of high yield clinical information and can be particularly useful when one is all alone assessing apatient at3 o’clock inthe morning. Other sections containmanyclinicalpearls thatareintended to help one to excel in patient care. We also included many comparison tables aimed at highlighting the distinguishing features between various clinical entities and numerous mnemonics (marked by w). For this new edition, we are very fortunate to have recruited a new associate editor, Dr. Alexander Leung, who brings with him a wealth of knowledge and outstanding commitment to medical education. We are most grateful to our section editors and contributors for their meticulous review of each subspecialty, providing expert input on the most up to date information. We would also like to take this opportunity to thank Jean Claude Quintal as a resident reviewer and the Canadian Federation of Medical Students for its support of the previous edition. Finally, we would like to thank all previous and current users of this manual for their support and feedback. We are pleased that Springer has taken this title under its direction and has helped to improve its quality in preparation for international release. We would particularly like to thank Laura Walsh, senior editor, and Stacy Lazar, editorial assistant, from Springer for their expert guidance and support throughout this mammoth project from design to production. Anderson Cancer Center, for believing in this work and making this collaboration possible. While every effort has been made to ensure the accuracy of information in this manual, the author, editors, and publisher are not responsible for omissions, errors, or any consequences that result from application of the information contained herein. Verification of the information in this manual remains the professional responsibility of the practitioner. Readers are strongly urged to consult other appro priate clinical resources prior to applying information in this manual for direct patient care. This is ix x Preface particularly important since patterns of practice and clinical evidence evolve constantly. We welcome any constructive feedback to help make this manual a more accurate, practical, comprehensive, and user friendly resource. Consider leuko sodes of fever, dyspnea, and productive cough triene antagonists or inhaled glucocorticoids if (brownish sputum). Other considerations include the distance between the top of thyroid cartilage need for non invasive mechanical ventilation and and suprasternal notch atend ofexpiration. Constrictive bronchiolitis (late, fibrotic, con Related Topics centric) is not responsive to glucocorticoids Cryptogenic Organizing Pneumonia (p. Not enough evidence to suggest smoking, cancer (high suspicion of occult malig any of the rules as superior.

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