GLAUCOMA

 

INTRODUCTION:  The presence of aqueous humor in the anterior cavity of the eye creates a pressure called intraocular pressure. An increase in this pressure is an important risk factor for glaucoma, which is now defined as a group of disorders that damage the optic nerve and cause loss of vision.  Other risk factors include high blood pressure and diabetes.

PATHOPHYSIOLOGY:  In the most common form of glaucoma, aqueous humor is not reabsorbed properly into the canal of Schlemm. Increased pressure in the anterior cavity is transmitted to the lens, the vitreous humor, and the retina and optic nerve. As pressure on the retina increases, halos may be seen around bright lights, and peripheral vision is lost. Frequently, however, there are no symptoms.

SIGNS AND SYMPTOMS:  A person with glaucoma may not notice the shrinking visual field in one eye before vision loss is far advanced. This happens because the brain will suppress a faulty image from one eye that it cannot easily integrate with the normal image of the other eye. When both eyes are affected, the person may not become aware of the gradual loss of peripheral vision, because close work such as reading does not require the edges of the visual fields.

PREVENTION AND TREATMENT: Glaucoma may often be controlled with medications that constrict the pupil and flatten the iris, thus opening up access to the canal of Schlemm. If these or other medications are not effective, laser surgery may be used to create a larger drainage canal.  Anyone over the age of 40 should have a test for glaucoma; anyone with a family history of glaucoma should have this test annually, as should those with diabetes or high blood pressure. If diagnosed early, glaucoma is treatable, and blindness can usually be prevented.

 

RELATED;

1.  BLOOD PRESSURE AND HYPERTENSION

2. DIABETES MELLITUS

3. MEDICAL CONDITIONS

4. REFERENCES

WOUND HEALING BY FIRST INTENTION (PRIMARY UNION)

 

INTRODUCTION: Wounds are some of the most common disruptions on the human skin and the leading ports of entry for microbes into the body.  Whether a wound is following a surgical operation, burns or an accidental injury if it is not catered for, it may cause infections from the external environment.  In our discussion here, we are looking at the process through which a surgical and clean wound will take to heal.

This type of healing occurs when there is no contamination of the wound, and the edges of the wound are approximated, thus closing the wound. The best example of this situation is the surgical incision where contamination of the wound is minimized and the wound is closed by suturing, once the wound is sutured, the incision space fills with blood, which contains fibrin and blood cells and which subsequently clots, the surface of this clot becomes dehydrated and forms a scab.

Within 24 hours, neutrophils appear at the edges of the incision and the epithelium at the edges of the incision begins to proliferate, it migrates under the scab and forms a thin continuous epithelial layer.

By 72 hours, macrophages are usually the most numerous inflammatory cells and granulation tissue starts to develop, collagen fibers are present but do not bridge the incision site, the epithelial cells continue to proliferate under the scab and the epidermal covering over the incision becomes thicker.

By day 5, the incision space is filled with granulation tissue and collagen fibers begin to bridge the incision, the epidermis returns to its normal thickness and keratinized architecture.

During the second week, there is continued accumulation of collagen fibers and proliferation of fibroblasts, inflammatory cells, edema disappears, and the process of blanching begins.

By the end of one month, a connective tissue scar is devoid of inflammatory cells and is covered by an intact epidermis.

RELATED;

1. WOUND HEALING BY SECONDARY INTENTION  

2. COMPLICATIONS OF WOUND HEALING  

3. CHRONIC INFLAMMATION

4.  BURNS

REFERENCES

CARDIOGENIC SHOCK

INTRODUCTION: Cardiogenic shock occurs when the heart’s ability to contract and to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues. The causes of cardiogenic shock are known as either coronary or non-coronary. Coronary cardiogenic shock is more common than non-coronary cardiogenic shock and is seen most often in patients with acute myocardial infarction. Non-coronary causes of cardiogenic shock are related to conditions that stress the myocardium (eg, severe hypoxemia, acidosis, hypoglycemia, hypocalcemia, and tension pneumothorax) and conditions that result in ineffective myocardial function (eg, cardiomyopathies, valvular damage, cardiac tamponade, dysrhythmias).

CLINICAL MANIFESTATIONS: Classic signs include low blood pressure (BP), rapid and weak pulse. Dysrhythmias are common. Angina pain may be experienced. Hemodynamic instability. Complaints of fatigue.

MEDICAL MANAGEMENT: Goals of medical treatment include limiting further myocardial damage, preserving the healthy myocardium, and improving cardiac function. It is necessary first to treat the oxygenation needs of the heart muscle, increasing oxygen supply to the heart muscle while reducing oxygen demands. First-line treatment includes administering supplemental oxygen, controlling chest pain, administering fluids, and administering vasoactive medications (eg, dobutamine, nitroglycerin, dopamine) and antiarrhythmic medications. Hemodynamic monitoring and laboratory marker monitoring are performed. 

Mechanical cardiac support may be necessary. Coronary cardiogenic shock may be treated with thrombolytic therapy, a percutaneous coronary intervention, coronary artery bypass graft surgery, and/or intra-aortic balloon pump therapy. Noncoronary cardiogenic shock may be treated with cardiac valve replacement, correction of dysrhythmia, correction of acidosis and electrolyte disturbances, or treatment of the tension pneumothorax.

RELATED;

1. OTHER TYPES OF SHOCK  

2.  HYPERTENTION.  

3.  CONGESTIVE CARDIAC FAILURE

4.  MEDICAL CONDITIONS

REFERENCES

ANAPHYLAXIS

 

INTRODUCTION: Anaphylaxis is a clinical response to an immediate (type I hypersensitivity) immunologic reaction between a specific antigen and an antibody. The reaction results from a rapid release of IgE-mediated chemicals, which can induce a severe, life-threatening allergic reaction. Substances that most commonly cause anaphylaxis include foods, medications, insect stings, and latex. Immunoglobulins

Foods that are common causes of anaphylaxis include peanuts, tree nuts, shellfish, fish, milk, eggs, soy, and wheat. Many medications have been implicated in anaphylaxis. Those that are most frequently reported include antibiotics (eg, penicillin), radiocontrast agents, IV anesthetics, aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids. Penicillins: Anaesthetic medication: Opioid analgesics  Closely related to anaphylaxis is a nonallergenic anaphylaxis (anaphylactoid) reaction.

Clinical Manifestations: Anaphylactic reactions produce a clinical syndrome that affects multiple organ systems. Reactions may be categorized as mild, moderate, or severe. The severity depends on the degree of allergy and the dose of allergen.  Mild Symptoms include peripheral tingling, a warm sensation, fullness in the mouth and throat, nasal congestion, periorbital swelling, pruritus, sneezing, and tearing eyes. Symptoms begin within 2 hours of exposure. Moderate Symptoms include flushing, warmth, anxiety, and itching in addition to any of the milder symptoms. More serious reactions include bronchospasm and edema of the airways or larynx with dyspnea, cough, and wheezing. The onset of symptoms is the same as for a mild reaction.

Severe: Severe systemic reactions have an abrupt onset with the same signs and symptoms described previously. Symptoms progress rapidly to bronchospasm, laryngeal edema, severe dyspnea, cyanosis, and hypotension.  Dysphagia, abdominal cramping, vomiting, diarrhea, and seizures can also occur.  Cardiac arrest and coma may follow.

Assessment and Diagnostic Methods: Diagnostic evaluation of the patient with allergic disorders commonly includes blood tests (complete blood cell count [CBC] with differential, high total serum IgE levels), smears of body secretions, skin tests, and the radioallergosorbent test (RAST).

Prevention: Prevention by avoidance of allergens is of utmost importance. If avoidance of exposure to allergens is impossible, the patient should be instructed to carry and administer epinephrine to prevent an anaphylactic reaction in the event of exposure to the allergen.  Health care providers should always obtain a careful history of any sensitivities before administering medications. Venom immunotherapy may be given to people who are allergic to insect venom. Insulin-allergic patients with diabetes or penicillin-sensitive patients may require desensitization.

Medical Management: Respiratory and cardiovascular functions are evaluated and cardiopulmonary resuscitation (CPR) is initiated in cases of cardiac arrest. Oxygen is administered in high concentration during CPR or when the patient is cyanotic, dyspneic, or wheezing. Patients with mild reactions need to be educated about the risk for recurrences. Patients with severe reactions need to be observed for 12 to 14 hours.

Pharmacologic Therapy: Epinephrine, antihistamines, and corticosteroids may be given to prevent recurrences of the reaction and to relieve urticaria and angioedema. Corticosteroids.  IV fluids (eg, normal saline solution), volume expanders, and vasopressor agents are administered to maintain blood pressure and normal hemodynamic status; glucagon may be administered. Plasmavolume expanders  Aminophylline and corticosteroids may also be administered to improve airway patency and function.

RELATED;

1. ASTHMA  

2.  ALLERGIC RHINITIS

3.  IMMUNOLOGY

4.  LACTOSE INTOLERANCE

REFERENCES

ANGINA PECTORIS

 

INTRODUCTION: Angina pectoris is a clinical syndrome characterized by paroxysms of pain or a feeling of pressure in the anterior chest. The cause is insufficient coronary blood flow, resulting in an inadequate supply of oxygen to meet the myocardial demand. Angina is usually a result of atherosclerotic heart disease and is associated with a significant obstruction of a major coronary artery. Factors affecting anginal pain are physical exertion, exposure to cold, eating a heavy meal, or stress or any emotion-provoking situation that increases blood pressure, heart rate, and myocardial workload. Unstable angina is not associated with the above and may occur at rest.

CLINICAL MANIFESTATIONS: Pain varies from a feeling of indigestion to a choking or heavy sensation in the upper chest ranging from discomfort to agonizing pain. The patient with diabetes mellitus may not experience severe pain with angina. Angina is accompanied by severe apprehension and a feeling of impending death. The pain is usually retrosternal, deep in the chest behind the upper or middle third of the sternum. Discomfort is poorly localized and may radiate to the neck, jaw, shoulders, and inner aspect of the upper arms (usually the left arm). A feeling of weakness or numbness in the arms, wrists, and hands, as well as shortness of breath, pallor, diaphoresis, dizziness or lightheadedness, and nausea and vomiting, may accompany the pain. Anxiety may occur with angina. An important characteristic of anginal pain is that it subsides when the precipitating cause is removed or with nitroglycerin.

ASSESSMENT AND DIAGNOSTIC METHODS: Evaluation of clinical manifestations of pain and patient history. Electrocardiogram changes (12-lead ECG), stress testing, blood tests. Echocardiogram, nuclear scan, or invasive procedures such as cardiac catheterization and coronary angiography.

MEDICAL MANAGEMENT: The objectives of the medical management of angina are to decrease the oxygen demand of the myocardium and to increase the oxygen supply. Medically, these objectives are met through pharmacologic therapy and control of risk factors. Alternatively, reperfusion procedures may be used to restore the blood supply to the myocardium. These include PCI procedures (eg, percutaneous transluminal coronary angioplasty [PTCA], intracoronary stents, and atherectomy) and coronary artery bypass graft (CABG).

PHARMACOLOGIC THERAPY: Nitrates, the mainstay of therapy (nitroglycerin). Beta-adrenergic blockers (metoprolol and atenolol). Calcium channel blockers/calcium ion antagonists (amlodipine and diltiazem). Antiplatelet and anticoagulant medications (aspirin, clopidogrel, heparin, glycoprotein [GP] IIb/IIIa agents [abciximab, tirofiban, eptifibatide]). Oxygen therapy.

RELATED;

1. ARTERIOSCLEROSIS  

2. BETA BLOCKERS  

3. CHAMBERS AND CIRCULATION THROUGH THE HEART

REFERENCES

BACK PAIN

 

INTRODUCTION: Most low back pain is caused by one of many musculoskeletal problems, including acute lumbosacral strain, unstable lumbosacral ligaments and weak muscles, osteoarthritis of the spine, spinal stenosis, intervertebral disk problems, and unequal leg length. Obesity, postural problems, structural problems, stress, overstretching of the spinal supports, and occasionally depression may also result in back pain. Back pain due to musculoskeletal disorders usually is aggravated by activity, whereas pain due to other conditions is not. Older patients may experience back pain associated with osteoporotic vertebral fractures, osteoarthritis of the spine, spinal stenosis, and spondylolisthesis, among other conditions.

CLINICAL MANIFESTATIONS: Acute or chronic back pain (lasting more than 3 months without improvement) and fatigue. Pain that radiates down the leg (radiculopathy, sciatica); presence of this symptom suggests nerve root involvement. Gait, spinal mobility, reflexes, leg length, leg motor strength, and sensory perception may be affected. Paravertebral muscle spasm (greatly increased muscle tone of back postural muscles) occurs with loss of normal lumbar curve and possible spinal deformity.

ASSESSMENT AND DIAGNOSTIC METHODS: Health history and physical examination (back examination, neurologic testing). Spinal x-ray. Bone scan and blood studies. Computed tomography (CT) scan. Magnetic resonance imaging (MRI). Electromyogram and nerve conduction studies. Myelogram, Ultrasound.

MEDICAL MANAGEMENT: Most back pain is self-limited and resolves within 4 weeks with analgesics, rest, and relaxation. Management focuses on relief of pain and discomfort, activity modification, and patient education. Bed rest is recommended for 1 to 2 days, for a maximum of 4 days and only if pain is severe. Other effective nonpharmacologic interventions include the application of superficial heat and spinal manipulation. Cognitive-behavioral therapy (eg, biofeedback), exercise regimens, spinal manipulation, physical therapy, acupuncture, massage, and yoga are all effective nonpharmacologic interventions for treating chronic low back pain but not acute low back pain. Most patients need to alter their activity patterns to avoid aggravating the pain. They should avoid twisting, bending, lifting, and reaching, all of which stress the back. A gradual return to activities and a program of low-stress aerobic exercise are recommended.

PHARMACOLOGIC THERAPY: Acute low back pain: nonprescription analgesics (eg, acetaminophen), nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, ibuprofen), and prescription muscle relaxants (eg, cyclobenzaprine). Chronic low back pain: tricyclic antidepressants (eg, amitriptyline). Others: opioids (eg, morphine), tramadol (Ultram), benzodiazepines (eg, diazepam [Valium]), and gabapentin (Neurontin).

RELATED;

1. CHRONIC PAIN  

2. INFLAMMATION  

3. OSTEOPOROSIS

4.  MEDICAL CONDITIONS

REFERENCES

MENINGITIS

 

INTRODUCTION:  Meningitis is an inflammation of the lining around the brain and spinal cord caused by bacteria or viruses. Meningitis is classified as septic or aseptic. The aseptic form may be viral or secondary to lymphoma, leukemia, or human immunodeficiency virus (HIV). The septic form is caused by bacteria such as Streptococcus pneumoniae and Neisseria meningitidis.

PATHOPHYSIOLOGY:  The causative organism enters the bloodstream, crosses the blood brain barrier, and triggers an inflammatory reaction in the meninges.  The blood brain barrier  Independent of the causative agent, inflammation of the subarachnoid and piamater occurs. Increased intracranial pressure (ICP) results. Meningeal infections generally originate in one of two ways: either through the bloodstream from other infections (cellulitis) or by direct extension (after a traumatic injury to the facial bones). Bacterial or meningococcal meningitis also occurs as an opportunistic infection in patients with acquired immunodeficiency syndrome (AIDS) and as a complication of Lyme disease. Bacterial meningitis is the most significant form. The common bacterial pathogens are; N. meningitidis (meningococcal meningitis) and S. pneumoniae, accounting for 80% of cases of meningitis in adults. Haemophilus influenzae was once a common cause of meningitis in children, but, because of vaccination, infection with this organism is now rare in developed countries. Streptococcus:

CLINICAL MANIFESTATIONS:  Headache and fever are frequently the initial symptoms; fever tends to remain high throughout the course of the illness; the headache is usually either steady or throbbing and very severe as a result of meningeal irritation.  Meningeal irritation results in a number of other wellrecognized signs common to all types of meningitis:  Nuchal rigidity (stiff neck) is an early sign.  Positive Kernig’s sign: When lying with thigh flexed on abdomen, patient cannot completely extend leg.  Positive Brudzinski’s sign: Flexing patient’s neck produces flexion of the knees and hips; passive flexion of lower extremity of one side produces similar movement for opposite extremity.  Photophobia (extreme sensitivity to light) is common.  Rash (N. meningitidis): ranges from petechial rash with purpuric lesions to large areas of ecchymosis.  Disorientation and memory impairment; behavioral manifestations are also common. As the illness progresses, lethargy, unresponsiveness, and coma may develop.  Seizures can occur and are the result of areas of irritability in the brain; ICP increases secondary to diffuse brain swelling or hydrocephalus; initial signs of increased ICP include decreased level of consciousness and focal motor deficits.  An acute fulminant infection occurs in about 10% of patients with meningococcal meningitis, producing signs of overwhelming septicemia: an abrupt onset of high fever, extensive purpuric lesions (over the face and extremities), shock, and signs of disseminated intravascular coagulation (DIC); death may occur within a few hours after onset of the infection.

ASSESSMENT AND DIAGNOSTIC FINDINGS: Computed tomography (CT) scan or magnetic resonance imaging (MRI) scan to detect a shift in brain contents (which may lead to herniation) prior to a lumbar puncture.  Key diagnostic tests: bacterial culture and Gram staining of CSF and blood.

PREVENTION:  The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC) (2008) recommends that the meningococcal conjugated vaccine be given to adolescents entering high school and to college freshmen living in dormitories.  Vaccination should also be considered as an adjunct to antibiotic chemoprophylaxis for anyone living with a person who develops meningococcal infection. Vaccination against H. influenzae and S. pneumoniae should be encouraged for children and at-risk adults. People in close contact with patients with meningococcal meningitis should be treated with antimicrobial chemoprophylaxis using rifampin, ciprofloxacin hydrochloride (Cipro), or ceftriaxone sodium (Rocephin). Therapy should be started within 24 hours after exposure because a delay in the initiation of therapy limits the effectiveness of the prophylaxis.

MEDICAL MANAGEMENT:  Vancomycin hydrochloride in combination with one of the cephalosporins (eg, ceftriaxone sodium, cefotaxime sodium) is administered by intravenous (IV) injection. Dexamethasone has been shown to be beneficial as adjunct therapy in the treatment of acute bacterial meningitis and in pneumococcal meningitis. Dehydration and shock are treated with fluid volume expanders. Seizures, which may occur early in the course of the disease, are controlled with phenytoin. Increased ICP is treated as necessary.

 

RELATED;

1.  CEREBRAL VASCULAR ACCIDENT

2.  THE BLOOD BRAIN BARRIER

3.  MEDICAL CONDITIONS 

REFERENCES

EPISTAXIS

 

INTRODUCTION:  Epistaxis is a hemorrhage from the nose caused by the rupture of tiny, distended vessels in the mucous membrane of any area of the nasal passage. The anterior septum is the most common site.

RISK FACTORS OF NOSEBLEEDS:  Risk factors include infections, low humidity, nasal inhalation of illicit drugs, trauma (including vigorous nose blowing and nose picking), arteriosclerosis, hypertension, nasal tumors, thrombocytopenia, aspirin use, liver disease, and hemorrhagic syndromes.

MEDICAL MANAGEMENT:  A nasal speculum, penlight, or headlight may be used to identify the site of bleeding in the nasal cavity. The patient sits upright with the head tilted forward to prevent swallowing and aspiration of blood and is directed to pinch the soft outer portion of the nose against the midline septum for 5 or 10 minutes continuously. Alternatively, a cotton tampon may be used to try to stop the bleeding. Suction may be used to remove excess blood and clots from the field of inspection. Application of anesthetics and nasal decongestants (phenylephrine, one or two sprays) to act as vasoconstrictors may be necessary. 

Visible bleeding sites may be cauterized with silver nitrate or electrocautery (high-frequency electrical current). If the origin of the bleeding cannot be identified, the nose may be packed with gauze impregnated with petrolatum jelly or antibiotic ointment. The packing may remain in place for 48 hours or up to 5 or 6 days if necessary to control bleeding. Antibiotics may be prescribed to prevent and manage infection.

 

RELATED;

1.  Anemia

2.  Thrombocytopenia

3.  Medical conditions

REFERENCES

ENDOMETRIOSIS

 

INTRODUCTION:  Endometriosis is a benign lesion with cells similar to those lining the uterus, growing aberrantly in the pelvic cavity outside the uterus. During menstruation, this ectopic tissue bleeds, mostly into areas having no outlet, which causes pain and adhesions. Endometrial tissue can also be spread by lymphatic or venous channels. There is a high incidence among patients who bear children later and have fewer children. It is usually found in nulliparous women between 25 and 35 years of age and in adolescents, particularly those with dysmenorrhea that does not respond to nonsteroidal anti-inflammatory drugs (NSAIDs) or oral contraceptives. There appears to be a familial predisposition to endometriosis. It is a major cause of chronic pelvic pain and infertility.

CLINICAL MANIFESTATIONS:  Symptoms vary but include dysmenorrhea, dyspareunia, and pelvic discomfort or pain (some patients have no pain).  Dyschezia (pain with bowel movements) and radiation of pain to the back or leg may occur.  Depression, inability to work due to pain, and difficulties in personal relationship may result.  Infertility may occur.

ASSESSMENT AND DIAGNOSTIC METHODS:  A health history, including an account of the menstrual pattern, is necessary to elicit specific symptoms. On pelvic examination, fixed tender nodules are sometimes palpated, and uterine mobility may be limited, indicating adhesions. Laparoscopic examination confirms the diagnosis and enables clinicians to determine the disease’s stage.

MEDICAL MANAGEMENT:  Treatment depends on symptoms, desire for pregnancy, and extent of the disease. In asymptomatic cases, routine examination may be all that is required. Other therapy for varying degrees of symptoms may be NSAIDs, oral contraceptives, gonadotropin-releasing hormone (GnRH) agonists, or surgery. Pregnancy often alleviates symptoms because neither ovulation nor menstruation occurs.

Pharmacologic Therapy:  Palliative measures (eg, use of medications, such as analgesic agents and prostaglandin inhibitors) for pain.  Oral contraceptives.  Synthetic androgen, causes atrophy of the endometrium and subsequent amenorrhea.  GnRH agonists decrease estrogen production and cause subsequent amenorrhea. Side effects are related to low estrogen levels (eg, hot flashes and vaginal dryness).

Surgical Management:  Laparoscopy to fulgurate endometrial implants and to release adhesions.  Laser surgery to vaporize or coagulate endometrial implants, thereby destroying the tissue.

RELATED;

1.  PELVIC INFLAMMATORY DISEASE

2.  OVULATION AND THE MENSTRUAL CYCLE

REFERENCES

RENAL FAILURE

 

INTRODUCTION:  Renal failure results when the kidneys are unable to remove metabolic waste and perform their regulatory functions. Acute renal failure (ARF) is a rapid loss of renal function due to damage to the kidneys. Three major categories of ARF are prerenal (hypoperfusion, as from volume depletion disorders, extreme vasodilation, or impaired cardiac performance); intrarenal (parenchymal damage to the glomeruli or kidney tubules, as from burns, crush injuries, infections, transfusion reaction, or nephrotoxicity, which may lead to acute tubular necrosis [ATN]); and postrenal (urinary tract obstruction, as from calculi, tumor, strictures, prostatic hyperplasia, or blood clots).

CLINICAL STAGES:  Initiation period: initial insult and oliguria.  Oliguric period (urine volume less than 400 mL/day): Uremic symptoms first appear and hyperkalemia may develop.  

Diuresis period: gradual increase in urine output signaling beginning of glomerular filtration’s recovery. Laboratory values stabilize and start to decrease.

Recovery period: improving renal function (may take 3 to 12 months).

CLINICAL MANIFESTATIONS:  Critical illness and lethargy with persistent nausea, vomiting, and diarrhea.  Skin and mucous membranes are dry.  Central nervous system manifestations: drowsiness, headache, muscle twitching, seizures.  Urine output scanty to normal; urine may be bloody with low specific gravity.  Steady rise in blood urea nitrogen (BUN) may occur depending on degree of catabolism; serum creatinine values increase with disease progression.  Hyperkalemia may lead to dysrhythmias and cardiac arrest.  Progressive acidosis, increase in serum phosphate concentrations, and low serum calcium levels may be noted.  Anemia from blood loss due to uremic GI lesions, reduced red blood cell life-span, and reduced erythropoietin production.

ASSESSMENT AND DIAGNOSTIC METHODS: Urine output measurements.  Renal ultrasonography, CT and magnetic resonance imaging (MRI) scans.  BUN, creatinine, electrolyte analyses.

MEDICAL MANAGEMENT:  Treatment objectives are to restore normal chemical balance and prevent complications until renal tissues are repaired and renal function is restored. Possible causes of damage are identified and treated.  Fluid balance is managed on the basis of daily weight, serial measurements of central venous pressure, serum and urine concentrations, fluid losses, blood pressure, and clinical status. Fluid excesses are treated with mannitol, furosemide, or ethacrynic acid to initiate diuresis and prevent or minimize subsequent renal failure.  Blood flow is restored to the kidneys with the use of intravenous (IV) fluids, albumin, or blood product transfusions.  Dialysis (hemodialysis, hemofiltration, or peritoneal dialysis) is started to prevent complications, including hyperkalemia, metabolic acidosis, pericarditis, and pulmonary edema.  Cation-exchange resins (orally or by retention enema).  IV dextrose 50%, insulin, and calcium replacement for the patient who is hemodynamically unstable (low blood pressure, changes in mental status, dysrhythmia).  Shock and infection are treated if present.  Arterial blood gases are monitored when severe acidosis is present.  Sodium bicarbonate to elevate plasma pH.  If respiratory problems develop, ventilatory measures are started.  Phosphate-binding agents to control elevated serum phosphate concentrations.  Replacement of dietary proteins is individualized to provide the maximum benefit and minimize uremic symptoms.  Caloric requirements are met with high-carbohydrate feedings; parenteral nutrition (PN).  Foods and fluids containing potassium and phosphorus are restricted.  Blood chemistries are evaluated to determine amount of sodium, potassium, and water replacement during oliguric phase.  After the diuretic phase, high-protein, high-calorie diet is given with gradual resumption of activities.

 

RELATED;

1.  GENITAL URINARY TRACT CONDITIONS AND INFECTIONS

2.  EXCRETION OF DRUGS

REFERENCES

OSTEOPOROSIS

 

INTRODUCTION:  Osteoporosis is characterized by reduced bone mass, deterioration of bone matrix, and diminished bone architectural strength. The rate of bone resorption is greater than the rate of bone formation. The bones become progressively porous, brittle, and fragile, and they fracture easily. Multiple compression fractures of the vertebrae result in skeletal deformity (kyphosis).  This kyphosis is associated with loss of height.

RISK FACTORS:  Patients at risk include postmenopausal women and small framed, nonobese Caucasian women. Other risk factors include inadequate nutrition, inadequate vitamin D and calcium, and lifestyle choices including but not limited to; smoking, caffeine intake, and alcohol consumption; genetics; and lack of physical activity.  Age-related bone loss begins soon after peak bone mass is achieved (in the fourth decade).  Withdrawal of estrogens at menopause or oophorectomy causes decreased calcitonin and accelerated bone resorption, which continues during menopausal years. Immobility contributes to the development of osteoporosis. Secondary osteoporosis is the result of medications or other conditions and diseases that affect bone metabolism. Specific disease states such as, celiac disease, hypogonadism and medications such as, corticosteroids, antiseizure medications that place patients at risk need to be identified and therapies instituted to reverse the development of osteoporosis.

ASSESSMENT AND DIAGNOSTIC FINDINGS: Osteoporosis is identified on routine x-ray films when there has been 25% to 40% demineralization.  Dual-energy x-ray absorptiometry (DEXA; DXA) provides information about spine and hip bone mass and bone mineral density (BMD).  Laboratory studies (eg, serum calcium, serum phosphate, serum alkaline phosphatase, urine calcium excretion, urinary hydroxyproline excretion, hematocrit, erythrocyte sedimentation rate [ESR]) and x-ray studies are used to exclude other diagnoses.

GERONTOLOGIC CONSIDERATIONS:  Elderly people fall frequently as a result of environmental hazards, neuromuscular disorders, diminished senses and cardiovascular responses, and responses to medications. The patient and family need to be included in planning for care and preventive management regimens. For example, the home environment should be assessed for safety and elimination of potential hazards (eg, scatter rugs, cluttered rooms and stairwells, toys on the floor, pets underfoot). A safe environment can then be created (eg, well-lighted staircases with secure hand rails, grab bars in the bathroom, properly fitting footwear).

MEDICAL MANAGEMENT:  Adequate, balanced diet rich in calcium and vitamin D.  Increased calcium intake during adolescence, young adulthood, and the middle years, or prescribe a calcium supplement with meals or beverages high in vitamin C.  Regular weight-bearing exercise to promote bone formation (20 to 30 minutes aerobic exercise 3 days/week).  Other medications: the bisphosphonates alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), and zoledronic acid (Reclast); calcitonin (Miacalcin); selective estrogen receptor modulators (SERMs) such as raloxifene (Evista); teriparatide (Forteo).  Osteoporotic compression fractures of the vertebrae are managed conservatively. Patients who have not responded to first-line approaches to the treatment of vertebral compression fracture can be considered for percutaneous vertebroplasty or kyphoplasty (injection of polymethylmethacrylate bone cement into the fractured vertebra, followed by inflation of a pressurized balloon to restore the shape of the affected vertebra).

 

RELATED;

1.  CALCITONIN  

2.  BACK PAIN

3.  GOUT

4.  MEDICINE AND SURGERY

REFERENCES

ULTERED LEVEL OF CONSCIOUSNESS

 

INTRODUCTION:  Unconsciousness also known as altered Level Of Consciousness (ALOC) is a condition in which the patient is unresponsive to and unaware of environmental stimuli, usually for a short duration. Coma is a clinical state which is an unarousable, unresponsive condition in which the patient is unaware of self or the environment for prolonged periods (days to months, or even years).  Akinetic mutism is a state of unresponsiveness to the environment in which the patient makes no voluntary movement. A persistent vegetative state is one in which the unresponsive patient resumes sleep–wake cycles after coma but is devoid of cognitive or affective mental function. Locked-in syndrome results from a lesion affecting the pons and results in paralysis and the inability to speak, but vertical eye movements and lid elevation remain intact and are used to indicate responsiveness.

CAUSES OF ALOC:  The causes of unconsciousness may be neurologic for example resulting from head injury or stroke, toxicologic such as following drug overdose, alcohol intoxication, or metabolic for example following hepatic or renal failure, diabetic ketoacidosis among others.

ASSESSMENT AND DIAGNOSTIC METHODS:  Neurologic examination (CT, MRI, positron emission tomography [PET], electroencephalography [EEG], single photon emission CT [SPECT]) to identify cause of loss of consciousness. Laboratory tests include; analysis of blood glucose, electrolytes, serum ammonia, and liver function tests; blood urea nitrogen (BUN) levels; serum osmolality; calcium level; and partial thromboplastin and prothrombin times.  Other studies may be used to evaluate serum ketones, alcohol and drug concentrations, and arterial blood gases.

MEDICAL MANAGEMENT:  The first priority is a patent and secure airway (intubation or tracheostomy). Then circulatory status (carotid pulse, heart rate and impulse, blood pressure) is assessed and adequate oxygenation maintained. An IV line is established to maintain fluid balance status, and nutritional support is provided (feeding tube or gastrostomy).  Neurologic care is based on specific pathology. Other measures include drug therapy and measures to prevent complications.

RELATED;

1.  The central nervous system

2.  Meningitis

3.  Hypoglycemia

4.  Parkinson's disease

5.  Medicine and surgery

REFERENCES

INFLAMMATORY BOWEL DISEASE

CLINICAL PRESENTATION:  Inflammatory bowel disease is distinguished from infectious entities by exclusion and by chronicity (months; not days or weeks). Patients often experience recurrent episodes of mucopurulent, bloody diarrhea characterized by lack of positive cultures for known microbial pathogens and failure to respond to antibiotics alone. Antibiotics:  Microbial pathogens

Because inflammatory bowel disease is characterized by exacerbations and remissions, favorable responses to therapy may be difficult to distinguish from spontaneous remissions occurring as part of the natural history of the disease.

ETIOLOGY:  Triggers for the development of IBD remain elusive. However, epidemiologic studies suggest that smoking and gastrointestinal infections are possible contributory factors. There are two forms of chronic inflammatory bowel disease: Crohn’s disease, which is transmural and granulomatous in character, occurring anywhere along the GI tract; and ulcerative colitis, which is superficial and limited to the colonic mucosa.  Ulcerative colitis

The exact causes of inflammatory bowel disease are unknown despite progress in understanding its pathogenesis.

PATHOLOGY & PATHOGENESIS:  Genetic risk and environmental factors are recognized as two key elements in the pathogenesis of inflammatory bowel disease. An explosion of newly recognized susceptibility genes for both Crohn disease and ulcerative colitis have been discovered through genome-wide associations. These studies evaluated thousands of single nucleotide polymorphisms (SNPs) in thousands of patients with inflammatory bowel disease and compared them with SNPs from thousands of people without the disease (controls). These studies found abnormalities in several categories of susceptibility genes in patients with inflammatory bowel disease. These included modulators of immune function, autophagy, and epithelial function that participate in the interaction of host and microorganism. Importantly, the relative risk of most of these susceptibility genes is low (most have a 20–30% increase in relative risk of developing disease).  Therefore, most people who harbor risk alleles for inflammatory bowel disease do not develop disease.  Genetic factors are clearly not the sole contributor to inflammatory bowel disease.  Many environmental factors have been found to contribute to the development of Crohn’s disease, including pathogenic microorganisms (bacteria and viruses), the repertoire of indigenous intestinal microbes (the microbiota), dietary factors, smoking, defective immune responses, and psychosocial factors.

RELATED;

1.  CONSTIPATION

2.  ULCERATIVE COLITIS

3.  MEDICAL CONDITIONS

REFERENCES

DIARRHEA

 

INTRODUCTION:  Diarrhea is a condition defined by an increased frequency of bowel movements that is to say, more than three per day, increased amount of stool, and altered consistency which is usually referred to as liquid stool. It is usually associated with urgency, perianal discomfort, incontinence, or a combination of these factors. Diarrhea can result from any condition that causes increased intestinal secretions, decreased mucosal absorption, or altered motility.

TYPES OF DIARRHEA:  Types of diarrhea include secretory, osmotic, malabsorptive, infectious, and exudative. It can be acute where it can be self-limiting and often associated with infection, or chronic which persists for a long period and may return sporadically. It can be caused by certain medications, tube feeding formulas, metabolic and endocrine disorders, and viral and bacterial infections. Other causes are nutritional and malabsorptive disorders, anal sphincter deficit, Zollinger–Ellison syndrome, paralytic ileus, acquired immunodeficiency syndrome (AIDS), and intestinal obstruction. Intestinal obstruction:  AIDS

CLINICAL MANIFESTATIONS:  Increased frequency and fluid content of stool.  Abdominal cramps, distention, intestinal rumbling, anorexia, and thirst.  Painful spasmodic contractions of the anus and ineffectual straining (tenesmus) with each defecation.  Other symptoms, depending on the cause and severity and related to dehydration and fluid and electrolyte imbalances, include the following: Watery stools, which may indicate small bowel disease.  Inflammatory bowel disease  

Loose, semisolid stools, which are associated with disorders of the large bowel.  Voluminous greasy stools, which suggest intestinal malabsorption.  Blood, mucus, and pus in the stools, which denote inflammatory enteritis or colitis.  Oil droplets on the toilet water, which are diagnostic of pancreatic insufficiency.  Nocturnal diarrhea, which may be a manifestation of diabetic neuropathy.

COMPLICATIONS:  Complications of diarrhea include cardiac dysrhythmias due to fluid and electrolyte (potassium) imbalance, urinary output less than 30 mL/h, muscle weakness, paresthesia, hypotension, anorexia, drowsiness, skin care issues related to irritant dermatitis, and death if imbalances become severe.

ASSESSMENT AND DIAGNOSTIC FINDINGS:  When the cause is not obvious: complete blood cell count; serum chemistries; urinalysis; routine stool examination; and stool examinations for infectious or parasitic organisms, bacterial toxins, blood, fat, electrolytes, and white blood cells. Endoscopy or barium enema may assist in identifying the cause. 

MEDICAL MANAGEMENT:  Primary medical management is directed at controlling symptoms, preventing complications, and eliminating or treating the underlying disease.  Certain medications such as, antibiotics, anti-inflammatory agents and antidiarrheals like, loperamide, diphenoxylate may reduce the severity of diarrhea and the disease.  Increase oral fluids; oral glucose and electrolyte solution may be prescribed.  Antimicrobials are prescribed when the infectious agent has been identified or diarrhea is severe. IV therapy is used for rapid hydration in very young or elderly patients.

RELATED;

1.  CONSTIPATION

2.  ULCERATIVE COLITIS

3.  INFLAMMATORY BOWEL DISEASE

4.  PEPTIC ULCER DISEASE

REFERENCES

MEGALOBLASTIC ANEMIA

 

INTRODUCTION:  In the anemias caused by deficiencies of vitamin B12 or folic acid, identical bone marrow and peripheral blood changes occur because both vitamins are essential for normal DNA synthesis.

PATHOPHYSIOLOGY:  Folic Acid Deficiency: Folic acid is stored as compounds referred to as folates. The folate stores in the body are much smaller than those of vitamin B12, and they are quickly depleted when the dietary intake of folate is deficient ( usually within 4 months). Folate deficiency occurs in people who rarely eat uncooked vegetables. Alcohol increases folic acid requirements; folic acid requirements are also increased in patients with chronic hemolytic anemias and in women who are pregnant. Some patients with malabsorptive diseases of the small bowel may as well not absorb folic acid normally.

Vitamin B12 Deficiency: A deficiency of vitamin B12 can occur in several ways. Inadequate dietary intake is rare but can develop in strict vegetarians who consume no meat or dairy products.  Faulty absorption from the GI tract is more common, as with conditions such as Crohn’s disease or after ileal resection or gastrectomy. Another cause is the absence of intrinsic factor. A deficiency may also occur if disease involving the ileum or pancreas impairs absorption.  The body normally has large stores of vitamin B12, so years may pass before the deficiency results in anemia.

CLINICAL MANIFESTATIONS:  Symptoms of folic acid and vitamin B12 deficiencies are similar, and the two anemias may coexist. Symptoms are progressive, although the course of illness may be marked by spontaneous partial remissions and exacerbations.  Gradual development of signs of anemia (weakness, listlessness, and fatigue).  Possible development of a smooth, sore, red tongue and mild diarrhea (pernicious anemia).  Mild jaundice, vitiligo.  Confusion may occur; more often, paresthesias in the extremities and difficulty keeping balance; loss of position sense.  Lack of neurologic manifestations with folic acid deficiency alone.  Without treatment, patients die, usually as a result of heart failure secondary to anemia.  Heart failure

ASSESSMENT AND DIAGNOSTIC FINDINGS:  Schilling test (primary diagnostic tool).  Complete blood cell count (Hgb value as low as 4 to 5 g/dL, WBC count 2,000 to 3,000 per ml of blood, platelet count fewer than 50,000 per ml of blood; very high MCV).  Serum levels of folate and vitamin B12 (folic acid deficiency and deficient vitamin B12)

MEDICAL MANAGEMENT: Folic Acid Deficiency:  Increase intake of folic acid in patient’s diet and administer 1 mg folic acid daily.  Administer IM folic acid for malabsorption syndromes. Prescribe additional supplements as necessary, because the amount in multivitamins may be inadequate to fully replace deficient body stores.  Prescribe folic acid for patients with alcoholism as long as they continue to consume alcohol.

Vitamin B12 Deficiency:  Provide vitamin B12 replacement: Vegetarians can prevent or treat deficiency with oral supplements with vitamins or fortified soy milk; when the deficiency is due to the more common defect in absorption or the absence of intrinsic factor, replacement is by monthly IM injections of vitamin B12.  A small amount of an oral dose of vitamin B12 can be absorbed by passive diffusion, even in the absence of intrinsic factor, but large doses (2 mg/day) are required if vitamin B12 is to be replaced orally.  To prevent recurrence of pernicious anemia, vitamin B12 therapy must be continued for life.

RELATED;

1.  Anemia

2.  Iron deficiency anemia

3.  Medical conditions

REFERENCES

CONSTIPATION

 

INTRODUCTION:  Constipation refers to an abnormal infrequency or irregularity of defecation, abnormal hardening of stools that makes their passage difficult and sometimes painful, decrease in stool volume, or prolonged retention of stool in the rectum. 

CAUSES OF CONSTIPATION:  It can be caused by certain medications; rectal or anal disorders; obstruction; metabolic, neurologic, and neuromuscular conditions; endocrine disorders; lead poisoning; connective tissue disorders; and a variety of disease conditions. 

Other causes may include weakness, immobility, debility, fatigue, and inability to increase intra-abdominal pressure to pass stools. Constipation develops when people do not take the time or ignore the urge to defecate or as the result of dietary habits such as, low consumption of fiber and inadequate fluid intake, lack of regular exercise, and a stress-filled life. 

CLINICAL MANIFESTATIONS:  Fewer than three bowel movements per week, abdominal distention, and pain and pressure.  Decreased appetite, headache, fatigue, indigestion, sensation of incomplete emptying.  Straining at stool; elimination of small volume of hard, dry stool.  Complications such as hypertension, hemorrhoids and fissures, fecal impaction, and megacolon.

ASSESSMENT AND DIAGNOSTIC METHODS:  Diagnosis is based on history, physical examination, possibly a barium enema or sigmoidoscopy, stool for occult blood, anorectal manometry (pressure studies), defecography, and colonic transit studies. Newer tests such as pelvic floor MRI may identify occult pelvic floor defects. 

MEDICAL MANAGEMENT:  Treatment should target the underlying cause of constipation and aim to prevent recurrence, including education, bowel habit training, increased fiber and fluid intake, and judicious use of laxatives. Discontinue laxative abuse; increase fluid intake; include fiber in diet; try biofeedback, exercise routine to strengthen abdominal muscles.  If laxative is necessary, use bulk-forming agents, saline and osmotic agents, lubricants, stimulants, or fecal softeners.  Specific medication therapy to increase intrinsic motor function such as cholinergics, cholinesterase inhibitors, or prokinetic agents.

RELATED;

1.  ULCERATIVE COLITIS  

2.  DIARRHEA

3.  MEDICAL CONDITIONS

REFERENCES