Medical Instructor, University of North Carolina School of Medicine
Dysphagia can be sought by asking the patient whether food "sticks medications known to cause seizures purchase sustiva 600 mg free shipping," is "hung-up treatment quality assurance unit generic 200mg sustiva," or "slows down" after swallowing medicine you take at first sign of cold buy sustiva 200 mg with visa. Symptoms of difficulty passing the bolus to the back of the mouth or initiating swallowing, regurgitation of food or liquid through the nose, coughing during swallows, and frank aspiration are all suggestive of oropharyngeal dysphagia [6]. If these are elicited, physical exam should search for focal or global neurologic deficits that might suggest an underlying etiology. Classically, dysphagia to solid foods alone or dysphagia for solids that progresses to solid and liquid dysphagia has been associated with structural disease. In contrast, dysphagia for liquids alone or for a combination of liquids and solids is indicative of a motor disorder. History should construct a careful timeline of the symptoms, paying attention to specific foods. It is also important to determine whether dysphagia is not "progressing" because the patient has adapted by eating smaller bites or softer foods, avoiding certain items altogether, or chewing thoroughly. Loss of weight and behaviors related to eating can also help quantify the severity of dysphagia for patients who might be minimizing symptoms with dietary modification. With the increasing recognition of eosinophilic esophagitis, it is important to inquire specifically about atopic diseases, longstanding dysphagia, episodes of food bolus or foreign body impaction, and dietary modification [7, 8]. While patients often point to a substernal area where they feel food "hanging-up," there can be poor correlation between this localization and a potentially causative structural lesion, particularly for proximal locations [9]. Physical examination is typically unrevealing in patients with esophageal dysphagia, except for the finding of tylosis palmaris (hyperkeratosis of the palmar surface of the hands rarely seen with esophageal cancer), but if a motor disorder is suggested on history, a thorough exam for signs of scleroderma. The presence of a succussion splash remote from eating on physical exam raises the issue of gastric outlet obstruction or gastroparesis. Abdominal Pain Abdominal pain is the most frequent presenting symptom the gastroenterologist encounters [11], and it should always be evaluated systematically. A complete history includes eliciting information about the acuity of onset, triggering events, location, radiation, quality, progression, and exacerbating and relieving factors. The quality of the pain is most useful for characterizing colic, a paroxysmal cramping sensation typical of an intermittently obstructed hollow viscus. Biliary colic is typically localized to the right-upper quadrant or the epigastrium. Pancreatic pain is frequently severe and bores into the mid-back from the epigastric region and may be eased by sitting and leaning forward. Pain related to mesenteric vascular insufficiency generally is postprandial and periumbilical, is said to present with abdominal pain out of proportion to the findings on exam, and can be difficult to diagnose in the early stages. A high level of suspicion for this condition is required, particularly in patients with vascular disease. Malabsorptive diarrhea, either from pancreatic insufficiency, bacterial overgrowth, or celiac disease, can be characterized by steatorrhea. Because many patients do not see frank fat, oil, or grease mixed with their stools, or because they do not actually look at each stool in detail, this sign is often difficult to elicit on history [13]. Instead, asking about "peanut butter" consistency and the color of the stool may provide a more "real-world" prompt for the patient. Diarrhea may be related to a wide variety of medications, making a good medication history imperative.
When turbulent flow exists medications 512 cheap 600mg sustiva amex, the relationship between pressure drop and flow is no longer governed by the Hagen-Poiseuille equation medications zoloft discount sustiva 600 mg with visa. Instead treatment questionnaire generic sustiva 200mg amex, the pressure gradient required (or the resistance encountered) during turbulent flow varies as the square of the flow rate. Flow through an orifice (defined as a tube whose length is smaller than its radius) is always somewhat turbulent. Clinically, airway obstructing conditions such as epiglottitis or inhaled obstructions are often best viewed as breathing through an orifice. Under such conditions, the approximate flow across the orifice varies inversely with the square root of the gas density. This is in contrast to laminar flow conditions, where gas flow varies inversely with gas viscosity. The viscosity values for helium and oxygen are similar, but their densities are very different (. Helium-Oxygen Mixtures the low density of helium allows it to play a significant clinical role in the management of some forms of airway obstruction. The usual available mixtures of helium and oxygen are 20% O2: 80% He and 30% O2: 70% He. These mixtures are usually administered by a non-rebreathing face mask in patients who face an increased work-of-breathing effort because of the presence of airway pathology. Laminar Flow When flow is low velocity and through long narrow tubes, it tends to be more orderly and streamlined and to flow in a straight line. During quiet breathing, laminar flow exists from the medium-sized bronchi down to the level of the bronchioles. During exercise, when the air flow is more rapid, laminar flow may be confined to the smallest airways. Turbulent Flow When air flows at higher velocities, especially through an airway with irregular walls, flow is generally disorganized, even chaotic, and tends to form eddies. This is called turbulent flow, and is found mainly in the largest airways, like the trachea (. She had a 2-month history of worsening dyspnea, especially when positioned supine. Noted on the chest X-ray were a large superior mediastinal mass and pulmonary metastases. Computed tomography revealed a large mass at the thoracic inlet and extending caudally. Almost instant relief was obtained by giving the patient a mixture of 78% He: 22% O2, with improvements in measured tidal volume and oxygenation. Here, anesthesia was conducted by applying topical anesthesia to the airway with awake laryngoscopy and intubation performed in the sitting position. Once the airway was secured using an armored tube, the patient was given a general anesthetic with an intravenous induction. As the kinetic energy increases, so the potential energy must fall as the total energy of the system must remain constant. This phenomenon is used in apparatus employing the Venturi principle; for example, gas nebulizers, Venturi flowmeters, and some oxygen face masks. If an opening is placed at the narrowing, the lower pressure due to the Bernoulli effect sucks in (entrains) air to mix with oxygen.
Order 200 mg sustiva with amex. Patient with thyroid symptoms brain fog migraines gets answers and her life back.
Osmotic diarrhea is caused by ingestion of a poorly absorbed substance that obligates water retention within the lumen to maintain osmotic equilibration with serum (the intestine is too permeable to water to allow an osmotic gradient to develop between the lumen and serum) medications are administered to cheap sustiva 600mg on line. Electrolyte absorption is unaffected medications like prozac purchase 600mg sustiva with mastercard, so stools have very low electrolyte concentrations symptoms of kidney stones proven sustiva 600 mg. Once the diarrhea has been categorized, the differential diagnosis becomes more manageable (Table 34. Case Continued Because there is no dominant diagnosis, this patient is most appropriately evaluated by categorizing the diarrhea and using an algorithmic approach. Fecal occult blood test is negative, fecal lactoferrin is negative, and stool fat excretion is 2 g/24 hours. Flexible sigmoidoscopy reveals normal appearances, but biopsies are interpreted as showing collagenous colitis. Therapeutics the treatment of chronic diarrhea ultimately depends on the underlying condition. For relapsing conditions, such as collagenous colitis, appropriate therapy can induce remission [10]. For all others, symptomatic therapy can diminish the impact of diarrhea on quality of life, both while evaluation is ongoing and chronically [11] (Table 34. The most effective and most widely applicable symptomatic therapy is antidiarrheal opiates [13]. Low-potency opiates include loperamide and diphenoxylate plus low-dose atropine (to reduce abuse potential). The key difference in using these agents to treat chronic rather than acute diarrhea is giving the antidiarrheal on a scheduled basis. Antidiarrheal drugs work best if given before meals, when they can blunt the physiological stimulus for defecation. When low-potency opiate antidiarrheal drugs fail to control diarrhea, higher-potency ones, such as codeine, morphine, or deodorized tincture of opium, should be used [11]. These agents should be started at a low dose and titrated up slowly to allow tolerance to sedative effects to develop in the brain. Tolerance does not develop to the constipating effects of these agents, so an effective dose that will control diarrhea but not produce sedation can usually be achieved. Clonidine and octreotide have non-specific antidiarrheal activity, but should be reserved for special cases, such as those that fail opiate therapy [11]. Management of diarrhea in clinical practice: strategies for primary care physicians. The practical value of comprehensive stool analysis in detecting the cause of idiopathic chronic diarrhea. Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children. Case Continued the patient is started on loperamide 4 mg three times per day as symptomatic therapy after the stool collection is completed. Stool frequency decreases from five to two bowel movements daily, but stools remains fluid. When the biopsy is reported as showing collagenous colitis, the patient is started on oral budesonide 9 mg daily, a drug shown to work well for this condition by meta-analysis [10]. The prognosis depends on the underlying diagnosis and the availability of treatment for the condition. Take Home Points r Chronic diarrhea is a common condition that is defined as having loose stools for more than 4 weeks.
This therapy is also used as a treatment for a number of thrombotic diseases including acute coronary syndromes (myocardial infarction and unstable angina) medicine 54 357 cheap sustiva online mastercard, deep vein thrombosis medicine used to stop contractions discount sustiva online, and pulmonary embolism treatment ibs buy sustiva 200 mg without a prescription. The ideal anticoagulant possesses a fast onset and offset of action, few drug interactions, and little interpatient variability in it anticoagulant effects. The overarching goal over the last several years has been to develop antithrombotic, anticoagulant, and antiplatelet drugs that carry more favorable pharmacological properties. This chapter focuses on the pharmacological properties of the most commonly used anticoagulants, antithrombotics, and antiplatelet drugs. The hematologic system involves a complex interaction of the vascular endothelium, platelets, and coagulation factors. As long as the fine-tuned interplay within the system is balanced, neither thrombus formation or bleeding and any associated consequences will take place (. Perioperatively, hemostasis is often challenged but perturbations of the integrity of the vascular endothelium and subsequent platelet activation may result in acute clot formation in the arteries or veins, which ultimately manifests as arterial or venous thromboembolism. This is where anticoagulant drugs, including antiplatelet therapies and antithrombotic agents are utilized to interfere with hemostasis. When selecting the most appropriate anticoagulant drug, thorough consideration of the efficacy-to-safety ratio is warranted. Heparin is an endogenously produced, linear polysaccharide that consists of repeating units of pyranosyluronic acid and glucosamine residues. Most important for the clinical effect of heparin is the accelerated inhibition of thrombin and factor Xa. This results in neutralization of factor Xa, which ultimately inhibits thrombin formation and thrombus development. Each pathway generates a series of reactions in which inactive circulating enzymes and their co-factors are activated. The key elements of the extrinsic pathway involve the release of tissue factor from trauma or vascular injury. Anticoagulants are interacting at various stages with this coagulation system and interrupt the enzymatic reactions (Reprinted with permission from Alquwaizani et al. Intravenously administered heparin can be effectively monitored and adjusted based on infusion rates. While functional assays have greater specificity than immunoassays they are also time-consuming and not as widely available. Intracranial, intraspinal, intraocular, mediastinal, or retroperitoneal bleeding is typically classified as major bleeding and usually results in hospitalization, transfusion, possible organ failure, and death. Patients receiving long-term heparin therapy are also at increased risk to suffer from osteoporosis and may be prone to vertebral fractures. Evidence-based guidelines for the perioperative management of antithrombotic therapy contain specific recommendations. Bridging therapy is recommended in patients at moderate to high risk of thromboembolism. Importantly, protamine is associated with development of a number of adverse effects, ranging from life-threatening anaphylactic complications in 0.
