By N. Mirzo. Inter American University of Puerto Rico.
Few medical offices provide information regarding the types and quantities of medical supplies that are recommended for the average household buy uroxatral 10 mg mastercard prostate cancer after surgery. These are my suggestions: Consider your area’s likely needs for the disasters that might befall it order 10mg uroxatral with amex prostate on ultrasound, and print lists of items that you would advise your patients to have in their homes. As well, provide resources for classes that your patients can take so that they will have the medical education necessary to deal with possible emergencies during these events. Direct them to sites recommended by the federal government for emergency preparedness, such as www. For your individual patients, especially those with chronic medical problems, you might consider providing the opportunity for them to keep a supply of needed medications by offering them an extra prescription to fill. In this manner, you can assure that your patients will have enough medicine to get them through situations which prevent them from contacting you in times of trouble. I’m not asking you to abandon your responsibility by throwing prescriptions at them; I am simply suggesting that they would benefit from having some extra supplies available to deal with unforeseen circumstances. Also, consider listing recommended over-the- counter medications that would be useful to have on hand. Our purpose as physicians is to improve the health of our people while doing no harm. Many doctors dedicate their entire lives to this purpose, and we must work to preserve the well-being of our patients in bad times as well as good times. The worst nightmare of your patients is the inability to reach you in a major disaster; help them become better prepared to deal with medical emergencies with education, compassion, and understanding. Thank you for all you do to keep your patients healthy, and for your time and attention in reading this letter. Certainly, you have accumulated a reasonable amount of medical supplies to prepare you for the role of survival medic. If you have been prudent, you have taken emergency courses offered by your municipality and availed yourself of other hands-on teaching resources. This book has taken an unusual route in assuming that no modern medical care or facilities will be available to you. Although we have attempted to be comprehensive in our approach, there is still much to learn. In power-down situations, you should have a number of printed medical books that you can refer to in times of trouble. In this section, we have given you a list that will be welcome assistance in your efforts to keep your people healthy. While you have power, you should also avail yourself of the many resources available on the internet. For many procedures, there is no substitute to seeing something done in real time, such as placing a cast. No prepared individual should be without a source of power in hard times, so have a solar cell or other method to give you the ability to review these when you need them. We refer to our library constantly to stay current on the options available to us, and so should you. I mentioned earlier that some reference books will be necessary for any aspiring medic.
Aetiology The apex is slow and thrusting in nature but not dis- This is almost invariably a congenital lesion either as an placed buy uroxatral 10mg with amex mens health 300 workout. On auscultation there may be a systolic ejection isolated lesion or as part of the tetralogy of Fallot order uroxatral 10mg with mastercard androgen hormone up regulation. Rarely click, followed by a mid-systolic ejection murmur heard itmaybeanacquiredlesionsecondarytorheumaticfever best in the right second intercostal space and radiating or the carcinoid syndrome. The murmur is best heard with the patient leaning forward with breath held in expiration. Pathophysiology The obstruction to right ventricular emptying results Investigations in right ventricular hypertrophy and hence decreased r Chest X-ray may show a post-stenotic dilation of the ventricular compliance, which leads to right atrial ascending aorta and left ventricular hypertrophy. If severe, the condition leads to right Chapter 2: Rheumatic fever and valve disease 47 ventricular failure, often with accompanying regurgita- Aetiology tion of the tricuspid valve and signs of right-sided heart Tricuspid regurgitation can be divided into functional, failure. Patients with mild r Organic tricuspid regurgitation occurs with rheuma- pulmonary stenosis are asymptomatic (diagnosed inci- tic mitral valve disease, infective endocarditis and the dentally from the presence of a murmur or the presence carcinoid syndrome. Patients the tricuspid valve is seen particularly in intravenous mayhavenon-speciﬁcsymptomssuchasfatigueordysp- drug abusers. Syncope is a sign of critical stenosis, which requires plasia of the tricuspid valve with abnormal valve urgent treatment. Auscultation reveals a click and harsh Pathophysiology mid-systolic ejection murmur heard best on inspiration Regurgitation of blood into the right atrium during sys- in the left second intercostal space often associated with tole results in high right atrial pressures and hence right a thrill. A left parasternal heave may also be felt due to atrial hypertrophy and dilatation. In the chronic un- cases intervention is required before decompensation of treated patient there can be hepatic cirrhosis from the the right ventricle occurs. Echocardiography is diagnostic and is also essential to assess right ventricular function. Tricuspid regurgitation Deﬁnition Management Retrograde blood ﬂow from the right ventricle to the Functional tricuspid regurgitation usually resolves with rightatrium during systole. Severe organic tricuspid 48 Chapter 2: Cardiovascular system regurgitation or refractory functional regurgitation may Sinus nodal arrhythmias require operative repair (or rarely replacement). Cardiac arrhythmias A cardiac arrhythmia is a disturbance of the nor- Aetiology mal rhythm of the heart. Tachycardias are also subdivided according to their Clinical features origin: Most patients are asymptomatic but occasionally post- r Sinustachycardia. If bradycardia is episodic and severe, syncope r Ventricular tachyarrhythmias such as ventricular may occur. However, in patients with bundle branch block Most cases do not require treatment other than with- and in cases where the rapid rate of supraventricu- drawal of drugs or treatment of any underlying cause. Chapter 2: Cardiac arrhythmias 49 Sinus tachycardia rate may be regular, bradycardic, tachycardic or variable with pauses. Carotid sinus massage typically leads to a Deﬁnition sudden and sometimes prolonged sinus pause. Aetiology/pathophysiology Sinustachycardia is a physiological response to main- tain tissue perfusion and oxygenation. Causes include Complications exercise, fever, anaemia, hypovolaemia, hypoxia, heart The most important complication is cardiac syncope, as failure, hyperthyroidism, pulmonary embolism, drugs in other forms of bradycardia. Clinical features Investigations Palpitations with an associated rapid, regular pulse rate. In addition anti-arrhythmic drugs may be required to Management controlanytachycardia.
Il sera important de prévenir l’apparition d’un diabète sucré par le respect d’un régime pauvre en sucre buy discount uroxatral 10 mg line man health yanbu. Il est imperative de surveiller la glycémie à jeun chez les patients sous corticoïdes au long cours effective 10mg uroxatral prostate oncology kalispell, et d’évoquer le diagnostic de diabète décompensé chez un malade qui maigrit au cours de premier mois d’un traitement corticoïde et qui présente un syndrome polyuro- polydypsique. Chez les patients dibétiques qui ont sous les corticoïdes au long cours, il necessite un réajustement du traitement antidibétique. La survenue d’une hypertension artérielle au cours des corticothérapies est prévunue par la mise en place d’un régime désodé strict. En tous cas, les mesures adjuvantes et les modalités de surveillances doivent êtres respectées. Maladies systémiques évolutives : Lupus érythémateux disséminé, vascularite, polymyosite, sarcoïdose viscérale. Dermatologiques : Dermatoses bulleuses auto-immune sévère, formes graves des angiomes du nourrisson, certaines formes de lichen plan, certaines urticaires aiguës, formes graves de dermatoses neutrophiliques. Digestives : Pousées évolutives de la rectocolite hémorragique et de la maladie de Crohn, hépatite chronique active auto-immune, hépatite alcoolique aiguë sévère. Endocriniennes : Thyroïdite subaiguë de de Quervain sévère, certaines hypercalcémies, traitement substitutif au cours de l’insuffisance surrénale. Hématologiques : Purpura thrombopéniques immunologiques sévères, anémies hémolytiques auto-immunes, en association avec diverses chimiothérapies dans le traitement d’hémopathies malignes lymphoïdes, érythro-blastopénies chroniques acquises ou congénitales. Infectieuses : Péricardite tuberculeuse et formes graves de tuberculose mettant en jeu le pronostic vital, pneumopathie à Pneumocystis Carinii avec hypoxie sévère. Néoplasiques : Traitement antiémétique au cours des chimiothérapies antinéoplasiques, pousée oedémateuse et inflammatoire associée au traitement antinéoplasique (radiothérapie et chimiothérapie). Neurologiques : Myasthénie, œdème cérébral de cause tumorale, spasme infantile, polyradiculonévrite chronique idiopathique inflammatoire, sclérose en plaques en poussée en relais d’une corticothérapie intraveineuse. Ophtalmologiques : Uvéite antérieure et postérieure sévère, exophtalmies oedémateuses, certaines neuropathies optiques. Respiratoires : Asthme persistante en cas d’échec du traitement par voie inhalée à fortes doses, exacerbation d’asthme aiguë grave, broncho-pneumopathie chronique obstructive, fibroses pulmonaires interstitielles diffuses. Rhumatologiques : Polyarthrite rhumatoïde et certaines polyarthrites, pseudo-polyarthrite rhizomélique et maladie de Horton, rhumatisme articulaire aiguë, névralgies cervico-brachiales sévères et rebelles. Transplantation d’organe et de cellules souches hématopoïétiques allogéniques :Prophylaxie ou traitement du rejet de greffe, prophylaxie ou traitement de la réaction du greffon contre l’hôte. Epidémiologie L’insuffisance surrénale est une pathologie classiquement rare (1/10000 d’habitants) selon les statistiques Françaises, mais potentiellement grave ; elle peut se voire à tous ème âges avec l’’incidence plus élevée vers la 4 décennie. Physiopathologie • L’insuffisance rénale périphérique (Maladie d’Addison) caractérisée par un déficit qui touche à la fois le cortisol et l’aldostérone. Etiologies - Causes d’insuffisance surrénale basse o Insuffisance surrénale auto-immune est l’étiologie la plus fréquente, environ 80% des cas. Complications Non traités ou non reconnus, les hypocorticismes sont mortels par insuffisance surrénale aiguë. Dans tous les cas, une suspicion clinique et biologique basée sur des examens simples suffit à mettre en route du traitement. Traitement de l’insuffisance surrénale chronique L’insuffisance surrénale chronique doit bénéficier d’un traitement à vie. Alimentation : L’apport en sel doit être normal (8 à 12 g /j de NaCl) Hormonothérapie • Glucocorticoïdes (Hydrocortisone*) : La dose de 30 mg/j en moyenne est la plus employée. En cas de corticothérapie prolongée il faut : éviter un arrêt brutal de la corticothérapie ; ajouter de l’hydrocortisone 100 à 200 mg par 24h soit par voie orale, soit par voie parentérale si c’est nécessaire (Ex. Insuffisance surrénale et grossesse: - L’Insuffisance surrénale connue avant la grossesse: Le traitement substitutif restaure la fertilité.
Analgesics: they can be administered if need uroxatral 10 mg line mens health eating plan, but without inﬂuencing in the clinical monitorization buy uroxatral 10 mg without a prescription prostate cancer 3 months, for example opiates non narcotics. Diet: it can begin with clear liquids at 6-8 hours, and according to tolerance give soft and normal diet after the 24 hours. Endovenous liquids: as the blood lost is higher and the diet is restricted, the infusion of 2. Diuresis: the bladder catheter should be maintained during the ﬁrst 6-8 hours to watch over the urine volume; in case of normal being and tolerance to the oral income, it could help to improve early walking. Surgical wound care: the wound should remain covered during the ﬁrst 24 hours unless there is evidenced of active bleeding. Walking: it should start early, but the difﬁculty that implies the surgical procedure makes it to be delayed for 6-8 hours depending on the tolerante walking. Nursing: in this case the immediate beginning is not possible for the maternal impossi- bility of attention the newborn, but as soon as the maternal condition allows for the process of the maternal nursing should be stimulated. Control of vaginal bleeding: the lochia’s aspect change during the mediate puerperium, it is hematic during the ﬁrst 72 hours, serohematic until the 5-7th day, and serous until disappearing around the 15th day. Control of uterine involution: the uterine size decreases 2 cm per day, found it throught abdominal wall until the 10th day. Milk production: during the ﬁrst 3 days the calostro appears and has a yellowish aspect and contains more minerals and proteins (especially globulins), but less sugars and fat than the mature milk. This last level is reached from the 4-5 day arriving at its maxi- mum maturity level at 4 weeks. Prevention and treatment of postpartum anemia: the pregnancy demands the increase of the iron requirements for the fetal growth with decrease of the reserve, the childbirth produces blood loss, and the nursing demands iron for milk production. Iron suple- mentation is recommended with 30-60 mgs of elementary iron and 400 mcgs of folic acid, during the ﬁrst two months of puerperium. Education: during the ﬁrst and second days postpartum the patient should receive in- formation about the changes in puerperium, newborn care, maternal nursing, early detection of complications, sexual activity and contraception. In the developed countries the inﬂuence is due to health insuranse companies and their cost studies. In developing countries it is the shortage of appropriate obstetric services with trained personnel for the attention of child- birth and puerperium; in this guide we propose an early but safe discharge. The discharge time depends of the type of patient, includes tolerance to walking and oral income, appropriate maternal nursing, education in normal evolution of puerperium, pue- riculture, and contraception. The minimum time of hospitalary stay for each particular patient depends on the childbirth type and the presence of risks. Low risk vaginal birth: — Normal clinical surveillance during the ﬁrst 24 hours postpartum. High risk vaginal birth: includes patients with prolonged premature rupture of ovular membranes, prolonged labor, Instrumental birth (forceps, vacuum, etc), high risk preg- nancies. Low risk cesarean birth: — Normal clinical surveillance during the ﬁrst 48 hours postpartum. High risk cesarean birth: — Normal clinical surveillance during the ﬁrst 72 hours postpartum — Normal white cells count. Decompensed or nonbalanced disease and vaginal or Cesarean birth: the patient will be discharged only when her condition can be managed in an ambulatory way.
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