Harrison's Internal Medicine Chapter 52. Approach to the Patient with a Skin Disorder
APPROACH TO THE PATIENT WITH A SKIN DISORDER: INTRODUCTION The challenge of examining the skin lies in distinguishing normal from abnormal, significant findings from trivial ones, and in integrating pertinent signs and symptoms into an appropriate differential diagnosis. The fact that the largest organ in the body is visible is both an advantage and a disadvantage to those who examine it.
Harrison's Internal Medicine Chapter 82. Infections in Patients with Cancer
Infections in Patients with Cancer: Introduction Infections are a common cause of death and an even more common cause of morbidity in patients with a wide variety of neoplasms. Autopsy studies show that most deaths from acute leukemia and half of deaths from lymphoma are caused directly by infection. With more intensive chemotherapy, patients with solid tumors have also become more likely to die of infection.
Meningococcemia. An example of fulminant meningococcemia with extensive angular purpuric patches. (Courtesy of Stephen E. Gellis, MD; with permission.)
Necrotizing vasculitis. Palpable purpuric papules on the lower legs are seen in this patient with cutaneous small vessel vasculitis. (Courtesy of Robert Swerlick, MD; with permission.)[newpage]
APPROACH TO THE PATIENT: SKIN DISORDER
In examining the skin it is usually advisable to assess the patient before taking an extensive history.
Harrison's Internal Medicine Chapter 77. Approach to the Patient with Cancer
Approach to the Patient with Cancer: Introduction The application of current treatment techniques (surgery, radiation therapy, chemotherapy, and biological therapy) results in the cure of nearly two of three patients diagnosed with cancer. Nevertheless, patients experience the diagnosis of cancer as one of the most traumatic and revolutionary events that has ever happened to them.
The recognition and treatment of depression are important components of management. The incidence of depression in cancer patients is ~25% overall and may be greater in patients with greater debility. This diagnosis is likely in a patient with a depressed mood (dysphoria) and/or a loss of interest in pleasure (anhedonia) for at least 2 weeks. In addition, three or more of the following symptoms are usually present: appetite change, sleep problems, psychomotor retardation or agitation, fatigue, feelings of guilt or worthlessness, inability to concentrate, and suicidal ideation.
Death and Dying The most common causes of death in patients with cancer are infection (leading to circulatory failure), respiratory failure, hepatic failure, and renal failure. Intestinal blockage may lead to inanition and starvation. Central nervous system disease may lead to seizures, coma, and central hypoventilation. About 70% of patients develop dyspnea preterminally. However, many months usually pass between the diagnosis of cancer and the occurrence of these complications, and during this period the patient is severely affected by the possibility of death. ...
With this edition of Biomedical Ethics Reviews we commence
a somewhat new focus for the series. Building on its solid
tradition of exploring and debating pressing bioethical issues of
the day, this series will now also examine the real-life implications
of these issues for patients and the health care system in
which care is delivered. With each topic, attention will be focused
not only on the theoretical and policy aspects of ethical
dilemmas, but also on the clinical dimensions of these challenges,
and effects on the patient–physician relationship....
Defining the Extent of Disease and the Prognosis The first priority in patient management after the diagnosis of cancer is established and shared with the patient is to determine the extent of disease. The curability of a tumor usually is inversely proportional to the tumor burden. Ideally, the tumor will be diagnosed before symptoms develop or as a consequence of screening efforts (Chap. 78). A very high proportion of such patients can be cured.
Pain Pain occurs with variable frequency in the cancer patient: 25–50% of patients present with pain at diagnosis, 33% have pain associated with treatment, and 75% have pain with progressive disease. The pain may have several causes. In ~70% of cases, pain is caused by the tumor itself—by invasion of bone, nerves, blood vessels, or mucous membranes or obstruction of a hollow viscus or duct.
The level of suspicion of infections with certain organisms should depend on the type of cancer diagnosed (Table 82-3). Diagnosis of multiple myeloma or CLL should alert the clinician to the possibility of hypogammaglobulinemia. While immunoglobulin replacement therapy can be effective, in most cases prophylactic antibiotics are a cheaper, more convenient method of eliminating bacterial infections in CLL patients with hypogammaglobulinemia.
Typhlitis Typhlitis (also referred to as necrotizing colitis, neutropenic colitis, necrotizing enteropathy, ileocecal syndrome, and cecitis) is a clinical syndrome of fever and right-lower-quadrant tenderness in an immunosuppressed host. This syndrome is classically seen in neutropenic patients after chemotherapy with cytotoxic drugs.
Having worked in a variety of specialty areas over the years as staff nurses, clinical
nurse specialists, educators, therapists, and managers, we realize that nurses
aspire to become highly proficient in their area of practice. But psychosocial skills
are often more difficult to perfect. Very often nurses feel inadequately prepared
to deal with complex behaviors and psychiatric problems on top of the demands
of providing physical care for the patient and family.
Bài giảng “Managing chronic heart failure patient in chronic kidney disease” trình bày các nội dung: Epidemiology, pathophysiolog, management, modification of risk factors, angiotensin-converting enzyme inhibitors,… Mời các bạn cùng tham khảo nội dung chi tiết.
Making a Treatment Plan From information on the extent of disease and the prognosis and in conjunction with the patient's wishes, it is determined whether the treatment approach should be curative or palliative in intent. Cooperation among the various professionals involved in cancer treatment is of the utmost importance in treatment planning.
Tumor markers may be useful in patient management in certain tumors. Response to therapy may be difficult to gauge with certainty. However, some tumors produce or elicit the production of markers that can be measured in the serum or urine and, in a particular patient, rising and falling levels of the marker are usually associated with increasing or decreasing tumor burden, respectively. Some clinically useful tumor markers are shown in Table 77-5.
Effusions Fluid may accumulate abnormally in the pleural cavity, pericardium, or peritoneum. Asymptomatic malignant effusions may not require treatment. Symptomatic effusions occurring in tumors responsive to systemic therapy usually do not require local treatment but respond to the treatment for the underlying tumor. Symptomatic effusions occurring in tumors unresponsive to systemic therapy may require local treatment in patients with a life expectancy of at least 6 months.
Pleural effusions due to tumors may or may not contain malignant cells.
A similar problem can affect patients whose lymph node integrity has been disrupted by radical surgery, particularly patients who have had radical node dissections. A common clinical problem following radical mastectomy is the development of cellulitis (usually caused by streptococci or staphylococci) because of lymphedema and/or inadequate lymph drainage. In most cases, this problem can be addressed by local measures designed to prevent fluid accumulation and breaks in the skin, but antibiotic prophylaxis has been necessary in refractory cases.
A. Papules related to Escherichia coli bacteremia in a neutropenic patient with acute lymphocytic leukemia. B. The same lesion the following day.
Candidemia (Chap. 196) is also associated with a variety of skin conditions and commonly presents as a maculopapular rash. Punch biopsy of the skin may be the best method for diagnosis.
Cellulitis, an acute spreading inflammation of the skin, is most often caused by infection with group A Streptococcus or Staphylococcus aureus, virulent organisms normally found on the skin (Chap. 119).
Sweet's syndrome, or febrile neutrophilic dermatosis, was originally described in women with elevated white blood cell (WBC) counts. The disease is characterized by the presence of leukocytes in the lower dermis, with edema of the papillary body. Ironically, this disease now is usually seen in neutropenic patients with cancer, most often in association with acute leukemia but also in association with a variety of other malignancies. Sweet's syndrome usually presents as red or bluish-red papules or nodules that may coalesce and form sharply bordered plaques.
Brain Masses Mass lesions of the brain most often present as headache with or without fever or neurologic abnormalities. Infections associated with mass lesions may be caused by bacteria (particularly Nocardia), fungi (particularly Cryptococcus or Aspergillus), or parasites (Toxoplasma). Epstein-Barr virus (EBV)–associated lymphoproliferative disease may also present as single or multiple mass lesions of the brain. A biopsy may be required for a definitive diagnosis.