Approach to the acutely

Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology (ACR) are intended to provide guidance for particular patterns of practice and not to dictate the care of a particular patient.

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Tuyển tập các báo cáo nghiên cứu về y học được đăng trên tạp chí y học Critical Care giúp cho các bạn có thêm kiến thức về ngành y học đề tài: Nebulised heparin: a new approach to the treatment of acute lung injury?

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Sepsis with Skin Manifestations (See also Chap. 18) Maculopapular rashes may reflect early meningococcal or rickettsial disease but are usually associated with nonemergent infections. Exanthems are usually viral. Primary HIV infection commonly presents with a rash that is typically maculopapular and involves the upper part of the body but can spread to the palms and soles. The patient is usually febrile and can have lymphadenopathy, severe headache, dysphagia, diarrhea, myalgias, and arthralgias.

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Purpura Fulminans (See also Chaps. 136 and 265) Purpura fulminans is the cutaneous manifestation of DIC and presents as large ecchymotic areas and hemorrhagic bullae. Progression of petechiae to purpura, ecchymoses, and gangrene is associated with congestive heart failure, septic shock, acute renal failure, acidosis, hypoxia, hypotension, and death. Purpura fulminans has been associated primarily with N. meningitidis but, in splenectomized patients, may be associated with S. pneumoniae and H. influenzae.

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Necrotizing Fasciitis This infection may arise at a site of minimal trauma or postoperative incision and may also be associated with recent varicella, childbirth, or muscle strain. The most common causes of necrotizing fasciitis are group A streptococci alone (Chap. 130) and a mixed facultative and anaerobic flora (Chap. 119). Diabetes mellitus, peripheral vascular disease, and intravenous drug use are associated risk factors.

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Brain Abscess (See also Chap. 376) Brain abscess often occurs without systemic signs. Almost half of patients are afebrile, and presentations are more consistent with a space-occupying lesion in the brain; 70% of patients have headache, 50% have focal neurologic signs, and 25% have papilledema. Abscesses can present as single or multiple lesions resulting from contiguous foci or hematogenous infection, such as endocarditis. The infection progresses over several days from cerebritis to an abscess with a mature capsule.

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Inhalational Anthrax (See also Chap. 214) Inhalational anthrax, the most severe form of disease caused by Bacillus anthracis, had not been reported in the United States for more than 25 years until the recent use of this organism as an agent of bioterrorism (Chap. 214). Patients presented with malaise, fever, cough, nausea, drenching sweats, shortness of breath, and headache. Rhinorrhea was unusual. All patients had abnormal chest roentgenograms at presentation. Pulmonary infiltrates, mediastinal widening, and pleural effusions were the most common findings.

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Adjunctive treatments may reduce morbidity and mortality and include dexamethasone for bacterial meningitis; intravenous immunoglobulin (IVIg) for TSS and necrotizing fasciitis caused by group A Streptococcus; low-dose hydrocortisone and fludrocortisone for septic shock; and drotrecogin alfa (activated), also known as recombinant human activated protein C, for meningococcemia and severe sepsis.

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Harrison's Internal Medicine Chapter 115. Approach to the Acutely Ill Infected Febrile Patient Approach to the Acutely Ill Infected Febrile Patient: Introduction The physician treating the acutely ill febrile patient must be able to recognize infections that require emergent attention. If such infections are not adequately evaluated and treated at initial presentation, the opportunity to alter an adverse outcome may be lost. In this chapter, the clinical presentations of and approach to patients with relatively common infectious disease emergencies are discussed.

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The Acutely Ill Patient: Treatment In the acutely ill patient, empirical antibiotic therapy is critical and should be administered without undue delay. Increased prevalence of antibiotic resistance in community-acquired bacteria must be considered when antibiotics are selected. Table 115-1 lists first-line treatments for infections considered in this chapter. In addition to the rapid initiation of antibiotic therapy, several of these infections require urgent surgical attention.

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Chronic Myelogenous Leukemia: Treatment The therapy of CML is changing rapidly because we have a proven curative treatment (allogeneic transplantation) that has significant toxicity and a new targeted treatment (imatinib) with excellent outcome based on 5-year follow-up data. Therefore, physician experience and patient preference must be factored into the treatment selection process. Discussion of both treatment options with a patient is indicated. The decision should focus on the outcomes, risks, and toxicities of the various approaches.

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Chemoprevention β-Carotene and cis-retinoic acid can lead to the regression of leukoplakia. However, cis-retinoic acid does not reduce the incidence of second primaries Treatment Complications Complications from treatment of head and neck cancer are usually correlated to the extent of surgery and exposure of normal tissue structures to radiation. Currently, the extent of surgery has been limited or completely replaced by chemotherapy and radiation therapy as the primary approach. Acute complications of radiation include mucositis and dysphagia.

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Approach to the Patient: Splenomegaly Clinical Assessment The most common symptoms produced by diseases involving the spleen are pain and a heavy sensation in the LUQ. Massive splenomegaly may cause early satiety. Pain may result from acute swelling of the spleen with stretching of the capsule, infarction, or inflammation of the capsule. For many years it was believed that splenic infarction was clinically silent, which at times is true.

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Allergic contact dermatitis (ACD). A. An example of ACD in its acute phase, with sharply demarcated, weeping, eczematous plaques in a perioral distribution. B. ACD in its chronic phase demonstrating an erythematous, lichenified, weeping plaque on skin chronically exposed to nickel in a metal snap. (B, Courtesy of Robert Swerlick, MD; with permission.) As in other branches of medicine, a complete history should be obtained to emphasize the following features: 1. Evolution of lesions a. Site of onset b. Manner in which the eruption progressed or spread c. Duration d.

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Approach to the Patient: Azotemia Once it has been established that GFR is reduced, the physician must decide if this represents acute or chronic renal injury. The clinical situation, history, and laboratory data often make this an easy distinction. However, the laboratory abnormalities characteristic of chronic renal failure, including anemia, hypocalcemia, and hyperphosphatemia, are often also present in patients presenting with acute renal failure. Radiographic evidence of renal osteodystrophy (Chap.

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Approach to the Patient: Gastrointestinal Bleeding Measurement of the heart rate and blood pressure is the best way to assess a patient with GIB. Clinically significant bleeding leads to postural changes in heart rate or blood pressure, tachycardia, and, finally, recumbent hypotension. In contrast, the hemoglobin does not fall immediately with acute GIB, due to proportionate reductions in plasma and red cell volumes (i.e., "people bleed whole blood"). Thus, hemoglobin may be normal or only minimally decreased at the initial presentation of a severe bleeding episode. ...

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Approach to the patient with polyuria. ATN, acute tubular necrosis; ADH, antidiuretic hormone Excessive filtration of a poorly reabsorbed solute such as glucose, mannitol, or urea can depress reabsorption of NaCl and water in the proximal tubule and lead to enhanced excretion in the urine. Poorly controlled diabetes mellitus with glucosuria is the most common cause of a solute diuresis, leading to volume depletion and serum hypertonicity. Since the urine Na concentration is less than that of blood, more water than Na is lost, causing hypernatremia and hypertonicity.

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Approach to the Patient: Hemoptysis The history is extremely valuable. Hemoptysis that is described as bloodstreaking of mucopurulent or purulent sputum often suggests bronchitis. Chronic production of sputum with a recent change in quantity or appearance favors an acute exacerbation of chronic bronchitis. Fever or chills accompanying bloodstreaked purulent sputum suggests pneumonia, whereas a putrid smell to the sputum raises the possibility of lung abscess. When sputum production has been chronic and copious, the diagnosis of bronchiectasis should be considered.

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Approach to the Patient: Cough A detailed history frequently provides the most valuable clues for the etiology of the cough. Particularly important questions include: 1. Is the cough acute, subacute, or chronic? 2. At its onset, were there associated symptoms suggestive of a respiratory infection? 3. Is it seasonal or associated with wheezing? 4.

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Approach to the Patient: Dyspnea (Fig. 33-3) In obtaining a history, the patient should be asked to describe in his/her own words what the discomfort feels like, as well as the effect of position, infections, and environmental stimuli on the dyspnea. Orthopnea is a common indicator of congestive heart failure, mechanical impairment of the diaphragm associated with obesity, or asthma triggered by esophageal reflux. Nocturnal dyspnea suggests congestive heart failure or asthma.

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