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A: As follows: • In early case: Small order levothroid with american express thyroid cancer donation, raised buy levothroid cheap thyroid gland slide, non-pruritic discount 200mcg levothroid overnight delivery thyroid myopathy, reddish purple nodule on the skin or discoloration of oral mucosa or swollen lymph node. A: Depends on the subtype, localized or associated with systemic disease: • Localized mucocutaneous disease responds to cryotherapy, radiotherapy, surgical excision, intralesional vinblastine, topical immunotherapy (imiquimod), interferon-a. Presentation of a case: • There are multiple hypopigmented macules of variable size and shape involving the front of the chest, both sides of neck and upper part of back. Pityriasis versicolor Pityriasis versicolor Pityriasis versicolor Pityriasis versicolor in neck in face in chest in back Q:What is pityriasis versicolor? A: It is a benign superfcial skin infection caused by fungus called Malassezia furfur. Oral antifungal: • Ketoconazole 200 mg daily for 1 week or 400 mg in a single dose, may be repeated at monthly intervals. Lupus pernio in Depressed nasal Puffy face in nephrotic Malar flush sarcoidosis bridge in Wegener’s syndrome granulomatosis Q:What are the causes of puffy face? Plethoric face in polycythaemia Plethoric face in Cushing syndrome Chloasma/melasma Q:What are the causes of chloasma or melasma? A: It is a discrete pigmentation in the face of females, due to imbalance between oestrogen and pro- gesterone. Wegener’s granulomatosis (nose) Wegener’s granulomatosis (eye) Clinical features: • Nasal discharge, epistaxis, nasal obstruction, nasal crust, rhinitis and sinusitis. Look carefully to the following points: • Rash distribution (check whether present in other parts of face) and character, scaly desquamation and redness or other colour, follicular plugging. Presentation of a Case: • There are multiple skin rashes on the face along the butterfy distribution, also involving the forehead and cheeks (mention, if any). Some are scaly and reddish with clear margin, more marked on the right (or left) side of face. A: It occurs due to the fan like fold of skin extending from shoulder to neck or an abnormal splaying, out of trapezius muscle. Webbing of neck Low hairline Short fourth metacarpal Shield-like chest Q:What is Turner’s syndrome? All or part of one X chromosome is deleted, leading to failure of ovary devel- opment. Hand looks small and round (short, broad hands) and has clinodactyly (short inward curving of little fnger). Mother with risk of Down’s syndrome: Chorionic villous sampling before 13 weeks of gestation or amniocentesis after 15 weeks of pregnancy may be done. Presentation of a Case: • There is bilateral swelling of parotid glands, which are frm and nontender. Bilateral parotid enlargement Bilateral parotid enlargement Q: What are the causes of bilateral parotid enlargement? Presentation of a Case: • There are yellowish plaque or nodular lesions at the upper eyelid (may be also in lower eyelid), near the inner canthus in one or both eyes.

A: As follows (mention according to the fndings and also age of the patient): If the patient is young 100mcg levothroid visa thyroid t3, causes are: • Lymphoma of stomach order genuine levothroid online thyroid extract. If the patient is middle-aged or elderly purchase levothroid 100 mcg on-line thyroid cancer epidemic, the causes are: • Mass in left lobe of liver: Hepatoma, secondaries and hydatid cyst. Other investigations according to the fndings in ultrasonography: • If gastric mass: Endoscopy and biopsy (to diagnose carcinoma of stomach and lymphoma). A: Tell the causes according to the age of the patient: If the patient is young or early-aged: • Appendicular lump (tender). A: Causes are (mention according to the age of the patient): If the patient is young (or also any age), the causes are: • Thick colon (in irritable bowel syndrome). Mass in left iliac fossa If the patient is elderly, the causes are: • Faecal mass. A: It is as follows: • In a jaundiced patient with palpable, non-tender gall bladder, the cause is unlikely to be gall stones, rather it is due to carcinoma of head of the pancreas, cholangiocarcinoma, carcinoma of ampulla of Vater and extrinsic pressure in bile duct. Reverse of the law is: • Obstructive jaundice without palpable gallbladder is unlikely to be carcinoma head of pancreas and extrinsic pressure in common bile duct. Exception of the law is: • Double impaction: Stones, simultaneously occluding the cystic duct and distal common bile duct. A: Gall stone is associated with chronic cholecystitis and gall bladder is fbrosed, which is unable to enlarge. Causes of mass in central abdomen (according to the age and sex): If the patient is young or early-aged, the causes are: • Lymphoma. If the patient is elderly or middle-aged, the causes are: • Intra-abdominal malignancy. A: As follows (mention according to your fndings, considering the age and sex of the patient): • In female: Pregnancy in young, fbroid uterus, ovarian cyst or other ovarian mass (e. A: As follows: Causes of unilateral renal mass: • Renal cell carcinoma (in middle-aged or elderly), Wilm’s tumour (in children). Presentation of a Case: • There is a mass in epigastric region, 9 3 7 cm, irregular, non-tender, margin is ill-defned, frm in consistency and not freely movable. A: I want to palpate left supraclavicular gland (Virchow’s gland, called Troisier’s sign). In carcinoma of stomach, there may be metastasis to left supra-clavicular lymph node. Any patient above 40 years of age presenting with 3 A’s (Anaemia, Anorexia, Asthenia). Paraneoplastic syndrome (such as acanthosis nigricans, dermatomyositis, thrombophlebitis migrans). Adenocarcinoma (95%) is of 2 types: • Intestinal (type 1): arising from areas of intestinal metaplasia (more common, with better prognosis). Diet: • Preservatives in diet: nitrites and nitrates, convert to N-nitroso compounds, which are carcinogenic. Nitrate is converted by nitrite reducing bacteria, which colonize in achlorhydric stomach.

If these measures are inadequate cheap levothroid 100 mcg with visa thyroid gland endocrine system, the patient can apply a solution that contains an antifungal drug (e buy levothroid 200 mcg amex thyroid nodules evaluation. Complications include development of language problems secondary to hearing deficits and development of drug-resistant bacteria (primarily as a result of not taking medication as directed or stopping them prematurely) purchase levothroid once a day thyroid gland cortisol. Identifying High-Risk Patients • Assess for penicillin allergy before prescribing amoxicillin or amoxicillin/clavulanate. For patients who have experienced a mild reaction to penicillins, guidelines recommend a cephalosporin such as cefdinir, cefuroxime, or cefpodoxime. For a severe reaction such as anaphylaxis, azithromycin or clarithromycin is recommended. Instead, prescribe a quinolone or quinolone/glucocorticoid combination because these are safe for patients who have perforated tympanic membranes. Before leaving the clinic, they should be instructed to return if they do not have improvement or if their condition worsens. For this reason, tympanometry and pneumatic otoscopy will not reflect a normal response to pressure changes for several weeks or even months. Many of these protocols allow for the replacement of electrolytes by the registered nurse. Three groups of agents are considered for replacement: (1) drugs used to correct disorders of fluid volume and osmolality, (2) drugs used to correct disturbances of hydrogen ion concentration (acid-base status), and (3) drugs used to correct electrolyte imbalances. Disorders of Fluid Volume and Osmolality Good health requires that both the volume and osmolality of extracellular and intracellular fluids remain within a normal range. If a substantial alteration in either the volume or osmolality of these fluids develops, significant harm can result. Maintenance of fluid volume and osmolality is primarily the job of the kidneys, and, even under adverse conditions, renal mechanisms usually succeed in keeping the volume and composition of body fluids within acceptable limits. However, circumstances can arise in which the regulatory capacity of the kidneys is exceeded. Abnormal states of hydration can be divided into two major categories: volume contraction and volume expansion. Volume contraction is defined as a decrease in total body water; conversely, volume expansion is defined as an increase in total body water. States of volume contraction and volume expansion have three subclassifications based on alterations in extracellular osmolality. For volume contraction, the subcategories are isotonic contraction, hypertonic contraction, and hypotonic contraction. In the clinical setting, changes in osmolality are described in terms of the sodium content of plasma. Sodium is used as the reference for classification because this ion is the principal extracellular solute. In most cases, the total osmolality of plasma is about 2 times the osmolality of sodium. Volume Contraction Isotonic Contraction Definition and Causes Isotonic contraction is defined as volume contraction in which sodium and water are lost in isotonic proportions.

Nutritional therapy includes bowel rest wit h t ot al parent eral nut rit ional support generic levothroid 50mcg with visa thyroid symptoms toddlers, element al feeding proven 100 mcg levothroid thyroid symptoms bloating, or omega-3 fatty acid supplementation cheap 50mcg levothroid otc thyroid gland bump. N utritional therapy has shown to improve sympt oms and in some cases cause disease remission, but t he major drawback is they are generally short-term treatments that are not sustainable. The first-line therapy for mild-to-moderate disease is usually either antimicrobial or anti-inflam- matory modalities. Antimicrobial treatments, such as metronidazole or ciprofloxa- cin, are effect ive in resolving act ive int est in al an d/ or per ian al diseases. Lon g-t er m metronidazole maintenance therapy is effective in preventing disease recurrence. The mechanisms of action of antimicrobial therapy are largely unknown and may be in part based on its immunosuppressive effects. Long-term metronidazole treat- ment is poorly tolerated because of its associated nausea, metallic taste, disulfiram- like react ions, and periph eral neuropat h ies. Moderate to severe disease refractory to antimicrobials and inflammatory medications are typically treated with corticosteroids. Steroids are most commonly applied for disease flar e-u p s an d t h en t ap er ed or d iscon t in u ed t o avoid t h eir lon g-t er m major sid e effect s. Budesonide is a newer cort icost eroid agent t hat is being ut ilized as it is met abolized more rapidly t han prednisone and is associat ed wit h fewer side effect s. In patients with moderate to severe disease in remission after a course of cor- ticosteroids treatment, immunomodulators are sometimes prescribed for main- tenance therapy. T h e major sid e effect s of t h ese medica- tions are bone marrow suppression, nausea, fever, rash, hepat itis, and pancreatit is. Methotrexate is also used in the treatment of active disease, and this medication can cau se n au sea, h eadach e, st omat it is, bon e m ar r ow suppr ession, h epat it is, an d pneumonitis. Infliximab is h igh ly effect ive in the t r eat m en t of p at ient s wh ose d isease is r efr ac- tory to all other treatments. Studies suggest that it may delay or obviate opera- tive treatments for some patients with severe disease. It can also be used as the fir st -lin e t r eat m en t of patient s wit h sever e p er ian al fist u lizin g d iseases. T h e major side effect s and complicat ions associat ed wit h t his t reat ment include opportunist ic infect ions and B-cell lymphoma development. Recently, there has been some debate within the gastroenterology circle regard- ing t he opt imal st rat egy in t he medical management of Croh n disease pat ient s. Some practitioners believe that the “top-down” approach that initiates treatments wit h t he most potent medicat ion, and t ransit ioning to t he less potent medicat ions aft er the pat ient s response is a bet t er approach t han t he t radit ional “t reat ment escalat ion” approach. Su r g ica l Ma n a g e m e n t The two most common reasons that surgeons are consulted for Crohn disease patients are medical treatment failures (unable to maintain employment, school- ing, diet ary int ake, or maint ain sufficient body weight s due t o failure t o t hrive or medical refractory disease), or when the medical treatment side effects affect qual- it y of life. At ot h er t imes, surgeons are asked t o h elp t reat disease complicat ions including obst ruct ion, fistulizat ion, and neoplast ic t ransformat ion.

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