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[KINDLE] USMLE Step 2 CK Lecture Notes: Pediatrics by Kaplan. Book file PDF easily for everyone and every device. You can download and read online. Hyperbilirubinemia and Jaundice USMLE Step 2 l Pediatrics 12 for persons aged 0 through 18 years – Kaplan ln's 2 ck pediatrics Read Case Files Microbiology, Third Edition (Case Files (Lange)) | PDF books. do, 21 mrt GMT USMLE Step 2 CK Lecture Notes Pediatrics Pdf Free [PDF] Usmle Step 2 Ck Lecture Notes Pediatrics Kaplan.
Blasting the Boards. A few specific conditions related to spinal cord injury follow. Endoscopy establishes diagnosis, and allows treatment with endoscopic clipping or coagulation. Red blood per rectum could come from anywhere in the GI tract including upper GI, as it may have transited too fast to be digested. The smoking history, or the presence of chronic obstructive pulmonary disease COPD , should lead to evaluation. There is colicky abdominal pain and protracted vomiting, progressive abdominal distention if it is a low obstruction ,. Diagnosis is bo confirmed with an abdominal CT scan that demonstrates a transition point ry between proximal dilated bowel and distal collapsed bowel at the site of the obstruction.
Embed Size px. Start on. Show related SlideShares at end. WordPress Shortcode. Published in: Full Name Comment goes here. Are you sure you want to Yes No. Kimberly Bolton Can you lose stomach fat in 2weeks? Show More. Vaishnavi Pathak , Student at Dr. Sayeed Ali Ali. No Downloads. Views Total views. Actions Shares. Embeds 0 No embeds. No notes for slide. Kaplan ln's 2 ck pediatrics 1.
All rights reserved. Published by Kaplan, Inc. Kaplan, Inc. Cvetnic, M. Koerner, M. Chapter 1: The Newborn and Resuscitation. Growth and Nutrition. Child Abuse and Neglect. Respiratory Disease. Allergy and Asthma. Immune-Mediated Disease. Disorders of the Eye. Disorders of the Ear, Nose, and Throat. Gastrointestinal Disease. Renal and Urologic Disorders. Endocrine Disorders. Orthopedic Disorders. Rheumatic and Vasculitic Disorders.
Infectious Disease. What is her Apgar score? Table What is the most likely diagnosis?
C5—C6; cannot abduct shoulder; externally rotate and supinate forearm; Klumpke: It is clearly demarcated and does not fade into the surrounding skin. A newborn has a flat, salmon-colored lesion on the glabella, which becomes darker red when he cries. What is the best course of management? Get x-ray first for surgical planning.
No treatment needed if good blood supply. Physical exam reveals a baby with eczema and a musty odor. Which screening test would most likely be abnormal?
Some examples: GI Physical exam reveals a large plethoric infant who is tremulous. A murmur is heard. Blood sugar is low.
Follow glucose carefully in infant after delivery. Anemia, Other: Infectious Metabolic Neurologic Respiratory distress syndrome RDS Shortly after birth, a week gestation infant develops tachypnea, nasal flaring, and grunting and requires intubation.
Chest radiograph shows a hazy, ground-glass appearance of the lungs. Surgical resection of necrotic bowel may be necessary. Surgical intervention is needed to correct the problem. Patients develop abdominal distention without tenderness, and x-rays show a massively dilated colon.
After fluid and electrolyte correction, it is imperative that mechanical obstruction be ruled out radiologically or by endoscopy, before giving IV neostigmine to restore colonic motility.
A long rectal tube is also commonly used.
Wound dehiscence is typically seen around post-operative day 5 after open laparotomy. It typically happens bo when the patient who may not have been recognized as having a dehiscence ry coughs, strains, or gets out of bed. The patient must be kept in bed, and the bowel covered with large sterile dressings soaked with warm saline. Emergency ge abdominal closure is required. It may harm the patient in a number of ways.
If it drains freely, sepsis is not encountered patient is typically afebrile with no signs of peritoneal irritation though there are 3 other potential problems: Fluid and electrolyte loss Nutritional depletion Erosion and digestion of the abdominal wall http: Nature will do so if.
Foreign body bo Radiation injury ry Infection or inflammatory bowel disease Epithelialization ge Neoplasm ur Distal obstruction Steroid use: The condition results in water loss from cells and typically presents as alterations in neurologic function.
The extent of brain dysfunction depends on the magnitude and time et frame over which the hypernatremia developed. This is ge achieved by using NS rather than D5W. In one scenario, a patient who starts with normal fluid volume adds to it by retaining water because of the presence of inappropriate amounts of ADH e. In slowly developing hyponatremia from inappropriate ADH, the brain has time to adapt, and therapy should be water restriction.
In the case of the hypovolemic, dehydrated patient losing GI fluids and forced et to retain water, volume restoration with isotonic fluids NS or lactated. Hypokalemia develops very ur rapidly over hours when potassium moves into the cells, most notably when diabetic ketoacidosis is corrected.
Therapy is obviously potassium replacement. The latter provides the quickest protection. Metabolic acidosis can occur from any of the following: Excessive production of fixed acids diabetic ketoacidosis, lactic acidosis, low-flow states Loss of buffers loss of bicarbonate-rich fluids from the GI tract Inability of the kidney to eliminate fixed acids renal failure et.
Metabolic alkalosis occurs classically in a setting involving loss of acid gastric fluid, for example with prolonged emesis or NG suction. Treatment involves replacement of chloride and potassium, thereby allowing the kidneys to correct the problem. Metabolic alkalosis can also develop if excess bicarbonate is administered. They are recognized by abnormal PCO2 low in alkalosis, high in acidosis in conjunction with the abnormal pH of the blood.
Therapy must be directed at correction of the underlying respiratory problem. For example, acute metabolic acidosis will result in tachypnea with lowering of pCO2 to mitigate the decrease in pH arising from the primary derangement in this case, metabolic et acid.
When the diagnosis is uncertain, pH monitoring can be helpul to establish the presence of reflux and its correlation with the symptoms. In that setting, endoscopy and biopsy are the indicated tests,: Appropriate in long-standing symptomatic disease that cannot be controlled by medical means using laparoscopic Nissen fundoplication Necessary when complications have developed ulceration, stenosis using laparoscopic Nissen fundoplication Imperative if there are severe dysplastic changes resection is needed http: Manometry studies are used for the definitive diagnosis.
Barium swallow is typically done first to evaluate for an obstructing lesion. Achalasia is seen more commonly in women. There is dysphagia that is worse for liquids; the patient eventually learns that sitting up straight and waiting allows the weight of the column of liquid to overcome the sphincter. There is et occasional regurgitation of undigested food. X-rays show megaesophagus. The most appealing current treatment is balloon ok dilatation done by endoscopy; however, recurrence is high and many patients ultimately require an esophagomyotomy Heller.
Significant weight loss is always seen. Squamous cell ur carcinoma is seen in men with a history of smoking and drinking.
Diagnosis is established by endoscopy and: Mallory-Weiss tear is a mucosal laceration at the junction of the esophagus and stomach. It occurs after prolonged, forceful vomiting and presents with bright red hematemesis.
Endoscopy establishes diagnosis, and allows treatment with endoscopic clipping or coagulation. There is continuous, severe, wrenching epigastric and low sternal pain of sudden onset, soon followed by fever, leukocytosis, and a very sick-looking patient. Contrast swallow with a water- soluble agent Gastrografin is diagnostic and emergency surgical repair should follow. Delay in diagnosis and treatment has grave consequences due to the morbidity of mediastinitis.
Instrumental perforation of the esophagus is by far the most common reason for esophageal perforation. Shortly after completion of endoscopy, symptoms as et described above will develop.
There may be emphysema in the lower neck. Contrast studies and prompt repair are ok imperative. Stomach Gastric adenocarcinoma is more common in the elderly. Symptoms include: Anorexia et Weight loss. CT scan helps assess operability. Surgery is the best therapy. Presentation and diagnosis are similar, but treatment is chemotherapy. There is colicky abdominal pain and protracted vomiting, progressive abdominal distention if it is a low obstruction ,.
Early on, high-pitched bowel sounds coincide ok with the colicky pain after a few days there is silence. X-rays show distended bo loops of small bowel, with air-fluid levels. Treatment starts with NPO, NG suction, and IV fluids, hoping for spontaneous resolution, while watching for ry early signs of strangulation or peritonitis. Surgery is done if conservative ge management is unsuccessful, within 24 hours in cases of complete obstruction or within a few days in cases of partial obstruction.
It starts as described above, but eventually the patient: Emergency surgery is required. Mechanical intestinal obstruction caused by an incarcerated inguinal hernia has the same clinical picture and potential for strangulation as described above, but the physical exam shows the irreducible hernia that used to be reducible.
Because we can effectively eliminate the hernia we cannot effectively eliminate adhesions , all of these undergo surgical repair, but the timing varies: Carcinoid syndrome is seen in patients with a small bowel carcinoid tumor with liver metastases. It includes diarrhea, flushing of the face, wheezing, and right- sided heart valvular damage look for prominent jugular venous pulse.
Diagnosis is made with hour urinary collection for 5-hydroxyindolacetic acid 5-HIAA. A blood sample taken afterward will be normal. Thus, a hour urinary collection is more likely to provide the diagnosis. Acute appendicitis is one of the most common gastrointestinal conditions that requires emergency surgery. Clinical presentation provides important diagnostic et clues. The classic picture of acute appendicitis begins with anorexia, followed.
CT scan has become the standard diagnostic modality for those cases. Colon Cancer of the right colon typically presents with anemia hypochromic, iron deficiency in the right age group age 50— Colonoscopy and biopsies are diagnostic; surgery right hemicolectomy is treatment of choice.
Cancer of the left colon typically presents with bloody bowel movements and obstruction. Blood coats the outside of the stool, there may be constipation, stools may have narrow caliber. Flexible proctosigmoidoscopic exam 45 or 60 cm and biopsies are usually the first diagnostic study. Before surgery is done, full colonoscopy is needed to rule out a synchronous second primary lesion more proximally.
CT scan helps assess operability and extent. Treatment is elective et surgical resection sigmoidectomy or L-colectomy and primary anastomosis for. Polyps that are not premalignant include juvenile, Peutz-Jeghers, isolated ur inflammatory, and hyperplastic. Definitive surgical treatment of CUC requires removal of affected colon, including all of the rectal mucosa which is always involved. Clostridium difficile associated disease CDAD or psuedomembranous http: Any antibiotic can do it.
Clindamycin was the first one described, and, currently, Cephalosporins are the most common cause. There is profuse, watery diarrhea, crampy abdominal pain, fever, and leukocytosis. Diagnosis is best made by identifying the toxin in the stool.
Stool cultures take too long, and the pseudomembranes are not always seen on endoscopy. The culpable antibiotic should be discontinued, and no antidiarrheals should be used.
Metronidazole is the treatment of choice oral or IV , with vancomycin oral an alternative. Hemorrhoids typically bleed when they are internal can be treated with rubber et band ligation , or hurt when they are external may need surgery if conservative. Internal hemorrhoids can become painful and produce itching if ok they are prolapsed. There is exquisite pain with defecation ry and blood streaks covering the stools.
The fear of pain is so intense that patients avoid bowel movements and get constipated and may even refuse proper ge physical examination of the area. Examination may need to be done under ur anesthesia the fissure is usually posterior, in the midline. A fistula, if present, could be drained with setons while medical therapy is underway. Remicade helps healing. Ischiorectal abscess perirectal abscess is very common. The patient is febrile, with exquisite perirectal pain that does not let him sit down or have bowel movements.
Physical exam shows all the classic findings of an abscess rubor, dolor, calor, and fluctuance lateral to the anus, between the rectum and the ischial tuberosity. Incision and drainage are needed, and cancer should be ruled out by proper examination during the procedure.
If patient is a poorly-controlled et diabetic, necrotizing soft tissue infection may follow; significant monitoring is. Epithelial migration from the anal crypts where the abscess originated ry and from the perineal skin where the drainage was done form a permanent tract. Patient reports fecal soiling and occasional perineal discomfort. Physical ge exam shows an opening or openings lateral to the anus, a cordlike tract may be ur felt, and discharge may be expressed.
Rule out a necrotic and draining tumor, and treat with fistulotomy. A fungating mass grows out of ht the anus, metastatic inguinal nodes are often palpable. Diagnose with biopsy. Treatment starts with the Nigro chemoradiation protocol 5-fluorouracil, mitomycin, and external beam radiation , followed by surgery if there is residual tumor. GI bleeding arising from the colon comes from angiodysplasia, polyps, diverticulosis, or cancer, all of which are diseases of older people.
Even hemorrhoids become et more common with age. The same is true when blood is recovered by an NG tube in a patient who presents with bleeding: The best next diagnostic test in that setting is upper GI endoscopy. Be sure to look at the mouth and nose first.
Start the workup with upper GI endoscopy. Red blood per rectum could come from anywhere in the GI tract including upper GI, as it may have transited too fast to be digested.
The first diagnostic http: If blood is retrieved, an upper source has been established follow with upper endoscopy as above. If no blood is retrieved and the fluid is white no bile , the territory from the tip of the nose to the pylorus has been excluded, but the duodenum is still a potential source and upper GI endoscopy is still necessary. If no blood is recovered and the fluid is green bile tinged , the entire upper GI tip of the nose to ligament of Treitz has been excluded, and there is no need for an upper GI endoscopy.
Bleeding hemorrhoids should always be excluded first by ok physical exam and anoscopy. Colonoscopy is not helpful during an active bleed as blood obscures the field. Once hemorrhoids have been excluded, management bo is based on the rate of bleeding. If the bleeding is slower, i.
The difficulty with the tagged red-cell study is that it is a slow test, and by the time it is finished, the patient is often no longer bleeding and the subsequent angiogram is useless.
In that case, at least there is some degree of localization of bleeding to indicate which side of the colon to resect if the patient rebleeds or emergently begins to exsanguinate.
If the tagged red cells do not show up on the scan, a subsequent colonoscopy is planned. Some practitioners always begin with the tagged http: With increasing frequency in clinical practice, when bleeding is not found to be in the colon, capsule endoscopy is done to localize the spot in the small bowel.
Of course this is done only when the patient is stable and upper and lower GI sources have been ruled out. Patients with a recent history of blood per rectum, but not actively bleeding at the time of presentation, should start workup with upper GI endoscopy if they et are young overwhelming odds ; but if they are old they need both an upper and.
Endoscopy will confirm. Angiographic embolization is the best therapeutic option. Each of these groups has some common identifying characteristics. Acute abdominal pain caused by perforation has sudden onset and is et constant, generalized, and very severe.
The patient is reluctant to move, and. Except in the very old or very sick, ok impressive generalized signs of peritoneal irritation are found: Free air under the bo diaphragm on upright x-rays confirms the diagnosis.
Perforated peptic ulcer is ry the most common example. Emergency surgery is indicated. Acute abdominal pain caused by obstruction of a narrow duct ureter, cystic, ge or common bile has sudden onset of colicky pain, with typical location and ur radiation according to source.
There are few physical findings, and they are limited to the area where the process is occurring. It is constant, starts as ill-defined and eventually localizes to the site of pathology, and often has typical radiation patterns.
There are physical findings of peritoneal irritation in the affected area, and except for pancreatitis systemic signs such as fever and leukocytosis. Ischemic processes affecting the bowel are the only ones that combine severe abdominal pain with blood in the lumen of the gut. Cultures of the ascitic fluid will yield a single organism in garden- variety acute abdomens, a multiplicity of organisms grow.
Treat with antibiotics, not with surgery. Treatment for a generalized acute abdomen is exploratory laparotomy, with no need to have a specific diagnosis as to the exact nature of the process. With the et exception of patients in whom SBP is suspected, other etiologies that mimic an. These ok include myocardial ischemia obtain an ECG , lower lobe pneumonia perform a chest x-ray , PE suspect in an immobilized patient , and abdominal processes bo that do not require surgical exploration, such as pancreatitis check serum ry amylase and lipase and urinary stones perform a non-contrast CT scan of abdomen.
Physical findings are relatively modest, but there may be vaguely localized discomfort in the ht epigastrium. Diagnose with serum amylase and lipase, CT if diagnosis is not clear. More details in pancreatic disease section. While gallstones are more common in women than http: Acalculous acute cholecystitis is more common in older men. Ureteral stones produce sudden onset colicky flank pain radiating to the inner thigh and scrotum or labia, sometimes with urinary symptoms like urgency and frequency; and with microhematuria discovered on urinalysis.
Non-contrast CT scan is the best diagnostic test. Treatment most often involves analgesics and vigorous hydration to facilitate stone passage. Radiologically guided percutaneous drainage of an abscess may be helpful and help prevent emergent surgical resection, but if successful, will usually require elective resection.
Colonoscopy is indicated around 6 weeks after an episode of diverticulitis to rule out an underlying malignancy endoscopy earlier in the presence of active inflammation increases the likelihood of perforation and decreases the diagnostic sensitivity. Abdominal CT scan of year-old Man with Acute: It presents with signs of intestinal obstruction and severe abdominal distention. Recurrent cases need elective sigmoid resection.
Because the very old do not mount impressive acute abdomens, often the: In very early cases, arteriogram and embolectomy might save the day, whereas once bowel ischemia is present, surgical resection is mandatory. Patients develop vague right upper quadrant discomfort and weight loss. CT scan will et show location and extent. Resection is done if technically possible. It is found by CT scan if follow-up for the treated primary bo tumor is under way, or suspected because of rising carcinoembryonic antigen ry CEA in those who had colonic cancer.
If the primary is slow growing and the metastases are confined to one lobe, resection can be done. Other means of ge control include radiofrequency ablation RFA.
CT scan is diagnostic. If symptomatic, oral contraceptives should be stopped immediately; emergency surgery is required for patients presenting with ht signs of rupture and massive hemorrhage. Patients may not resume birth control pills. Pyogenic liver abscess is seen most often as a complication of biliary tract disease, particularly acute ascending cholangitis. Patients develop fever, leukocytosis, and a tender liver.
Sonogram or CT scan is diagnostic. Percutaneous drainage is required. Presentation and imaging diagnosis are similar to pyogenic liver abscesses, but can be treated with metronidazole and rarely require drainage. Definitive diagnosis is made by serology, but because the test takes weeks to be reported, empiric treatment is started in those clinically suspected.
If they improve, it is continued; if not, drainage is indicated. There is no bile in the urine. Workup should determine what is chewing up the red cells. Hepatitis is the most common example, and workup should: Obstructive jaundice has elevations of both fractions of bilirubin, modest ht elevation of transaminases, and very high levels of alkaline phosphatase. In obstruction caused by stones, the stone that is obstructing the common duct is seldom seen, but stones are seen in the gallbladder, which because of chronic irritation cannot dilate.
In malignant obstruction, a large, thin-walled, distended gallbladder is often identified Courvoisier-Terrier sign. The next step in that case is an endoscopic retrograde cholangiopancreatography ERCP to confirm the diagnosis, perform a sphincterotomy, and remove the common duct stone. Cholecystectomy should usually follow during the same hospitalization.
Obstructive jaundice caused by a tumor could be caused by adenocarcinoma of the head of the pancreas, adenocarcinoma of the et ampulla of Vater, or cholangiocarcinoma arising in the common duct itself. Pancreatic cancers that have produced obstructive jaundice are often big enough to bo be seen on CT.
However, endoscopy will show ur ampullary cancers and the cholangiography will show intrinsic tumors arising from the duct apple core or small pancreatic cancers. Percutaneous biopsy is not indicated to avoid seeding the abdominal wall with tumor; if cancer is ht suspected and a tumor is identified on CT or ERCP, it should be resected if no contraindications are present i.
Ampullary cancer should be suspected when malignant obstructive jaundice coincides with anemia and positive blood in the stools. Can bleed into the lumen like any other mucosal malignancy, at the same time that it can obstruct biliary flow by virtue of its location. Pancreatic cancer is seldom cured, even when resectable by the Whipple operation pancreatoduodenectomy.
There ok is a spectrum of biliary disease caused by gallstones, as noted below. Asymptomatic ry gallstones are left alone.
It occurs when a stone temporarily occludes the cystic ur duct. The episode is self-limited ht 10, 20, maybe 30 minutes , or easily aborted by anticholinergics. Acute cholecystitis starts as a biliary colic, but the stone remains at the cystic duct until an inflammatory process develops in the obstructed gallbladder. Pain becomes constant, there is modest fever and leukocytosis, and there are http: Liver function tests are minimally affected. In equivocal cases, a radionuclide scan HIDA would show tracer uptake in the liver, common duct, and duodenum, but not in the occluded gallbladder.
Cholecystectomy is usually performed during the same hospital admission as et an urgent case, though it is rarely a true emergency. Emergency percutaneous bo cholecystostomy may be the best temporizing option in the very sick with a ry prohibitive surgical risk. IV antibiotics and emergency decompression of the common duct is lifesaving; this is performed ideally by ERCP, alternatively percutaneous http: Eventually, cholecystectomy has to be performed.
Obstructive jaundice without ascending cholangitis can occur when stones produce complete biliary obstruction, rather than partial obstruction. Presentation and management were detailed in the jaundice section.
Biliary pancreatitis is seen when stones become impacted distally in the et ampulla, temporarily obstructing both pancreatic and biliary ducts. The stones. If not, ERCP and sphincterotomy may be required to dislodge the impacted stone. Acute pancreatitis may be edematous, hemorrhagic, or suppurative pancreatic abscess.
Late complications include pancreatic pseudocyst and chronic pancreatitis. Epigastric and midabdominal pain starts after a heavy meal or bout of alcoholic intake, is constant, radiates straight through to the back, and is accompanied by nausea, vomiting, and after the stomach is empty continued retching.
There is tenderness and mild rebound in the upper abdomen. Serum amylase and lipase are elevated, and often serum hematocrit levels are high due to hypovolemia. Acute severe pancreatitis is a much more deadly disease. It typically begins as an episode of acute pancreatitis but progresses to include pancreatic necrosis. The condition is accompanied by marked leukocytosis, hyperglycemia, and. Mortality can be high and scoring systems have been developed ok to classify the severity and predict mortality, e.
If drained fluid is positive: Necrosectomy is the best way to deal with necrotic pancreas, but timing is crucial. Most practitioners will wait as long as possible before necrosectomy is offered, as it requires the dead tissue to delineate well and mature for dissection.
Patients do far better by waiting at least 4 weeks before debridement of the dead pancreatic tissue. Many pancreatic abscesses are not amenable to percutaneous or open drainage and will require open drainage or debridement. Imaging studies done at that time will reveal the collection s of pus, and percutaneous drainage and imipenem or meropenem will be indicated.
Pancreatic pseudocyst can be a late sequela of acute pancreatitis, or of pancreatic upper abdominal trauma, with unrecognized ductal injury. There is a collection of pancreatic juice outside the pancreatic ducts. Treatment is dictated by the size and age of the pseudocyst. The cyst can be drained percutaneously: People who have repeated episodes of pancreatitis usually alcoholic eventually develop calcified burned- out pancreas, steatorrhea, diabetes, and constant epigastric pain.
The diabetes and steatorrhea can be controlled with insulin and pancreatic enzymes, but the pain is resistant to most modalities of therapy and can be incredibly debilitating.
If ERCP shows specific points of obstruction and dilatation, operations that drain the pancreatic duct may help. Exceptions include: Those that have been irreducible for years need elective repair. Gross Appearance of Large Umbilical Hernia http: The only sure way to rule out cancer is to get tissue for the pathologist. Age correlates best with the odds for cancer: Women with a family history are at greater risk from an earlier age.
Other risk factors for the development of breast cancer include first period at a young age, et radiation exposure, later menopause, and never having been pregnant. A breast mass that might be missed by bo palpation may be seen on mammogram and the opposite can also be true. Mammography can be done if necessary during pregnancy. Annual MRI screening, in addition to mammography, may be considered in patients with significant risk factors for developing breast cancer e.
Fine-needle aspirate FNA or core biopsy is sufficient to establish diagnosis. Removal is optional in uncomplicated cases. Giant juvenile fibroadenoma is seen in very young adolescents, where it has very rapid growth. Removal is needed to avoid deformity and distortion of the breast. Cystosarcoma phyllodes tumors are most common in women in their 30s and 40s, but women of any age can have them. They can become very large, et distorting the entire breast, yet not invading or becoming fixed. Most are benign,.
Core biopsy is needed FNA is not ok sufficient , and removal is mandatory. It often presents with bilateral tenderness related to the menstrual cycle and multiple lumps ge cysts that seem to come and go they are cysts also following the menstrual ur cycle.
However, any patient with a bloody nipple discharge is cancer until proven otherwise. Mastitis and breast abscesses are most commonly seen in lactating women; what appears to be a breast abscess at other times is cancer until proven otherwise.
Mastitis is treated with oral antibiotics alone, whereas ultrasound- http: Other strong indicators of cancer include: Ill-defined fixed mass Retraction of overlying skin et Recent retraction of the nipple. Treatment of resectable breast cancer starts with lumpectomy partial mastectomy plus post-op radiation or total mastectomy; either way, axillary sentinel lymph node sampling is performed simultaneously. The sentinel node biopsy is performed only when nodes are not palpable on physical exam.
Infiltrating or invasive ductal carcinoma is the common standard form of breast cancer. Other variants lobular, medullary, tubular, mucinous tend to have slightly better prognosis and are treated the same way as the standard infiltrating ductal.
Lobular has higher incidence of bilaterality. Inflammatory cancer is a clinical presentation of advanced breast cancer.
It has et a much worse prognosis and is treated with chemotherapy prior to surgery. Inflammatory breast cancer is also one of the few times where radiation is added following a total mastectomy. It mimics mastitis but is not an bo infectious process, and antibiotics do not play a role in treatment.
Since ge it is confined to the ducts, it cannot metastasize thus no axillary sampling is ur needed. Lumpectomy with or without radiation is used if the lesion s are confined to a limited portion of the ht breast. Inoperable cancer of the breast is breast cancer that is not amenable to surgical resection. Inoperability is based primarily on local extent not metastases.
Treatment for inoperable breast cancer can include any combination of chemotherapy, hormone therapy if hormone receptor positive , or radiation, and is often considered palliative.
In some cases, chemotherapy may shrink the cancer making it feasible for surgery. Anti- estrogen hormonal therapy is an option for adjuvant systemic therapy if the tumor is estrogen receptor-positive. Women with small, low-risk tumors may be offered hormonal therapy alone i.
Premenopausal women receive tamoxifen et Postmenopausal women receive an aromatase-inhibitor e. Brain ry metastases can be radiated or resected. The vertebral body and pedicles are the favorite location in the spine. FNA is the diagnostic et method of choice. Clinical signs of: Laboratory confirmation can be done with thyrotropin TSH; low or thyroxine T4; high. Nuclear scan will show if the nodule is the source. Repeat calcium determinations, look for low phosphorus, and rule out cancer with bone metastases.
If findings persist, do parathyroid hormone PTH determination and interpret in light of serum calcium levels. Osteoporosis, diabetes, hypertension, and mood changes may be present. Suppression at a higher dose identifies pituitary microadenoma. No suppression at higher dose identifies adrenal adenoma or paraneoplastic syndrome. Do appropriate imaging studies MRI for pituitary, CT scan for adrenal and remove the offending adenoma. Some patients also have watery diarrhea.
Measure gastrin and do a secretin test; if values are equivocal, locate the tumor with CT scan with contrast of the pancreas and nearby areas and resect it. Omeprazole helps those with metastatic disease. Insulinoma produces CNS symptoms because of low blood sugar, always when et the patient is fasting. Differential diagnosis is with reactive hypoglycemia. In the latter ok the patient has reason to be familiar with insulin some connection with the medical profession, or with a diabetic patient , and in plasma assays has high bo insulin but low C-peptide.
In insulinoma, both are high. Do CT with contrast of ry the pancreas to locate the tumor and then resect it. Glucagonoma produces severe migratory necrolytic dermatitis, resistant to all forms of therapy, in a ge patient with mild diabetes, mild anemia, glossitis, and stomatitis.
Glucagon assay ur is diagnostic, CT scan is used to locate the tumor, resection is curative. Somatostatin and streptozocin can help those with metastatic, inoperable disease. In both cases the key finding is hypokalemia in a hypertensive usually female patient who is not on diuretics. Other findings include modest hypernatremia and metabolic alkalosis. Aldosterone levels are high, whereas renin levels are low. Adrenal CT scans localize the lesion, and surgical removal provides cure. By the time patients are seen, the attack has subsided and blood pressure may be normal, leading to a frustrating lack of diagnosis.
Surgery requires careful pharmacologic preparation with alpha-blockers, followed by beta-blockers. Meticulous intraoperative monitoring and anesthesia care are also an essential part of surgical resection. Chest x-ray shows scalloping of the ribs erosion from large collateral intercostals.
CT angiogram CTA is diagnostic and surgical correction is curative. Renovascular hypertension is seen in 2 distinct groups: Workup is ok multifactorial, but Duplex scan of the renal vessels and CTA have prominent roles. Therapy is imperative in the young women—usually balloon dilatation bo and stenting—but it is much more controversial in older patients with ry atherosclerotic disease, many of whom have short life expectancy from the other manifestations of the arteriosclerosis.
In some cases clusters are seen. Esophageal atresia presents with excessive salivation noted shortly after birth et or with choking spells when first feeding is attempted. A small NG tube is. If ok there is normal gas pattern in the bowel, the baby has the most common form of the 4 types, in which there is a blind pouch in the upper esophagus and a fistula bo between the lower esophagus and the tracheobronchial tree.
If so, the others have to be ruled out as detailed above. If present, repair can be delayed until further growth but before toilet training time. If not present, do a colostomy for high rectal pouches and definitive repair at a later date. Jacq rated it it was amazing Jul 07, Karim rated it liked it Oct 15, Vash Ed rated it liked it Aug 08, Ihab rated it really liked it Mar 07, Alaa rated it liked it Oct 20, Abu Shiban rated it it was amazing Dec 07, Marichelle Perete rated it really liked it Nov 30, Aooash Aladwani rated it it was amazing Mar 09, Samah rated it really liked it Apr 16, Zainab Ismaeel rated it it was ok Mar 29, Joanna Catrina rated it liked it Jun 16, Juthathip Kaeokumnoi rated it really liked it Jan 16, Lala rated it it was amazing Oct 13, Nasir rated it it was amazing Feb 26, Tariq Al-karmawy rated it really liked it Jun 10, Cam Tu rated it liked it Mar 17, Adam Al-ta'ani rated it it was amazing Feb 24, Esra'a Abed aljaleel is currently reading it Apr 27, Sam added it May 22, Sonam Tariq marked it as to-read May 24, Tin Zar marked it as to-read May 28, Junaid Jahangir marked it as to-read Jun 05, Mayda marked it as to-read Jun 05, Sahar Sheikhbahaee marked it as to-read Jul 01, Lamees marked it as to-read Jul 11, Charbel is currently reading it Jul 14, Subhash Chander marked it as to-read Jul 20, Nibras marked it as to-read Aug 08,