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Occasionally the disease presents as tuberculous meningitis gastritis diet queen cheap macrobid 50 mg on line, and in the later stages there may be enlargement of the liver and spleen gastritis diet gastritis symptoms macrobid 50 mg visa. Choroidal tubercles (yellowy/white raised lesions about one-quarter the diameter of the optic disc) are occasionally seen in the eye. There are often no physical signs, although occasionally signs of a pneumonia or pleural effusion may be present. Tuberculous disease (as above) must be differentiated from latent tuberculous infection. Infection implies the presence of small numbers of tubercle bacilli in the body; the tuberculin test is positive (as with disease), but the chest X-ray is normal and the patient asymptomatic. This is to minimize the risk of transmission to other patients in a confirmed case. Culture of sputum is more sensitive than microscopy and allows antibiotic sensitivity testing. Where pulmonary tuberculosis is suspected, serial sputum samples on at least three occasions (ideally immediately upon waking) should be collected. This may involve lymph node biopsy, bone biopsy, urine testing or aspiration of pericardial fluid. A 6-month regimen comprising rifampicin, isoniazid, pyrazinamide and ethambutol for the initial 2 months followed by rifampicin and isoniazid for a further 4 months, is standard treatment. Four drugs should be continued for longer than 2 months if susceptibility testing is still outstanding. Pyridoxine 10 mg daily is given to reduce the risk of isoniazid-induced peripheral neuropathy. A transient asymptomatic rise in the serum aminotransferase level may occur with rifampicin, but treatment is only stopped if hepatitis develops. The major causes of treatment failure are incorrect prescribing by the doctor and inadequate compliance by the patient. Vagrants, alcoholics, homeless and the mentally ill are most likely to be non-compliant with therapy. Prevention and chemoprophylaxis Close contacts of a case are screened for evidence of disease with a chest X-ray and a Mantoux test (positive if area of induration! Antituberculous treatment is given if the chest Xray shows evidence of disease or if the Mantoux test is negative initially but becomes positive on repeat testing 6 weeks later. In adults, an initial positive tuberculin test with a normal chest X-ray is not usually taken as indication of disease. Patients with tuberculous infection identified by tuberculin testing are usually treated with one drug for 6 months (chemoprophylaxis) to prevent progression to disease. Patients with chest X-ray changes compatible with previous tuberculosis and who are about to undergo treatment with an immunosuppressive agent should also receive chemoprophylaxis with isoniazid. The process involves not only the interstitial space but also the alveoli, bronchioles and blood vessels. Presentation is with shortness 546 Respiratory disease Diffuse parenchymal lung diseases Granulomatous lung disease Inhalation of dust Idiopathic interstitial pneumonias Autoimmune rheumatic diseases Drug induced Other forms Organic dust Inorganic dust Idiosyncratic. Pulmonary infection, malignancy and pulmonary oedema may mimic interstitial lung disease. Granulomatous lung disease A granuloma is a mass or nodule of chronic inflammatory tissue formed by the response of macrophages and histiocytes to a slowly soluble antigen or irritant. Sarcoidosis Sarcoidosis is a multisystem granulomatous disorder of unknown cause typically affecting young and middle-aged adults. In about half of cases, the disease is detected incidentally on a routine chest X-ray in an asymptomatic individual. Epidemiology Sarcoidosis has a female preponderance, is most common in northern Europe and is uncommon in Japan.

These patients are also prone to atrial and occasionally ventricular fibrillation gastritis and diet pills purchase discount macrobid line. Symptoms the usual history is of rapid regular palpitations gastritis diet x garcinia discount 50mg macrobid visa, usually with abrupt onset and sudden termination. Cardiac arrhythmias 429 Haemodynamically stable patient: Increase vagal stimulation of the sinus node by the Valsalva manoeuvre (ask the patient to blow into a 20-mL syringe with enough force to push back the plunger) or right carotid sinus massage (contraindicated in the presence of a carotid bruit). Long-term management Radiofrequency ablation of the accessory pathway via a cardiac catheter is successful in about 95% of cases. It also occurs, particularly in a paroxysmal form (stopping spontaneously within 7 days), in younger patients. In some patients, it is an incidental finding; in others, symptoms range from palpitations and fatigue to acute heart failure. Randomized studies in heart failure and in older patients have shown that neither strategy has net benefits compared with the other. Other agents used depend on the presence (use amiodarone) or absence (sotalol, flecainide, propafenone) of underlying heart disease. Catheter ablation techniques such as pulmonary vein isolation are used in patients who do not respond to antiarrhythmic drugs. Longer-term anticoagulation is indicated in underlying rheumatic mitral stenosis or in the presence of a mechanical heart valve. Trial data have shown them to be equally effective and safer as compared to warfarin. However, these agents require dose reduction or avoidance in patients with renal impairment, elderly patients or those with low body weight. Ventricular tachyarrhythmias Ventricular ectopic premature beats (extrasystoles) these are asymptomatic or patients complain of extra beats, missed beats or heavy beats. It is common in patients with heart disease (and in a few individuals with normal hearts). The patient is pulseless and becomes rapidly unconscious, and respiration ceases (cardiac arrest). The causes include congenital (mutations in sodium and potassium-channel genes), electrolyte disturbances (hypokalaemia, hypocalcaemia, hypomagnesaemia) and a variety of drugs. Circulation Circulation is assessed by palpation of the carotid pulse at the same time as assessing for respiratory effort. In acquired cases, treatment is that of the underlying cause and intravenous isoprenaline. The patient is unconscious and apnoeic with absent arterial pulses (best felt in the carotid artery in the neck). Irreversible brain damage occurs within 3 minutes if an adequate circulation is not established. Resuscitation is stopped when there is return of spontaneous circulation and a pulse, or further attempts at resuscitation are deemed futile. Prognosis In many patients resuscitation is unsuccessful, particularly in those who collapse out of hospital and are brought into hospital in an arrested state. In patients who are successfully resuscitated, the prognosis is often poor because they have severe underlying heart diseases. It is a common condition, with an estimated annual incidence of 10% in patients over 65 years. The long-term outcome is poor and approximately 50% of patients are dead within 5 years. Aetiology Ischaemic heart disease is the most common cause in the developed world and hypertension is the most common cause in Africa (Table 10. Any factor that increases myocardial work (arrhythmias, anaemia, hyperthyroidism, pregnancy, obesity) may aggravate existing heart failure or initiate failure. Pathophysiology When the heart fails, compensatory mechanisms attempt to maintain cardiac output and peripheral perfusion.

Inflammation and ulceration can occur throughout the gut but clinically is most apparent in the stomach and duodenum (dyspepsia gastritis symptoms burning sensation purchase macrobid overnight, erosions gastritis journal articles purchase macrobid 50mg on-line, ulceration, bleeding, perforation). Other side effects Other side effects are hypersensitivity reactions (particularly rashes, bronchospasm, angio-oedema), blood disorders, fluid retention (may precipitate cardiac failure in the elderly), acute kidney injury, hepatitis, pancreatitis and exacerbation of colitis. Therapeutics 323 Drugs affecting bone metabolism Bisphosphonates Mechanism of action these synthetic analogues of bone pyrophosphate are adsorbed onto hydroxyapatite crystals in bone and inhibit growth and activity of osteoclasts, thereby reducing the rate of bone turnover. Treatment and prevention of osteoporosis: 10 mg daily at least 30 minutes before breakfast or 70 mg once weekly. Because of severe oesophageal reactions (oesophagitis, oesophageal ulcers and strictures), patients should be advised to take the tablets with a full glass of water on rising, to take them on an empty stomach at least 30 minutes before the first food or drink of the day and to stand or sit for at least 30 minutes. Also advise patients to stop the tablets and seek medical attention if symptoms of oesophageal irritation develop. Each 60 mg must be diluted with at least 250 mL sodium chloride and given over at least 1 hour. Osteolytic lesions and bone pain in bone metastases associated with breast cancer or multiple myeloma: 90 mg every 4 weeks (or every 3 weeks to coincide with chemotherapy in breast cancer). Hypercalcaemia of malignancy: give as single infusion of 4 mg zoledronic acid over at least 15 minutes. Side effects Gastrointestinal side effects (dyspepsia, nausea, vomiting, abdominal pain, diarrhoea, constipation), influenza-like symptoms, oesophageal reactions (see above), musculoskeletal pain. With intravenous disodium pamidronate: biochemical abnormalities (hypophosphataemia, hypocalcaemia, hyper- or hypokalaemia, hypernatraemia), anaemia, thrombocytopenia, lymphocytopenia, seizures, acute kidney injury, conjunctivitis. Atypical femoral fractures are reported rarely and mainly in association with long-term treatment. Cautions/contraindications Correct vitamin D deficiency and hypocalcaemia before starting. Indications Hypocalcaemia, osteomalacia, when dietary calcium intake (with or without vitamin D) is deficient in the prevention and treatment of osteoporosis. Preparations and dose Calcium carbonate Chewable tablets (calcium 500 mg or Ca2+ 12. Dispersible tablets: 400 (calcium 400 mg or Ca2+ 10 mmol), 1000 (calcium 1 g or Ca2+ 25 mmol). Side effects Gastrointestinal disturbances; with injection, peripheral vasodilatation, fall in blood pressure, injection-site reactions. Cautions/contraindications Conditions associated with hypercalcaemia and hypercalciuria. Therapeutics 325 Vitamin D Mechanism of action Fat-soluble vitamin whose main action is to promote intestinal absorption of calcium. Asians consuming unleavened bread and in elderly patients, particularly those who are housebound or live in residential or nursing homes. Preparations and dose Cholecalciferol Capsules: 800 units (equivalent to 20 ng of vitamin D3). Side effects Symptoms of overdosage include anorexia, lassitude, nausea and vomiting, polyuria, thirst, headache and raised concentrations of calcium and phosphate in plasma and urine. All patients on pharmacological doses of vitamin D should have plasma calcium concentration checked at intervals (initially weekly) and if nausea and vomiting are present. Cautions/contraindications Contraindicated in hypercalcaemia and metastatic calcification. Water and electrolytes are taken in as food and water, and lost in urine, sweat and faeces. The reference maintenance fluid, electrolyte and nutrient intake in adults is given in Table 8. In certain disease states the intake and loss of water and electrolytes is altered and this factor must be taken into account when providing fluid replacements.

Syndromes

• Damage to the urethra or bladder
• Keep the chin lifted and head tilted.
• Alcohol or drug abuse
• Confusion
• Examination of the cerebral spinal fluid (CSF) (may show cancerous cells)
• Quickly stop moving and change direction while running, landing from a jump, or turning
• Nitrates
• Infection

Symptoms are the result of: the primary tumour Metastases the coagulopathy of cancer may cause deep venous thromboses and pulmonary emboli erosive gastritis definition purchase cheap macrobid online, particularly in association with cancers of the pancreas gastritis pediatric symptoms order macrobid 100 mg visa, stomach and breast. These are a consequence of the cancer but are not due to the local presence of the cancer and may be mediated by hormones or cytokines secreted by the cancer. Investigations To confirm the presence of malignancy in a patient with suspicious symptoms or signs. This is by radiological imaging (with the specific test depending on the site) and biopsy of a suspicious lesion. In many cases they are requested inappropriately as most tumour markers are neither sensitive nor specific for a particular malignancy and can also be raised in benign conditions. Biopsy is necessary to confirm the tissue diagnosis and to inform treatment decisions. Staging the cancer will divide the patients into groups of different prognoses, which can guide treatment selection. Discussion with the patient about the treatment plan at each step will allow them to make a fully informed choice about their management. In some solid tumours, treatment (chemotherapy, radiotherapy or hormone) is given after the primary treatment. Neoadjuvant therapy is given before the primary treatment to shrink the tumour in order to improve the efficacy of the local excision and to treat micrometastases as soon as possible. If effective, these treatments should lead to an increased chance of cure or overall disease-free survival. They therefore affect not only tumour cells, but also the rapidly dividing normal cells of the bone marrow, gastrointestinal tract and germinal epithelium. Side effects include tiredness, bone marrow suppression (leading to anaemia, thrombocytopenia and neutropenia), mucositis (causing mouth ulceration), hair loss (alopecia) and sterility. To minimize side effects, chemotherapy is given at intervals to allow some recovery of normal cell function between cycles. Nausea and vomiting may be severe with some drugs, such as cisplatin, and are related to the direct actions of cytotoxic agents on the brainstem chemoreceptor trigger zone. Chemotherapy drugs may themselves cause cancer, particularly acute leukaemia presenting years after treatment. The complications of radiotherapy depend on the radiosensitivity of normal tissue in the path of the radiation field. There may be damage to the skin (erythema and desquamation), gut (nausea, mucosal ulceration and diarrhoea), testes (sterility) and bone marrow (anaemia, leucopenia). Tamoxifen is a mixed agonist and antagonist of oestrogen on the oestrogen receptor and is used as an adjuvant therapy in breast cancer and in advanced metastatic breast disease. They have greater efficacy than tamoxifen in the treatment of metastatic breast cancer and equal efficacy in the adjuvant setting. Biological therapy this group includes a range of protein molecules, from small peptide chemokines and larger cytokines to complex antibody molecules, made available by genetic engineering. The latter is a syndrome in which donor T lymphocytes infiltrate the skin, gut and liver, causing a maculopapular rash, diarrhoea and liver necrosis. The main advantage is the short time for blood count recovery because peripheral blood progenitor cells are more differentiated. This technique has been particularly effective in relapsed leukaemias, lymphomas, myeloma and germ cell tumours. Oncological emergencies these arise as a result of the tumour itself or as a complication of treatment. Neutropenic sepsis is the most common cause of attendance in the emergency department for any cancer patient and must be always considered in any patient who is unwell within a month of chemotherapy. Superior vena cava syndrome can arise from any upper mediastinal mass but is most commonly associated with lung cancer and lymphoma. Presentation is with difficulty breathing and/or swallowing, oedematous facies and arms, and venous congestion in the neck with dilated veins in the upper chest and arms. Treatment is with immediate steroids, vascular stents, radiotherapy and chemotherapy for sensitive tumours. Acute tumour lysis syndrome occurs as a result of treatment producing massive and rapid breakdown of tumour cells, leading to increased serum level of urate, potassium and phosphate with secondary hypocalcaemia. It is most 258 Malignant disease commonly seen as a complication of treatment of acute leukaemia and high-grade lymphoma unless preventive measures are taken.