Mark Corson

By W. Chenor. The Rockefeller University. 2018.

The majority of T is converted from the less active 3 r Octreotide or lanreotide 800 mg renagel visa, a long-acting somatostatin T4 by peripheral tissues quality 400mg renagel. Disorders of the thyroid axis are analogue buy 400mg renagel free shipping, may be used prior to surgery, following in- shown in Table 11. Fur- Age ther classification is based on whether the patient is hy- Increases with age. Irregularmultinodularenlargementofthethyroidgland, which may be hyperthyroid (toxic) or is commonly eu- thyroid (nontoxic). Clinical features Patients may present for cosmetic reasons, with thyro- Incidence/prevalence toxic symptoms, or because of complications. Multin- 25% of cases of thyrotoxicosis are due to multinodular odular goitre can present with a particularly promi- goitre. Causes include the following: r Benign follicular adenoma: Single lesions with well- Macroscopy/microscopy developed fibrous capsules. Nodules may be cystic, haemorrhagic and fi- hormones, which may result in hyperthyroidism. Enlargement of the gland can cause tracheal compres- r Thyroid cyst (15–25%): These may be simple cysts sion leading to shortness of breath and choking. About more common with retrosternal goitre, when the nod- 15% are necrotic papillary tumours. Toxic multinodular goitre has a particularly high incidence of cardiac arrhythmias and other cardiac complications. Clinical features Patients may present with a palpable lump or may be diagnosed on incidental imaging. Ultrasound scanning of the thyroid may be useful r History of neck irradiation exposure. Cystsand r Malignancy is more common in children and patients nodules may be aspirated by fine needle aspiration for over 60 years. Investigations Management r Thyroid function tests are used to determine thyroid Subtotal thyroidectomy may be required for cosmetic status. Isotope scans may also be used to demon- reasons or due to compression symptoms or thyrotoxi- strate either a cold nodule, a hyperactive gland (toxic cosis. Patients must be medically treated and euthyroid multinodular goitre) or a ‘cold’ gland containing a before surgery. A solitary mass within the thyroid gland that may be r Fine needle aspiration for cytology is used to differen- solid or cystic. Incidence Management 5% of population have a palpable solitary thyroid nod- Benign lesions only require treatment if they cause hy- ule. Up to 50% of population have a solitary nodule at perthyroidism or for cosmetic reasons. Chapter 11: Thyroid axis 431 If suspicious cells are identified on cytology a thyroid r The autoantibody can cross the placenta, causing lobectomy should be performed. Clinical features Graves’ disease (primary thyrotoxicosis) Hyperthyroidism produces palpitations, nervousness, fatigue, diarrhoea, sweatiness, tremor and intolerance Definition of heat. Weight loss with increased or normal appetite Graves’ disease is an autoimmune thyroid disease. Proptosis (exophthalmos) with lid retraction, stare and Sex lid lag are prominent features, and in its most severe F > M form it may cause sight loss due to damage to the optic nerve. Thyroid dermopathy (also called pretibial myxoedema) r Fifteen per cent of patients have a close relative with is a thickening or ‘orange-peel appearance’ of the skin, Graves’, and 50% of relatives have circulating thyroid most often affecting the lower leg. Microscopy The thyroid epithelial cells are increased in number and size with large nuclei. This causes a generalised, uncontrolled stimulation lymphocyte infiltration may also be seen. After many years the gland becomes non-functional and Investigations the patient becomes hypothyroid. Other complica- is made by a combination of clinical features and detec- tions of Graves’ disease may also be due to similar tion of thyroid autoantibodies. Thesecomplicationsdonotresolveontreat- Management ment to reduce the overactivity of the thyroid. Antithyroid drugs (usually carbimazole) are given to r Some symptoms of Graves’ disease relate to apparent suppress the gland. Graves’ disease commonly enters catecholamine (noradrenaline and adrenaline) excess, remission after 12–18 months, so a trial of withdrawal for example tachycardia, tremor and sweating. Patients who are severely symptomatic roid hormones induce cardiac catecholamine recep- with hyperthyroidism also benefit from β-blockers. Subtotal thyroidectomy results in normali- Primary Idiopathic/autoimmune thyroid atrophy sation of thyroid function in 70%. The patient must be made Iatrogenic: radioactive iodine, surgery, drugs euthyroid before surgery with antithyroid drugs and β- Iodine deficiency (common in Nepal, Bangladesh) blockers (see page 436). Inborn errors of hormone synthesis Secondary Panhypopituitarism due to pituitary adenoma Iatrogenic: pituitary ablative therapy/surgery Prognosis Tertiary Hypothalamic dysfunction (rare) Thirty to fifty per cent of patients used to undergo spon- Peripheral resistance to thyroid hormone (rare) taneous remission without treatment. Hypothyroidism (myxoedema) Thyrotoxic crisis (storm) Definition Definition Hypothyroidism is a clinical syndrome resulting from a Arare syndrome of severe acute thyrotoxicosis, which deficiency of thyroid hormones. Pathophysiology Congenital hypothyroidism causes permanent develop- Pathophysiology mental retardation. In children it causes reversible de- Levels of thyroid-binding protein in the serum fall and layedgrowthandpuberty,anddevelopmentaldelay. This results in increased cocious puberty may occur in juveniles, due to pituitary free T3 and T4, coupled to increased sensitivity of the hypertrophy. In adults it causes decreased removal of heart and nerves due to the presence of catecholamines.

Externally renagel 800mg low price, it is used in the treatment of in Food Drugs and Cosmetics safe renagel 800 mg, John Wiley & Sons Inc discount 800mg renagel fast delivery. Lehrbuch der Biologischen Arzneimittel, Bde 1-3, Because of its secretion-activating effect, the drug should not Nachdruck, Georg Olms Verlag Hildesheim 1979. Springer No health hazards or side effects are known in conjunction Verlag Heidelberg 1992. Phytopharmaka und Mode of Administration: Comminuted herb for infusions and pflanzliche Homoopathika. Fischer-Verlag, Stuttgart, Jena, New ^^ other bitter-tasting preparations for internal use. Centella asiatica Daily Dosage: The average daily dose is 6 gm of drug or 1 to See Gotu Kola 2 gm of extract; single dose is 1 gm. The powdered drug is taken 3 times daily on a wafer with honey; the infusion is taken 1/2 hour before meals. See Red-Spur Valerian Storage: Keep protected from light and moisture in sealed containers. Schimmer O, Mauthner H, Polymethoxylated xanthones from the herb of Centaurium erythraea with strong antimutagenic properties in Salmonella typhimurium. In other animal experiments, an inhibition of lactation and a normalization of stress-induced hyperprolac- tin anemia was observed. In clinical studies, the positive effect on symptoms resulting from hyperprolactin anemia Chaste Tree was proven. Vitex agnus-castus A dopaminergic effect via bonding on D2-receptors was also shown. It is surrounded up to two-thirds in cup-like It is also used to control libido, increase milk flow, reduce fashion by the calyx. They have 5 to 7 entire-margined, up to 10 cm Homeopathic Uses: Chaste Tree is used for male sexual long, lanceolate leaflets. The under surface of the leaf is disturbances, disturbances of milk flow, and nervous white and tomentose. Production: Chaste Tree fruits consist of the ripe, dried fruits of Vitex agnus-castus. Daily Dosage: The daily dosage of aqueous-alcoholic j^ extracts is 30 to 40 mg of the drus. Nachdruck, Haug compounds in extracts of Agnus castus, direct evidence for a Verlag, Heidelberg 1992. Madaus G, Lehrbuch der Biologischen Arzneimittel, Bde 1-3, Nachdruck, Georg Olms Verlag Hildesheim 1979. The composition of the essential oil of Vitex Steinegger E, Hansel R, Pharmakognosie, 5. Ausfallserscheinungen nach Hysterektromie unter Belassung der Wagner H, Wiesenauer M, Phytotherapie. Schnieders M, Sieder C, Zur dosisabhangigen Vertraglichkeit eines Agnus-castus-Spezialextraktes. Z Phytother Abstractband, heart-shaped, three-veined cotyledons and a straight radical. Triglycerides: chief fatty acids D-hydnocarpic acid, D-chaul- moogric acid, D-gorli acid (cyclopentene fatty acids) Sleumer, (1947) Pharm Ztg 83:165. Chinese Medicine: In China, Chaulmoogra is used for leprosy, scabies and furuncles. Gheken Indian Medicine: Uses include leprosy, skin diseases, itching, leocodermia, eczema, flatulence and diabetes. It is severely irritating Flower and Fruit: The flowers are usually solitary, occasion- in local application. The stamens are numerous but Following stomach and intestinal emptying (inducement of small. The fruit is a red or black- vomiting, gastric lavage with burgundy-colored potassium violet, glabrous, globular berry, 6 to 8 mm in diameter. It has permanganate solution, sodium sulfate), the treatment for 2 to 3 seeds which are dark, lentil-shaped and are about 4 poisonings consists of the instillation of activated charcoal mm in diameter. Intubation and to 1 cm wide, entire-margined, very shortly petioled with oxygen respiration may also be required. Bitter substances Flower and Fruit: The flowers are erect and in slender Volatile oil: including alpha-pinene, 1,8-cineol racemes 10 to 12 cm long with 3 mm pedicles. The smooth kernel within the fruit is ovoid The ethanol extract inhibits xanthinoxydasis. An antibacterial and antimycotic effect has also been Leaves, Stem and Root: The plant is an evergreen shrub or demonstrated. In the agar diffusion test, the leaf oil was tree, completely glabrous, and grows up to 6 m high. The effective against Pseudomonas acruginsosa, Trichophyton bud scales drop early. The leaf blades are obovate-lanceolate and 8 to 15 metabolism: the oil is used against hyperlipoprotinemia. They are curved, entire or with a finely serrate ^^used as a tonic, a diuretic and an expectorant. Unproven Uses: In South American folk medicine, a decoction of the leaves is used in the treatment of diarrhea, Characteristics: Poisonous.

Chapter 3: Obstructive lung disorders 109 Incidence Pathophysiology 20% of children renagel 800mg on-line, 5–14% of adults renagel 400 mg line, increasing in preva- The clinical picture of asthma results from mixed acute lence buy cheap renagel 800 mg on-line. With time this repeated stimula- Can present at any age, predominantly in children. They secrete mediators of acute and 2 Intrinsic asthma tends to present later in life. There is chronic inflammation including enzymes and oxygen no identifiable allergic precipitant. Patients with occupational asthma from the listed causes are entitled to compensation under in- inflammation recruiting and activating fibroblasts dustrial injuries legislation in the United Kingdom. They also lead, through r Forall patients, non-specific irritant trigger fac- mechanisms which are not yet clearly defined, to tors include viral infections, cold air, exercise, bronchialhyperresponsiveness–anexaggeratedbron- emotion, atmospheric pollution, dust, vapours, choconstrictor response to non-specific insults to the fumes and drugs particularly nonsteroidal anti- airways. The pattern of airway reaction following inhalation of an allergen: i An acute reaction occurring within minutes, peaking Table3. Non IgE related Isocyanates, colophony fumes (from ii A late reaction occurring 4–8 hours after inhalation solder), hardwood dust, complex (the chronic inflammatory response). If there is diagnostic difficulty in patients with mild symp- Mild–moderate Life-threatening attack Severe attack attack toms or just cough, exercise tests or peak flow diary card r r r recordings as above. Occasionally, a trial of oral corti- Speech normal Unable to Silent chest costeroids for 2 weeks can be used. Skin tests are used complete sentences to identify specific allergens and serum can be taken for r Pulse <110 r Pulse ≥110 r Cyanosis total and specific IgEs. An asthma attack is characterised by rapid inspiration, r Allergen avoidance can be advised, e. However these rarely have a major im- tial severity of asthma patients require rapid assessment pact on disease. An acute asthma attack is classified r Drug therapy includes: short acting β agonists for 2 according to clinical severity (see Table 3. Night-time waking, early phyllines and other agents with additional activities morning wheeze, acute exacerbations in the preceding (see Fig. Once disease control is achieved the steroid dose is reduced under regular review to Complication the minimum dose required to maintain disease Pneumothorax, surgical emphysema due to rupture of control. How- should not be reduced more frequently than every 3 ever, the test may be falsely negative if the asthma is months. Chapter 3: Obstructive lung disorders 111 Step 5: Continuous or frequent oral steroids Daily oral steroids in lowest dose providing adequate control whilst continuing maximal inhaled steroids and use of other steroid sparing agents. Refer patient for specialist care Step 4: Persistent poor control Consider trial of: • Very high dose inhaled steroid • Addition of a fourth drug e. Prognosis Most children and teenagers with asthma improve as Prevalence they get older, although asthma may recur in adult life. Em- All patients should be advised not to smoke and to avoid physematous spaces are found in 50% of smokers aged potential work allergens. Chronic bronchitis and emphysema Sex Definition M > F Chronicbronchitishasaclinicaldefinitionofcoughpro- ductive of sputum on most days for at least 3 months of Geography the year for more than 1 year. New regression equations for predicting Patients with severe asthma (indicated by need for admission) and adverse peak expiratory flow in adults. Expiratory wheeze and cough are present Virtually confined to cigarette smokers and related to the but the cough is dry. As emphysema be- causes pan-acinar emphysema and accounts for 5% of comesmoresevereothersignsbecomeevidentinclud- patients with emphysema. One in 5000 births have a ho- ing tachypnoea, cachexia, the use of accessory muscles mozygousdeficiencyandmostthesegoontodevelopthe of respiration, intercostal recession, pursed lips on ex- lung disease. Patients tend to be young (below 40 years) piration, poor chest expansion (a hyperinflated chest especiallyifsmokers,inwhomthediseaseismuchworse. The pink puffer is typical of relatively of airways and luminal narrowing resulting in airway pure emphysema and the blue bloater is typical of rel- obstruction. Mucus respiratory bronchioles whilst the more distal alveolar gland hypertrophy and hyperplasia can be quantified by ducts and air spaces tend to be well preserved. The theReidindexwhichistheratioofglandtowallthickness alveolar dilatation results from loss of elastic recoil in within the bronchus. Smoking Microscopy also causes glandular hypertrophy (chronic bronchi- Both emphysema and chronic bronchitis are inflam- tis) and has an adverse effect on surfactant favouring matory diseases of the lung. In pan-acinar emphysema destruction involves the Eosinophilsarealsoseenespeciallyinchronicbronchitis, whole of the acinus. Theclinicalfeaturesdepend Complications on the degrees of chronic bronchitis and of emphysema Airway obstruction and alveolar destruction eventually contributing to the overall picture. Pulmonary vasculature re- ductive of sputum, expiratory wheeze and progres- sponds to hypoxia by vasoconstriction which increases sive shortness of breath. Symptoms of emphysema the arterial pressure, causing pulmonary artery hyper- are dominated by progressive breathlessness, initially tension, which leads to right heart failure (cor pul- only on exertion but eventually on mild exertion such monale). There may be secondary polycythaemia due Chapter 3: Obstructive lung disorders 115 to hypoxia. Cyanosis, hypercapnia and cor r Bronchodilators:Shortactingbronchodilatorspro- pulmonale develop only late in the disease after pro- duce significant clinical benefit, helping patients gressive decline in lung function. Amoxycillin resis- feel less short of breath (although objective im- tant Haemophilus respiratory infections are common in provement in lung function tests may be slight). Long acting β2 agonists and bacterial or mixed infections are common resulting in longactinganticholinergicsimprovelungfunction, major morbidity and mortality. There may also be a deficiency sputum is purulent, should be given promptly in of bloodvesselsintheperipheralhalfofthelungfields acute exacerbations in an attempt to minimise lung in comparison to the proximal vessels.

Fluid administration very likely will be helpful renagel 800mg with amex, as the patient’s dizziness and anxiety are signs of hypovolemic shock discount 400 mg renagel with visa. Bleeding with diverticulosis is described as painless and abrupt cheap renagel 800 mg fast delivery, “as though a water faucet was suddenly turned on. The main priorities are to determine whether there has been significant blood loss and to maintain hemodynamic stability. International consensus recommendations on the management of patients with nonvaiceal upper gastrointestinal bleeding. The paramedics who transported her were not able to obtain any infor- mation about her past medical history but did bring her bag of medications, which includes furosemide. She has jugular venous distension to the angle of the jaw, rales in both lung fields, and +2 pretibial edema bilaterally. Her medications include furosemide, strongly suggesting a history congestive heart failure. Once the patient is stabilized, it is important to try to identify any precipitants of the exacerbation. The right side of the heart receives blood from the peripheral circulation and sends it to the lungs for oxygenation. The left side subsequently receives oxygen- ated blood from the lungs and pumps it back into the circulation. The term “congestive” refers to abnormal fluid retention resulting from this loss of contractility. Failure of the right side of the heart results in increased systemic venous pressures while left-sided failure causes increased pulmonary venous pressures. Each has dif- ferent symptoms and physical findings (Table 38–1), although the two conditions often occur concomitantly. As a result, they may be sensitive to reductions in diastolic filling volumes (due to aggressive diuresis or venodilation) and become hypotensive. In addition, the clinician must try to determine what caused the patient’s condition to decompensate. The most common precipitants are cardiac causes (eg, myocardial ischemia or infarc- tion) and noncompliance with medications or dietary restrictions. Other causes include uncontrolled hypertension, valvular dysfunction, arrhythmia, infection, volume overload, pulmonary embolism, thyrotoxicosis, and iatrogenic etiologies. Those with significant respiratory distress require aggressive interventions while a focused history, physical examination, and diagnostic testing are performed simulta- neously. Important historical points include the onset, duration, and character of respiratory complaints; any associated symptoms (such as chest pain or fever); past medical history (including prior heart disease and cardiac workup); and current medications (including recent changes in doses and any missed doses). If the patient is hypotensive, intra- arterial blood pressure monitoring is important because noninvasive measurements are often inaccurate in vasoconstricted individuals. The cardiac examination may also reveal the murmur of a ventricular septal defect or acute mitral regurgitation or the irregularly irregular rhythm of atrial fibrillation—all of which can precipitate acute pulmonary edema. Although x-ray findings may lag behind clinical symptoms by up to 6 hours, chest radiography still provides valuable information for the clinician. As the pulmonary congestion increases, interstitial edema and Kerley B lines become prominent, followed by opacification of the air spaces with alveolar edema. The x-ray may also help exclude other causes of dyspnea and respiratory distress (eg, pneumothorax or pneumonia). Laboratory studies should include complete blood count, electrolytes, blood urea nitrogen/creatinine, and urinalysis. If there is a suspicion of acute coronary syndrome, cardiac enzymes should be sent. Liver enzymes may be of use in patients with hepatomegaly, and lactate levels in those with suspected cardiogenic shock. Treatment Treatment of cardiogenic pulmonary edema consists of oxygenation, vasodilation, diuresis, and augmentation of cardiac contractility if needed. Noninvasive positive-pressure ventilation via continuous or biphasic positive airway pressure may be necessary if hypoxia continues. Ultimately, the patient may require intubation if refractory to the aforementioned interventions. This is most effectively and rapidly achieved with nitroglycerin, which can be given via sublingual, topical, or intrave- nous routes. Diuresis with furosemide or bumetanide effectively reduces intravascular volume and preload, thus reducing pulmonary congestion. If patients do not improve with this therapy, an inotrope, such as dobutamine, may be given to increase myocardial contractility. The patient has had congestive heart failure, previ- ously controlled with oral digoxin and furosemide. On examination, his blood pressure is 150/100 mm Hg and heart rate 104 beats per minute. Which of the following is the most effective and most rapid method of reducing pre- load in this patient? Left-sided heart failure can present with dyspnea, orthopnea, paroxysmal nocturnal dyspnea, tachypnea, crackles or wheezes, and an S3 or S4 gallop. The lack of jugular venous distension and/or hepatomegaly suggests absence of right-sided heart failure. Diagnostic and prognostic usefulness of natriuretic peptides in emergency department patients with dyspnea. Acutely decompensated heart failure: diagnostic and therapeutic strategies for the new millennium. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. When they apprehended her, they noted her pupils were large and that she seemed “high.