Ann Julia Brown, MD
- Professor of Medicine
- Vice Dean for Faculty
- Professor in Obstetrics and Gynecology
https://medicine.duke.edu/faculty/ann-julia-brown-md
Acute porphyrias characterized by acute abdominal and neurological attacks without cutane ous manifestation prostate kidney . Reactive oxygen species and peroxides damage cell membranes man health and fitness , resulting in the release of mediator from the mast cells and also damage hepatic and epidermal microsomal cytochrome P450 prostate cancer what is it , as well as lysosomal and mitochondrial membranes prostrate juniper . Protoporphyrin prostate 5lx new chapter , but not uroporphyrin prostate 1 vogel , is able to induce mast cell mediator release under the Soret band radiation action. Small serous or hemor rhagic vesicles or blisters, in general, without any erythematous halo, develop after mini mal trauma; less frequently, lesions may be sunlight induced. The lesions appear most commonly on the dorsum of the hands, but may also occur on other areas, such as the face or limbs. Simultaneous occurrences of vesiculobullous lesions, erosions, scars, and milia produce a characteristic polymorphous appearance. Nail Alterations in Cutaneous Porphyrias 163 plate may be visible with or without moderate pain. Disappearance of the lunula, onycholy sis, and onychodystrophy may also occur (Figure 12. Rarely, patients may present increased ocular photosensitivity, conjunctivitis, photopho bia, and excessive tearing. In addition, as in all cutaneous forms of porphyria, photo and trauma protection must be recommended. Usually, visible manifestations are preceded by itch, a burning sensation, or pain. Acute light-induced manifestation may also develop in the dorsal periungueal area of fngers. Progressive severe fnger mutilations due to long term action of light and repeated trauma. Light avoidance and the resultant vitamin D defciency may contribute to the problem. Mild or moderate disease appeared in compound heterozygotes of two different mutations, only one being C73R. Hemochromatosis genes and other factors contributing to the pathogenesis of porphyria cutanea tarda. Inheritance in erythropoietic protoporphyria: A common wild-type ferrochelatase allelic variant with low expression accounts for clinical manifestation. Erythropoietic uroporphyria associated with myeloid malignancy is likely distinct from autosomal recessive congenital erythropoietic porphyria. Although the term is neutral concerning the nature of the pigment causing this discoloration, most clinicians mean melanin pigmentation when speaking of melanonychia. A systematic examination of 1000 consecutive patients with dark nail pigmentation showed eight subun gual hematomas but no melanocytic lesion. The exact numbers for melanocyte activa tion, lentigo, and nevus-derived melanonychias do not exist. Functional melanonychia is probably more frequent than matrix lentigo, and this is, again, more frequent than nevus. Acquired subungual lentigines and nevi occur both in Caucasians and, probably even more frequently, in Asians3 and are often a matter of concern for patients and/or their parents. A subtotal excision had been performed roughly 2 years prior to consultation at our department. Nevi represent a manifestation of a punctual mosaicism as they develop from a postzygotic muta tion. Clinical Features A brown band running from the matrix, usually emerging from under the proximal nail fold, to the free end of the nail is called a longitudinal melanonychia. The so-called functional melanonychias are usually light brown with a grayish background. Dermatoscopically, they appear as regular brown bands with evenly distributed narrow streaks. Longitudinal melanonychia due to a lentigo is usually more brown, and the longitudinal streaks within it are regular on a brown-to-grayish background. Particularly in young children, they often display brown spots that are visible to the naked eye and represent intraungual collections of nevus cells. Acquired melanonychias are usually not wider than 5 mm, although they may widen insidiously or even abruptly to occupy almost the whole nail width. On the other hand, subungual melanomas of 2 mm diameter have been described in adults. New sophisticated and expensive techniques like optical coherence microscopy and refectance confocal laser scanning microscopy permit the melanin to be precisely local ized in the nail plate. Confocal laser microscopy enables the examiner also to discern single melanocytes and nevus cell nests in the nail. In most cases, it is recommended to gently separate the nail plate from the matrix before taking the biopsy. It has to be stressed that the staining of serial sections of the same specimen very often yields different staining intensity and patterns with the various melanocyte markers and is thus useful in doubtful cases. A matrix lentigo is characterized by a numerical increase of melanocytes with marked pigmentation (Figure 13. Immunohistochemically and with special melanin stains, long but slender dendrites can be identifed (Figure 13. They are usually much larger and darker than acquired ones and the entire nail plus periungual tissue may be involved, occasionally leading to nail deformation. A particular cut-off age, up to which a brown band can be considered to be benign, is yet to be established. On the other hand, long-standing melanonychias in children have been observed to gradually lighten and fnally disappear. More than 35 years ago, it was stated that an acquired longitudinal melanonychia in a fair-skinned adult should rather be seen as malignant than benign,38 which contrasts with melanonychia in children. Since approximately two-thirds to three-quarters of all nail melanomas start as a longitudinal melano nychia,39 they theoretically offer an excellent chance for early diagnosis. A brown back ground and regular brown lines were linked with nevus, whereas melanoma shows a brown background and irregular brown lines. Depending on the width of the melanonychia, different techniques such as punch, fusiform, crescentic, or lateral longitudinal biopsies are available. The superfcial tangential biopsy allows large areas of the matrix to be biopsied virtually without the risk of postbiopsy nail dystro phy. Furthermore, the material is scraped out and it can be differentiated using the benzidine reaction: the clotted blood is collected in a tiny test tube, a drop of water is added, and a test stripe for the diagnosis of blood in urine or feces is dipped into the test tube after a few minutes; in the case of blood, the test stripe turns positive. This is a very safe test for blood, but it has to be kept in mind that a bleeding melanoma will also be positive. Note the increased pigmentation of the proxi toe in a 51-year-old woman starting in late adolescence. The staining grows out with its proximal margin being parallel to the free margin of the nail fold, which is proof of the exogenous nature of the dark nail stain. A few large studies have observed the children over a period of 10 years and more. It is said that a certain percentage will fade after the age of 14 years, but this does not give any information for a single case allowing the patients and parents to be reassured on a scientifc ground. This may be correct for many cases, particularly in children; however, over a period of more than 30 years the number of invasive thick ungual melanomas that we have seen has dramatically decreased, and we believe that the early excision of suspicious lesions is the right way to avoid thick melanomas. Mosaicism in Human Skin: Understanding Nevi, Nevoid Skin Disorders, and Cutaneous Neoplasia. Tangential excision of pigmented nail matrix lesions respon sible for longitudinal melanonychia: Evaluation of the technique on a series of 30 patients. Patterns of nail matrix and bed of longitudinal melano nychia by intraoperative dermatoscopy. Proposed classifcation of longitudinal melanonychia based on clinical and dermoscopic criteria. Understanding the progression of melanocytic neoplasia using genomic analysis: From felds to cancer. Even though some doubts have been initially expressed on the real value of dermoscopy of the nail,7 many reports conclude that there is an increased accuracy of the diag nosis of nail tumors with dermoscopy compared with the naked eye and a consensus has been reached among the community of the nail melanoma specialists that dermoscopy gives interesting information in order to better determine if a nail matrix or nail-unit biopsy is needed in the case of longitudinal nail pigmentation. This is why our group proposed, 8 years ago, the creation of an international register of congenital or nearly congenital cases of nail pigmentation under the auspices of the International Dermoscopy Society. Indeed, continued follow-up of this cohort is necessary in order to better understand the evolution of these cases; however, our original and exclusive experience allows us to recommend (1) follow-up as the best management option and (2) continuous inclusion of new cases in our register in order to increase our knowledge and better support our conclusions. Exceptional cases of prepubertal nail-unit melanoma have been published in the literature. In contrast, congenital (present at birth) and congenital type (not visible yet probably present at birth and then diagnosed before the age of 5) are rare but are not uncommon conditions. This later type of nevi is mainly acquired after puberty and progressively involutes by progressively fading off during adulthood, and then being rarely observed in the elderly. The discovery of a malformation-type mode of development of early-diagnosed nail-unit pigmented lesion, i. However, if the majority of nevus-associated melanomas on skin is found in combination with a congenital type of nevus, it is also widely accepted that in comparison with the very common prevalence of small-sized congenital nevi, the individual risk for each single one is very little. We have observed only one case of involvement of two adjacent fngers in a case of medium-sized congenital nevus involv ing the hand of a 2-year-old patient. Needless to say also that the histopathological evaluation of early biop sied congenital nevus is extremely diffcult, especially in acral sites, with a high risk of overdiagnosis of melanoma. Misleading Dermoscopical Features of Congenital (or Congenital-Type) Nevus of the Nail Unit In adults, the benign type of melanocytic pigmentation of the nail unit is typically quite easily opposed to the malignant one. After puberty, a nevus will typically show, on dermoscopy, a regular pattern of the longitudinal lines overlying the brown background and will be opposed to a melanoma showing irregular longitudinal lines with irregular col oration, irregular thickness, and irregular spacing of the bands; however, staying parallel along the nail plate at least during the early stages. Disruption of longitudinal parallelism of the longitudinal band is a feature dermoscopically observed in only advanced cases of nail-unit melanoma. At frst or early evaluation, congenital nevi often show a markedly irregular pattern of the longitudinal bands with different shades of brown or gray and black with uneven width and spacing of the lines (Figure 14. Weakness of the nail plate is also often observed and responsible on nail plate erosions and grooves. Moreover periungual pigmentation, in most cases visible to a naked eye, is better visualized through the dermoscope (Figure 14. Note that periungual pigmentation in glabrous (plantar) skin shows a mix of parallel furrow pattern and fbrillar pattern, two well-known benign patterns of acral skin pigmentation. However, our published work in adults has shown that the dermoscopical features observed in melanoma-associated periungual pigmentation show one or another or both classical features of acral melanoma that are the parallel ridge pattern of the pigmentation and irregular diffuse pattern of the acral pigmentation. It is not consistently found associated with this condition, but, when present, the diagnosis can be considered as almost certain. However, the clinically unapparent lesion cannot probably be considered as the complete resolution of the entire lesion.
The vulva should be posi (1) external examination of the female genital tioned vertically below the anus prostate cancer vs breast cancer statistics . The lips of the vulva system man health be , should normally be of approximately similar size (2) rectal examination of the genital system includ and should have no visible space between them man health policy . Sinking of the anus in an anterior direction is seen in When possible and appropriate all components of many older cows mens health 3 day workout . As a result natal check 21 days after calving man health guide , speci c checks are of anal displacement the upper commisure of the made for uterine involution androgen hormone junkie , evidence of uterine in vulva is dragged forwards, causing a variable degree fection and ovarian activity. When the cow is pre of distortion of the vulva; thus the vulval seal may be 128 Clinical Examination of the Female Genital System Sunken anus displacing the vulva Figure 10. This type of discharge can also be seen in cases or just within the vulva, areas ofnecrotic vaginitismay of necrotic vaginitis and in association with infected be present caused by fetal or human pressure at calv wounds in the vaginal wall. Early lesions appear dark and congested; later smelling discharge in a very sick animal may be an lesions are green and necrotic. The In the immediate postparturient period, the vulval clinician must always check, through a full clinical lips may be oedematous and bruising may be pre examination, that any unpleasant odour at the hind sent. Scar formation in the tissues of the vulval lips end of the patient is actually emanating from the may follow injuries sustained during calving. Granular vulvovaginitis may be caused by can also reduce the ef ciency of the vulval seal and mycoplasma infection. The clear bulling string, the red Ballottement of the right side of the abdomen in the last metoestrus bloodstained discharge and the appear trimester of pregnancy will often make contact with ance of retained fetal membranes have been men the fetus and sometimes cause it to move. Absence purulent material may originate from the bladder or of movement, either spontaneous or by ballottement, renal pelvis, most bovine vulval and/or vaginal dis does not necessarily mean that the fetus is dead. A ther evaluation of fetal well-being can be made by white or yellowish discharge may indicate the pres rectal examination and by ultrasonography. A foul-smelling part of the fetus can be scanned per rectum in the rst bloody and purulent discharge may be associated trimester of pregnancy. After this time the fetus slips with acute septic metritis or with a macerated fetus. The accuracy of such ndings the clipped ank in late pregnancy usually con rms can be enhanced in many cases by the use of ultra the presence of fetal uids and placentomes. Parts of sonographyper rectumand also by an appraisal of the the fetus can sometimes be seen, depending on its progesterone pro le of the cow. It may be possible to detect fetal heart ductive history of a cow may be inaccurate. The movements, check fetal pulse rate and the expected ndings reported must always be those actually absence of echogenicity in the normal clear fetal identi ed and where possible con rmed. The use of ultrasonography in examination cases a further rectal examination after a nite period of the female genital system is discussed in greater of time may be necessary to con rm a tentative clini detail below. Findings should be accurately recordedand preserved at the time of each rectal examination. Both arms should be covered with long plastic sleeves, and ideally these should be changed between cows. Some clinicians prefer to use both genital system hands sequentially during a rectal examination. This must be carried out methodically and with great the ngers and thumb are formed into a cone care and sensitivity. The examination should provide and the gloved hand is covered with obstetrical useful information about all palpable parts of the fe lubricant. The size and condition of the cervix, the uterine body and hand is gently but rmly advanced through the anus horns, and the right and left ovaries. The anus normally relaxes after a possible to identify and assess the ovarian bursae few moments allowing the hand and wrist to enter and the oviducts. Any faeces are gently removed by enclos ily detected when they are diseased than when they ing them in the hand and carrying them out through are normal. As a result of rectal examination it should be possi Care must be taken to avoid large quantities of air ble to determine whether the animal is more than 6 entering the caudal rectum. The risk of this occurring weeks pregnant, whether she is cycling and the stage can be reduced by the clinician easing faecal material of her oestrous cycle. The reproductive information through the anal ring without fully withdrawing and history available for each animal will to some ex the hand on each occasion. If distended with air, the tent direct the rectal and other examinations, to pro rectal wall becomes so tense that palpation of struc vide the detailed assessment required at that time. Thus in the recently calved cow rectal examination the cow can usually be encouraged to expel rectal air. By making gentle stroking movements 130 Clinical Examination of the Female Genital System with the ngers on the rectal wall muscular tension is Middle uterine artery this is the main source of restored and atus is expelled. The artery arises from the internal iliac artery shortly after this vessel leaves the Position of the female genital tract aorta. In non-pregnant animals it passes caudally In heifers and young cows the whole genital tract through the broad ligament, over the wing of the may be palpable lying on the pelvic oor. It then enters the concave animals part or all of the uterus may hang over ventral surface of the uterus. In these animals it is necessary to es the artery is pulled forwards by the enlarging attempt to retract the uterus into the pelvis so that its uterus. By the second half of pregnancy it may be pal component parts can be more readily examined. The this may be done by hooking a nger over the inter blood ow through the middle uterine artery in cornual ligament or by using the hand to scoop the creases greatly as pregnancy progresses. Once retracted, the uterus is held in place passed laterally and upwards from the uterus and by gentle manual pressure before being examined cervix. The internal iliac artery is relatively immobile and then released to slip back over the pelvic brim. The the genital tract of the cow is supported by the pudendal artery is palpable in the wall of the pelvic broad ligament of the uterus which is attached to the canal 10cm anterior to the anus. The bony limits of the pelvis, the cervix is found on the pelvic oor ap the pelvis can be readily identi ed as rm immobile proximately half way between the caudal border of structures. The cervix is sacrum and coccygeal vertebrae, the walls by the much rmer than adjacent soft tissues and can be wing of the ilium on either side and the oor by moved laterally to a limited extent. The caudal border of the lobed In older multiparous cows the cervix is 4 to 5cm left kidney can be palpated just anterior to the pelvic in width and 8cm in length. Just before and after inlet: it lies just to the right of the midline beneath the calving the cervix feels softer to the touch and may be lumbar vertebrae. It may lie just behind, on or variable depending on the age of the animal and its over the pelvic brim. The cervix is usually readily movement of the cervix is very limited as it is pulled found and the other parts of the tract can be identi ed tightly forwards by the weight of the pregnant uterus. Uterus this is located by moving the hand for Cervix this is found close to the midline of the wards from the cervix. The body and horns be palpated per rectum and can be further evaluated may lie on the abdominal oor anterior to the pelvic by ultrasonography. Retraction may be impossible in Pregnancy diagnosis by rectal palpation Details pregnant animals or in those in which uterine adhe are beyond the scope of this book. The uterine horns are coiled and may be summarised as follows: their anterior extremities are not directly palpable. In heifers allantoic membrane slipping independently of the the uterine body is approximately 3cm in length. Disparity non-pregnant animals the two uterine horns should between pregnant and non-pregnant horns is normally be approximately the same size (2 to 3cm more distinct (Fig. The uterus undergoes great enlargement dur meter, increasing to 6 to 8cm towards the end of ing pregnancy. Initial involution is rapid in healthy animals initially quite close together but later, as allantoic but may be delayed by dystocia, uterine inertia and uid volume increases, they move further apart. The anterior poles of the Cotyledons are readily detected by advancing uterus should be palpable by 14 days postpartum. Postpartum uterine uid normally disappears wards stroking the dorsal wall of the uterus. After that time the cotyledons are palpated as elevations in the uterus should contain little uid. The presence of purulent material can be con the tense amniotic vesicle in the rst 10 weeks of rmed by ultrasonography. After this, fetal extremities may be pal Large amounts of purulent material are present in pable through the uterine wall. By 14 weeks the the uterus in cases of pyometra but the animal rarely fetus has often passed beyond reach. In the serious disease ities may be palpable again from 26 weeks of preg acute septic metritis the uterine wall may be hard nancy. In the last 4 weeks of pregnancy the calf is and occasionally emphysematous on rectal examina usually readily palpable as it increases in size. In the last few days of pregnancy the feet of the calf often enter the pelvis in preparation for birth. Occasionally, if the calf is very large and heavy, in late pregnancy it may slip under the cau dal parts of the rumen and cannot be palpated per rectum. Ovaries In non-pregnant animals these are located on the pelvic oor approximately level with and quite close to the junction of the body and horns of the uterus (Fig. In searching for themper rectum the clinician should remain in manual contact with the uterus to which they are attached. Maintaining contact with the uterus enables the clinician to limit the area in which the ovaries may be sought. Occasionally one ovary, often the left, is not immedi ately palpable and may have slipped under the an terior border of the broad ligament. Ovulation may Right ovary Left ovary occur sequentially on the same ovary or alternate Figure 10. The absence of follicles or mature follicle on her left ovary and the regressing corpus luteum from the corpora lutea may suggest that the patient is in previous cycle on her right ovary. Further evaluation of the ovaries by ultrasonography and a plasma or the ovaries are rmer than adjacent tissues and milk progesterone pro le of the patient are extre one, currently the more active ovary, is larger than mely useful in con rming the physiological state of the other. In most cases a single ovary is may be considerably enlarged and are discussed involved, but occasionally bilateral cysts are seen. Cysts are de ned as being uid lled structures Once located, the ovaries should be palpated in de greater than 2. They can be picked up by the clinician using the cysts may be grossly enlarged and their overall diam thumb and second nger. As much of are broadly classi ed into two main groups whose the ovarian surface as possible is explored, testing for clinical and diagnostic features are summarised shape and consistency. This is later palpable as the spongy corpus thick walled (>3mm); progesterone is secreted. Corpora lutea project from the ovarian sur Granulosa cell tumours these large irregular tu face and are rm and non-compressible to the touch mours are uncommon in cattle.
Classically prostate cancer karyotype , the onset of lobar of the lungs due to gravitation of the secretions man health belly off . The major symptoms are: shaking surface androgen hormone needed , these patchy consolidated lesions are dry man health policy , chills prostate cancer 97 , fever mens health six pack , malaise with pleuritic chest pain, dyspnoea and granular, firm, red or grey in colour, 3 to 4 cm in diameter, cough with expectoration which may be mucoid, purulent slightly elevated over the surface and are often centred or even bloody. These patchy areas are tachycardia, and tachypnoea, and sometimes cyanosis if the best picked up by passing the fingertips on the cut surface. There is generally a marked Histologically, the following features are observed neutrophilic leucocytosis. Culture of the organisms in the sputum and antibiotic ii) Suppurative exudate, consisting chiefly of neutrophils, sensitivity are most significant investigations for institution in the peribronchiolar alveoli. The response to antibiotics is usually iii) Thickening of the alveolar septa by congested rapid with clinical improvement in 48 to 72 hours after the capillaries and leucocytic infiltration. However, complete Bronchopneumonia or lobular pneumonia is infection of the resolution of bronchopneumonia is uncommon. There is terminal bronchioles that extends into the surrounding generally some degree of destruction of the bronchioles alveoli resulting in patchy consolidation of the lung. The resulting in foci of bronchiolar fibrosis that may eventually condition is particularly frequent at the extremes of life. The patients of bronchopneumonia viral respiratory infections such as influenza, measles etc. The common organisms responsible for aspiration of gastric contents or upper respiratory infection. Chest radiograph shows mottled, focal opacities in both the lungs, chiefly in the lower zones. Grossly, bronchopneu the salient features of the two main types of bacterial monia is identified by patchy areas of red or grey pneumonias are contrasted in Table 17. The sectioned surface shows multiple, small, grey-brown, firm, patchy areas of consolidation around bronchioles (arrow). Others are Mycoplasma pneumoniae and many Viral and mycoplasmal pneumonia is characterised by viruses such as influenza and parainfluenza viruses, patchy inflammatory changes, largely confined to interstitial adenoviruses, rhinoviruses, coxsackieviruses and cyto tissue of the lungs, without any alveolar exudate. Occasionally, psittacosis (Chlamydia) used for these respiratory tract infections are interstitial and Q fever (Coxiella) are associated with interstitial pneumonitis, reflecting the interstitial location of the pneumonitis. Interstitial pneumonitis may occur in all confined to the upper respiratory tract presenting as common ages. Occasionally, it may extend lower down to involve the it may be severe and fulminant. The bronchioles as well as the adjacent alveoli are filled with exudate consisting chiefly of neutrophils. The alveolar septa are thickened due to congested capillaries and neutrophilic infiltrate. Definition Acute bacterial infection of a part of a lobe Acute bacterial infection of the terminal of one or both lungs, or the entire lobe/s bronchioles extending into adjoining alveoli 2. Predisposing factors More often affects healthy individuals Preexisting diseases. Common etiologic agents Pneumococci, Klebsiella pneumoniae, Staphylococci, streptococci, Pseudomonas, staphylococci, streptococci Haemophilus influenzae 5. Pathologic features Typical case passes through stages of Patchy consolidation with central congestion (1-2 days), early (2-4 days) and granularity, alveolar exudation, late consolidation (4-8 days), followed thickened septa by resolution (1-3 weeks) 6. Investigations Neutrophilic leucocytosis, positive blood Neutrophilic leucocytosis, positive blood culture, culture, X-ray shows consolidation X-ray shows mottled focal opacities 7. Prognosis Better response to treatment, resolution Response to treatment variable, common, prognosis good organisation may occur, prognosis poor 8. In more severe cases, there may be interstitial logic agent, the pathologic changes are similar in all cases. Majority of cases of interstitial involvement may be patchy to massive and widespread pneumonitis initially have upper respiratory symptoms with consolidation of one or both the lungs. Sectioned surface of dry, hacking, non-productive cough with retrosternal the lung exudes small amount of frothy or bloody fluid. Histologically, hallmark of viral pneumonias is the interstitial nature of the inflammatory reaction. There is necrotising bronchiolitis, reactive hyperplasia bacterial infection supervenes. Isolation of following investigation into high mortality among those the etiologic agent, otherwise, is difficult. Impaired host defenses in the (such as Pneumocystis carinii pneumonia and Legionella form of immunodeficiency, corticosteroid therapy, old age pneumonia) and certain non-infective varieties. Grossly, there are chan ges of widespread bronchopneumonia involving many Pneumocystis carinii Pneumonia lobes and there may be consolidation of the entire lung. Pneumocystis carinii, a protozoon widespread in the Pleural effusion is frequently present. Common organisms as an opportunistic infection in neonates and features are as under: immunosuppressed people. Other immunosuppressed groups are patients phages by special stains or by immunofluorescent on chemotherapy for organ transplant and tumours, techniques. Grossly, the affected parts headache and muscle-aches followed by high fever, chills, of the lung are consolidated, dry and grey. Systemic manifestations unrelated Microscopically, the features are as under: to pathologic changes in the lungs are seen due to i) Interstitial pneumonitis with thickening and bacteraemia and include abdominal pain, watery diarrhoea, mononuclear infiltration of the alveolar walls. A number of factors predispose to inhalation iv) No significant inflammatory exudate is seen in the air pneumonia which include: unconsciousness, drunkenness, spaces. There is rapid onset of dyspnoea, immediately from asphyxiation or laryngospasm without tachycardia, cyanosis and non-productive cough. Non-sterile aspirate causes widespread broncho 475 pneumonia with multiple areas of necrosis and suppu ration. A granulomatous reaction with foreign body giant cells may surround the aspirated vegetable matter. Hypostatic Pneumonia Hypostatic pneumonia is the term used for collection of oedema fluid and secretions in the dependent parts of the lungs in severely debilitated, bed-ridden patients. The accumulated fluid in the basal zone and posterior part of lungs gets infected by bacteria from the upper respiratory tract and sets in bacterial pneumonia. Hypostatic pneumonia is a common terminal event in the old, feeble, comatose patients. These are: inhalation of oily are introduced into the lungs from one of the following nasal drops, regurgitation of oily medicines from stomach mechanisms. A number of preparation to reluctant children or to debilitated old foreign materials such as food, decaying teeth, gastric patients. Endogenous origin of tissue from lesions in the mouth, upper respiratory tract or lipids causing pneumonic consolidation is more common. This occurs particularly in the sources of origin are tissue breakdown following favourable circumstances such as during sleep, obstruction to airways. Grossly, the exogenous pneumonia in a debilitated patient may develop into lung lipid pneumonia affects the right lung more frequently abscess. Other infective conditions like tuberculosis, due to direct path from the main bronchus. Quite often, bronchiectasis and mycotic infections may occasionally result the lesions are bilateral. Infected emboli originating from macrophages forming foamy macrophages within the pyaemia, thrombophlebitis or from vegetative bacterial alveolar spaces. Primary lung abscess that develops in an otherwise normal iv) Direct extension from a suppurative focus in the lung. The microorganisms commonly commonly located in the lower part of the right upper isolated from the lungs in lung abscess are streptococci, lobe or apex of right lower lobe. Cut surface of the lung shows multiple cavities 1-4 cm in diameter, having irregular and ragged inner walls (arrow). B, the photomicrograph shows abscess formed by necrosed alveoli and dense acute and chronic inflammatory cells. Extensive haematogenous spread of millimeters to large cavities, 5 to 6 cm in diameter. The aspergillus infection may result in widespread changes in cavity often contains exudate. An acute lung abscess is lung tissue due to arterial occlusion, thrombosis and initially surrounded by acute pneumonia and has poorly infarction. Grossly, pulmonary aspergillosis may occur within preexisting pulmonary cavities or in bronchiectasis as fungal Histologically, the characteristic feature is the destruction ball. The cavity is initially surrounded by acute Microscopically, the fungus may appear as a tangled mass inflammation in the wall but later there is replacement by within the cavity. Mucormycosis or phycomycosis is fever, malaise, loss of weight, cough, purulent expectoration caused by Mucor and Rhizopus. Secondary lesions are especially common in patients of diabetic amyloidosis may occur in chronic long-standing cases. Mucor is distinguished by its broad, non-parallel, nonseptate hyphae which branch at an obtuse angle. These infections in healthy individuals albicans is a normal commensal in oral cavity, gut and vagina are rarely serious but in immunosuppressed individuals may but attains pathologic form in immunocompromised host. General aspects of mycotic infections are covered Angioinvasive growth of the organism may occur in the in Chapter 7. Aspergillosis is the most common fungal capsulatum, by inhalation of infected dust or bird droppings. A, Acute angled septate hyphae lying in necrotic debris and acute inflammatory exudates in lung abscess. The lesions in the body may Chronic bronchitis and emphysema are quite common range from a small parenchymal granuloma in the lung to and often occur together. The lesions consist of peripheral parenchymal Chronic bronchitis is a common condition defined clinically granuloma in the lung. It is an uncommon condition caused by least three months of the year for two or more consecutive Blastomyces dermatitidis. Quite frequently, chronic bronchitis is the classical and most common example of chronic infection associated with emphysema. The two most important etiologic caused by Mycobacterium tuberculosis and other mycobacteria factors responsible for majority of cases of chronic bronchitis have already been discussed along with general aspects of are: cigarette smoking and atmospheric pollution. Other tuberculosis and other granulomatous inflammations in contributory factors are occupation, infection, familial and Chapter 6. The incidence of chronic bronchitis is higher in industrialised urban areas where air is polluted. Some of the atmospheric pollutants which increase the risk of developing chronic bronchitis are sulfur dioxide, nitrogen dioxide, particulate dust and toxic fumes. Workers engaged in certain occupations such as in cotton mills (byssinosis), plastic factories etc. Bacterial, viral and mycoplasmal infections do not initiate chronic bronchitis but usually occur secondary to bronchitis. Cigarette smoke, however, predisposes to infection responsible for acute exacerbation in chronic bronchitis. There appears to be a poorly-defined familial tendency and genetic predisposition Figure 17. Thus, emphysema is defined morphologically, wall is thickened, hyperaemic and oedematous. Since the two of the bronchi and bronchioles may contain mucus plugs conditions coexist frequently and show considerable overlap and purulent exudate. The increase generations of respiratory bronchioles and a variable number in thickness can be quantitatively assessed by micrometer of alveolar ducts and alveolar sacs (page 461). The bronchial epithelium may show squamous definition of pulmonary emphysema, it is classified according metaplasia and dysplasia. There is little chronic to the portion of the acinus involved, into 5 types: centri inflammatory cell infiltrate. The non-cartilage containing acinar, panacinar (panlobular), para-septal (distal acinar), small airways show goblet cell hyperplasia and intra irregular (para-cicatricial) and mixed (unclassified) luminal and peribronchial fibrosis. A classification based on these principles is clinical features of chronic bronchitis and pulmonary outlined in Table 17. Underlying pathology Hypertrophy of mucus-producing Inflammatory narrowing of bronchioles and cells destruction of septal walls 3.
A ward attender is when the patient is attended by a nurse/doctor but not admitted prostate 1 plus enlarged . A day case is when the patient occupies a bed for a procedure no matter how short the visit man health lifestyles . Finance Every time a patient is seen on the ward by a doctor or nurse we have to make a charge mens health girl next door . If you see a patient for five minutes or five hours prostate oncology 2016 , whether for a blood test/review/etc man health zone , please fill out a discharge summary form to tell us prostate cancer psa , so we can deal with it. Tracking All Paediatric notes are kept behind reception for 14 days (unless they have an apt elsewhere) All Surgical notes are kept for one week. We obtain notes for all appointments that appear in the diaries and they are kept behind reception in alphabetical order or in the outpatient area in date order. For the areas in between, patients will often know which hospital is nearest, so check with them first. For those neonates requiring follow up from the post natal ward, please inform the consultant and his/her secretary by e mail so that appropriate follow up is arranged. Stoke Mandeville Wycombe Hospital Dr Dutta Dr Tang Dr Shrestha Dr Chawda Dr Alzoubidi Dr Sawhney Dr Dey Dr Russell-Taylor Dr Sarkar Dr Salgia Dr McDonald Dr McDonald Dr Cheesebrough Dr Cheesebrough To arrange a blood test for a child or baby at Wycombe Hospital please ring (120) 6487 and for Stoke ring 6426. Blood clinic and jaundice clinic You may be requested to help with the blood Clinic on Thursday if there is a difficulty. If you arrange an appointment for a child, you must provide enough information for the clerks to be able to identify the patient. Notes for jaundiced babies are kept in the appropriately named tray behind reception. The department is looking in to making this a nurse led clinic which is being piloted currently. This is important because, as a common example, a child may have gone home on antibiotics to which an infection is resistant, and renal damage could result. We hang them on a clip at the back of the nursing station on the Medical Side every day, when they are actioned; they can be put in the confidential waste bin. Please make a written entry in clinical continuation sheet on Evolve when you have actioned an abnormal result, esp when you have called and left a message on an answer phone. Paediatric Emergencies Overview Within the department you will always be working as part of a team however there may be situations where you will need to recognize and manage a seriously unwell child while help arrives. You should make a point of familiarizing yourself with the location of paediatric resuscitation equipment in these locations. It is important to remember that children are different to adults and normal values are different in children. You need to work out what should be normal for the age of child you are dealing with. For example children with a high fever may be tachycardic and tachypnoeic but an afebrile child with a tachycardia or abnormal blood pressure (high or low) should be urgently assessed. Take a moment to read the explanation of the system printed on the back of every observation chart. If you are concerned about a baby or child then you should call for help or ask someone to call for help. In the appendices you will find basic algorithms for the management of a) unwell children (Appendix E Paediatric life support) b) Neonates (Appendix F Neonatal Life support). There are specific guidelines for different conditions in resuscitation areas and you should make an effort to locate them early in your placement. The baby checks should run as a clinic in the Paeds room, with the nursery nurse/midwife bringing babies with mothers and notes. The 2 person can do reviews at the bedside, whilst the third acts as a float and helps with community referrals regarding poor feeding, jaundice etc. There is scope to interact with mothers and explore maternal health and well-being and the support services that is available for them. Being able to see plenty of normal babies and common postnatal problems makes this a valuable learning exercise. You will often have pressure from many directions to do things in particular orders. Try to bear in mind which are the sick babies and which are well and just eager for home. This is important both for your competence but also your confidence, and it is highly recommended that you arrange this. There are trained midwives in the postnatal ward who can supervise you doing a baby check. Thyroid function tests Babies of hyperthyroid mothers may have antibody related hyperthyroidism. Mothers with hypothyroidism may have been hyperthyroid and had thyroid ablation, so check about this. Hip ultrasound: May be required if breech, fixed talipes or torticollis (see hip section). Renal Tract Ultrasound and trimethoprim: May be required if there was renal pelvic dilatation (check guideline below). They have significant respiratory distress and patchy shadowing with air trapping on x-ray. Risk factors are used to identify babies at greater risk and reduce the risk of infection by giving antibiotics during labour and/or to the baby. Management of neonate Before antibiotic treatment is started, a partial or full septic screen would be required. See empirical antibiotic guidelines in the Paed clinical guideline section of the intranet. Consider stopping antibiotics at 48 hours if neonate is well and cultures remain negative. If pathogen is isolated, review antibiotic regimen in light of sensitivities and clinical condition of neonate. Routine surface culture specimens including gastric aspirates are not necessary if neonate is well. Babies on the post natal ward with abnormal observations or clinical concerns should be discussed with registrar and considered for a sepsis screen and antibiotics. A partial septic screen is needed if baby is being given antibiotics purely due to protocol. Antibiotics are continued for at least 48 hours, until 48 hour blood culture is back and negative. They present in many ways, including poor feeding, mild hypothermia below 36 degrees, or persistent hypoglycaemia. Plot the bilirubin level on gestation appropriate charts according to age in hours. If risk factors identified antenatally (maternal antibodies) midwives should send off cord blood for these tests. Hypoglycaemia Healthy term babies can cope on small amounts of milk in the first 1-2 days by using stores. Some babies risk hypoglycaemia due to inadequate stores or hormonal/metabolic derangement. Nursery nurses normally do these but at times you will be asked and you will be asked to make decisions on actions required. The foot will naturally hold a talipes-like position, but can manually be brought into normal position. If you scratch foot (as if testing plantar reflex) the normal foot should respond with dorsiflexion, eversion and fanning of toes. Associated with breech presentation, oligohydramnios, amniotic band, genetic defects (Eg Edwards), maternal ecstacy use and smoking. If more severe, bilateral or parental concern can refer to physio (forms in folder). Some important associations (Sturge-Weber Syndrome, Klippel Trenaunay-Weber, glaucoma if trigerminal distribution) so discuss with SpR. Capillary haemangiomas/ strawberry naevus/infantile haemangioma Raised red lumpy areas anywhere on body, made up of disorganised proliferation of endothelial cells. Most will get bigger over 6 months, then get start to break down and involute by 10 years. If over critical areas* or very extensive they should be referred to Dermatology to consider oral propranolol or active monitoring. Of no significance, but helpful to point out and document present from birth to avoid future child protection concerns. Ears Pre-auricular pits: benign in isolation but flag to look for other cranio-facial abnormalities, renal problems). No action required Pre-auricular skin tags: can be associated with facial problems, renal problems or chromosomal problems. An ultrasound to look for spina bifida is only required if there is a hairy tuft, a lipoma, or if the dimple is outside of the natal cleft and more than 5mm from the midline. Point out and reassure Vaginal skin tags: also common, if small no action, most will regress. Male Genitalia: Hypospadias: the opening of the urethral orifice on ventral surface of penis. It is essential that the child is not circumcised as the foreskin tissue is used in the repair. Absent testis: If one testis can be palpated, but not the other one explain that it may descend later. However brief support and advice from a doctor can mean a lot to parents, and the way that we approach breastfeeding in babies with hypoglycaemia, jaundice, weight loss and prematurity can influence breastfeeding rates. Here are three high impact actions: Key facts Firstly, give brief motivational advice 1. Mums Helps Mum lose weight (uses 500 calories/day) may need to express if baby is not Saves time and money (formula costs 30 40/month, feeding well prep of bottles is time consuming) 4. D3) hand expressing is best and you can reassure Mum that she will only get a small volume (eg a few drops the first time) but this will gradually increase the more she expresses. Feeding Plans A feeding plan is a specific volume of milk that baby needs to be offered 3 hourly. This three-stage process is extremely draining so reassure mums it is only for the short term until baby stabilises. Because they are able to mobilise ketone bodies they are unlikely to suffer any ill effects. They should start hand expressing as 33 soon as possible after birth, ideally within the hour, and they will need to express at least 8 times a day, including once in the middle of the night. The earliest we would expect a baby to feed directly from the breast for short periods would be 32-34 weeks. Also note that for preterm babies the feeding plan volumes are one day ahead as they start at 60ml/kg/day for day 0-1: 60/80/100/120/150.
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