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Treatment of venous thrombosis injury generic buspar 10 mg without prescription anxiety and depression, limit and localize thrombus forma- thrombotic events may occur either spon- requires a higher daily dose cheap buspar 5mg free shipping symptoms 9f anxiety, typically given tion order cheap buspar online anxiety before period, at the site of such injury order buspar uk anxiety 12 step groups. Lupus anticoagulant or anticardiolipin Lupus anticoagulant was frst described in Antiplatelet Therapy antibody syndrome. Oral contraceptive or estrogen therapy an anticardiolipin antibody (IgG,IgA or IgM boxane A2. Tere may be Recombinant tissue plasminogen activator themia chronic myelogenous leukemia. The most common presentation consists management of thrombophilia able and may be given in addition to sub- of venous thrombosis of the ileofemoral system cutaneous heparin to cover surgical pro- with or without pulmonary embolism. Concentrates of protein C and S • Another well-characterized disorder is the Anticoagulation is used to prevent throm- are not yet available. Total body water in a 70 kg man is 60 percent and oliguria prior to surgery carries with it a = 42 liters. Tus if the cells of the body • One-third is extracellular = 14 liters are to function efciently, their internal envi- Water accounts for 60 percent of normal • Two-thirds of the extracellular compart- ronment, i. In an ment is extravascular = 9 liters lular and intracellular fuids, must remain average adult female having more fat, the • One-third of the extracellular compart- constant. For this, it is necessary that water water content is about 10 percent less while ment is intravascular = 5 liters and diferent electrolytes used up in the vari- the new- born infants are 75 percent water. In the normal healthy person this mainly because of larger surface area, poorer takes place by ingestion of appropriate quan- concentrating power of the kidneys and their tities of water and food as dictated by thirst increased metabolic activity. It is thus obvi- and appetite, both of which are extremely ele- ous that besides sex total body water content gant mechanisms of regulation of the internal also varies with age, body weight and body fat environment. At the extracellular (high sodium and low potassium same time in many surgical illnesses as well concentrations). Bicarbonate 25 10 ference between capillary and interstitium water in dense connective tissue and carti- ii. Tey are the principal solutes in the body interstitial space is regulated at the capillaries luminal fuid and volume is relatively small fuids and therefore, account for most of and lymphatics. The hydrostatic pressure in the vessel and large, it may be called the ‘third space’ because ences the properties and behavior of excita- ii. The colloidal osmotic pressure also called fuid in this compartment is not readily ble membranes, e. Nerve cells and the per- the oncotic pressure of the interstitial fuid exchangeable with the rest of the extracellular formance of many intracellular enzymes. Inward pressure, of body’s water is present in dense connective For practical purposes, one should only K = Filtration constant for the capillary tissue and bone and is liable to be included consider the plasma, the interstitial space, the membrane in the intracellular moiety in equilibration intracellular space and the barriers between Edema-Excessive extravascular accumu- measurement. Causes: The Normal Distribution of • Increased capillary hydrostatic pressure, Electrolytes in the Body Water The Capillary Membrane e. The electrolyte composition of the intra- The barrier between the plasma and inter- • Decreased capillary oncotic pressure, e. In the intracellular fuid, the principal cat- lytes (small particles) but restricts the passage • Increased tissue oncotic pressure resulting ions are potassium and magnesium and the of larger molecules such as proteins. The barrier between the extracellular and lytes in the body fuids is as follows: Only a small quantity of albumin (Mol. Sodium is therefore mainly an extracellular cellular cellular The osmotic efect of proteins is about cation as already said, while potassium is the fluid fluid 50 percent greater than would be expected for main intracellular cation. The reason for this is that Water moves across the cell membrane in Cations most proteins are negatively charged, attract- either direction if there is any diference in i. Na+ 135–145 4–10 ing positively charged ions such as sodium osmolality between the two sides. For dilute solutions, the osmotic activity (blood, albumin or gelatin solution) will is very nearly equal to the actual concentra- remain within this compartment because tion of the particles: A solute concentration the capillaries are impermeable to the col- of 1 millimole per liter has an osmotic activ- loid, water will then be retained by osmosis. A millimole is If one liter of colloid is administered to a one-thousandth of a mole or gm molecular shocked patient with an intravascular vol- weight. Tus, the smaller contribution from calcium, magne- saline thus expands only the extracellular intravascular volume will be increased by sium, protein, phosphate, etc. From the above soon it gets distributed throughout the extra- description, it is clear that only colloid or It should be noted that cellular space. Osmolarity = Solute concentration per liter of cular + 10 liters interstitial) to 14 liters, an solution. It is to be noted that the colloids con- cell membrane is freely permeable to water tribute very little to total osmolality as the but impermeable to sodium. If a liter of 5 number of particles is small although, as percent dextrose is administered to an actu- Relative Fluid Deficit stated above they play an important role in ally shocked patient with an intravascular fuid movement across the capillaries. Since osmolality must be the same ii) Tird space losses – expands the extra- intravenous fuid administration. Tis may be 34 Chapter 5 Fluid and Electrolyte Balance considerable and are ofen underesti- Table 5. If an organ with a large surface area Cations (meq/L) Anions (meq/L) such as bowel, is handled and traumatized, even small degrees of edema can increase Na – 142 (Range 137-148) Cl – 103 (Range 99-108) the extravascular volume considerably. Urine and feces account for The average requirements of sodium and a similar formula is used except that the the rest. Humans are very efcient at con- stituted for the equivalent weight of the serving sodium and can tolerate much lower element. Urine – 1500 intracellular cation, there may be a consider- maintains acid base equilibrium. Feces – 100 able fall in total body potassium before the tial to optimize both sodium balance and c. Skin – 600 as to know the dangers of imbalance of either Total – 2600 Total – 2600 Electrolyte Balance electrolyte. When inorganic salts are in solution as in Maintenance fluid: (Given as per kg the extracellular or intracellular fuids of the Sodium Balance body wt. Ions are of two Sodium is all important in sustaining the cati- The precise water requirements of a kinds! Cations which are electropositive and Total body sodium = 5000 mmol (112 gm temperature. The anions include Children require relatively more water chloride, phosphate, bicarbonate and sul- Regulation than adults. In any solution, the concentrations of (a) Renal: method to calculate their requirements is the cations must be equal to that of anions. Aldosterone - Secreted by the zona glomerulosa of adrenal cortex is the most Disturbance of Water Balance Treatment powerful conservator of sodium. It has Tis is done by increased water intake orally an important infuence on the exchanges ‘Pure’ Water Depletion through a Ryles tube in mild cases and intra- on Na, K and hydrogen in the distal (i. Causes The mechanism involves the renin-angi- ‘Pure’ Water Excess otensin system and results in increased 1. Diminished intake-Tis may result from Causes Na reabsorption by the distal tubule. The commonest cause in the surgical or vasopressin secreted by supraoptic and Tis loss may be as much as 500 ml wards in the large infusions of 5 per- paraventricular nuclei of hypothalamus in excess of the normal insensible cent glucose solution to postoperative and stored in the posterior pituitary.
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The prickle cell layer hypertro- • Neurofbroma Tere are two types of glossitis viz order 5mg buspar otc anxiety 9 code. Acute-Acute superfcial glossitis which • The underlying dermis is infltrated with • Lingual thyroid discount buspar generic anxiety natural treatment. Malignant tumors Herpes of tongue may be included in type to be replaced later by fbrous tissue order buspar 10 mg free shipping anxiety symptoms checklist 90. Chronic irritations caused by: (Leukoplakia) Age-Usually occurs afer 50 years of age discount 5mg buspar amex anxiety symptoms grief. Other sites of the body where leukoplakia Stage 1-Appearance of a thick gray transpar- Site can be seen include glans penis, vulva and ent flm on the afected part. The six well known etiological factors, known Stage 3-Hyperkeratosis produces warty out- 3. Dorsal surface of anterior 2/3rd of tongue – as 6S’s of chronic superfcial glossitis are: growths. Anterior 2/3rd-Squamous cell carcinoma Hematogenous Spread is not commonly radiation causes bone necrosis. Telecobalt therapy-Tis is usually is helped by the rich lymphatic plexus in in cancer of posterior 1/3rd of tongue. Growths in the anterior 2/3rd • Dysphagia due to ankyloglossia and for growths in the posterior 1/3rd cannot spread across the midline because mechanical disadvantage. A growth in the • Salivation-Due to difculty in swallow- diameter or 1 cm in depth). From the anterior 2/3rd, to the foor of • Voice change-Especially in case of a mass 3. Surgery: the mouth, alveolar process, mandible in the posterior 1/3rd causing obstruction. If the growth is more than 1cm The lymphatic spread is mostly by permeation Investigations initially radiotherapy is given. The In case of proliferative growth, punch months of completion of treatment, rapid spread is due to the presence of inter- biopsy is recommended. X-ray chest-To rule out aspiration or The types of surgery are as follows phatics and excessive mobility of the tongue. Tis is 1/3rd of tongue drain bilaterally into jugu- done for growths on the lateral lodigastric and juguloomohyoid nodes. Lateral or marginal vessels drain the lat- It consists of (A) Management of the primary c. Subtotal glossectomy-Tis means eral borders of anterior 2/3rd of the tongue growth, (B) Management of the neck nodes excision of the whole of anterior homolaterally to the submandibular nodes and (C) Management of advanced cases. Preliminary measures mandibulectomy is done in addition to side of the median raphe and may run • To maintain oral hygiene with regular glossectomy. Tis is done for large growths from growth on the margins of anterior 2/3rd ment of choice. Tis opera- is homolateral while that from the posterior contraindicated in the following situa- tion is so named because of its extensive 1/3rd and tip of tongue are bilateral. Minor salivary gland, tumors which • Usual presentation is a nodule or an ulcer ii. However, radio- Carcinoma Lip • Submental, submandibular and upper therapy is of little value for the unresect- deep cervical nodes may get enlarged. Exposure to sunlight Differential Diagnosis growth trigeminal nerve block with 5 per- ii. Treatment of the primary lesion Prognosis Carcinoma of lips is slow growing and can If lymph nodes are involved 5 years survival Pathology be cured by surgery or radiotherapy. Plastic reconstruction is needed in skin, fat, fbrous tissue, muscles, blood Blood spread is rare. From the upper lip, to the submental and managed in the same line as in case of car- ii. Hemangioma (Juguloomohyoid and Jugulodigastric is 80 percent if the lymph nodes are not v. It arises from a damaged sublingual gland (Tese sublin gual glands are called glands of Blandin and Nuhn). The lining wall is composed of deli cate capsule of fbrous tissue, and the content Fig. Section 5 Head and Neck Swellings complication • Bursting and reformation • Infection • Difculty in speech or eating if the tongue is pushed upwards. Diagnosis-by bidigital palpation (one finger in the oral cavity and the other on the neck). The ranula is not attached to the over lying mucosa, mylohyoid or muscles of the tongue. Chapter 22 Neck Swellings which proliferate and ultimately liquify in thyroglossal cyst • The cyst is sof, cystic, fuctuant and tran future to form the cystic swelling. Types (as to position) • Beneath the foramen cecum • In the foor of the mouth complications Median variety Lateral variety • Above the hyoid bone 1. Abscess and fstula formation The patient’s age is usually between 10 On the thyroid cartilage 3. Supramyelohyoid or sublingual type- nant of the thyroglossal duct, the other name Excision–Fistula with entire thyroglossal Cystic swelling in the foor of mouth placed being median thyroid diverticulum which tract is excised. Removal is Diferential diagnosis – Ranula the tuberculum (see below fate of thyroglos facilitated by pressing the posterior 1/3rd of b. Care should be taken not to perfo swelling in the region of the submandibular Structures which move up with deglutition rate the thyrohyoid membrane. Preoperative measure-For better visu are approached via a curved incision • Content-Tick jelly like fuid. BrancHial cySt It is a cystic swelling arising in connection with the persistent cervical sinus which is formed due to the fusion of overgrowing 2nd branchial arch, with the 6th branchial arch (Fig. Normally the cervical sinus disappears, but if it persists, accumulation of fuid occurs inside the sinus and gives rise to the branchial cyst. Differential Diagnosis Usually seen in growing adults, but can The fuid is usually secreted by the appendages, occur at any age. Cold abscess-A caseating tuberculous Nature of discharge: Mucoid or Mucopurulent dermal lining of the enclosed space. It is soft, If the epithelial lining remains, recurrence • Sometimes a second incision is needed cystic, fluctuant and transillumination will follow. Tis is known as ‘step Fluctuation is ofen difcult to elicit as the be held by any tissue forceps. If • Branchial cartilage-Elongated piece of contents are aspirated it contains choles cartilage deep to the cutaneous dimple types: See above terol crystals. If so one should recon • Cervical auricle-It is the cutaneous pro Site sider the diagnosis in favor of cold abscess. Tis muscle at the junction of lower and mid Precaution during Operation can be explained because of the develop dle 1/3rd.
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She is also given nitroglycerin tablets to be taken in case of an anginal attack or as a prophylaxis against angina in anticipation of physical exertion beyond normal daily activities buspar 5mg for sale anxiety workbook. During one morning order buspar 10mg fast delivery anxiety wikipedia, a couple of hours after applying her nitroglycerin skin patch order buspar 5 mg visa anxiety symptoms 5 year old, she takes a nitroglycerin tablet in anticipation of doing some gardening but decides to lie down for a few moments before starting work effective buspar 10mg anxiety symptoms crying. Within 10 minutes of lying down, the patient bolts from her supine position to answer her telephone. However, within seconds of rising from the supine to the standing position, she becomes light-headed and dizzy. Her heart rate starts to increase rapidly and she can feel her heart pounding in her chest. Within a couple of steps, her vision narrows and blackens and she collapses onto the floor unconscious. Shortly after this episode, the patient regains consciousness and is able to stand only after slowly arising. What cardiovascular phenomenon is most likely responsible for the loss of consciousness in this patient? What changes in blood volume distribution normally occur immediately when one moves from a supine to a standing position? What immediate effects do these have on cardiac output and arterial blood pressure? What reflex mechanisms are brought into play in response to these changes in blood pressure? Nitroglycerin is a rapidly absorbed, quick-acting direct vasodilator that relaxes smooth muscle in veins more than arteries. How does this selective effect of nitroglycerin relate to the responses of the patient suddenly standing? Loss of consciousness can result from numerous factors, but the most likely related to the cardiovascular system is a sudden severe drop in blood pressure below the autoregulatory limit of the cerebral circulation. This would cause a drop in blood flow and oxygen supply to the brain that would likely induce neurological effects such as darkening vision, dizziness, and fainting. Upon changing from the supine to the standing position, blood tends to fall toward the lower extremities due to the influence of gravity. Blood vessels are compliant with veins being much more compliant and distensible than arteries. Consequently, upon standing, blood tends to pool in the veins of the lower extremities, effectively translocating blood volume away from the central circulation. This causes a sudden drop in ventricular filling and cardiac output along with a drop in arterial pressure. Normally, cardiovascular reflexes activate sympathetic nerves to veins and arteries resulting in venous and arteriolar constriction in response to this initial drop in arterial pressure. Venous constriction helps move blood from the lower extremities into the central circulation and thus supports cardiac output. Stimulation of cardiac output helps prevent any drop in arterial blood pressure when rising to a standing position. Blood pressure is further supported by increased vascular resistance from reflex sympathetic–mediated constriction of systemic arteries in all vascular beds except the heart and brain. This support of blood pressure, along with strong autoregulation of blood flow in the brain, prevents any significant drop in cerebral blood flow that would otherwise occur should the body not be able to compensate for the drop in blood pressure that occurs upon standing against gravity. By directly relaxing smooth muscle in veins and arteries, nitroglycerin antagonizes any constrictor effect on those blood vessels. Because this agent relaxes veins more than arteries, there is a greater reduction in venous than arterial compliance and blood tends to pool more easily in the veins than normal. In addition, the actions of nitroglycerin blunt any reflex sympathetic vasoconstriction of veins in response to standing, preventing those reflexes from counteracting pooling of blood away from the central circulation and into the lower extremities. The action of nitroglycerin on arteries also antagonizes reflex arterial vasoconstriction during standing. As a result, a patient on nitroglycerin can experience a significant, precipitous drop in arterial pressure when moving suddenly from a supine to a standing position such that blood supply to the brain may become inadequate. Nitroglycerin does not have any direct effect on cardiac or skeletal muscle contraction. Therefore, the drop in arterial pressure seen upon standing while on nitroglycerin will activate neurogenic reflexes that will increase heart rate and myocardial contractility. Therefore, the patient in this study also experienced tachycardia and palpitations upon standing. Explain why alveolar ventilation measures the amount of fresh air that enters the lung. Explain what keeps the airways from becoming compressed during forced explanation. Predict how restrictive and obstructive lung disorders affect the work of breathing. The inrush of air at birth sets off a series of events that allows the newborn to progress from a dependent, placental life support system to an independent air breathing system. A breath in and a breath out 12 to 15 times every minute may seem like a simple process to build the entire human respiratory system, which brings in, on an average, 7 L (~1. At rest, breathing 7 L of air per minute supplies enough oxygen to sustain the metabolism of trillions of cells in the body. However, this simplicity is deceptive because breathing is amazingly responsive to small changes in blood chemistry, mood, level of alertness, and physical activity. In the previous chapters, you learned that a major function of the cardiovascular system was to distribute blood throughout the body in order to deliver nutrients, oxygen, and other chemicals to the tissues and remove carbon dioxide and other metabolic waste products. In the respiratory chapters, you will learn that the respiratory and cardiovascular systems are closely linked, and the lungs are solely responsible for transferring oxygen from the atmosphere to the blood and removing carbon dioxide from the blood to the atmosphere. You will also learn that the human lungs are so efficiently designed that gas exchange can increase over 20-fold to remove carbon dioxide and to supply oxygen to tissues in order to meet the body’s energy demands. For example, a marathon runner who staggers across the 26-mile finish line in <3 hours or someone who swims the English Channel in record time is rarely limited by the amount of oxygen taken up or carbon dioxide removed by the lungs. These examples of human activity not only underscore the functional capacity of the lungs but also illustrate the important role respiration plays in body’s extraordinary adaptability to the external environment. Finally, you will learn that respiratory physiology plays a critical role in medicine, because of the impact that many of the respiratory diseases (e. Gas exchange involves the transfer of oxygen and carbon dioxide between the atmosphere and the lungs. The first involves the exchange of oxygen and carbon dioxide from the cells of the body. The second step is intracellular and involves a series of complex metabolic reactions that burns fuel, releasing carbon dioxide and energy.