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A: As follows: • In early case: Small buy paroxetine 40mg line, raised generic paroxetine 30 mg overnight delivery, non-pruritic paroxetine 20mg line, reddish purple nodule on the skin or discoloration of oral mucosa or swollen lymph node. A: Depends on the subtype, localized or associated with systemic disease: • Localized mucocutaneous disease responds to cryotherapy, radiotherapy, surgical excision, intralesional vinblastine, topical immunotherapy (imiquimod), interferon-a. Presentation of a case: • There are multiple hypopigmented macules of variable size and shape involving the front of the chest, both sides of neck and upper part of back. Pityriasis versicolor Pityriasis versicolor Pityriasis versicolor Pityriasis versicolor in neck in face in chest in back Q:What is pityriasis versicolor? A: It is a benign superfcial skin infection caused by fungus called Malassezia furfur. Oral antifungal: • Ketoconazole 200 mg daily for 1 week or 400 mg in a single dose, may be repeated at monthly intervals. Lupus pernio in Depressed nasal Puffy face in nephrotic Malar flush sarcoidosis bridge in Wegener’s syndrome granulomatosis Q:What are the causes of puffy face? Plethoric face in polycythaemia Plethoric face in Cushing syndrome Chloasma/melasma Q:What are the causes of chloasma or melasma? A: It is a discrete pigmentation in the face of females, due to imbalance between oestrogen and pro- gesterone. Wegener’s granulomatosis (nose) Wegener’s granulomatosis (eye) Clinical features: • Nasal discharge, epistaxis, nasal obstruction, nasal crust, rhinitis and sinusitis. Look carefully to the following points: • Rash distribution (check whether present in other parts of face) and character, scaly desquamation and redness or other colour, follicular plugging. Presentation of a Case: • There are multiple skin rashes on the face along the butterfy distribution, also involving the forehead and cheeks (mention, if any). Some are scaly and reddish with clear margin, more marked on the right (or left) side of face. A: It occurs due to the fan like fold of skin extending from shoulder to neck or an abnormal splaying, out of trapezius muscle. Webbing of neck Low hairline Short fourth metacarpal Shield-like chest Q:What is Turner’s syndrome? All or part of one X chromosome is deleted, leading to failure of ovary devel- opment. Hand looks small and round (short, broad hands) and has clinodactyly (short inward curving of little fnger). Mother with risk of Down’s syndrome: Chorionic villous sampling before 13 weeks of gestation or amniocentesis after 15 weeks of pregnancy may be done. Presentation of a Case: • There is bilateral swelling of parotid glands, which are frm and nontender. Bilateral parotid enlargement Bilateral parotid enlargement Q: What are the causes of bilateral parotid enlargement? Presentation of a Case: • There are yellowish plaque or nodular lesions at the upper eyelid (may be also in lower eyelid), near the inner canthus in one or both eyes. Xanthelasma Corneal arcus Tuberous xanthoma Tendon xanthoma in (elbow) Achilles tendon Tendon xanthoma (feet) Lipaemia retinalis Tendon xanthoma Eruptive xanthoma (knuckle) Q:What is xanthelasma? A: These are yellowish plaque in the subcutaneous or intracutaneous tissues due to deposition of cholesterol or lipids in the eyelids. A: Corneal arcus, xanthoma in other parts (patella, Achilles tendon and dorsum of the hand) and evidence of primary disease. A: Xanthomas are deposits of fatty material in the skin and subcutaneous tissue and tendons due to primary or secondary hyperlipidaemia. Q:What diseases are associated with hypercholesterolaemia and hypertriglyceridaemia? General measures: • Weight reduction in obesity, exercise, diet (avoid cholesterol-containing diet and animal fat). Presentation of a Case: • There is port-wine stain (reddish, slightly pigmented area) at the right outer part of face near the outer and upper part of right eye. A: It is a disease characterized by capillary or cavernous haemangioma (port-wine stain) along the cuta- neous division of trigeminal nerve (commonly frst or second division). There is venous haemangioma in subjacent leptomeninges, which may spread causing atrophy of cortex. Underlying brain damage is a rare cause of infantile hemiplegia, mental retardation and epilepsy. A: As follows: • X-ray of the skull that shows tramline calcifcation (in cortical capillaries). Presentation of a Case: • There is telangiectasia in lip, face, under surface of tongue, palate, buccal mucosa and nasal mucosa. My diagnosis is Hereditary haemorrhagic telangiectasia (also called Osler–Weber–Rendu syndrome). A: It is found in lip, face, tongue (also under surface), buccal mucosa, nasal mucosa, nail bed, palm, feet and gastrointestinal tract, also, in any part of the body (lungs, nervous system, liver etc. Telangiectasia Telangiectasia Telangiectasia Telangiectasia (lip) (palate) (tongue) (toe and sole) Q:What are the causes of telangiectasia? A: It is a disease inherited as autosomal dominant, characterized by the formation of multiple telangi- ectasia in the skin and mucous membrane in different parts of the body. A: As follows: • Epistaxis (common), usually recurrent and sometimes, the only site of bleeding. If epistaxis is the main symptom: • Oestrogen therapy (induces squamous metaplasia of nasal mucosa). Lung arteriovenous malformation: embolization or ligation of artery or surgical resection. Presentation of a Case: • The nails are thick, curved from side to side and yellow (or greenish yellow) with onycholysis (separation of distal part of nail plate from its bed). Yellow nail (fingers) Yellow nail (toes) Yellow nail syndrome (lymphoedema) Q:What is yellow nail syndrome? A: It is an inherited disease associated with hypoplasia of the lymphatic system, characterized by thick and yellow nails and lymphoedema of legs. A: As follows: • Thyroid disease (hypothyroidism, Hashimoto’s thyroiditis, thyrotoxicosis). Common sites are chronically sun-exposed areas such as scalp, ears, face and dorsum of hands. It develops as a painful keratotic nodule in a pre-existing area of dysplasia or newly developed ery- thematous, infltrated, warty nodule or plaque which may ulcerate. It may be well-differentiated or poorly differentiated which may be infltrative and may ulcerate. Other options are curettage and cautery for small, low risk lesions and radiotherapy, if surgery is not possible. Treatment of choice is wide excision with histology to ensure clear and adequate tumour margins. Melanoma is common in later life but can occur at any age, any site and in either sex, but typically affects the leg in females and back in males, rare before puberty.

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Because the quadrangular cartilage is inherently made to determine their etiology purchase cheap paroxetine line. The most common causes are rigid and sits firmly in an osseous foundation from the nasal spine trauma and previous surgery generic paroxetine 20 mg overnight delivery. In some cases generic paroxetine 20mg line, these types of along the maxillary crest and up the osseous septum to the nasal deformities may be congenital. In the case of saddle nose or col- bones, it provides significant stabilization to the nose. Active nasal buttressing caudal element forms the basis of the L-shaped granulomatous or rheumatic disease, continued cocaine abuse, strut—the most structurally important aspect of the quadran- and other progressive destructive processes of the nasal septum gular cartilage. Compromise to the caudal component may lead to nasal tip ptosis, particularly in the presence of weak 15. Traumatic or iatrogenic injury is most often the Analyses of these types of deformities must be meticulous and cause. On the frontal view, the symmetry and width of ginous septum in cadavers has been shown to result in a signifi- the nose should be assessed. The external nasal contour and the ness at the middle vault, and width again at the tip. Most importantly, tip support should be determined by palpation and noting the degree of resistance and recoil. Lack of support noted by ease of downward compression of the middle nasal vault may indicate complete loss of underlying septal support, which will dictate the method of reconstruction. Severe loss of nasal tip support may indicate total loss of caudal septal support. The three-quar- ters view aids in confirming the assessment made with the aforementioned views. Deviation of the caudal septum may cause canting of the tip, lobule, or columella. Severe caudal septal deformities can result in foreshortening of the nose and loss of the normal columellar/lobular angle. The entire caudal septum should be palpated to localize the deformity (anterior septal angle, midcaudal septum, or posterior septal angle). Dorsal or caudal deviation of the septum may correspond to distorted areas of the middle vault, tip, and nasal base. The internal angle between the septum and upper lateral cartilage is normally 15 degrees. In such cases, inspection may reveal dynamic collapse of the upper lateral car- tilages with inspiration. The non-L-strut sep- tum must be assessed to determine impact on the nasal airway, need for excision or rearrangement, and availability of cartilagi- Fig. Management of is clear that there is insufficient cartilage in the septum to pro- posttraumatic nasal deformities: the crooked nose and the saddle vide adequate grafting material, the surgeon may need to har- nose. In some techniques used to correct common nasal deformities related to cases, the direction of deviation varies at different levels of the the L-strut. On the lateral view, the projection of the radix, bony dorsum, cartilaginous dorsum, and nasal tip must be evaluated. However, considerable normal variation of the dorsal line exists depending on ethnic- In some crooked nose deformities, the attachment of the dorsal ity and familial traits of the individual. If a saddle nose deform- septum and upper lateral cartilages to the bony septum and ity is present, the areas of maximum deficiency should be local- nasal bones will allow the middle vault and tip to move into ized along the dorsal line. An attempt should be made to quan- favorable position with bony vault repositioning. In some of these position should be assessed by determining the projection as cases, medial and lateral osteotomies will reposition the oss- compared with the length of the nose. The nasolabial angle is a eous vault and allow the tilted septum to return to the midline, helpful metric to assess nasal tip rotation, though is not reliable bringing the middle vault and nasal tip with it. If the lower two Analysis of these types of deformities must be meticulous and thirds of the nose do not straighten with bony vault correction, methodical. On the frontal view, the symmetry and width of it is likely that the deviations are related to inherent cartilagi- the nose should be assessed. The parallel dorsal lines of the nous deformities of the septum, upper lateral cartilages, or 116 Management of Naso-septal L-strut Deformities lower lateral cartilages or distortion of the relationships Prior to addressing the caudal-septal strut, the remaining between these structures. Significant dorsal or caudal septal deviations are best Harvesting of this cartilage may be performed through the approached through the external rhinoplasty approach. If it is likely that the native L-strut can be deformities pose technical challenges, which require direct vis- preserved while still making the necessary changes to the nose, ualization and wide exposure. As this strut has significant implications for later be modified depending on the residual deformities. Frac- nasal appearance and structural support, the external approach ture, crush injury, or thinning of portions of the strut must be is preferable to ensure precise, stable realignment. If internal inspection reveals significant dorsal or caudal sep- tal deformities requiring correction, the nasal septum must be Dorsal Deviations: Mild to Moderate widely exposed and isolated. Bilateral mucoperichondrial flaps should then be internal valve narrowing, dynamic middle vault collapse, and elevated from the floor to the dorsum. Subtle or moderate deflections may be lages can then be sharply separated from the dorsal septum treated with the placement of spreader grafts between the car- while preserving the mucosal transition from septum to upper tilaginous septum and upper lateral cartilages. At this point, the osseous vault should be help to correct a narrow or asymmetric middle vault. The addressed, as the septum may become repositioned after dimensions of spreader grafts should be customized to the spe- osteotomies. The areas of deviation should be local- than one graft on each side may be needed depending on avail- ized by region: dorsum, anterior septal angle, midcaudal mar- ability and thickness of grafting material and the degree of gin, or posterior septal angle. Typically, a thicker spreader graft is placed on the depend on the site(s) involved and the severity of the deform- concave side to create an overall balanced result. Once the septum is returned to a midline position, the The thicker end of the spreader graft is beveled and positioned upper lateral cartilages and lower lateral cartilages may be cephalad toward the rhinion to create the normal appearance restabilized by suture to the septum, restoring symmetry and of slightly increased width in this area. Manage- ment of posttraumatic nasal deformities: the crooked nose and the saddle nose. To provide initial fixation An alternative to cartilaginous grafts is the use of ethmoid bone of the grafts, 5. Addi- straight segments of bone with opposing drill holes are used to tional sutures are then placed through the upper lateral sandwich the curved portion of cartilage to bend the segment into cartilages, spreader grafts, and dorsal septum to complete the a straight orientation. The caudal upper lateral cartilages should be pulled structural support, bone poses a higher risk of palpable internal or caudally during the suture stabilization to straighten any external irregularity, and is more difficult to suture fixate. The dorsal profile of the spreader grafts, upper lat- eral cartilages, and septum should be coplanar and smooth. In Caudal Deviation: Mild to Moderate situ trimming of the grafts can ensure an even dorsal surface. The caudal septum may be deviated at the anterior septal angle, Spreader grafts serve two potential functions in the posterior septal angle, or anywhere in between. For small to moderate deviations in rela- exist to correct or camouflage these deformities.

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Suggested structure includes: • Ask patient what they know • Answer any queries they have • Convey any pieces of information crucial to decision-making • Ask if they have any further questions • Confrm that they have understood the key issues • Summarize the plan of care from hereon paroxetine 30mg with mastercard. Do not wait for patients to volunteer symptoms discount paroxetine 20mg without a prescription, consider using a stand- ardized questionnaire purchase discount paroxetine online. Present turning of the defbrillator function as a simple step to improving the quality of the last few days of life. Emergency deactivation can usually be accomplished by placing a magnet over the defbrillator box; the magnet must remain in place for continued deactivation. Fluid overload should be treated with diuretics such as loop, thiazide, and aldosterone antagonists. For example, 4 hours at one infation in every two cardiac cycles (‘ in 2’) would be the relatively rapid weaning in a patient that might be expected to tolerate removal. Care should be taken to monitor patients closely in the frst 24 hours post IaBp removal looking for evidence of decompensation. Prognosis the -year survival following Ctx is 85%, with a conditional median survival of 3 years. Patient selection for heart transplantation the selection of patients for Ctx is difcult. It is important to identify those at the highest risk of mortality prior to listing, as Ctx has a -year mortality of 75%. Risk factors and contraindications Whenever possible, intrinsic organ damage should be diferentiated from reversible abnormalities secondary to heart failure. Immediate post-transplant management the perioperative management of heart transplant recipients ofers sev- eral unique challenges to the cardiothoracic intensivist. Management • epicardial pacing wires are placed on the atrium and ventricle at the time of surgery. Myocardial stunning the total ischaemic time of the donor heart (cross-clamp on donor heart to cross-clamp of after implantation) is directly correlated with postoperative myocardial performance. While the shorter the time the better, transplant teams aim for an ischaemic time of <4 hours with an i mortality observed for total ischaemic time >5 hours. Some surgeons also use a left atrial line to allow direct monitoring of left-sided flling pressures. Opportunistic infection prophylactic antibiotics are used in the early postoperative phase. Cardiac allograft rejection rejection can be either cellular or antibody mediated, although in the non-sensitized patient, cellular rejection is the most common form of acute rejection. Endomyocardial biopsy In 973, philip Caves frst described transvenous endomyocardial biopsy to diagnose cardiac allograft rejection. Most centres continue to use this tech- nique in the early phase after Ctx, when the risk of rejection is highest, and while immunosuppressive therapy is slowly weaned to maintenance doses. Ltx was frst performed in 963 by James Hardy, although the patient only survived for 8 days. Multiple other attempts were thwarted by rejection until Joel Cooper performed the frst successful single Ltx in 983, followed by double Ltx in 986. Targets • tidal volume 6–8mL/kg • peep 4–8cm/H2O (note: a high peep may cause a deterioration in bronchial anastomotic healing, barotrauma, or over-infation of the native lung in single Ltx) • peak inspiratory pressure <30cmH2O • pulmonary toilet 2-hourly • Chest drain <5cm/H2O suction • Fibreoptic bronchoscopy if atelectasis/infltration seen, or prior to extubation (to assess bronchial anastomosis and colour of distal bronchus). For that reason, infection needs to be rigorously excluded for the accurate and reproducible interpretation of pulmonary allograft biopsies. Ill-defned peri-hilar and lower zone nodules and septal lines may raise the suspicion of rejection, although a normal appearance does not exclude an episode of rejection. Immunosuppression the majority of lung transplant centres now employ an immunosuppressive strategy that uses a combination of tacrolimus and mycophenolate, with a reducing dose of corticosteroids. Infection Infection is very common after lung transplantation due to denervation, bronchial anastomosis, impaired mucociliary function, immunosuppres- sion, and bronchiolitis obliterans occurring as a chronic rejection. International guidelines for the selection of lung transplant candidates: 2006 update. The number of procedures reported to be performed worldwide is declining, with 50% of centres performing only one such transplant per year. The procedure the donor heart and lungs are harvested with minimal handling, with the heart fushed with cold cardioplegia solution, and the lungs with modifed Collins solution. Care should be taken to keep the donor trachea as short as possible because of the limited vascularity of the area. Prognosis although the prognosis has improved in recent years, the -year mortality is 728%, and around half of patients are dead at 3 years. However, patients surviving the frst year have an average life expectancy of nearly 0 years. Calcineurin inhibitors Ciclosporin (cyclosporine) • Commenced when haemodynamics are stable, without evidence of hepatic or renal failure. Chapter 23 239 Acute cardiology Out-of-hospital cardiac arrest 240 Endocarditis 243 Aortic dissection 246 240 ChAptEr 23 Acute cardiology Out-of-hospital cardiac arrest Introduction Cardiovascular disease is the leading cause of death in the developed world. It is unfortunately a common event with a high mortality, and survival rate to discharge home is typically <0%. Principles of management • Efective cardiopulmonary resuscitation (Cpr) with minimal interruption • Optimize oxygenation • Early defbrillation • Appropriate drug treatment. Early, aggressive management of these patients has potential to signifcantly infu- ence their outcome and neurological status. Treatment of seizures Seizures are common following hypoxic neurological insult: • Insufcient evidence for prophylactic treatment. Temperature control pyrexia is common in the 48 hours following cardiac arrest; poor neuro- logical outcome has been associated with temperatures of 38°C and above. Both trials demonstrated improvement in anoxic neurological injury, relating to improved functional outcomes and reduced mortality. Due to the adverse physiological efects of cooling, it is important to assess the risk of beneft versus harm on an individual basis. Despite advances in medicine over the last 30 years neither the incidence nor mortality of the condition has changed. Up to 5% of cases are the result of Coxiella burnetii (Q fever), Bartonella,Leg ionella,Mycoplasma, and Chlamydia. Diagnosis the Duke criteria for diagnosis of infective endocarditis require 2 major or  major and 3 minor or 5 minors: Major criteria • positive blood cultures: either typical organism in 2 sets, or persistently positive blood cultures (3+ sets >2 hours apart), or single positive blood culture for Q fever/phase  IgG antibody titre > :800. Minor criteria • predisposing factors • pyrexia > 38°C • positive blood cultures • Echocardiogram that do not meet major criteria • Vascular or immunological signs. Investigations • Blood cultures: at least 3 sets taken 30 minutes apart from separate sites. In patients in whom a high suspicion remains despite previously negative fndings should be rescanned 7–0 days later.

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The virus spread throughout the United States and has now been diagnosed in thousands of patients annually with significant morbidity and mortality 10 mg paroxetine. Localized or focal encephalitis is the most common presenta­ tion of toxoplasmosis buy paroxetine 30mg lowest price. This is in contrast to primary central nervous system lymphoma and toxoplasmosis in which mass efect may occur cheap paroxetine 10 mg amex. Neurologic deficits typically persist in survivors proportionate to the disease severity at the time of presentation. Other parasitic infections such as those caused by Trypano­ soma brucei, T cruzi, and Toxoplasma gondii are among those with a protozoan etiol­ ogy. He has also had a rapid loss of weight, night sweats, and frequent low­ grade fever. Other significant findings included the presence of oral thrush, splenomegaly, bilateral lower extremity weakness, and hyperrefexia. The India ink stain, cryptococcal antigen test, and culture for fungi were nega­ tive. He underwent a cadaveric kidney trans­ plantation 10 months ago, and his immunosuppressive regimen includes pred­ nisone and azathioprine. The lesions are generally bilateral, asymmetric, nonenhancing, and peri-ventricular or subcortical in distribution. A negative serologic test for toxoplasma-specific IgM would add additional support to the exclusion of toxoplasmic encephalitis. The most appropriate empiric therapy is ampicillin (the drug of choice for Listeria), with ceftriaxone and/or vancomycin. Empiric vancomycin and ceftriaxone are recommended for the treat­ ment of meningitis in patients 2 to 50 years of age. She has a history of a cerebral vascular accident and residual neurological defcits and has been hospitalized fo r the past 3 weeks. On examination, her pulse rate is100 beatsjminute, respiratory rate is 22 breaths/ minute, and blood pressure is 11Of84 mm Hg. The patient is currently on the third day of ciprofoxacin fo r empiric treatment of her recurrent urinary tract infection. She has an elevated temperature despite antibiotic treatment and has developed fngemia as well. To learn antimicrobial treatment strategies that may reduce the occurrence of antimicrobial resistance. Co nsidertions This is a 74-year-old woman with significant residual neurologic deficits and renal insufficiency after sufering from a cerebral vascular accident. When a patient does not respond to antimicrobial therapy, it is generally important to determine if another source of infection is present and/or if the antibiotic treatment regimen is inappropriate or insuficient against the microorganisms responsible for the infection. Since the same bacteria is isolated from her urine and her blood stream, the infection is severe, systemic, and inadequately controlled with the current antimi­ crobial regimen. In addition, fungal species isolated on blood culture strongly sug­ gests that fungal sepsis is contributing to the worsening clinical picture. Infection with drug-resistant organisms contributes to prolonged hospitalization, higher hos­ pital costs, and a poorer prognosis. The emergence of antibiot­ ic-resistant bacteria is a significant problem in intensive care units. The inappropriate administration of broad-spectrum antibiotics can lead to even more dificult-to-treat infections. The therapy is started based on clinical suspicion of infection based on physiologic parameters. Patients with suspected infections are treated with broad-spectrum antibiotics aimed at most probable organisms that are causing the infections with narrowing (or discontinuing altogether) of the antibiotic coverage as soon as culture results become available, or if no infections are documented. Similarly, duration of treatment may be shortened when patients with uncomplicated infections show clinical improvement/resolution. Consequently, antibiotics are one ofthe most common therapies utilized in the intensive care unit. The rea­ son for this elevated level of drug-resistant infections is multifactorial. In addition to patient-specific risk factors, there are other general factors such as excessive antimicrobial use, poor aseptic technique, and inadequate hand hygiene of health-care providers that con­ tribute to the increased infectious risks. The inappropriate choice and duration of antibiotics therapy can also contribute to the problem by selecting for resistant bac­ teria overgrowth and infection. Microbial resistance is increasing in bothgram-negative andgram-positive bacteria. The inadequate empiric coverage of these resistant bacteria can lead to a higher morbid­ ity and mortality. However, the inappropriate use of broad-spectrum antibiotics can lead to the increase in emergence of resistant bacteria. Thus, the challenge to the physician is to use antibiotics that will cover the resistant bacteria without over­ treatment that can lead to resistance. When a patient is septic, antibiotics must be initiated promptly, preferably, within 1 hour of diagnosis. Each hour of delay over the next 6 hours has been shown to contribute to a decrease in survival of 7. The initial choices of the preemptive antimicrobial therapy need to adequately address the potential infective organisms to minimize the mortality associated with the infection. Inadequate initial therapy usually involves either the failure to cover a specific microbe or utilizing antibiotics to which the organism is resistant. It is obligatory that before antibiotics are started, cultures should be obtained. Once the culture isolates with their associated antibiotic sensitivities are identified, the antimicrobial therapy should be immediately adjusted to more narrow-coverage antibiotics that have bactericidal activity against the bacteria. This de-escalation therapy allows for treatment ofthe infection while reducing the risk of antimicrobial resistance. Another key component in the selection of antibiotic choice is based on the basic pharmacokinetics (necessary dosage to achieve adequate levels, tissue pen­ etrance, etc). This is important so that under-dosing does not occur, as this can lead to an increase in the emergence of resistant organisms. This is particularly important in patients with renal insuficiency; adjustments of drug dosing and frequency of administrations are often needed when patient are receiving hemodialysis. Infected high­ risk patients should be started on combination broad-spectrum antibiotics based on presumed infectious sources and local antibiograms (Table 18-1). Antibiotics have difrent tissue penetrations and should be taken into account when treating infections. Source control of the infection, such as abscess drainage, should be performed immediately. Different resistance rates are found at diferent hospitals, so antibiograms that show local antibiotic susceptibility should be used as a guide for initiating therapy that will cover local resistance. Once the cultures return with antibiotic susceptibility, antibiotic therapy should be de-escalated in spectrum and duration.

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