By K. Hurit. Seton Hall University.
Include all active problems buy cheap kamagra gold 100mg online, major inactive problems generic kamagra gold 100mg with amex, significant past medical his- tory buy kamagra gold 100mg otc. Include vital signs discount 100 mg kamagra gold with visa, pulmonary artery catheter data generic kamagra gold 100 mg on-line, ventilator settings, laboratory and culture data. Prophylaxis (ie, DVT, ETOH, stress ulcer, etc) With each of the areas listed in item 9, try to anticipate and avoid complications G. It is written for a trauma patient but can easily be modified for any clinical setting. Sample ICU Progress Note PROBLEM LIST: • S/P MVA • Left pulmonary concussion • Left hemopneumothorax S/P left chest tube • Grade 4 splenic injury S/P splenectomy • Acute renal failure • ARDS • Complex past medical history: Hypertension Gout • Allergic: Morphine sulfate EVENTS OF PAST 24 HOURS: • Increasing FiO2 and PEEP • Renal Consult CURRENT MEDICATIONS • Dopamine • Fentanyl infusion • Ativan infusion • Pepcid 20 • Vancomycin FLOW SHEET DATA: • P 150 (NSR), BP 110/65, I/O: 3400/2210, (continued) 20 Critical Care 391 Sample ICU Progress Note (continued) • PAP 45/20, PCWP 14, CO 3. Chest tube in place • Gastrointestinal: Midline incision healing well, soft, nondistended, no guarding, + bowel sounds • Extremities: Warm well perfused ASSESSMENT: • Neurologic: Stable, continue sedation while on ventilator. Will obtain CXR this AM and wean FiO2 and increase PEEP as tolerated by BP and CO. CARDIOVASCULAR SYSTEM Cardiovascular instability is one of the most common problems faced in the ICU. Under- standing the approach to the evaluation of the cardiovascular system is essential to treating any critically ill patient. Inspection Inspection of the cardiovascular system is divided into three main areas: 20 Jugular Venous Distention • Daily examination of the patient in the ICU should include examination of neck veins to look for JVD. A patient sitting at a 45-degree angle who has distended neck veins has a CVP of 12–15 cm H2O or higher. Such an injury pattern should alert the physician to the possibility of a myocardial contusion. Treatment of this condition consists of continuous ECG monitoring and vigorous correction of arrhythmias. Extremity Perfusion • Check all four extremities for distal perfusion, including pulses, color, temperature, and capillary refill. In a young, previously healthy individual, an adequate BP usually corresponds to a MAP of greater than 70 mm Hg. Technical Tip: If the cuff is too small an obese arm will give a systolic BP 10–15 mm Hg higher than the actual pressure. Systolic Hypertension: A systolic blood pressure >140 mm Hg with a normal diastolic pressure. In the acute care setting, systolic hypertension is thought to be secondary to in- creased cardiac output. Systolic hypertension is seen in the following situations: • Generalized response to stress • Pain • Thyrotoxicosis • Anemia Diastolic Hypertension: A diastolic pressure >90 mm Hg. Isolated diastolic hypertension is associated with three general disease categories: • Renal disease • Endocrine disorders • Neurologic disorders Treatment of Hypertension: Hypertension is of concern in the ICU when confronting a new MI or a vascular anastomosis and especially following carotid artery surgery. Ideally, 20 the systolic blood pressure in this instance is maintained above 130 and below 160. These include nitroprusside (Nipride), hydralazine (Apresoline), labetalol (Normodyne), a beta-blocker, or nitroglycerin. Beta-blockade should be used with Nipride in treating hypertension associated with an 20 Critical Care 393 aortic aneurysm. The emergency management of hypertension is discussed in Chapter 21, page 470 and the specific agents are discussed on page 439 and in Chapter 22. Pulse Pressure Pulse pressure is the difference between systolic and diastolic blood pressures. A wide pulse pressure is associated with: • Thyrotoxicosis • Arterial venous fistula • Aortic insufficiency Narrow Pulse Pressure: A pulse pressure <25 mm Hg. A narrow pulse pressure is associated with: • Significant tachycardia • Early hypovolemic shock • Pericarditis • Pericardial effusion or tamponade • Ascites • Aortic stenosis Mean Arterial Blood Pressure MAP is calculated by taking the diastolic pressure plus one third of the pulse pressure. Paradoxical Pulse: Paradoxical pulse is a function of the change in intrathoracic pres- sures during inspiration and expiration. If this variation occurs over a range >10 mm Hg, the patient is said to have a paradoxical pulse (Figure 20–1). Conditions associated with a paradoxical pulse: • Pericardial tamponade • Asthma and COPD • Ruptured diaphragm • Pneumothorax Heart Murmurs Monitor the ICU patient for the development of a new murmur. All new murmurs should be characterized by their intensity, location, and variation with position and respiration. Systolic Murmurs: Abrupt onset caused by conditions that have clinical significance 20 for the acutely ill patient: 1. Papillary muscle dysfunction following AMI is characterized by an apical systolic murmur.
Buckup buy kamagra gold 100 mg cheap, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved buy 100mg kamagra gold with mastercard. Procedure: The seated patient is asked to press both hands together in maximum dorsiflexion and to maintain this position for one minute kamagra gold 100mg overnight delivery. Paresthesia in the region supplied by the median nerve is a sign of carpal tunnel syndrome order 100 mg kamagra gold otc. Buckup purchase kamagra gold 100mg with visa, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. Procedure: The patient is seated with both hands and forearms in supination on the examining table. Assessment: Weakness in active pronation against resistance in one arm as compared with the contralateral side indicates a median nerve lesion. In the presence of a median nerve lesion distal to the elbow, the patient may be able to actively pronate the forearm against resistance because the pronator teres is still largely functional. The muscle for this motion is the adductor pollicis, which is supplied by the ulnar nerve. Assessment: Where there is weakness or loss of function in this muscle, the interphalangeal joint of the thumb will be flexed due to contraction of the flexor pollicis brevis supplied by the median nerve. Occasional volar hypesthesia on the ring and little fingers is also a characteristic sign. Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. Assessment: Where the ring and little fingers remain extended, flexion in the metacarpophalangeal and proximal interphalangeal joints of these finger is not possible. Patients with a long history of chronic ulnar nerve palsy will exhibit significant muscle atrophy between the fourth and fifth and first and second digital rays of the hand. Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. Procedure: The patient is asked to hold a piece of paper between the ring and little fingers. Assessment: In the presence of ulnar nerve neuropathy, adduction in the little finger will be limited and the patient will be unable to hold on to the paper. A positive Tinel sign and paresthesia on the ring and little fingers are additional signs of compression. Complete ulnar nerve palsy results in loss of function in the intrinsic muscles of the hand. The fingers are then hyperextended in the metacarpophalangeal joints and flexed in the proximal and distal interphalangeal joints. O Test Procedure: The pinch mechanism is a combined motion involving sev- eral muscles. Assessment: In an anterior interosseous nerve syndrome with paraly- sis of the flexor digitorum profundus of the index finger and flexor pollicis longus, the thumb and index finger remain extended in the distal interphalangeal joints. Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. Assessment: Weakness in active flexion against resistance indicates paresis or paralysis of the flexors in the forearm, especially the flexor carpi radialis. Weakness in active flexion against resistance indi- cates a problem with the median nerve at the level of the elbow or further proximally. Complete inability to flex the wrist against resist- ance could indicate a lesion involving both the median and ulnar nerves. Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. In children and adolescents, it is usually a sign of a serious disorder and therefore always requires a thorough diagnostic workup. Patients usually report hip pain in the groin or posterior to the greater trochanter, occasionally radiating into the medial aspect of the thigh as far as the knee. For this reason, especially in children, a hip disorder can be easily misinterpreted as a knee disorder. The differential diagnosis should include disorders of the adductor tendons, lumbar spine, and, especially, the sacroiliac joints. Many of the hip disorders associated with pain correlate with a certain age group. Frequent causes of pain in the hip include chronic hip dislocations and Legg–Calvé–Perthes disease in children and slipped capital femoral epiphysis in adolescents. In contrast, osteoarthritis of the hip is the primary cause of hip pain in adults.
In almost all patients purchase kamagra gold 100mg line, obesity and retinal degenera- GALE ENCYCLOPEDIA OF GENETIC DISORDERS 137 some also have undescended testes purchase kamagra gold 100 mg on line. In women with BBS buy kamagra gold 100 mg low cost, the genitalia buy generic kamagra gold 100 mg on line, ovaries buy 100 mg kamagra gold with amex, fallopian tubes, and uterus may or may Brachydactyly—Abnormal shortness of the fingers not be underdeveloped. Though some women with BBS do not menstruate, others menstruate irregularly, and some Electroretinogram (ERG)—A measurement of women are able to have children. Intravenous pyelogram—An x ray assessment of Some research indicates that people with BBS have kidney function. Occasionally, individuals with BBS have liver dis- Retinitis pigmentosa—Degeneration of the retina ease or heart abnormalities. While some BBS Syndactyly—Webbing or fusion between the fin- patients show normal intelligence, others have mild to gers or toes. These patients are often developmentally delayed—they are slower than most children to walk, speak, or reach other developmental tion begin in early childhood. Difficulty with language and comprehension present, are identified in school-aged children, if not ear- may continue into adulthood. Failure to menstruate leads to diagnosis of some ado- more severe mental retardation occurs. Infertility brings some young adults to vision handicap and developmental delay appear to be medical attention. Some parents report that their children with BBS Due to progressive degeneration of the retina, vision have behavioral problems that continue into adulthood. Specific vision defects These include lack of inhibition and social skills, emo- include poor night vision during childhood, severe tional outbursts, and obsessive-compulsive behavior. A Most people with BBS prefer fixed routines and are eas- few patients suffer from retinitis pigmentosa, a condi- ily upset by a change in plans. Diagnosis Many infants with BBS are born with a kidney Diagnosis of BBS is a challenge for medical profes- defect affecting kidney structure, function, or both. Not only do the symptoms of BBS vary greatly specific abnormality varies from patient to patient and from patient to patient, but some of these symptoms may be aggravated by lifelong obesity, another common occur in other conditions, many of which are more com- problem for BBS patients. Instead, it is the association of many BBS symptoms in BBS patients may have extra fingers or toes (poly- one patient that generally leads to a clinical diagnosis. Syndactyly, the fusion throughout childhood, patients diagnosed as infants of two or more fingers or toes, may also occur. Some BBS families, all affected members display at least some disorders historically confused with BBS include of these limb abnormalities. Lawrence-Moon syndrome, Kearns-Sayre syndrome, and Many individuals with BBS have genital abnormali- McKusick-Kaufman syndrome. Most boys with BBS have a very small penis and also caused by mutation in the MKKS gene; in fact, the 138 GALE ENCYCLOPEDIA OF GENETIC DISORDERS gene took its name from McKusick-Kaufman syndrome. Genetic symptoms as BBS patients, the specific MKKS mutation counseling is available to help fertile BBS patients differs between the conditions. Prognosis These are retinal degeneration, polydactyly, obesity, The outlook for people with BBS depends largely on learning disabilities, kidney abnormalities, and genital the extent of the birth abnormalities, prompt diagnosis, defects (in males). At this time there is no treatment for should receive three particular diagnostic tests. However, exam called an electroretinogram is used to test the elec- good health care beginning in childhood can help many tric currents of the retina. An ultrasound is used to exam- people with BBS avoid other serious effects of this disor- ine the kidneys, as is an intravenous pyelogram (IVP). Researchers are actively exploring genetic causes, IVP is an x-ray assessment of kidney function. Treatment and management Resources Unless they have severe birth defects involving the BOOKS heart, kidneys, or liver, patients with BBS can have a “Bardet-Biedl Syndrome. Because BBS carriers also appear prone to kidney disease, parents and siblings of patients with BBS should ORGANIZATIONS take extra precautions. Executive Plaza 1, Suite 800, for kidney defects or cancer, as well as preventive health 11350 McCormick Rd. NW, #404, Washing- In order to conserve vision to the extent possible, ton, DC 20008.
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