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Uitgever: Mcgraw-Hill Education - Europe. Co-auteur: Josephson Scott. Samenvatting The authority of Harrison's in a handy, full-color paperback devoted exclusively to Neurology in Clinical Medicine This book is highly recommendedfor everybody interested inclinical neurology. For students whohave not yet received much exposureto patients with neurologicaldisease, it serves as a textbook thatbrings the structure that they needto understand neurology.
For experiencedneurologists who are beingconfronted with clinical neurologicalproblems on a daily basis, itserves as a stable, reliable, and up-to-date source of information thatcannot be equaled by the Internet. This new edition provides a necessary update, highlighting advances in the field that are of key clinical importance.
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Its quality, organization, and clinical relevance are outstanding. Students and practitioners in neurology, psychiatry, and primary care will find it a worthwhile resource. Over 80 questions and answers and over 50 chapters written by physicians, make for a powerful set of references and articles. Patlan; Mark T. Warner, Internal Medicine Multimedia ClinicalKey.
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Clinical Trials. Critical Care Subject guide. Family Medicine Subject guide. Infectious Disease Subject guide. Around half of such cases have asthma or will go on to develop asthma over the next few years. Half of the rest have rhinitis or sinusitis with a postnasal drip. In around 20 per cent the cough is related to gastro-oesophageal reflux. Cough is a common side effect in patients treated with angiotensin-converting enzyme ACE inhibitors. In this patient the diagnosis of asthma was confirmed with an exercise test, which was associ- ated with a 25 per cent drop in FEV after completion of 6 min of vigorous exercise.
Alternative bronchoprovocation tests include the use of inhaled methacholine or histamine, and a fall in FEV1 greater than 20 per cent. After the exercise test, an inhaled steroid was given, and the cough settled after 1 week. In some cases, the persistent dry cough associated with asthma may require more vigorous treatment than this. Inhaled steroids for a month or more or even a 2-week course of oral steroids may be needed to relieve the cough. The successful management of dry cough relies on establishing the correct diagnosis and treating it vigorously.
Twenty-four hours previously she developed a continuous pain in the upper abdomen that has become progressively more severe.
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The pain radiates into the back. She feels nauseated and alternately hot and cold. Her past medical history is notable for a duodenal ulcer, which was successfully treated with Helicobacter eradication therapy 5 years earlier. Examination The patient looks unwell and dehydrated. She is febrile, Cardiovascular and respiratory system exami- nation is normal. She is tender in the right upper quadrant and epigastrium, with guarding and rebound tenderness. Bowel sounds are sparse. Investigations Normal Haemoglobin Figure 5. Cholecystitis is most common in obese, middle-aged women and classically is triggered by eating a fatty meal.
Cholecystitis is usually caused by a gallstone impacting in the cystic duct. Continued secretion by the gallbladder leads to increased pressure and inflammation of the gallbladder wall. Bacterial infection is usu- ally by Gram-negative organisms and anaerobes. Ischaemia in the distended gallbladder can lead to perforation, causing either generalized peritonitis or formation of a localized abscess. Alternatively the stone can spontaneously disimpact and the symptoms spontane- ously improve.
Gallstones can become stuck in the common bile duct, leading to cholangitis or pancreatitis. Rarely, gallstones can perforate through the inflamed gallbladder wall into the small intestine and cause intestinal obstruction gallstone ileus. The typical symptom of acute cholecystitis is sudden-onset right upper quadrant abdominal pain that radiates into the back. An episode of prolonged right upper quadrant pain associ- ated with fever, suggests acute cholecystits rather than simple biliary colic. Jaundice usually occurs if there is a stone in the common bile duct.
In this patient the leucocytosis and raised CRP are consistent with acute cholecystitis. If the serum bilirubin and liver enzymes are very deranged, acute cholangitis due to a stone in the common bile duct should be suspected. The abdominal X-ray is normal; the majority of gallstones are radiolucent and do not show on plain films. Myocardial infarction or right lower lobe pneumonia may also mimic cholecystitis. This patient should be admitted under the surgical team.
Serum amylase should be measured to rule out pancreatitis. Blood cultures should be taken.
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Chest X-ray should be performed to exclude pneumonia and erect abdominal X-ray to rule out air under the diaphragm, which occurs with a perforated peptic ulcer. An abdominal ultrasound will show gallstones and inflammation of the gallbladder wall.
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The patient should be kept nil by mouth, given intra- venous fluids, analgesia and commenced on intravenous cephalosporins and metronidazole. The patient should be examined regularly for signs of generalized peritonitis or cholangitis. If the symptoms settle down the patient is normally discharged to be readmitted in a few weeks once the inflammation has settled down to have a cholecystectomy. There is a trend to performing immediate cholecystectomy in low risk patients. Her appetite is unchanged and normal; she has no nausea or vomiting, but over the last 2 months she has had an altered bowel habit with constipation alternating with her usual and normal pattern.
She has not seen any blood in her faeces and has had no abdominal pain. She has had no post-menopausal bleeding. There is no relevant past or family history, and she is on no medication. She has smoked 20 cigarettes daily for 48 years and drinks 20—28 units of alcohol a week.
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