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Medical Instructor, Texas A&M Health Science Center College of Medicine
The nurse assists the patient to prepare physically and psychologically for these procedures and monitors carefully for signs and symptoms of dehydration and exhaustion muscle relaxant gel uk imuran 50 mg visa. Medical Management the goal of management is to eradicate the tumor before metastasis occurs (Kirkali infantile spasms 4 year old order generic imuran online, Tuzel & Munga muscle relaxant for sciatica purchase imuran 50 mg fast delivery, 2002) spasms after urinating buy imuran 50 mg otc. Radiation therapy, hormonal therapy, or chemotherapy may be used along with surgery. For patients with bilateral tumors or cancer of a functional single kidney, nephron-sparing surgery (partial nephrectomy) may be considered. Favorable results have been achieved in patients with small local tumors and a normal contralateral kidney. Nephron-sparing surgery is increasingly being used to treat patients with solid renal lesions. After surgery, the patient usually has catheters and drains in place to maintain a patent urinary tract, to remove drainage, and to permit accurate measurement of urine output. The patient requires frequent analgesia during the postoperative period and assistance with turning. Turning, coughing, use of incentive spirometry, and deep breathing are encouraged to prevent atelectasis and other pulmonary complications. The patient and family require assistance and support to cope with the diagnosis and uncertainties about the prognosis. The patient is taught to inspect and care for the incision and perform other general postoperative care. Additionally, the patient learns about activity and lifting restrictions, driving, and use of pain medications. Instructions are provided about follow-up care and when to notify the physician about problems (fever, breathing difficulty, wound drainage, blood in the urine, pain or swelling of the legs). The patient is encouraged to eat a well-balanced diet and to drink adequate liquids to avoid constipation and to maintain an adequate urine volume. Education and emotional support are provided related to the disease process, treatment plan, and continuing care because many patients are concerned about the loss of the other kidney, the possible need for dialysis, or the recurrence of cancer. The patient who has had surgery for renal carcinoma should have a yearly physical examination and chest x-ray because late metastases are not uncommon. If follow-up chemotherapy is necessary, the patient and family are informed about the entire treatment plan or chemotherapy protocol, what to expect with each visit, and how to notify the physician. Cancers arising from the prostate, colon, and rectum in males and from the lower gynecologic tract in females may metastasize to the bladder (Chart 45-14). Clinical Manifestations Bladder tumors usually arise at the base of the bladder and involve the ureteral orifices and bladder neck. Infection of the urinary tract is a common complication, producing frequency, urgency, and dysuria. Any alteration in voiding or change in the urine, however, may indicate cancer of the bladder. Biopsies of the tumor and adjacent mucosa are the definitive diagnostic procedures. Transitional cell carcinomas and carcinomas in situ shed recognizable cancer cells. Cytologic examination of fresh urine and saline bladder washings provide information about the prognosis, especially for patients at high risk for recurrence of primary bladder tumors (Amling, 2001). Bladder tumor antigens, nuclear matrix proteins, adhesion molecules, cytoskeletal proteins, and growth factors are being studied to support the early detection and diagnosis of bladder cancer. There are an increasing number of molecular assays available for the detection of bladder cancer (Saad, Hanbury, McNicholas et al. Medical Management Treatment of bladder cancer depends on the grade of the tumor (the degree of cellular differentiation), the stage of tumor growth (the degree of local invasion and the presence or absence of metastasis), and the multicentricity (having many centers) of the tumor. It affects men more than women (3:1) and is more common in whites than in African Americans. Bladder cancer is the fourth leading cause of cancer in American men, accounting for more than 12,000 deaths in the U. There are two forms of bladder cancer: superficial (which tends to recur) and invasive. About 80% to 90% of all bladder cancers are transitional cell (which means they arise from the transitional cells of the bladder); the remaining types of tumors are squamous cell and adenocarcinoma.
After prick or scratch tests spasms while high effective 50 mg imuran, intradermal skin testing is performed with allergens that did not elicit positive reactions knee spasms pain best purchase for imuran. Because a larger antigen challenge is being used muscle relaxant comparison chart order imuran uk, local or systemic reactions could occur if the same antigens that produced positive skin or scratch reactions are used spasms while pregnant imuran 50mg with visa. The back is the most suitable area of the body for skin testing because it permits the performance of many tests. The multitest applicator is a commercially available device with multiple test heads that allows simultaneous administration of antigens by multiple punctures at different sites. Interpretation of Skin Test Results Familiarity with and consistent use of a grading system are essential. The grading system used should be identified on a skin test sheet for later interpretation. A positive reaction, evidenced by the appearance of an urticarial wheal (round, reddened skin elevation). The needle is inserted with the bevel facing upward and the syringe parallel to the skin. The skin is penetrated superficially, and a small amount of the allergen solution is injected to create a bleb (raised area) approximately 5 mm in diameter. Chapter 53 Assessment and Management of Patients With Allergic Disorders 1589 Negative wheal 1+ wheal Reaction Guide 2+ wheal 4+ 3+ 2+ 1+ 0. The major disadvantages include the limited allergen selection, reduced sensitivity compared with intradermal skin tests, lack of immediate results, and cost. The use of skin tests to diagnose immediate hypersensitivity to medications is limited because metabolites of medications, not the medications themselves, are usually responsible for causing hypersensitivity. Allergic Disorders There are two types of IgE-mediated allergic reactions: atopic and nonatopic disorders. While the underlying immunologic reactions of the two types of disorders are the same, predisposing factors and manifestations are different. The atopic disorders are characterized by a hereditary predisposition and production of a local reaction to IgE antibodies produced in response to common environmental allergens (Kay, 2001a). The nonatopic disorders lack the genetic component and organ specificity of the atopic disorders (Porth, 2002). Examples of atopic disorders are allergic rhinitis, allergic asthma, and atopic dermatitis (Kay, 2001a). A type I hypersensitivity response results in atopic (allergic) diseases, which affect 10% to 20% of the U. Disorders characterized as atopic include anaphylaxis, allergic rhinoconjunctivitis, atopic dermatitis, urticaria and angioedema, gastrointestinal allergy, and asthma. This type of testing is helpful in identifying clinically significant allergens in patients with a large number of positive tests. Major disadvantages of this type of testing are the limitation of one antigen per session and the risk of producing severe symptoms, particularly bronchospasm, in patients with asthma. After the serum is centrifuged, radioimmunoassay detects the allergen-specific IgE antibody. An anaphylactic reaction can be triggered by exposure to an antigen through inhalation, injection, ingestion, or skin contact. Chart 53-3 Common Causes of Anaphylaxis Pathophysiology Anaphylaxis is caused by the interaction of a foreign antigen with specific IgE antibodies found on the surface membrane of mast cells and peripheral blood basophils. The subsequent release of histamine and other bioactive mediators causes activation of platelets, eosinophils, and neutrophils and the coagulation cascade. Smooth muscle spasm, bronchospasm, mucosal edema and inflammation, and increased capillary permeability result. These systemic changes characteristically produce clinical manifestations within seconds or minutes of antigen exposure (Neugut et al. Closely related to anaphylaxis is an anaphylactoid (anaphylaxis-like) reaction, which is described in Chart 53-2. Substances that most commonly cause anaphylaxis include foods, medications, insect stings, and latex (Chart 53-3). Foods that are common causes of anaphylaxis include peanuts, tree nuts, shellfish, fish, milk, eggs, soy, and wheat.
Genetic engineering and identification of cancer genes may make gene therapy a future possibility muscle spasms 37 weeks pregnant buy cheap imuran line. Radiation may be helpful and is more useful in some types of ovarian cancer than others muscle relaxant norflex purchase imuran now. After adjunct therapies are completed spasms spanish generic 50 mg imuran, a second-look laparoscopy or a laparotomy may be performed in some clinical centers to evaluate the treatment results and to obtain multiple tissue samples for biopsy spasms in stomach imuran 50mg sale. Occasionally, catheters are left in place if radioactive agents are to be used postoperatively. Malignant conditions often require a total abdominal hysterectomy and bilateral salpingo-oophorectomy (removal of fallopian tubes and ovaries). Laparoscopically assisted hysterectomy is performed by some physicians with excellent results and rapid recovery. This method is most often used for vaginal hysterectomy and is performed as a short-stay procedure or ambulatory surgery in carefully selected patients. Patients have a short hospital stay and a low incidence of postoperative infection. The number of hysterectomies in the United States per year has stabilized at 600,000, despite an increase in the number of babyboomers who have reached the age when this procedure is likely to be performed. The rate may be stabilizing because women often seek second opinions, and the number of therapeutic options (ie, laser therapy, endometrial ablation, and medications to shrink fibroid tumors) has increased. The lower half of the abdomen and the pubic and perineal regions may be shaved, and these areas are cleaned with soap and water (some surgeons do not require that the patient be shaved). The intestinal tract and the bladder need to be empty before the patient is taken to the operating room to prevent contamination and injury to the bladder or intestinal tract. An enema and antiseptic douche may be prescribed the evening before surgery, and the patient may be instructed to administer these treatments at home. Emotional support, comfort measures, and information, plus attentiveness and caring, are meaningful aids to the patient and her family. Nursing interventions after pelvic surgery to remove the tumor are similar to those after other abdominal surgeries. If ovarian cancer occurs in a young woman and the tumor is unilateral, it is removed. After childbirth, surgical re-exploration may be performed and the remaining ovary may be removed. Nursing care may include administering intravenous therapy to alleviate fluid and electrolyte imbalances, initiating parenteral nutrition to provide adequate nutrition, providing postoperative care after intestinal bypass to alleviate an obstruction, and providing pain relief and managing drainage tubes. These conditions are complex and often require assistance and support from an oncology nurse specialist. Comfort measures for women with ascites may include providing small frequent meals, decreasing fluid intake, administering diuretic agents, and providing rest. Patients with pleural effusion may experience shortness of breath, hypoxia, pleuritic chest pain, and cough. In addition, because the surgical site is close to the bladder, voiding problems may occur, particularly after a vaginal hysterectomy. Edema or nerve trauma may cause temporary loss of bladder tone (bladder atony), and an indwelling catheter may be inserted. During surgery, the handling of the bowel may cause paralytic ileus and interfere with bowel functioning. If the hysterectomy is performed to remove a malignant tumor, anxiety related to fear of cancer and its consequences adds to the stress of the patient and her family. These women may be at greater risk for psychological symptoms, physical symptoms, postmenopausal syndrome, and increased use of health care Hysterectomy A total hysterectomy involves removing the uterus and the cervix. Concerns such as the inability to have children and the effect on femininity may surface, as may questions about the effects of surgery on sexual relationships, function, and satisfaction. The patient needs reassurance that she will still have a vagina and that she can experience sexual intercourse after a temporary postoperative abstinence while tissues heal. Information that sexual satisfaction and orgasm arise from clitoral stimulation rather than from the uterus reassures many women. Most women note some change in sexual feelings after hysterectomy, but they vary in intensity. In some cases, the vagina is shortened by surgery, and this may affect sensitivity or comfort.
Reduction mammoplasty (discussed later in this chapter) is an elective procedure for the patient who is physically or emotionally distressed by this condition zma muscle relaxant buy genuine imuran on line. Pain and redness occur as a result of a superficial thrombophlebitis in the vein that drains the outer part of the breast muscle relaxant g 2011 generic 50mg imuran otc. Malignant Conditions of the Breast Breast cancer is a major health problem in the United States muscle relaxant without drowsiness discount imuran 50mg overnight delivery. For example muscle relaxant herniated disc discount imuran 50 mg mastercard, the risk for developing breast cancer by age 35 years is 1 in 622; the risk for developing breast cancer by age 60 years is 1 in 23. According to the American Cancer Society, more than 193,000 cases of breast cancer are diagnosed each year, with an estimated 40,000 deaths. Atypical hyperplasia is an abnormal increase in the ductal or lobular cells in the breast and is usually found incidentally in mammographic abnormalities. It involves inserting a microcatheter through the nipple while instilling saline and retrieving the fluid for analysis. It has been shown to identify atypical cells in this population (Dooley, Ljung, Veronisi et al. This disease is characterized by the proliferation of malignant cells within the ducts and lobules, without invasion into the surrounding tissue; therefore, it is a noninvasive form of cancer and is considered stage 0 breast cancer. Chapter 48 Ductal Carcinoma in Situ Assessment and Management of Patients With Breast Disorders 1457 Medullary Carcinoma Medullary carcinoma constitutes about 6% of breast cancers and grows in a capsule inside a duct. In some cases, lumpectomy alone is an option, but this is decided on a case-by-case basis. In 1999, a large study demonstrated that tamoxifen (Nolvadex) significantly reduced local recurrence rates (Fisher, Dignam, Wolmark et al. A mucin producer, it is also slow-growing and thus has a more favorable prognosis than many other types. Because axillary metastases are uncommon with this histology, prognosis is usually excellent. Inflammatory Carcinoma Inflammatory carcinoma is a rare type of breast cancer (1% to 2%) with symptoms different from those of other breast cancers. These symptoms rapidly grow more severe and usually prompt the woman to seek health care sooner than the woman with a small breast mass. The disease can spread to other parts of the body rapidly; chemotherapeutic agents play a major role in attempting to control the progression of this disease. It is commonly associated with multicentric disease and is rarely associated with invasive cancer. Another option is a bilateral prophylactic mastectomy to decrease risk; current research (Hartmann et al. The neoplasm is ductal and may be in situ alone or may also have invasive cancer cells. Often, a tumor mass cannot be palpated underneath the nipple where this disease arises. Mammography may be the only diagnostic test that detects the tumor, but results of the mammogram are often negative, making biopsy of the lesion the only definitive test. Current Research in Breast Cancer Because of the incidence, significant mortality, and lack of a cure, breast cancer survivors, advocates, and activists have brought social and political attention to this disease and put it in the national spotlight. Activists have demanded and obtained increased federal funding for a national program aimed at finding a cure for breast cancer. Preventing the development of cancer through the use of medications is a relatively new and exciting area of research. In April 1998, the results of the Breast Cancer Prevention Trial were released to the general public. This nationwide, randomized, double-blind, placebo-controlled clinical trial evaluated tamoxifen (Nolvadex) versus a placebo in more than 13,000 women considered to be at high risk for the development of breast cancer. The women who received tamoxifen had a 45% reduction in the incidence of breast cancer (Fisher et al. Much attention has been focused on this medication, and it is Infiltrating Lobular Carcinoma Infiltrating lobular carcinoma accounts for 5% to 10% of breast cancers. These tumors typically occur as an area of ill-defined thickening in the breast, as compared with the infiltrating ductal types.
Personal transition to the profession: a novel longitudinal professional development and wellness medical student curriculum muscle relaxant hair loss buy cheap imuran on line. Impetus: Medical student wellness may be able to be specifically taught through thoughtful curriculum design and implementation muscle relaxant topical purchase generic imuran online. Students prepare for each session by reviewing a learning guide and completing written exercises on a blog to stimulate reflection and narrative spasms to right side of abdomen order discount imuran on-line, then meet in small groups to process the exercise muscle relaxant lyrics order imuran 50mg online. Topics cover personal and educational goals and relationships with peers, positive psychology techniques, psychological struggles common in the profession of medicine such as perfectionism and impostor syndrome, and professional identity formation. Quantitative evaluations in the first two years included satisfaction measures by small group leaders and students (N=140). The majority of students felt more prepared to transition to medical school and more self-aware, and reported being willing to seek help if they need it. Some students were not comfortable discussing personal topics in small groups, and the facilitation of the faculty leader impacted group dynamics. The authors comment that an unintended effect of exposure to psychiatry faculty may have been to decrease stigma in seeking mental health care. Contribution: this study is limited by its lack of measurement of validated wellbeing metrics and lack of a comparison group. The strengths of this study include its high satisfaction measures and the in depth topical curriculum that is described. Cost: Unknown: the study did not report on costs directly, but direct and indirect costs would include preparation for monthly meetings, writing blogs, and participating in the one hour monthly meetings for all students and 20 faculty annually. Impetus: One potential reason why fewer than half of primary care doctors counsel their patients on lifestyle behaviors is the lack of structured training in medical school on lifestyle medicine. Description: In 2009 Harvard Medical School developed a voluntary medical student lecture series on lifestyle medicine through the Lifestyle Medicine Interest Group. The curriculum is led by student with a faculty advisor and began as a Lunch and Learn format with 4-5 lectures (4-8 curricular hours) each year. During the first year, 26 students participated; by 2013, 35 students participated annually. Survey data from 2013 (N=12, 35% response rate) revealed low baseline self-rated confidence in counseling patients for behavior change; the follow-up survey did not measure skills acquisition but qualitative comments suggested improved confidence. Contribution: Although this program has limited evaluation data, it provides a description of learning objectives for a curriculum to meet physician competencies in lifestyle medicine, and includes a model for implementation. The intervention included physician self-care skills in the lecture series, but no evaluation data were provided for this aspect of the intervention. Frates indicated that faculty time was the greatest cost (personal communication). Impetus: Although several studies have described reactive or supplemental approaches to medical student mental health, few studies have assessed curricular changes to prevent the negative psychological and emotional effects of medical school. Description: Curricular changes were first instituted in the 2009-2010 school year, using person-in-context primary prevention model to proactively target contextual elements within the curriculum that could contribute to poor mental health. Changes were made based on data from 2008 indicating that 57% of students had moderate-high anxiety and 27% had moderate-severe depression; volume and level of detail of material and competition were identified as drivers and were the impetus for changes. Curricular changes included: (1) a pass/fail grading system for preclinical courses, replacing the honors/near honors/pass/fail grading system; (2) a reduction in contact hours across the first two years of curriculum by 10% and reducing unnecessary detail in courses through course-specific faculty development; (3) the institution of longitudinal electives to allow students more time to explore their interests, create mentorship relationships, and to engage in service and/or research with more continuity; and (4) the establishment of learning communities composed of students and faculty who share common interests and passions beyond the classroom. In 2010-2011, a six-hour Resilience and Mindfulness program based in positive psychology was added to the first year clinical skills course. In 2011-12 anatomy was rescheduled to later in the year and exam design was changed. Students took an annual Center for Epidemiological Studies Depression Scale, Spielberger State-Trait Anxiety Inventory, Perceived Stress Scale, and Perceived Cohesion Scale. Postchange classes, compared to the historical cohort of pre-change classes, exhibited lower rates of moderate to severe depression symptoms and a substantial decrease in mean anxiety scores, as well as a nonstatistically significant decrease in the mean stress levels. Mean group cohesion and student satisfaction with the program scores were higher in the post-intervention cohorts. Although the design was not randomized, the evaluation strategy used validated measurement scales and compared the intervention group to a historical cohort.
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