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By: M. Jorn, M.B.A., M.D.

Deputy Director, University of Missouri-Columbia School of Medicine

Bradycardia If the heart rate is <60 beats/min gastritis diet åâðîñïîðò cheap 20 mg pantoprazole otc, the patient gastritis diet 80 purchase 20 mg pantoprazole with visa, by definition gastritis questionnaire buy pantoprazole 20 mg without prescription, has a brady cardia (an arbitrary definition). A slow pulse can be physiological (in trained athletes) but may also be indicative of potentially serious cardiac disease. Breathlessness Dyspnoea is the perception of breathlessness and may be exertional or, when more advanced, occur at rest. Ask how far the patient can walk without stopping (often an unreliable history) and how many pillows he/she uses in bed at night (in orthopnoea). Note: Remember metabolic acidosis—diabetic and alcoholic ketoacidosis, 17 lactic acidosis (in metformin-treated patients, especially if renal impairment). Note: Occasionally, diabetic ketoacidosis may present in the absence of marked hyperglycaemia. In alcoholic ketoacidosis, plasma glucose may not be ele vated and Ketostix reaction may be misleading (p151). Bruising Easy bruising is a common complaint and warrants careful assessment of onset and nature. Recent onset of spontaneous and unusual bruising or bleeding may suggest a serious acquired defect. Examine: skin, mouth, dependent areas and fundi for mucocutaneous bleeding and purpura (non-blanching haemorrhages into the skin). Coagulopathy 2 Congenital—mucocutaneous bruising is suggestive of a platelet-medi ated defect. Calf swelling 19 Assess whether swelling is bilateral or unilateral, precipitating factors and duration of onset. Careful examination of the affected leg should be extended to a full examination, particularly of abdominal and cardiovas cular systems. Thrombophilia screening for younger patients (age <55), atypical site and extensive clots, spontaneous onset, family history. A detailed history coupled with careful clinical examination can often clarify the diagnosis with a high degree of probability. Most commonly, symptoms are attributable to mus 20 culoskeletal causes, cardiac ischaemia or pleuritic disease. Pulmonary causes 2 Pulmonary embolism (associated infarction causes pleuritic pain). Sometimes a period of observation in hospital is required to exclude serious pathology. Increased availability of specific cardiac muscle protein (troponin I or T) helps to stratify risk in patients with acute coronary syndromes. The severity of pain is not always a reliable indicator of the seriousness of the disease. There is an increase in the soft tissue so that the distal phalanx becomes larger in all directions. The angle 22 between the nail and the nail bed is lost, the nail becomes curved, both longitudinally and laterally, and there is increased sponginess of the nail bed. Assess level of consciousness and determine whether this is stable, fluctu ating, improving or deteriorating on serial assessments. Glasgow Coma Scale Eye opening 1 Nil 2 To pain 3 To voice 4 Spontaneously Motor response 1 Nil 2 Extension 3 Flexion 4 Withdrawal from pain 5 Localising to pain 6 Voluntary Vocal response 1 Nil 2 Groans 3 Inappropriate words 4 Disorientated speech 5 Orientated speech 2 Cerebral tumour (associated local cerebral oedema may respond to dexamethasone). Always assess Airway, Breathing, Circulation before assessment of the cause of 5 consciousness. Confusion A reliable witness, family member or carer may be vital in assessing a patient with confusion, and care must be taken to discriminate between acute and chronic symptoms. Acute confusional states carry a very broad differential diagnosis and require careful initial evaluation. Constipation 26 Patients may use the term constipation to mean infrequent, hard, small volume or difficult to pass faeces. Patients vary enormously in their threshold to seek medical advice about bowel habit. Cyanosis Cyanosis refers to blue/purplish discoloration of tissues due to 4 in deoxy genated Hb content in blood (usually when >5g/dL). Central cyanosis refers to discoloration of mouth and tongue as well as peripheries. Cyanosis is easier to detect in individuals with polycythaemia and normal Hb, and may be missed if the patient has significant anaemia.

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The material on the spatula is spread in a thin layer in one movement over the middle third of the slide high fiber diet gastritis buy generic pantoprazole 20mg on line. Standard request form the fixed specimen is left to gastritis symptoms worse night order 40mg pantoprazole visa air dry and subsequently packed in the holder gastritis diet indian cheap pantoprazole online mastercard. Three categories are distinguished: satisfactory (synonyms: adequate, optimal) satisfactory for evaluation but limited by (qualify with reason) (synonym: suboptimal) unsatisfactory (qualify with reason), (synonym: inadequate or poor) Four kinds of criteria are used for the quality evaluation of the smear: identity details of the woman and specimen, availability of adequate and pertinent clinical data, cellular composition and technical interpretability. The quality of the smear to a great extent determines the accuracy of the cytological interpretation. Below is the definition of the three categories of quality evaluation: Satisfactory Satisfactory labelling of the specimen matching the identification details on the request form. The requirement for the presence of a transformation zone/endocervical component does not change with age and applies equally for pre and post menopausal women. The presence of metaplastic squamous cells and/or columnar cells as well as squamous cells or mucus indicate that the transformation zone has been sampled. On the basis of the cellular composition alone, the cytologist cannot guarantee that the entire circumference of the transformation zone has been sampled. Satisfactory for evaluation but limited by Between 50% and 75% of the specimen cannot be read because of interfering elements (blood, inflammation, aggregation of cells, defective fixation, drying artefacts, cytolysis, contamination etc. Unsatisfactory Too few squamousl cells: well-preserved and recognisable squamous cells covering less than 10% of the area of the smear. Smears in which abnormalities of the epithelial cells are discovered are not labelled “unsatisfactory”. With the specification of “satisfactory for evaluation but limited by” and ”unsatisfactory” the reason is given (see Table 2). Quality evaluation 0 Satisfactory 0 Satisfactory but limited by 0 Unsatisfactory Reasons: exclusively endocervical cells too much blood, pus no endocervical cells extensive cytolysis poor or unsatisfactory fixation poor smear technique too little cellular material other. Thompson [1989] considers the finding of squamous metaplasia to be a strong indication that a sample has been taken from the target zone. The presence of endocervical columnar cells proves that cellular material from beyond the transformation zone has been included in the specimen. The presence of squamous metaplastic and/or columnar cells as well as pavement cells, however, does not prove that the entire transformation zone was sampled. Many observations support the thesis that the presence of endocervical or metaplastic squamous cells increase the likelihood of finding cytological lesions. A few recent longitudinal studies do not support this contention [Kivlahan, 1986; Mitchell, 1991]. Boon [1993] stands by the contention that the presence of immature metaplastic cells and/or columnar cells is associated with the detection of high-grade intra-epithelial lesions. If low grade lesions are also included in the definition of a positive smear, this connection disappears. Boon [1993] also reports that the progressive nature of squamous cell lesions increases the closer they are to the metasquamo-columnar junction and therefore also pleads for double endocervical/exocervical sampling. Histological examination of conisation material and colposcopic observations confirm this latest thesis [Burghardt, 1998]. The exclusive presence of columnar cells (with no squamous cells) indicates a non-representative smear. Oorsprong staal cervix vagina Gynaecologische status Vorig uitstrijkje Datum laatste menses. Afname-instrument Gevolgde therapie Gecombineerde spatel Chemotherapie Pelvische radiotherapie Spatel en Cytobrush Anti-oestrogenen Cervex-Brush Andere:(preciseer) Andere relevante inlichtingen uit de anamnese of het klinisch onderzoek. A smear taken unsatisfactorily is a significant cause of false negative and false positive results. Below is a concise summary of “A technical guideline: collection of adequate Pap smears of the uterine cervix” compiled by the technical Sampling Working Group. The aim is to propagate the consensus amongst all general practitioners, gynaecologists, pathologists and other healthcare workers involved in the detection of cervical cancer in Flanders. Therefore, it is important that cell material be sampled primarily from this zone. An optimum smear contains metaplastic and columnar endocervical cells as well as squamous cells. The presence of significant quantities of blood cells or inflammatory cells can reduce the quality of the smear. Quality evaluation of the smear (satisfactory, satisfactory but limited and unsatisfactory) is an essential component of the cytology report.

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Other causes include excessive intake of alcoholic drinks chronic gastritis years purchase cheap pantoprazole online, regular eating of foods rich in protein and carbohydrates and lack of proper exercise gastritis diet óëûáêà cheap pantoprazole 40 mg free shipping. During the alarm reaction gastritis diet on a budget order pantoprazole in india, millions of body cells are destroyed and large quantities of uric acid freed from these cells enter the tissues after being neutralised by sodium. The patient should undertake a fast for five to seven days on orange juice and water. Sometimes the condition may worsen in the early stages of fasting when uric acid, dissolved by juices, is thrown into the bloodstream for elimination. In severe cases, it is advisable to undertake a series of short fasts for three days or so rather than one long fast. After the acute symptoms of gout have subsided, the patient may adopt an all-fruit diet for a. In this regimen, he should have three meals a day of juicy fruits such as grapes, apples, pears, peaches, oranges and pineapple. After the all-fruit diet, the patient may gradually embark upon the following diet: Breakfast: Fruits such as oranges, apples, figs, apricot, mangoes, whole wheat bread or dalia and milk or butter-milk. Lunch: Steamed vegetables such as lettuce, beets, celery, water-cress, turnips, squash, carrots, tomatoes, cabbage and potatoes, chappatis of whole wheat flour, cottage cheese and butter-milk. Dinner: Sprouts such as alfalfa and mung beans, a good-sized salad of raw vegetables such as carrots, cabbage, tomatoes, whole wheat bread and butter. The patient should avoid all purine and uric acid producing foods such as all meats, eggs, and fish. He should also avoid all intoxicating liquors, tea, coffee, sugar, white flour and its products and all canned and processed foods. Foods high in potassium such as potatoes, bananas, leafy green vegetables, beans and raw vegetable juices are protective against gout. Carrot juice in combination with juices of beet and cucumber, is especially valuable. The juice of French or string beans has also proved effective in the treatment of gout. Most headaches are functional, caused by temporary upsets and are not related to any organic changes in the brain. A headache is often nature’s warning that something is wrong somewhere in the body. The actual pain, however, arises from irritation to nerve endings in the shoulder, neck and scalp muscles and also in the smooth muscles encircling the blood vessels which serve these areas. Taking an aspirin or tranquiliser may provide temporary relief but it does not remove the cause. Moreover, the frequent use of pain-relievers causes nervous debility, weakens the heart and brings on other complications. The common causes of headaches are allergy, emotional reasons, eyestrain, high blood pressure, hangover, infection, low blood sugar, nutritional deficiency, tension, the presence of poisons and toxins in the body, and migraine. The foods to which some people are allergic and which can trigger headaches are milk and milk products, chocolates, chicken liver, alcohol and strong cheese. Many people who outwardly appear to have a pleasant disposition may actually be simmering about a job, or may bear resentment towards a person or something. It is important, therefore, that negative feelings should not be bottled up, but should find some safe means of expressions. Simple eye exercises such as moving the eyes up and down and from side to side, palming, rotating the head, with neck outstretched, forward and backward three times, then thrice clockwise and thrice anti-clockwise, can relieve eye-strain. A safe method of treatment for this is to immerse your legs to calf-level in a tub of hot water for 15 to 20 minutes. This draws the blood away from the head and down to the feet, giving relief from the headache. A hangover headache can be avoided by taking a vitamin B-1 (thiamine) tablet with the drink. For a cold, high doses of vitamin C should be taken at hourly intervals with the appearance of the first symptoms like a sore throat, runny nose, etc.

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Lubricants should be applied on the outside of the condom gastritis alcohol cheap pantoprazole online amex, in the vagina diet with gastritis buy pantoprazole amex, or in the anus gastritis diet xyngular buy pantoprazole 20mg mastercard. A drop or two of lubricant on the inside of the condom before it is unrolled can help increase the sensation of sex for some men. Materials that should not be used include: any oils (cooking, baby, coconut, mineral), petroleum jelly, lotions, cold creams, butter, cocoa butter, and margarine. Also if: o Client has difficulty using condoms correctly or every time he or she has sex. Give clients any information or help that they need (see Managing Any Problems, p. Give clients more condoms and encourage them to come back for more before their supply runs out. Helping Continuing Users of Male Condoms 205 Managing Any Problems Problems With Use May or may not be due to the method. If the client reports any problems, listen to the client’s concerns and give advice. The wrong lubricant or too little lubricant can increase breakage (see Lubricants for Latex Condoms, p. Difficulty putting on the condom o Ask clients to show how they put the condom on, using a model or other item. Difficulty persuading partner to use condoms or not able to use a condom every time o Discuss ways to talk about condoms with partner (see Bringing Up Condom Use, p. Mild irritation in or around the vagina or penis or mild allergic reaction to condom (itching, redness, rash, and/or swelling of genitals, groin, or thighs during or after condom use) o Suggest trying another brand of condoms. Tell the client to stop using latex condoms if symptoms become severe (see Severe allergic reaction to condom, below). Female partner is using miconazole or econazole (for treatment of vaginal infections) o A woman should not rely on latex condoms during vaginal use of miconazole or econazole. Severe allergic reaction to condom (hives or rash over much of body, dizziness, difficulty breathing, or loss of consciousness during or after condom use). Helping Continuing Users of Male Condoms 207 Questions and Answers About Male Condoms 1. When used consistently and correctly, only 2 of every 100 women whose partners use condoms become pregnant over the first year of use. Many people, however, do not use condoms every time they have sex or do not use them correctly. Plastic condoms are expected to provide the same protection as latex condoms, but they have not been studied as thoroughly. On average, about 2% of condoms break or slip off completely during sex, primarily because they are used incorrectly. Thus, it is important to teach people the right way to open, put on, and take off condoms (see Correctly Using a Male Condom, p. What can men and women do to reduce the risk of pregnancy and StIs if a condom slips or breaks during sex If a condom slips or breaks, taking emergency contraceptive pills can reduce the risk that a woman will become pregnant (see Emergency Contraceptive Pills, p. In one study, however, users reported less breakage when 2 condoms were used at once, compared with using 1 condom. Aren’t condoms used mainly in casual relationships or by people who have sex for money In Japan, for example, 42% of married couples use condoms—more than any other family planning method. Allergy to latex is uncommon in the general population, and reports of mild allergic reactions to condoms are very rare. A mild reaction involves redness, itching, rash, or swelling of the skin that comes in contact with latex rubber. A severe reaction involves hives or rash over much of the body, dizziness, difficulty breathing, or loss of consciousness after coming in contact with latex. More Protection against pregnancy: effective o As commonly used, about 21 pregnancies per 100 women using female condoms over the first year.