Daniel Y Song, M.D.
https://www.hopkinsmedicine.org/profiles/results/directory/profile/0010241/danny-song
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Flat and upright abdominal plain films should be obtained first in a patient complaining of abdominal pain unless a diagnosis of ischemia is clear anxiety symptoms in dogs order pamelor 25mg overnight delivery. Laparoscopy and enteroscopy may also be indicated in the appropriate clinical setting. Additionally, in patients with chronic kidney disease or impaired kidney function, gadolinium may not cause the contrast induced nephropathy seen with iodine. It can, however, uncommonly lead to nephrogenic systemic fibrosis, which is an irreversible condition. Describe the role of Doppler ultrasound studies in diagnosis Doppler ultrasound is a noninvasive test that evaluates the patency of and blood flow through the major mesenteric vessels. It should be performed while the patient is fasting and subsequently meal-stimulated. It is most helpful in diagnosing multivessel stenosis in suspected mesenteric angina by demonstrating narrowing or occlusion at a vessel origin and excessively turbulent flow. Of note, duplex ultrasound has limited capabilities in obese patients as ultrasound waves must pass through body tissue prior to producing a diagnostic image. What is the diagnostic role of endoscopy (sigmoidoscopy, colonoscopy, enteroscopy) and laparoscopy In spite of the fact that a small number of published case reports describe diagnostic findings of mesenteric ischemia via enteroscopy, this approach can be extremely dangerous because of the high risk of bowel perforation. Lower endoscopy, however, has been shown to be relatively safe and can aid in determining the diagnosis of a patient with suspected ischemic colitis (see Questions 24-28). Laparoscopy, although invasive, has also been shown to be a relatively safe technique in assisting with diagnosis and assessing the degree of injury to the intestines. It can easily detect full-thickness mesenteric injury; however, it is limited in the fact that it will miss the earlier stages of potentially reversible ischemia because injury starts mucosally and then moves transmurally to the serosa. Additionally, when intraperitoneal pressure exceeds 20 mm Hg, a level often attained after insufflation during laparoscopy, splanchnic blood flow decreases. When the diagnosis and treatment of ischemic bowel disease is delayed and peritoneal signs and acidosis ensue, the mortality rate increases significantly. Angiography is the gold standard for diagnosis of mesenteric arterial occlusion and can help to differentiate between embolic and thrombotic etiologic factors. The cutoff of a major artery in the absence of collateral vessel enlargement is indicative of an embolic cause, whereas vessel narrowing with the development of collaterals signifies thrombosis. Additionally, the venous phase of angiography may demonstrate venous occlusive disease. Angiography can also be used as a therapeutic modality by selectively infusing vasodilating drugs or thrombolytics, and aiding in the completion of angioplasty, balloon embolectomy, or stent placement. Because of the risks associated with the administration of thrombolytic agents, their use should probably be limited to poor surgical candidates without peritoneal signs, to those in whom the ischemic event is considered to be reversible or of short duration, and to tertiary care centers with technical expertise. Atherosclerosis commonly involves the femoral artery, which is usually the site of entry for the angiographic catheter.
Her antinuclear antibody anxiety pills cheap 25 mg pamelor otc, antimitochondrial antibody, and smooth muscle actin were negative. She was diagnosed with Budd Chiari syndrome and placed on anticoagulation and diuretics, although she continued to have ascites and lower-extremity edema. A transjugular intrahepatic portosystemic shunt procedure was performed, which markedly improved her fluid status. The patient is asymptomatic, although he does endorse 25 pounds of weight gain in the last 10 years coincident with a knee injury that decreased his activity level. He was diagnosed with diabetes approximately 5 years ago and takes metformin 500 mg twice daily only along with lisinopril/hydrochlorothiazide for hypertension. Physical examination is notable for an obese Hispanic male (body mass index 36) with a protuberant abdomen and a liver edge palpable 3 cm below the costal margin. Complete blood count is notable only for a platelet count of 156,000, basic metabolic panel is normal, and international normalized ratio is 1. Right upper quadrant ultrasound demonstrates increased echogenicity consistent with a fatty liver and mild hepatomegaly. The patient is counseled that he has a significant risk of progression to cirrhosis as he already has stage 3 early bridging. He is started on pioglitazone 30 mg daily and enrolled in a supervised diet program with the goal of 8% to 10% body weight loss in 12 months. After clearance from his primary care physician to begin an exercise program, he begins a combined cardiovascular and weight training program, working up to a goal of 45 minutes four times per week of moderate-intensity exercise. His primary care provider is advised to restart the simvastatin, which was held for the elevated liver enzymes to modify his cardiovascular disease risk. He is counseled to avoid alcohol and consider moderate daily unsweetened caffeinated coffee intake. He will be seen in follow-up every 6 months with consideration of screening for hepatocellular carcinoma given his advanced fibrosis. Virtually all patients who receive a liver transplant for hepatitis C will have recurrent infection, with 20% to 40% developing cirrhosis by the fifth postoperative year. Development of cirrhosis in this setting may result in an accelerated course, leading to clinical decompensation in more than 40% of patients within 1 year, followed by a decline in 1-year survival to as low as 40%. Most patients will have mild to moderate elevations in aminotransferases and evidence of fibrosis on liver biopsy. Surveillance liver biopsies are typically performed 6 to 12 months after surgery (or whenever liver function tests are elevated) to determine the extent of histologic injury. A patient who had an uncomplicated transplant is noted to have rising liver enzymes on day 10 after transplantation.
Her pain is located in the right upper quadrant anxiety back pain purchase 25mg pamelor, radiates to the back, and on two occasions has been associated with elevation in hepatic enzymes, which then normalize when the pain is improved at time of follow-up with her primary care manager. Medical and surgical history is remarkable for left knee reconstruction 10 years ago. Her family history is remarkable for grandmother, aunt, mother, and two sisters who had cholecystectomy for symptomatic gallstones. Physical examination shows normal blood pressure tachycardia (104 beats per minute [bpm]), afebrile, and 20 respirations per minute. Sclera are white, lungs exhibit rales, the abdomen is tender to palpation in the midepigastrium, and bowel sounds are absent. Control of pain with narcotics is essential, but one must monitor with pulse oximetry. Some favor the use of magnetic resonance cholangiopancreatography or endoscopic ultrasound to exclude the persistence of common bile duct stone preoperatively. Laparoscopic cholecystectomy should be performed during the same admission; otherwise recurrent pancreatitis is seen in 25% to 50% of cases. Gallstone pancreatitis: Does discharge and readmission for cholecystectomy affect outcome The pain was characterized as acute-onset midpain that radiated direct to the back-identical to prior episodes. Medical and surgical history is remarkable for hepatitis C infection successfully treated 4 years ago, recurrent calcific pancreatitis for the last 3 years, and cesarean section. Physical examination shows normal blood pressure tachycardia (104 beats per minute), afebrile, and respirations of 20 per minute. Sclera are white, lungs exhibit rales, abdomen is tender to palpation in the midepigastrium, and bowel sounds are absent. Pancreas demonstrates diffuse stippled calcification of the gland and "chain of lakes" changes of the pancreatic duct. Long-term management will include small meals, a low-fat diet, and abstention from all alcohol and tobacco. The utility of supplemental pancreatic enzymes is not clear for diminishing recurrent attacks, but is important for those with steatorrhea and fat malabsorption caused by exocrine insufficiency. Autoimmune pancreatitis: An update on classification, diagnosis, natural history and management. Based on this finding, the patient was referred to a gastroenterologist for further evaluation. Given the minimal enteropathy findings and low positive serologic results, the patient underwent repeat endoscopy and multiple biopsies were taken from second portion of duodenum and duodenal bulb. The final histologic examination revealed Marsh 3 lesions, which confirmed celiac disease in the setting of positive serologic findings. The patient was placed on a gluten-free diet with resolution of her symptoms over the following months.
The inferior mesenteric vein joins the splenic vein near the juncture of the superior mesenteric and splenic veins anxiety vertigo cheap 25 mg pamelor mastercard. An extensive collateral circulatory system exists between the systemic and splanchnic vascular networks. Schematic representation of collateral channels between the three major mesenteric arteries. The development of alternative anastomoses and collateral flow makes it theoretically possible that any single artery could supply all of the abdominal viscera with arterial blood given sufficient time and opportunity, that is, gradual occlusion of one or two of the other major arterial vessels. The marginal artery of Drummond is an arterial connection that provides a continuous channel of collateral flow via the vasa recta to the small and large intestines. Autoregulation is the concept by which blood flow remains relatively constant via the response of arterioles and venules to changes in perfusion. A steep gradient of pressure exists between the artery and proximal portion of the arteriole. If there is a decrease in arterial perfusion or an increase in oxygen demand (as in the postprandial state), arterioles dilate and additional capillaries are recruited to prevent tissue hypoxia. Additionally, adjustments in the resistance of the venous system are employed to maintain adequate cardiac output. Ischemic bowel disease can be sorted into various categories based on the vascular component affected (arterial or venous), the duration of reduction of blood flow through the vessel (acute or chronic), and the cause of the reduction in flow (occlusive or nonocclusive). The assured delivery of oxygen-rich arterial blood to the various layers of the small and large intestinal wall during basal, meal-stimulated, and stress states depends on the interplay between various anatomic and physiologic factors, including blood viscosity, red blood cell oxygen saturation, arteriole length and resistance to flow, tone of precapillary sphincters, tone of vascular smooth muscle, and venous capacitance. Classification of mesenteric vascular disease based on the extent of resulting ischemia. This particular classification, proposed by Williams, may facilitate more effective evaluation and management by focusing on extent of gut involvement. As the radius of an artery decreases, the resistance to flow increases by a power of 4. Autoregulation (see Question 4) results in vasodilation to maintain flow up to a finite point, beyond which flow decreases. Examples of such instances are acute or chronic arterial thrombi, an embolus, or transient vasoconstriction. Abdominal angina refers to chronic, recurrent abdominal pain caused by a decrease in arterial blood flow through the mesenteric arteries, usually resulting from stenosis from atherosclerotic lesions. The postprandial state can be regarded as an exercise stimulus; food entering the stomach causes an increase in oxygen demand thereby decreasing blood flow to the intestines (steal phenomenon). Initially, abdominal angina is usually minimal; however, it progressively increases in severity over weeks to months. Long-term hypoxia of the small intestinal mucosa can cause villous atrophy leading to diarrhea, protein-losing enteropathy, steatorrhea, weight loss, and malnutrition.
For patients with known ischemic cardiac disease anxiety questionnaire pdf generic 25mg pamelor with mastercard, much closer monitoring is recommended, with reduction or discontinuation of therapy if the hemoglobin decreases by more than 2 g/dL compared with baseline. Other side effects from ribavirin include rash, shortness of breath, nausea, sore throat, cough, and glossitis. The other side effects are generally not life-threatening and can be treated symptomatically. Because ribavirin is teratogenic, both men and women should be advised to practice effective contraception during therapy and for 6 months after completion. As a result, a rapid and significant drop in hemoglobin is often seen early during therapy, nadir hemoglobin levels usually occur by week 12 of therapy. Hemoglobin levels should be monitored every 7 to 14 days initially and ribavirin dose reduction used to manage the anemia. A hemoglobin decrease below 10 g/dL requires reduction of ribavirin dose to 600 mg daily, and a hemoglobin level below 8. When ribavirin dose is reduced in response to anemia, there is no decrease in sustained response rates. Rash or pruritus develops in more than 50% of treated patients, but in the majority of patients the rash is mild and does not require drug discontinuation. In mild cases, management consists of topical steroids and systemic antihistamines; systemic corticosteroids should not be used. In less than 10% a severe rash involving more than 50% of the body surface develops and requires discontinuation of telaprevir. Rare cases of serious rash events such as drug reaction with eosinophilia and systemic symptoms or Stevens-Johnson syndrome have been described, including reports of deaths secondary to skin reactions. The likelihood of serious skin events can be decreased by careful patient monitoring once rash develops and prompt discontinuation of telaprevir in patients with severe rash. Other side effects from telaprevir that rarely lead to therapy discontinuation include gastrointestinal symptoms such as nausea and diarrhea, and anorectal discomfort. Boceprevir side effects consist mainly of anemia and dysgeusia or changes in taste. The anemia with boceprevir therapy is similar in onset and severity to that seen with telaprevir and is managed in the same way. Dysgeusia has no specific management; although it may contribute to weight loss during therapy, it rarely leads to treatment interruption. Boceprevir therapy is not associated with an increased incidence in skin problems. Although only a few drugs are contraindicated in combination with telaprevir or boceprevir (Table 15-4), the blood levels of many others may be affected. It is not recommended for patients with decompensated cirrhosis because it is less effective and may worsen liver disease. If hepatitis C infection is diagnosed during pregnancy, treatment should be initiated only after delivery and breastfeeding have been completed.
With the infraclavicular approach anxiety scale proven pamelor 25mg, the surgeon has complete access to the anterior and posterior divisions; the lateral, posterior, and medial cords of the brachial plexus and their branches; and the musculocutaneous, subscapular, thoracodorsal, axillary, radial, ulnar, median, lateral, and medial pectoral nerves. The divisions of all three trunks help form the three cords of the brachial plexus. The anterior divisions of the upper and middle trunks unite to form the lateral cord, distal to the clavicle. The anterior division of the lower trunk continues to form the medial cord, which is medial to the axillary artery. All posterior divisions of the three trunks unite to form the posterior cord of the brachial plexus, which is situated behind the axillary artery. The musculocutaneous nerve descends into the biceps and the brachialis after supplying branches to the coracobrachialis muscle. The lateral pectoral nerve arises from the lateral cord and sends a ramus to the medial pectoral nerve, which forms a loop and penetrates through the clavipectoral fascia to innervate the pectoralis major muscle. The upper subscapular nerve is a small branch that runs posterior to the axillary artery and innervates the upper part of the subscapular muscle. The distal division, cords (yellow) and terminal branches are accessible via the infraclavicular approach. The lower subscapular nerve innervates the lower part of the subscapularis and teres major muscles. The axillary nerve generally arises from the posterior cord but can also arise from the posterior divisions of the upper and middle trunks. It runs anterior to the subscapularis muscle and passes through the quadrilateral space, which is bounded above by the subscapularis and teres minor muscles, below by the teres major muscle, medially by the long head of the triceps, and laterally by the surgical neck of the humerus. The axillary nerve innervates the articular shoulder joint, the deltoid and teres minor muscles, and the skin overlying the deltoid. The radial nerve is a large terminal branch of the posterior cord, which runs inferiorly toward the humeral groove and wraps around the humerus. Meticulous hemostasis can be achieved through the use of the bipolar cautery throughout the dissection. Placement of tourniquets around the extremities is seldom required, and their use can cause ischemia to tissue or further compressive and ischemic damage to an already injured nerve. The cephalic vein is typically ligated as it crosses the axillary vein close to the clavicle. Dissection After the subclavicular muscle and vein are dissected and ligated, the clavicle can be mobilized and retracted superiorly by using a moistened sponge, which is placed under and around the clavicle to expose the infraclavicular portion of the brachial plexus. After self-retaining retractors, such as an Adson, are placed between the deltoid and pectoralis major muscles along the deltopectoral groove, the clavipectoral fascia is identified and then divided to expose the origin of the pectoralis minor muscle at the coracoid process.
It produces liver injury in virtually all animals who consume toxic doses anxiety 5 4 3-2-1 buy pamelor 25mg with amex, although there is variability in the doses required. Idiosyncratic reactions may or may not be accompanied by immunoallergic manifestations such as fever, peripheral eosinophilia, skin rash, and arthralgias. Mallory-Denk bodies are cytoplasmic hyaline inclusions in hepatocytes and may develop as a result of alcoholic or nonalcoholic steatohepatitis. Peliosis hepatis is the presence of cystic, blood-filled cavities (vascular lesions) distributed randomly throughout the liver parenchyma. Phospholipidosis is the excessive accumulation of phospholipids in cells, which can be seen as foamy macrophages or cytoplasmic vacuoles on light microscopy, or lamellar inclusions or myeloid bodies in electron microscopy. After 5 years of oral contraceptive use, the relative risk of developing a hepatic adenoma has been estimated to increase 116-fold. Hepatic adenomas often regress when exogenous estrogen is removed and can recur during pregnancy. Hepatic adenomas are usually asymptomatic but can be associated with abdominal fullness, pain, hepatomegaly, and hemorrhage. Diclofenacrelated liver injury is seen more often in older women with osteoarthritis. Reexposure can cause recurrence and features suggest an immune and allergichypersensitivity etiologic foundation. It was removed from the market in 2000 following reports of severe hepatotoxicities and fatalities. Metformin is safe if dose adjustments are made in renal-liver impairment, surgery, and contrast studies. Use with caution in patients with history of sulfonamide hypersensitivity or hepatotoxicity. Steroid Derivatives Anabolic Steroids Methyltestosterone, methandrostenolone, oxymetholone, danazol, fluoxymesterone, stanazol, norethandrolone, oxandrolone Oral Contraceptives Tamoxifen They cause cholestasis or canalicular liver injury. Alkylation of the C-17 position of testosterone made anabolic steroids available in oral form. Liver injury is thought to be due to an idiosyncratic reaction to tamoxifen metabolites. Amiodarone Metabolites can form intralysosomal inclusions, a hallmark of phospholipidosis. Diuretics There have been no case series to suggest hepatotoxicity among this class. Hydralazine -methyldopa Toxic metabolic intermediates act as antigenic haptens in susceptible hosts. It can cause acute-chronic hepatitis, cholestatic hepatitis, fulminant liver failure, and cirrhosis. Antihyperlipidemics Fenofibrates Typically hepatocellular injury, but mixed and cholestatic patterns are reported.
The medial pectoral nerve is a branch of the medial cord and its axons belong to C8 and T1 in the majority of cases anxiety blog generic pamelor 25 mg otc. It can be harvested during the dissection of the infraclavicular space and connected to the axillary nerve directly or with an interpositional graft from the medial antebrachial cutaneous nerve. Another surgical strategy to regain deltoid function after axillary nerve damage is a radial nerve transfer. In such cases, the radial nerve branch for the lower triceps medial head and anconeus is transferred to the anterior division of the axillary nerve. Dissection of the radial branch and exposure of the axillary nerve are performed through a larger skin incision than that of the posterior approach to the axillary nerve. The nerve to the lower triceps medial head and anconeus isdissecteddistally,thensectionedandflipped180degreesto be sutured to the axillary nerve. Other nerves that can be used for axillary nerve neurotization include the long thoracic, intercostals, thoracodorsal, suprascapular, and distal accessory nerve. Conclusion Lesions of the axillary nerve limit the abduction of the arm and cause loss of sensation in the superior lateral brachial cutaneous dermatome. Depending on the features of the lesion and the anatomic location, an anterior or posterior approach may be selected. The surgeon treating a discontinuing lesion of the axillary nerve may be familiar with the different neurotization techniques for reconstruction. Early involvement of the physical therapy team is essential for optimal recovery of function. Medial pectoral nerve to axillary nerve neurotization following traumatic brachial plexus injuries: indications and clinical outcomes. Exhaustive hemostasis is combined with generous irrigation of saline solution containing antibiotic agents during standard multilayer closure. Bohnen, Joseph Weiner, and Aruna Ganju the upper limb is innervated by the anterior rami of spinal nerves C5 to T1. Collectively, these rami form a network of nerves referred to as the brachial plexus, which extends from the neck and courses distally through the axilla, providing motor and sensory innervation to the upper limb. As the plexus courses distally, it forms roots, trunks, divisions, cords, and terminal branches. In the proximal arm, it receives the majority share of its blood supply from the anterior circumflex humeral artery and from the brachial artery more distally. It provides motor innervation to anterior compart ment muscles, including the coracobrachialis, brachialis, and biceps brachii.
Dolok, 52 years: The nerve itself is freed surgically; however, the subsequent healing process only produces more scar. Small lacerations to the liver or spleen are readily identifiable and should be treated with aggressive resuscitation. The lower subscapular nerve innervates the lower part of the subscapularis and teres major muscles. Jaundice caused by biliary obstruction is the most common (>50%) presentation among patients with pancreatic head cancer (Table 38-1).
Mazin, 45 years: Lateral femoral cutaneous neuropathy and its surgical treatment: a report of 167 cases. The vast majority of patients improve about 10 months after therapy has been discontinued. In either case, the lesions may be plaques (occasionally with Wickham striae), small papules, or exfoliative erythema. C, Central diaphragm sign refers to free intraperitoneal air, which outlines the entirety of the diaphragm, the central portion of which (black arrow) is not normally visualized because of contact with the heart.
Pavel, 29 years: If pseudocyst is the cause of the biliary obstruction, decompression of the pseudocyst should be the initial approach, and if not amenable to endoscopic drainage then surgical biliary decompression may be combined with cystojejunostomy. Note the appearance of thumbprints in the transverse colon (arrows) seen on barium enema. Physical examination shows normal blood pressure tachycardia (104 beats per minute [bpm]), afebrile, and 20 respirations per minute. Chromic acid burns, which may be seen in electroplating and dye production occupations, may result in extensive tissue necrosis and acute renal damage.
Chris, 64 years: Sorbic acid is a rare sensitizer among the preservatives; however, it is a cause of facial flushing and stinging through its action as an inducer of nonimmunologic contact urticaria. Adenocarcinoma can present with an annular narrowing, an intraluminal polypoid mass, or eccentric lobulated wall thickening. Age and preexistent comorbidities, especially obesity, osteoporosis, and cirrhosis, also contribute. The nonacetylated salicylates (trilisate and salsalate) do not crossreact with aspirin in patients experiencing bronchospasm and may be safe alternatives.
Enzo, 44 years: The lack of circulation produces edema, paresthesias, and damage to the blood vessels. Ann Plast Surg 1995;35:590 594 Benezis I, Boutaud B, Leclerc J, Fabre T, Durandeau A. Interventions for treating the radial tunnel syndrome: a systematic review of observational studies. Mast cell granules stain metachromatically with toluidine blue and methylene blue (in Giemsa stain) because of their high content of heparin.
Ramirez, 38 years: Patients present in the third trimester with fever, systemic symptoms, and possibly vesicular cutaneous rash. American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected]. Complications can include hemorrhoids, anal fissures, fecal impaction, rectal prolapse, and stercoral ulcers, among others. Dilution by water or hypotonic urine will falsely lower fecal electrolyte concentrations and will elevate the calculated osmotic gap.
Mason, 25 years: They are classified as genotypes 1 through 6, with several subtypes denoted as 1a, 1b, 2a, and so forth. Any combination of these is subsumed under the expression "syndrome of immediate reactions. This is analogous to the exposure of the median nerve behind the flexor digitorum sublimis muscle. It is not a constant ligament, present in only 1% of humans, and it may be acquired or congenital.
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