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His a b d o m e n is so ft wit h a ct ive b o we l so u n d s a n d m ild epigastric tenderness buy 15 mg mobic, but there is no guarding or rebound tenderness discount 15 mg mobic free shipping, and no masses or organomegaly are appreciated buy mobic 15 mg low cost. Rectal examination shows black effective 7.5mg mobic, sticky stool, which is strongly positive for occult blood. H e is t ach ycar dic an d h as or t h ost at ic h yp o- tension, likely indicating significant hypovolemia as a result of blood loss. Rather than being a primary problem wit h his coronary art eries, such as t hrombosis or vasospasm, the cardiac ischemia is likely secondary to his acute blood loss and consequent tachycardia and loss of hemoglobin and its oxygen-carrying capacity. For a slowly developing, chronic anemia in pat ient s wit h good car diopu lmon ar y r eser ve, sympt om s m ay n ot be n ot ed u nt il the h em oglobin level falls ver y low, for example, t o 3 or 4 g/ dL. For pat ient s wit h serious underlying car diopulmonar y disease wh o depend on adequat e oxygen-carr ying capacit y, smaller declines in hemoglobin level can be devast at ing. Such is t he case wit h t he man in this clinical scenario, who is suffering a cardiac complication as a conse- quence of his anemia, in this case, unstable angina. Unstable angina is characterized by ischemic chest pain at rest, of new onset, or occurring at a lower level of activity. H e had been t reated wit h medical management, including dual antiplatelet therapy with aspirin and clopidogrel. In this case, it is more likely that his angina is secondary to the acute drop in hemoglobin rather than new car diac disease. In this case of secondary angina, the anemia must be corrected, which requires an underst anding of t ransfusion medicine. Anemia is generally considered to be a hemoglobin level less than 12 g/ dL in women or less than 13 g/ dL in men. Although lower values often can be tolerated or underlying et iologies treated, blood transfu- sions have been bot h necessary and lifesaving at t imes. Indicat ions for use of each of t hese blood comp on ent s are d escr ibed below. Many believe that a hemoglobin level of 7 g/ dL is adequate in the absence of a clear ly d efin ed in cr eased n eed, su ch as car d iac isch em ia, for wh ich a h emat ocr it level of at least 30% may be desired. Transfusion carries a small but definite risk, including transmission of infec- tion, reactions, and consequences. Rarely, bacterial cont amination (eg, Ye r - sin ia en t er ocolit ica ) causes fevers, sepsis, and even death during or soon after trans- fu sion. Par asit es (eg, m alar ia) are scr een ed for by qu est ion in g a d on or ’s med ical an d travel history. W ith respect to immune mechanisms, it is possible that a recipient has preformed natural antibodies that lyse foreign donor erythrocytes, which can be associated wit h t he major A and/ or B or O blood t ypes or wit h ot her ant igens (eg, D, D uffy, Kidd). Because hemolysis can ensue, a “type and cross” is first performed, in which blood samples are tested for compatibility prior to transfusion. The most common cau se of this r eact ion act u ally is cler ical (ie, m islabelin g). Acute hemolytic reactions may present with hypotension, fever, chills, hemoglobinuria, an d flank pain. T h e transfusion must be halted immediately, and fluid and diuretics (or even dialysis) should be given to prot ect t he kidney from failure via immune-complex depos- it s. Less predictably, milder, delayed hemolytic reactions involving amnestic responses from the recipient can occur. Febrile n on h emolyt ic t ran sfu sion react ion s can occur an d may be h elped by ant i- pyretics. Reactions range from urticaria treated with diphenhydramine and trans- fu sion in t er r u p t ion t o an aph ylaxis, in wh ich case the t r an sfu sion mu st be st op p ed, and epinephrine and steroids are needed. Adjust ing the volume and rat e and using diuret ics will prevent this complicat ion. Multiple and frequent transfu- sions can cause iron overload and deposition (hemosiderosis), leading to cirrhosis, car diac pr oblem s (eg, ar r h yt h mia, h ear t failu r e), or d iabet es. It also can be used in patients who are banking a pre- surgical aut ologous t ransfusion to encourage quicker recovery of t heir hemoglobin levels prior t o surgery. Cell savers salvage some int raoperat ive blood losses, wh ich are then t ransfused back into the patient. Some patients may not wish to have foreign blood product s t ran sfused based on religious convict ions. In t h ese cases, we can increase t he baseline hemoglobin level by using eryt h ropoiet in and iron before planned surgery, minimize phlebotomy for laboratory testing, and use cell savers during surgery. When 3 a pat ient has a platelet count of less than 50,000/ mm and has significant bleed- ing, or when a pat ient is at risk for spont aneous bleeding wit h a level of less t han 3 10,000/ mm, plat elet s can be t r an sfused. Platelet transfusion is contraindicated in pat ient s wit h t h rombot ic t hrombocyt openic purpura ( T T P ), as it may worsen microvascular thrombosis and cause worsening neurologic symptoms or renal failure. H e is not ed t o be in hypovolemic shock wit h a blood pressure of 60/ 40 mm H g. Which of t he following is the most appropriate t ype of blood t o be transfused? W hich of the following labo- ratory tests would most likely confirm an acute transfusion reaction? This patient needs a blood transfusion immediately, as evidenced by his dangerously low blood pressure. Even t h ough the pat ient ’s wife is “absolut ely sure” about t he blood t ype, hist ory is not complet ely reliable, and in an emer- gen t sit u at ion su ch that u n cr oss-m at ch ed blood mu st be given, O -n egat ive blood (universal donor) usually is administered. This patient is su ffer in g fr o m acu t e h em o lyt ic t r a n sfu sio n r eact io n ch a r ac- terized by fever, evidence of hypotension and hemolysis. When life-threatening acute bleeding occurs in the face of coagulopathy due to warfarin (Coumadin) use, the treatment is fresh frozen plasma. Sometimes vit am in K ad m in ist r at ion can b e h elp fu l if the b leed in g is n ot sever e. She also noticed small, reddish spots on her lower extremities when she got out of the bed this morning. Th e p a t ie n t re p o rt s sh e h a d d e ve lo p e d a n u p p e r re sp irat o ry in fe ct io n 2 weeks prior to the emergency room visit, but the infection has now resolved. Her menses have been normal, and her last menstrual period was approximately 2 weeks ago. She denies excessive bleeding in the p a st, e ve n a ft e r d e live rin g h e r b a b y. Prio r t o this e p iso d e, sh e n e ve r h a d epistaxis, easy bruisability, or bleeding into her joints. On e xa m in a t io n sh e is a le rt, o rie n t e d, a n d so m e wh at a n xio u s. He r b lo o d p re s- sure is 110/70 mm Hg, her heart rate is 90 bpm, and she is afebrile. Skin examination reveals multiple 1-mm flat reddish spots on her lower extremities. She denies excessive bleeding with menses or childbirth, easy bruis- abilit y, or bleeding int o her joint s. Physical examination is significant only for the blood oozing from h er n ose an d for the pet ech iae on h er legs. Learn the clinical approach to bleeding disorders, specifically platelet disorders ver su s co agu lat ion d isor d er s. Co n s i d e r a t i o n s This patient presents with mucosalbleeding,petechiae,and thrombocytopenia. She has no other history, symptoms, or physical examination findings of any systemic disease, so her problem appears to an isolated hematologic problem. H er coagu lat ion studies ( P T an d P T T ) are also n or mal; if they were deranged, we would suspect a consumpt ive coagulopat hy causing the t h rombocyt openia and a serious underlying disorder. H er current level of t hrombocytopenia does not pose a risk for spont aneous hemorrhage, but plat elet count s less t han 10,000/ µL might place her at risk for serious or life-threatening bleeding. For a pat ient wit h abn or mal bleedin g, the most imp or- tant history relates to any prior history of bleeding. One should inquire about history of epistaxis, menorrhagia, excessive prolonged bleeding from minor cuts, bruising, prolonged or profuse bleeding after dental extraction, excessive bleeding aft er major surgery or obst et ric delivery, or t rauma.

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Considerations A young infant with fever and irritability is presumed to have a serious bacterial or viral infection order mobic 7.5 mg visa. Bacterial causes in this age include group B Streptococcus purchase mobic american express, Listeria buy 7.5 mg mobic amex, and gram-negative pathogens such as Escherichia coli order mobic 7.5 mg with amex. Con- versely, the risk of transmission is less than 2% if the mother is having reactivation of infection at the time of delivery. Investigation for an inborn error of metabolism would be needed if this patient did not have fever, vesicles, or meningoencephalitis. Most primary infections are subclinical, but they can cause localized lesions or severe systemic symptoms. Neonatal infection is most commonly acquired during delivery but can also be acquired postnatally from an infected caregiver’s mouth or hand. Intrauter- ine infection is rare but an affected infant would be expected to be born with skin vesicles (or their scars), chorioretinitis, and microcephaly. Congenital rubella can also present with meningoencephalitis, micro- cephaly, seizure, and thrombocytopenia but would be characterized by cataracts and a purpuric rash (blue-gray nodules known as “blueberry muffin rash”). Congenital syphilis may have symptoms of chorioretinitis, aseptic meningitis, pneumonitis, transaminitis, thrombocytopenia, and fever; the rash is characteristically maculopapular. Recognition of the symptoms and laboratory findings is important as 50% of neonates without treat- ment will die. Disseminated disease has multiple signs and symptoms in 1- to 2-week- old neonate: fever, lethargy, irritability, apnea, a bulging fontanelle, or seizures (focal or generalized). Serologic tests for herpes virus are not helpful in the acute setting because titers rise late in the infection’s course. Tzanck preparation of lesions and antigen detection methods applied to the specimens can aid in rapid diagnosis, but the sensitivity is low. Infected individuals often have moderate peripheral leukocy- tosis, elevated serum transaminase levels, and thrombocytopenia. Suppressive antiviral therapy starting at 36 weeks of gestation can reduce how many symptomatic recur- rences the mother has, but it does not completely eliminate viral shedding and does not prevent neonatal infection. It can stop the viral replication at the site of inoculation (skin, mouth, nares, eyes). Ophthalmologic involvement warrants the use of topical ophthalmologic drops in addition to parenteral treatment. Hyperbilirubinemia can be a sign of sepsis in the new- born, and Group B Streptococcus is the most common cause of bacterial infection in the newborn period. She reports that she is generally healthy, except that she has an outbreak of geni- tal herpes approximately once per year. To prevent transmission of the virus to her infant, her physician should do which of following? Perform a cesarean delivery if herpetic lesions or prodromal symptoms are present when labor has begun. No change in management is indicated; the risk of infant transmission is low even if she has an outbreak at delivery. On examination, he is afebrile, cries during venipuncture, urine catheteriza- tion, and lumbar puncture but otherwise sleeps through the examination. Weight and head circumference are less than 5th percentile, and length at 10th percentile. Notable laboratory results include platelets of 22,000/mm3 and elevated total and direct bilirubin levels. Surveillance cul- tures are not recommended; negative results a few days prior to delivery do not preclude a later outbreak, and results of analysis of a more recently obtained specimen may not be available. Neo- natal herpes infection in any presentation should prompt an ophthalmology examination because topical ophthalmic antiviral therapy will be needed in addition to intravenous acyclovir if chorioretinitis or keratitis is present. The triad of hydrocephalus, intracranial calcifications, and chorioretinitis is a classic presentation for congenital toxoplasmosis. With cytomegalovirus, the intracranial calcifications would be in a periventricular distribution and the typical rash would be the blueberry muffin rash. Approxi- mately 30% of infants with systemic infection die despite aggressive anti- viral therapy. Shortly after birth, he begins to cough, followed by a choking episode, difficulty handling secretions, and cyanosis. During the resuscitation, placement of an orogastric tube meets resistance at 10 cm. Considerations In this newborn with choking and coughing, esophageal atresia is suspected when there is failure to pass the orogastric tube. Infants with esophageal atresia cannot handle oral secretions and require constant esophageal pouch drainage to prevent aspiration. They are monitored in the neonatal intensive care unit while awaiting surgical intervention. Infants with the “H-type” fistula (~4% of cases) often present later in life with recurrent aspiration pneumonia or feeding difficulty. The esophageal pouch requires constant suctioning while await- ing surgery to ligate the fistula and anastomose the esophagus. Postsurgical com- plications include leak and stenosis of anastomosis, fistula recurrence, esophageal dysmotility, and chronic gastroesophageal reflux is common. The infant likely has a previously undetected, associated finding of imperforate anus. When he first arrived at their home, he was active and playful, but now he is too tired to play. They have few details, but they know that he had neonatal surgery for a problem with his “esophagus being connected to his lungs” and that he takes no medications. Patients with esophageal atresia and distal fistula present in the first hours of life because of their inability to swallow oropharyngeal secretions. DiGeorge syndrome (thymic hypoplasia) results from abnormal third and fourth pharyngeal pouch formation during fetal development. Neighboring structures formed during the same fetal growth period are often affected. Associated conditions include anomalies of the great vessels, esophageal atre- sia, bifid uvula, congenital heart disease, short philtrum, hypertelorism, anti- mongoloid slant palpebrae, mandibular hypoplasia, and low-set, notched ears. DiGeorge syndrome may present in neonates as hypocalcemic seizures because of parathyroid hypoplasia. The infant’s mother had good prenatal care including vaginal cultures negative for group B Streptococcus. Within the first hour of birth, he has tachypnea, nasal flaring, and mild retractions. Considerations This term infant presents soon after birth with mild respiratory distress following an uneventful pregnancy and delivery. Because meconium may plug small airways, areas of air trapping are often present and may lead to the development of pneumothorax. Radiographic findings include a characteris- tic reticulonodular “ground glass” pattern with air bronchograms and decreased aeration. Cannulation of the carotid artery and jugular vein is required to link the neonate to the system. Chest radiography reveals perihilar streaking and fluid in the fissures; lungs are aerated. Shortly after birth they present with symptoms of respiratory distress including poor oxygenation, grunt- ing, retracting, and poor air movement. Radiographically they have findings includ- ing a reticulonodular “ground glass” pattern with air bronchograms and decreased aeration of the lungs. Supportive care includes supplemental oxygen as needed to maintain oxygen saturation of 90% to 95% and intravenous fluids or nasogastric feeding to maintain hydration because the degree of tachypnea usually precludes oral feeding. Exogenous surfactant is available and is administered by the resuscita- tion team in an effort to ameliorate the effects of surfactant deficiency. The infant born to a diabetic mother (Case 2) has an increased incidence of polycythemia and hypoglycemia, both of which can result in tachypnea. In addition, these infants have a higher incidence of surfactant deficiency at later gestational ages, again resulting in tachypnea. Group B streptococcal infection (Case 4) and neonatal herpes simplex virus infection (Case 6) are common infections in the newborn period; both can cause pneumonia that may present with an increased respiratory rate among other symptoms.

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Recurrent bacterial sinusitis is not typical for a child this age unless an underlying disorder is found generic mobic 7.5mg on line. Although the condition can be familial mobic 15 mg sale, clubbing is uncommon in children order 15 mg mobic with visa, usually indicating chronic pulmonary purchase cheap mobic, hepatic, cardiac, or gastrointestinal disease. The loss from the eccrine glands of the skin causes a hyponatremic, hypochloremic alkalosis. These children will have symptoms of cough and wheezing that mimic asthma and bronchiolitis. Bacteria then proliferate in the inspissated mucus and damaged respiratory cilia, resulting in pneumonia. Lung function is lost with the destruction from recurrent inflammation, obstruction, and infection. Exocrine function is usually lost, resulting in frequent passage of oily, malodorous, and floating stools which can eventually lead to malnutrition and failure to thrive. The resulting fat-soluble vitamin deficiencies may manifest as periph- eral neuropathy and hemolytic anemia (vitamin E), night blindness (vitamin A), or mucosal bleeding (vitamin K). In this condition, meconium becomes inspissated in the ileum and the infant will not pass stool; abdominal distention and emesis fol- low. A positive sweat test is defined by a sweat chloride content of 60 mEq/L or greater. Infants with positive results on the newborn screen undergo sweat chloride testing for definitive diagnosis. Optimal nutrition is dependent on pancreatic enzyme replacement and vitamin supplements. The prognosis varies depending on disease severity, and most patients reach adolescence or adulthood. The mother reports she is concerned her daughter is around “toxic mold” because she has had five to six prior episodes of bron- chitis since they moved to a new apartment at 6 months of age. She states that albuterol and an antibiotic are always given for treatment, and symp- toms resolve in 2 weeks. Bronchiectasis occurs as a sequela to impaired mucus clearance combined with inflammation and injury to the bronchial walls. He has experienced no recent trauma, and his past medical history is unremarkable. He has tenderness over the right knee, hepatosplenomegaly, and petechiae on his cheeks and chest. He has a low-grade fever, hepatosplenomegaly, and petechiae on his face and chest. Rapid diagno- sis and referral to a pediatric cancer center can increase survival. Acute lymphoblastic leukemia affects the lymphoid cell line and comprises approx- imately 75% of leukemia cases in children. A physical examination includes the child’s general appearance and energy level, vital signs (note if antipyretics taken), bleeding, bruis- ing, petechiae, pallor, pain upon palpating bones or joints, and hepatosplenomegaly. Lymphadenopathy, arthralgias, bone pain, and hepatosplenomegaly are unusual findings. Atypical lymphocytes resembling leukemic lym- phoblasts are characteristic of these viral illnesses. Infiltration of the marrow by other types of malignant cells (neuroblastoma, rhabdomyosarcoma, Ewing sarcoma, and retinoblastoma) occasionally produces pancytopenia. These tumor cells usually are found in clumps in the normal marrow but occasionally replace the marrow completely. Almost half of the children with newly diagnosed leukemia have total leukocyte counts less than 10,000/mm3. Therefore, the diagnosis of leukemia is established by examination of bone marrow, most commonly aspirated from the posterior iliac crest. African American and Hispanic popu- lations historically have lower remission and higher relapse rates, although newer studies suggest this might be due to factors other than race. The karyotypes of leu- kemic cells have diagnostic, prognostic, and therapeutic significance. Patients with hyperdiploidy generally have a more favorable prognosis; those with hypodiploidy and pseudodiploidy do less well. Consolidation treatment, aimed at further reducing residual leukemia, delivers multiple chemotherapies in a relatively short period of time. Maintenance therapy with methotrexate and 6-mercaptopurine, vincristine, and prednisone is given for 2 to 3 years to prevent relapse; therapy is discontinued for children who remain in complete remission for 2 to 3 years. Patients with greater than 25% blasts after induction chemother- apy or greater than 5% blasts after consolidation chemotherapy have a high risk of relapse. Therefore, allogeneic hematopoietic stem cell transplantation is recom- mended after the first complete remission in this patient population. The hematologic finding of sickle cell disease (Case 13) typically is isolated to the red blood cell while that of leuke- mia affects all cell lines. The school will not allow the child to reg- ister until his immunizations are up-to-date. Call the school nurse or principal to inform him or her that this child should not receive immunizations while he is taking chemotherapy. Call the school nurse or principal to inform him or her that this child will never receive immunizations because of the alteration in his immune system. Laboratory testing reveals a normal hemoglobin, hematocrit, and white blood cell count and differential. A high susceptibility to leukemia is associated with certain heritable dis- eases (Klinefelter syndrome, Bloom syndrome, Fanconi syndrome, ataxia tel- angiectasia, neurofibromatosis) and chromosomal disorders such as Down syndrome. Children with Down syndrome have a 10- to 15-fold increased risk for developing leukemia and should have routine screening performed at well-child checks. Although the viruses in the vaccine are attenu- ated, immunosuppression from treatment can be profound and viral disease can result. Immunizations without live virus (diphtheria, tetanus, inactivated poliovirus vaccine, hepatitis A and B) are not absolutely contraindicated in this case, but the immunosuppression with chemotherapy often inhibits anti- body responses. The platelet count frequently is less than 20,000/mm3, but other laboratory test results are normal, including the bone marrow aspiration (which may show an increase in megakaryocytes). She reports he developed nasal congestion and sore throat 24 hours prior, then a cough a few hours previously. Over the past 2 hours, he has complained of chest pain and has been breathing rapidly. His mother adminis- tered a unit dose of albuterol via the nebulizer and then a second dose 5 minutes later. Your examination reveals an afebrile man with a respiratory rate of 40 breaths/minute, oxygen saturation of 88% by pulse oximetry, and a heart rate of 130 beats/min. His blood pressure is normal, but his capillary refill is sluggish at 4 to 6 seconds. Intravenous administration of fluids and medications is indicated for a patient with this degree of distress. Know how to classify asthma severity and give the management of each level (Table 20–1). Less likely conditions include anaphylaxis, cystic fibrosis, foreign-body aspiration, and congestive heart failure. His drowsiness is of particular concern, indicat- ing impending respiratory failure; his respiratory and circulatory status must be assessed frequently. The paucity of wheezes results from severe airway obstruction and reduced air movement; wheezing is likely to increase when therapy allows more air movement. A variance of greater than 10 mm Hg between inspiration and expiration suggests severe obstructive airway disease, pericardial tamponade, or constrictive pericarditis. For patients with asthma, this test demonstrates airflow obstruction and reversibility, and can be used to determine an individual’s response to treatment. The median age at onset is 4 years, but 20% of children develop symptoms within the first year of life. More than half of children with asthma have symptom resolution by young adulthood. Heavy exposure to pollution, aller- gens, or cigarette smoke makes resolution less likely. An immediate immunoglobulin (Ig) E response to environmental triggers occurs within 15 to 30 minutes and includes vasodilation, increased vascular permeability, smooth-muscle constriction, and mucus secretion.

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