- A nonspecific chronic inflammatory disease of the gastrointestinal system most commonly affecting the distal ileum and the colon.
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- Hypersecretion of glucocorticoids by the adrenal gland, which produces a characteristic constellation of clinical abnormalities, including a moon face and truncal and neck fat pad deposits. It is classified into adrenocorticotropic hormone (ACTH)-dependent (75%) and ACTH-independent (25%) forms. ACTH-dependent forms are also referred to as Cushing’s disease.
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- An inherited disease of the exocrine glands that results in multisystem involvement primarily by affecting the respiratory and gastrointestinal systems. It typically is characterized by chronic obstructive pulmonary disease, abnormally high loss of electrolytes through the sweat glands, and pancreatic enzyme insufficiency, leading to digestive impairments and malabsorption syndrome.

Causes and Incidence Cystic fibrosis (CF) is caused by a defective gene that is inherited from both parents as an autosomal recessive trait. The gene is responsible for encoding a membrane-associated protein called cystic fibrosis transmembrane conductance regulator (CFTR). The exact function of CFTR is unknown, but research shows that it is closely tied to chloride transport. Current research focuses on the causes of seemingly unrelated multisystem effects.
CF is the most common lethal genetic disease among white children and young adults in the United States, with an incidence of 1 in approximately every 2,400 live births. Blacks also are affected, but the rate is about 1 in 17,000 births. CF is rare in Asians and Native Americans.

Disease Process In CF, the exocrine glands are affected in one of three ways: (1) they produce and become obstructed by thickened, sticky mucus; (2) they produce excess normal secretions; or (3) they secrete excess sodium and chloride. The lungs are normal at birth, but bronchioles and bronchi soon become clogged with thick mucous plugs, leading to associated opportunistic infections and overinflation of the lungs. Bronchial walls thicken and airways remain filled with purulent secretions, leading to fibrosis and atelectasis. Chronic hypoxemia leads to hypertrophy of the pulmonary arteries, which leads to pulmonary hypertension and right ventricular hypertrophy. The pancreatic ducts also become clogged with mucous plugs, which interfere with pancreatic enzyme activity. Digestive enzymes fail to reach the small intestine, and as a result, digestion and absorption of nutrients are markedly impaired, leading to excess fat and protein in the stools. The biliary tracts in the liver become plugged with mucus and fibrose over time. Salivary glands and bile ducts may also become clogged. Sweat glands secrete abnormal levels of sodium and chloride, leading to excessive loss of these electrolytes.

Symptoms Signs and symptoms vary widely, involve several systems, and change as the disease progresses. Some children show manifestations at birth, whereas others do not develop symptoms for years. Manifestations range from mild to life threatening. The earliest sign is a meconium ileus, seen at birth in about 10% of infants with CF. All children display sweat gland abnormalities, 85% to 90% have pancreatic and gastrointestinal (GI) tract involvement, and 50% show respiratory involvement.

Sweat glands/skin
Salty tasting skin; salt crystals on nose, forehead and hairline; dehydration, alkalosis in heat or with fever

Pancreas/GI tract
Meconium ileus, with cramps, nausea, vomiting, abdominal distention; frequent, bulky, oily, and foul-smelling stools; normal or voracious appetite; weight loss, failure to thrive; pot belly, wasted buttocks, thin extremities; sallow skin; anemia, easy bruising; rectal prolapse

Respiratory tract
Wheezing, dry cough, rhinitis, gagging; dyspnea; intercostal retractions, use of accessory muscles to breathe; barrel chest, digital clubbing, cyanosis; repeated episodes of upper respiratory infection (URI), bronchial pneumonia

Reproductive system
Delayed onset of puberty; amenorrhea, viscous cervical secretions that block sperm entry in women; sterility in men

Potential Complications Complications are numerous and can include biliary cirrhosis, esophageal varices, portal hypertension, diabetes mellitus, pneumothorax, cor pulmonale, congestive heart failure, peptic ulcer, intestinal obstruction, intussusception, pancreatitis, cholecystitis, and cardiac arrhythmias. CF is a terminal disease. However, the median death rate has climbed, from 7 1/2 years in 1966 to 28 years in 1993. A few individuals have survived to 50 years of age or older.

Diagnostic Tests

Clinical evaluation
Any of the above manifestations, particularly salty skin, failure to thrive, and frequent URIs; family history

Quantitative pilocarpine
Sodium or chloride concentration .60 mEq/L

Iontophoresis sweat test
To obtain definitive diagnosis

Treatments

Surgery
Heart-lung or liver transplantation with advanced disease; treatment of complications (e.g., resection of bowel obstructions, cholecystectomy, portal shunt for esophageal varices).

Drugs
Antibiotics to treat pulmonary infections; amiloride HCl (aerosol) to inhibit sodium and water reabsorption in the lungs; DNase and other drugs to thin mucus; alphaantitrypsin to reduce inflammation; pancreatic enzyme replacements (e.g., pancrelipase); bronchodilators to aid breathing.

General
Diet therapy, with 50% increase in normal caloric and protein intake, high fat intake, multivitamins, water-miscible vitamin E, sodium supplements, enteral supplementation in severe cases Prophylaxis against respiratory infection with pertussis, measles, and flu vaccines Chest physiotherapy to increase movement of mucus from lungs (postural drainage, percussion, vibration, and assisted coughing; oxygen therapy for hypoxia; exercise to stimulate mucus movement) Long-term psychologic counseling for individual and family; genetic counseling for parents; support groups; home care, respite care.

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- A slow-growing, benign cystic tumor found in the subcutaneous tissue below the skin or in the intradermal tissue of the skin.

Causes and Incidence Cyst formation is commonly caused by inflammation, internal rupture of an acne pustule or whitehead, impaired localized circulation, or trauma. Some individuals may be genetically predisposed to cyst formation.

Disease Process Cysts contain a soft, yellow-white, cheesy substance that is often fetid and that forms when a hair follicle becomes obstructed. The contents of the cyst are determined by the type of cyst. Dermoid cysts are located deep in the subcutaneous tissue; have walls of keratinizing epidermis containing sweat glands, hair follicles, and sebaceous glands; and are often present at birth. Epidermal cysts (i.e., acne cysts) are found in the epidermis on the face, scalp, neck, and back; they contain laminated layers of keratin. Sebaceous cysts, or wens, occur primarily on the scalp and contain soft keratin, epidermal debris, and greasy material.

Symptoms Cysts are found on or under the skin, are generally less than 3 cm in diameter, and are round, firm, globular, and movable to the touch. They are nontender unless infected. Cysts, particularly sebaceous type, can grow as large as a grapefruit.

Potential Complications Cysts may become infected.

Diagnostic Tests A characteristic lesion is seen on clinical examination.

Treatments

Surgery
Excision of the cyst and cyst wall; incision and drainage of infected cysts.

Drugs
Antibiotics for infected cysts.

General
Instruction not to touch, squeeze, or pick lesions, since this may lead to infection.

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- Ischemic necrosis and ulceration of tissues that overlie a bony prominence and that have been subjected to prolonged external pressure from a supporting surface such as a bed or wheelchair.

Causes and Incidence Decubiti are caused by prolonged pressure on tissues compressed between an internal body structure, such as bone, and an external surface. The force and duration of the pressure directly determine the size of the ulcer. Contributing factors include immobilization, sensory and motor deficits, reduced circulation, malnutrition, anemia, edema, infection, friction, moisture, incontinence, shearing forces, decreased tissue integrity or viability, and aging.

Disease Process Pressure exerted over an area interferes with the blood supply to the tissue, producing ischemia and increasing capillary pressure. This leads to edema and multiple small-vessel thromboses and sets up an inflammatory reaction. If the pressure is not relieved, the ischemic tissue necroses and ulcerates.

Symptoms Decubitus formation has six definable stages with characteristic signs and symptoms.

Stage 1
Redness that blanches with pressure; skin is warm and soft to the touch

Stage 2
Redness, edema, and induration; skin often abraded or blistered

Stage 3
Breaks in the skin as it becomes necrotic; exposure of subcutaneous tissue; drainage from wound

Stage 4
Necrosis extends to subcutaneous tissue; drainage is foul smelling and yellow

Stage 5
Necrosis extends through fat to muscle; wound may develop a black, leathery eschar around the edges; drainage is greenish

Stage 6
Necrosis extends to bone; deep tunnels form in fat and muscle; body cavities (e.g., rectum or bladder) are eroded; bone is destroyed through periostitis and osteitis

Potential Complications Bacteremia and septicemia are common complications. Osteomyelitis, septic arthritis, and pathologic fractures also can occur.

Diagnostic Tests Clinical evaluation revealing the characteristic picture described under Clinical Manifestations; history of one or more predisposing and contributing factors.

Treatments

Surgery
Stages 4-6: debridement and closure; skin grafting, skin flaps, muscle flaps; joint disarticulation may be required with large stage 5 or stage 6 ulcers.

Drugs
Topical applications (e.g., enzymatic ointments) to debride necrotic tissue, hydrophilic gels for reepithelialization; topical antibiotics for debridement and to suppress infection; platelet-derived epidermal growth factors for tissue healing.

General
Elimination of pressure through frequent turning, special beds, mattress overlays, and wheelchair pads filled with gels, air, water, sand, or other pressurerelieving ingredients; use of lifting devices to prevent shearing; debridement with wetdry dressings; irrigation with whirlpool baths; electrical stimulation to promote antibacterial effect and stimulate muscle protein synthesis; balanced nutrition; control of incontinence and careful cleansing; instruction in ulcer prevention: frequent use of pressure relief measures (turning, raising off buttocks, weight shifts when seated); daily skin inspections; use of pressure relief mattress overlays and wheelchair cushions; clean, dry clothing and bed linens free of wrinkles and treated with fabric softener; lotion on all skin surfaces, especially over bony prominences, to reduce friction.

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