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By W. Zarkos. Monroe College.

Delayed hypersensitivity is depressed and this also applies to other components of the immune response cheap 20mg nexium free shipping. Sweat gland responses to heating decrease nexium 20mg discount, and the rate of sebum secretion also decreases, although this is less marked than many other functions in the elderly. Sensory discrimination decreases in the elderly, but, unfortunately, not the sen- sations of itch or pain! However, there are many disorders that are more common in the aged, and others that have a differ- ent natural history and appearance. Dry and itchy skin As the skin ages, it becomes drier and tends to become itchier. This tendency is heightened by: ● low relative humidity ● frequent hot bathing and vigorous towelling ● low ambient temperature. The itchiness can be disabling and it is important to try to reduce the desiccat- ing stimuli to which the skin is exposed. The generous use of emollients as top- ical applications as cleansing agents and of bath additives is mandatory. Although itchiness due to dry skin in the elderly is quite common, it has to be remembered that scabies and the other causes of generalized pruritus also occur in this age group and should be diligently sought. In most cases, no cause is found for the development of eczema, particularly in elderly people, in whom it can spread rapidly and become extremely disabling. Atopic dermatitis is uncommon in the elderly and is as trying and uncomfortable as at other times of life when it does occur. Discoid eczema is a form of constitutional eczema that is more common in the elderly. Eczema craquelée is an eczematous disorder that is virtually specific to the skin of the elderly, occurring against a background of generalized xerosis, or drying of the skin surface. Photosensitive eczema is more common in elderly men and is often very per- sistent, causing great difficulties in its management. Minor degrees of seborrhoeic dermatitis are very common in the elderly and occasionally the disorder can spread to become generalized. However, emollients are even more important and there should be greater readiness to use systemic remedies, including cyclosporin, azathioprine and corticosteroids. After being in hospital for 4 days, his chest improved with the use of antibiotics, but he began to develop an odd, itchy, ‘crazy paving’ pattern of rash on his shins. This eczema craquelée was due to the increased washing and decreased humidity in the hospital. Skin tumours Skin tumours are a frequent reason for the elderly consulting a physician. Seborrhoeic warts are found in virtually everyone over the age of 60 years and, although benign, often result in minor symptoms and some cosmetic embarrass- ment. They can easily be removed by curettage and cautery, but when present in large numbers, can present an insoluble problem. Solar keratoses are another fre- quent cause of presentation – some 4 per cent of all new patient consultations in the dermatology department of the University Hospital of Wales were for solar ker- atoses. Although very few progress to squamous cell cancer, they indicate that seri- ous solar damage has occurred and that more significant lesions may develop. They are uncommon below the age of 45 years and very common over the age of 60 years. As with seborrhoeic warts, solar keratoses may also cause minor symptoms and some cosmetic problems. Because of their capacity for local invasion and tissue destruction, they cause considerable morbidity. Squamous cell carcinomas (see page 211) are much less common, but can metastasize as well as cause local tissue destruction. Malignant melanoma (see page 219) is slightly more common in the elderly compared to young age groups, but lentigo maligna (see page 219) is virtually restricted to the elderly. Management of skin disorders in the elderly Through no fault of their own, the elderly are often physically, socially and eco- nomically deprived. Their housing, hygiene, nutrition, clothing and means of heating may all be deficient, and this should be taken into account when design- ing treatments. If they live alone, as is often the case, they may well be unable to find anyone to help with the application of ointments to body parts they cannot reach themselves or to assist with bandages because of lack of mobility. It must be remembered that the elderly may also have difficulty in hearing, understanding and/or remembering instructions, especially if these are complex 236 Summary and involve more than one medicament. If possible, instructions on the medica- tions should also be given to an accompanying relative or legibly written out. The above potential difficulties need to be taken into account when trying to help an elderly patient with a skin problem. Summary ● Neonatal skin is not mature functionally, so that toxin of a particular phage type of Staphylococcus excess water loss may occur, leading to dehydration.

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However discount nexium 40 mg otc, chest pain is not typical in any of these conditions in the pedi- atric cage group discount 20 mg nexium overnight delivery. These conditions are associated with significant murmurs such as pansystolic, continuous or mitral regurgitation murmur or gallop rhythm that sug- gests myocardial dysfunction. These patients should be referred for evaluation by a pediatric cardiologist for assessment and treatment. Hypertrophic obstructive cardiomyopathy: This hereditary lesion has an auto- somal dominant pattern and patients have positive family history of the same disorder or a history of sudden death. Children with this disorder have a harsh systolic ejection murmur that is exaggerated with standing up or performing Valsalva maneuver. Echocardiogram is the study of choice to evaluate this condi- tion, referral to a pediatric cardiologist should be done to evaluate patient and his/ her family. Case Scenarios Case 1 History: A 14-year-old girl previously healthy comes to your office complaining of chest pain that started 6 months ago. Pain lasts for few seconds, sometimes related with exercise but without difficulty in breathing. Medical attention was sought due to chest pain and desire to join school’s basketball team. Physical exam: Vital signs are within normal limits, physical examination is normal except for tenderness when palpating the left 3, -4, -5 costochondral junctions. Diagnosis: History and the physical examination are highly suggestive of costo- chondritis. The nature of pain, lack of any significant findings through history and physical examination and the ability to induce chest pain while pressing on affected costochondral junctions point to the diagnosis of costochondritis. Treatment: Reassurance that the pain is benign and is not related to the heart is essential. Pain and inflammation of the affected costochondral junction can be eliminated through a 5–7 days course of nonsteroidal anti-inflammatory agent such 420 I. Case 2 History: A 6-year-old boy presents to the emergency room with a 1 day history of severe chest pain localize to the left side of the chest. The mother states that the child was noted to have fever and decrease in appetite of 1 day duration. Past medical history is significant for surgical repair of sinus venosus atrial septal defect 2 weeks ago. Surgical repair was uneventful and the child was discharged home 4 days after surgery in stable condition. Vital signs dem- onstrate rapid respiratory and heart rates, normal oxygen saturation and normal blood pressure measurements. Diagnosis: the past medical history and finding of friction rub is suggestive of pericarditis. The cause of pericarditis and chest pain in this child is post-pericardiotomy or Dressler’s syndrome. Treatment: In view of the small volume of pericardial effusion, compromise of cardiac output is not a present concern. If pericardial effusion continues to enlarge despite medical therapy then pericardiocentesis can be used to remove pericardial fluid. Chapter 36 Innocent Heart Murmurs Ra-id Abdulla Key Facts • Innocent heart murmurs are encountered in 50% of all children. Instead, mild turbulence of blood flow, combined with the rapid heart rate and thin chest wall in children allow nor- mal blood flow through normal cardiovascular structures to be audible. Heart murmurs resolve spontaneously as child grows older with slower heart rate and thicker chest wall. Narrowing of passageways of blood results in turbulence which is characterized by eddies or recirculation. Eddies produces vibrations which can be heard through auscultation and in severe cases palpable as a thrill. On the other hand, laminar flow of blood is relatively silent and not audible through auscultation. Narrowing of blood vessels or cardiac valves results in rapid change (drop) in pressure, also referred to as pressure gradient, this causes fluid to accelerate which in turn results in eddies or recirculation phenomenon. Eddies produce the vibrations which result in murmurs or when significant a thrill which can be felt by hand through palpation. Types of Innocent Heart Murmurs Innocent heart murmurs are defined by the cardiac structure producing the murmur. Different types of innocent heart murmurs are caused by different physiological processes (Table 36. When examining a child with a heart murmur features of pathological murmurs should be carefully examined to rule out presence of con- genital heart disease (Table 36. Heart murmurs conforming to any type of inno- cent heart murmurs do not necessarily require referral to a pediatric cardiologist. On the other hand, lack of clarity of the nature of the murmur examined or in the presence of any feature that may indicate that the murmur is pathological in nature, referral to a pediatric cardiologist for further evaluation is necessary (Table 36.

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It may occur as a feature of severe mental disorder and in that case should not be classified here but in the corresponding major category buy generic nexium 20 mg on line. Patients with mixed neuroses should not be classified in this category but according to the most prominent symptoms they display generic nexium 20 mg with mastercard. The personality is abnormal either in the balance of components, their quality and expression or in its total aspect. Because of this deviation or psychopathy the patient suffers or others have to suffer and there is an adverse effect upon the individual or on society. It includes what is sometimes called psychopathic personality, but if this is determined primarily by malfunctioning of the brain, it should not be classified here but as one of the nonpsychotic organic brain syndromes (310). When the patient exhibits an anomaly of personality directly related to his neurosis or psychosis, e. Such persons may feel helplessly humiliated and put upon; others, likewise excessively sensitive, are aggressive and insistent. During periods of elation there is unshakeable optimism and an enhanced zest for life and activity, whereas periods of depression are marked by worry, pessimism, low output of energy and a sense of futility. Cycloid personality Depressive personality Cyclothymic personality Excludes: affective psychoses (296. Behavior may be slightly eccentric or indicate avoidance of competitive situations. The outbursts cannot readily be controlled by the affected persons, who are not otherwise prone to antisocial behavior. There may be insistent and unwelcome thoughts or impulses which do not attain the severity of an obsessional neurosis. There is perfectionism and meticulous accuracy and a need to check repeatedly in an attempt to ensure this. Compulsive personality Obsessional personality Excludes: obsessive-compulsive disorder (300. Psychoinfantile personality Histrionic personality Excludes: hysterical neurosis (300. Lack of vigor may show itself in the intellectual or emotional spheres; there is little capacity for enjoyment. Dependent personality Passive personality Inadequate personality Excludes: neurasthenia (300. People with this personality are often affectively cold and may be abnormally aggressive or irresponsible. Their tolerance to frustration is low; they blame others or offer plausible rationalizations for the behavior which brings them into conflict with society. Amoral personality Asocial personality Antisocial personality Excludes: disturbance of conduct without specifiable personality disorder (312. The limits and features of normal sexual inclination and behavior have not been stated absolutely in different societies and cultures but are broadly such as serve approved social and biological purposes. The sexual activity of affected persons is directed primarily either towards people not of the opposite sex, or towards sexual acts not associated with coitus normally, or towards coitus performed under abnormal circumstances. If the anomalous behavior becomes manifest only during psychosis or other mental illness the condition should be classified under the major illness. It is common for more than one anomaly to occur together in the same individual; in that case the predominant deviation is classified. There is no consistent attempt to take on the identity or behavior of the opposite sex. The resulting behavior is directed towards either changing the sexual organs by operation or completely concealing the bodily sex by adopting both the dress and behavior of the opposite sex. Cross-dressing is intermittent, although it may be frequent, and identification with the behavior and appearance of the opposite sex is not yet fixed. Less severe degrees of this disorder that also give rise to consultation should also be coded here. Impotence--sustained inability, due to psychological causes, to maintain an erection which will allow normal heterosexual penetration and ejaculation to take place. Dyspareunia, psychogenic Excludes: impotence of organic origin normal transient symptoms from ruptured hymen transient or occasional failures of erection due to fatigue, anxiety, alcohol or drugs 302. If dependence is associated with alcoholic psychosis or with physical complications, both should be coded. Acute drunkenness in Chronic alcoholism alcoholism Dipsomania Excludes: alcoholic psychoses (291. Excludes: when due to mental disorders classified elsewhere when of organic origin 307.

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There are two methods of classifying hypertrichosis: the distribution of the hair on the body (generalized or localized/regional) cheap 20mg nexium, and the cause of the hypertrichosis (congenital or acquired) order nexium 20mg without a prescription. The hair in hypertrichosis is longer than is typically seen for that portion of the body, and can be vellus-like or terminal-like, depending on the cause (see Fig. Hypertrichosis can be a severe cosmetic alteration, but it may also signify an underlying systemic disease. It is important to be familiar with the various causes of hypertri- chosis, as well as how to manage this entity (47,48). Unfortunately, the triggers of these mechanisms are still largely not understood, so we continue to classify hypertrichosis based on clinical presentation, rather than on actual pathophysiology (47). The rst mechanism involved in hypertrichosis is that there is a switch from vellus to terminal hair growth in regions of the body that do not typically possess terminal hair. This is similar to hirsutism, which is excess hair growth in females caused by hyperandrogenism in a male-pattern distribution. In hypertrichosis, the switch of vellus hair to terminal hair can occur in either sex and in any area of the body that does not typically have terminal hair, not neces- sarily in a male-pattern distribution (47). A common theory behind this switch from vellus to terminal hair is that androgens may inuence abroblast transfer that leads to an increase in the volume of the papillary dermis. This increase in volume theoretically leads to a marked increase in follicle size and anagen length (49). Over the scalp, hair spends a longer portion of time in anagen than do hair follicles on other parts of the body with shorter hair. In hypertrichosis, the hair follicle undergoes an anagen phase that is longer than normal for that particular location of the body (47,49). There- fore, if a therapy could selectively induce catagen, or stop a prolonged telogen phase, a therapy for hypertrichosis and even for hirsutism would be born (49). The mechanism of hair growth with many of these medications is that they cause hyperpolarization of the potassium channels of the hair follicle, which ultimately leads to increased growth (51). Other drugs can be associ- ated with hypertrichosis, though not to the extent of the above mentioned medications. Approximately 5% reported an adverse reaction to a hair dye compatible with allergic contact dermatitis, but only one in six of these affected individuals reported these reactions to their healthcare provider. Therefore, many allergic reactions to hair dyes occur but often are underreported. There are four main types of hair dyes: permanents dyes, semi-permanents/temporary dyes, hair restorers, and vegetable dyes. Table 6 provides a current list of hair dyes reported in the literature to cause allergic contact dermatitis. Permanent dyes are the most popular type of hair dye in the United States because of the vari- ety of colors available (10). Unfortunately, they are also the most common class to elicit allergic contact reactions (4). Permanent dyes are formed within the hair cortex and can therefore with- stand more than ten washings. These dyes generally involve a mixture of color intermediates and hydrogen peroxide in a viscous lotion base. First, the hydrogen peroxide bleaches the original hair melanin, thus allowing for better coloring. Second, oxidation of the primary intermediate dyes by hydrogen peroxide results in highly reactive benzoquinone mono- and di-imines, which rapidly react with other compounds present known as couplers. The choice of intermediates and reaction conditions determine a wide variety of colors. Imidazolidinyl urea (Germall 115) is the most commonly used preservative after parabens and is one of the weakest sensitizers among formaldehyde releasers (56). It is effective against both gram-positive and gram-negative bacteria (10), but is often combined with parabens for increased coverage against yeast and fungi (known as Germaben). Sensitization appears more related to the entire molecule and less to the release of formaldehyde. Parabens, which include a family of alkyl esters, are the most commonly used group of pre- servatives (66). In 1995, a European study showed that parabens were found in 99% of all leave-on products and 77% of rinse-off products (82). Parabens are effective against fungi and gram-positive bacteria (10,83), and are generally used in concentrations ranging from 0. Although parabens are the most common preservative used in hair products, they are one of the weakest sensitizers (12). Cooper and Shaw reported a 74-year-old-woman who developed severe itching and erythema of the face and scalp, and eyelid edema, which was attributed to a paraben allergy from a tar shampoo (84).

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