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Esophageal manometry with provocative testing in patients with non-cardiac angina-like chest pain effective himcolin 30gm. However generic 30 gm himcolin, this test appears to lack specificity, as the patient with a positive provocative test may experience seemingly identical spontaneous pain episodes that are unrelated to esophageal dysfunction. Ambulatory 24-hour pH monitoring can be extremely useful in correlating pain episodes with reflux events, but patients must have frequent (i. If symptom resolution occurs, then a diagnosis of reflux-induced pain can be presumed and the patient managed accordingly. More in-depth esophageal testing can then be reserved for those patients who fail this empiric therapy and have persisting troublesome pain, especially if associated with considerable anxiety surrounding the diagnosis. Management of angina-like chest pain of esophageal origin should be directed at the specific pathophysiological process. Shaffer 75 triggered by gastroesophageal reflux, then antireflux treatment may be quite helpful. If the pain is due to esophageal spasm, smooth-muscle relaxants such as nitrates and calcium channel blockers may help, although few controlled clinical trials have demonstrated any significant benefit. Tricyclic antidepressants in relatively low dosage have been shown to be beneficial and should be tried in patients with frequent pain episodes that are not caused by reflux or severe esophageal spasm. These are most likely to be useful in patients with abnormal visceral nociception, or the so-called irritable esophagus. Simple reassurance and education are probably the most important part of treatment. Symptoms often improve once the patient is given a positive diagnosis and no longer fears that underlying heart disease is the cause. Esophageal Neoplasms A large number of different tumors can involve the esophagus (Table 2). Classification of esophageal tumors Benign tumours o Epithelial origin Squamous cell papilloma o Non-epithelial origin Leiomyoma Granular cell tumor Hemangioma Lymphangioma Malignant tumors o Epithelial origin Squamous cell carcinoma Adenocarcinoma Adenoid cystic carcinoma Mucoepidermoid carcinoma Adenosquamous carcinoma Undifferentiated carcinoma; small-cell carcinoma o Non-epithelial origin Leiomyosarcoma Carcinosarcoma Malignant melanoma o Secondary tumors Malignant melanoma Breast carcinoma Tumor-like lesion o Fibrovascular polyp o Heterotopia o Congenital cyst o Glycogen acanthosis First Principles of Gastroenterology and Hepatology A. Shaffer 76 Carcinoma of the esophagus is a relatively uncommon malignancy in Canada, with only 3 to 4 new cases per 100,000 population per year in males and just over 1 new case per 100,000 population per year in females. Nevertheless, because of its poor prognosis, esophageal cancer ranks among the 10 leading causes of cancer death in Canadian men 45 years of age and older. Although several different types of primary and secondary malignancies can involve the esophagus (Table 2), squamous cell carcinoma and adenocarcinoma are by far the most common esophageal malignancies. Adenocarcinoma Adenocarcinoma used to make up approximately 10% of all esophageal cancers. However, its incidence has been increasing in recent decades such that now it comprises up to 4060% of esophageal cancers in North America. Rarely, primary esophageal adenocarcinomas arise from embryonic remnants of columnar epithelium or from superficial or deep glandular epithelium. Adenocarcinoma of the cardia of the stomach may also involve the distal esophagus and give the appearance that the cancer arises from the esophagus. The true incidence of Barretts-related cancer is uncertain, but most studies suggest that patients with Barretts esophagus will develop adenocarcinoma at a rate of about 0. This is a significant problem given the large number of reflux patients with Barretts metaplasia. Because dysplasia develops prior to frank carcinoma in Barretts epithelium, current guidelines recommend that these patients should undergo surveillance endoscopy with multiple biopsies every 2-3 years to identify those who are likely to progress to cancer (Section 7). The clinical presentation and diagnostic evaluation of patients with adenocarcinoma of the esophagus are similar to those of squamous cell carcinoma (Section 12. Neoadjuvant therapy with concomitant radiation and chemotherapy followed by surgical resection of the esophagus has a 13% absolute benefit in survival at 2 years versus surgery alone. Esophageal squamous cell carcinoma: possible factors o Alcohol o Tobacco o Nutritional exposure Nitrosamines: bush teas containing tannin and/or diterpene phorbol esters o Nutritional deficiencies (riboflavin, niacin, iron) o Chronic esophagitis o Achalasia o Previous lyle-induced injury o Tylosis o Plummer Vinson (Paterson-Kelly) syndrome First Principles of Gastroenterology and Hepatology A. This has led to several theories concerning certain environmental agents that may be important etiologically (Table 3). In North America, squamous cell carcinoma is associated with alcohol ingestion, tobacco use and lower socioeconomic status. Characteristically these cancers, similarly to adenocarcinoma, extend microscopically in the submucosa for substantial distances above and below the area of the gross involvement. They also have a propensity to extend through the esophageal wall and to regional lymphatics quite early. Furthermore, they usually produce symptoms only when they have become locally quite advanced. For these reasons approximately 95% of these cancers are diagnosed at a time when surgical cure is impossible.

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List the etiologies & animal reservoirs of the different types of leishmaniasis 4 buy himcolin 30gm free shipping. Refer suspected cases of leishmaniasis to hospitals for investigation & treatment 12 discount himcolin 30 gm free shipping. Design appropriate methods of prevention andcontrol of leishmaniasis Definition: is an infectious disease caused by the protozoa called Leishmania Classification of leishmaniasis There are three major clinical forms of leishmaniasis: Visceral leishmaniasis Cutaneous leishmaniasis Mucocutaneous leishmaniasis Etiologic Agents The different clinical forms of leishmaniasis (listed above) are caused by different species of leishmanial parasites which are listed under each of these diseases. The parasites are seen in two forms Leishmanial form:- ( amastogote ) this is non flagellate form seen in man and extra human vertebrate reservoir Leptomonad forms (also called promastigotes) are flagellated forms The parasite is transmitted by the bite of vectors of the species phlebotomus, Sand flies 56 Internal Medicine Life Cycle of Leshimaniasis Transmitted by the bite of an infected female phlebotomine Sand fly, the leishmaniases are globally widespread diseases. Sand flies are primarily infected by animal reservoir hosts, but humans are also a reservoir for some forms. Animal Reservoirs: include Rodents - Commonly in East Africa, Ethiopia, the Sudan and Kenya and Canines - Mediterranean and Asia. As the sandfly feeds, promastigote forms of the leishmanial parasite enter the human host via the proboscis. Within the human host, the promastigote forms of the parasite are ingested by macrophage where they metamorphose into amastigote forms and reproduce by binary fission. They increase in number until the cell eventually bursts, then infect other phagocyctic cells and continue the cycle. The parasites are transformed inside the fly and delivered to a new host, and the life-cycle continues Fig 3. It is characterized by chronic irregular fever, profound wasting, debility and hepatosplenomegally. Epidemiology Visceral leishmaniasis affects many countries in Africa, mainly Ethiopia and the Sudan the Middle East, Southern soviet union, India and S. Transmission The commonest way of transmission is by inoculation of promastigotes into humans by the bite of sand flies which breed in termite hills and forests. The source of the aflagellate forms may be either humans or extra human vertebrate reservoirs, and the disease may have life cycles that involve humans and sand flies only, or humans, sand flies and extra human vertebrate reservoirs together. Pathogenesis The common site of entrance is the skin where primary cutaneous lesion appears at the sites of sand fly bite. Here a cellular reaction by lymphocytes and plasma cells develop around the amasitigote-filled histiocytes in the dermis. As immune response develops epitheloid and giant cells appear, to be followed in some by healing. In others usually 4-6 months later amastigotes escape to the blood in macrophages, hematogeneous spread occurs and colonize the cells of reticuloendothelial system, where they multiply further and released after rupture of the cells and transported to new cells. The cells affected include that of spleen, liver, bone marrow and lymphatic glands, where the parasite multiplies and cause overcrowding of cells and as a result these organs are enlarged. The liver with its Kuppfer cells packed with amastigotes is enlarged & progress to cirrhosis. Clinical Features Incubation period usually varies from weeks to months but can be as long as years. Diagnosis Definitive diagnosis is based on demonstration of the Parasite - Giemsa stained smear of peripheral blood (in Indian form) and tissue touch preparation of organ aspirates and examined by light microscopy. Following the bite of sand flies, leishmania multiply in the macrophages of the skin. Single or multiple painless nodules occur on exposed areas (mainly the face) within one week to 3 months of the bite. The nodules may enlarge and ulcerate with erythematous raised border and overlying crust which may spontaneously heal over months to years. Different clinical patterns are described depending on the etiologic agents as follows:- 60 Internal Medicine Table I- 3. Investigation for Diagnosis Giemsa staining of smear from a split skin: This demonstrates leishmania in 80% of cases Culture followed by smear 61 Internal Medicine Leishmanin skin test is positive in over 90% of cases although it is negative in diffuse cutaneous leishmaniasis. However large lesions or those on cosmetically important sites require treatment either 0 Locally - by surgery, curettage, cryotherapy or hyperthermia (40-42 c) or Systemic therapy: with drugs like Pentostam. Treatment is less successful than visceral leishmaniasis as antimonials are poorly concentrated in the skin L. Bolivia, Uruguay and Northern Argentina) In the early stage it affects the skin, but in secondary stage of the disease it involves the upper respiratory mucosa. This leads to nasal obstruction, ulceration, septal perforations and destruction of the nasal cartilage called Espundia. Death usually occurs from secondary bacterial infection 62 Internal Medicine References: th 1. Tuberculosis Learning Objective: At the end of this unit the student will be able to 1. Understand the different treatment categories of Tuberculosis be able to categorize any type of Tuberculosis 11. Refer complicated cases of Tuberculosis diseases to hospitals for better management 14. Design appropriate methods of prevention and control of Tuberculosis Definition: Tuberculosis is a Chronic necrotizing disease caused by Mycobacterium tuberculosis complex.

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P reface to th e irst ditio This book is intended primarily for the junior hospital working knowledge in a clinical situation purchase 30 gm himcolin otc. It should doctor in the period between qualication and the not be forgotten that some rare diseases are of great examination for Membership of the Royal Colleges importance in practice because they are treatable or of Physicians order himcolin 30 gm without a prescription. Some for higher specialist qualications in surgery and conditions are important to examination candidates anaesthetics. The experienced phy- We have not attempted to cover the whole of sician has acquired some clinical perspective through medicine, but by cross-referencing between the two practice: we hope that this book imparts some of this sections of the book and giving information in sum- to the relatively inexperienced. A short account of psychiatry is given in the section The book as a whole is not suitable as a rst reader on neurology since many patients with mental illness for the undergraduate because it assumes much basic attendgeneralclinicsanditishopedthatreadersmaybe knowledge and considerable detailed information has warned of gaps in their knowledge of this important had to be omitted. The section on dermatology is incomplete but textbook of medicine and the information it contains should serve for quick revision of common skin must be supplemented by further reading. In are most commonly seen and where possible have the rst part we have considered the situation which a listed them in order of importance. The frequency candidate meets in the clinical part of an examination with which a disease is encountered by any individual or a physician in the clinic. This part of the book thus physician will depend upon its prevalence in the resembles a manual on techniques of physical exam- district from which his cases are drawn and also on ination, though it is more specically intended to help his known special interests. Nevertheless, rare condi- the candidate carry out an examiners request to tions are rarely seen; at least in the clinic. Wehave We should like to thank all those who helped included most common diseases but not all, and we us with producing this book and, in particular, have tried to emphasise points which are under- Sir Edward Wayne and Sir Graham Bull who have stressed in many textbooks. Accounts are given of kindly allowed us to benet from their extensive many conditions which are relatively rare. It is neces- experience both in medicine and in examining for sary for the clinician to know about these and to be on the Colleges of Physicians. Supplementary reading is essential to un- derstandtheirbasicpathology,buttheinformationwe David Rubenstein give is probably all that need be remembered by David Wayne the non-specialist reader and will provide adequate November 1975 1 T h e m edical in terview Good communication between doctor and patient forms the basis for excellent patient care and the clinical consultation lies at the heart of medical prac- Effective consultation tice. Good communication skills encompass more Effective consultations are patient-centred and ef- than the personality traits of individual doctors they cient, taking place within the time and other practical forman essentialcorecompetencefor medicalpracti- constraints that exist in everyday medical practice. In essence, good communication skills pro- Theuseofspeciccommunicationskillstogetherwith duce more effective consultations and, together with a structured approach to the medical interview can medical knowledge and physical examination skills, enhance this process. Important communication lead to better diagnostic reasoning and therapeutic skills can be considered in three categories: content, intervention. These skills are evidence-base shows that health outcomes for pa- closely interrelated so that, for example, effective tients and both patient and doctor satisfaction within use of process skills can improve the accuracy of the therapeutic relationship are enhanced by good information gathered from the patient, thus enhan- communication skills. Providing structure to the consultation is one of the There are a number of different models for most important features of effective consultation. They are generally similar and all em- that is responsive to the patient and exible for dif- phasise the importance of patient-centred inter- ferent consultations. Like all clinical skills, com- examination) munication skills can only be acquired by experien-. Before meeting a patient, the doctor should prepare by focusing him- or herself, Theinitialpartofaconsultationisessentialtoformthe tryingtoavoiddistractionsandreviewinganyavailable basis for relationship building and to set objectives for information such as previous notes or referral letters. Gathering information An accurate clinical history provides about 80% of the Explanation and planning information required to make a diagnosis. Tradition- ally, history-taking focused on questions related to the Explanationandplanningiscrucially importantto the biomedical aspects of the patients problems. Establishment of a manage- evidencesuggeststhatbetteroutcomesareobtainedby ment plan jointly between the doctor and the patient including the patients perspective of their illness and has important positive effects on patient recall, un- by taking this into account in subsequent parts of the derstanding of their condition, adherence to treat- consultation. Patient expectations should therefore include exploring the history from have changed and many wish to be more involved in boththebiomedicalandpatientperspectives,checking decision-making about investigation and treatment thattheinformationgatherediscompleteandensuring options. The goals of this part of the consultation are thatthepatientfeelsthatthedoctorislisteningtothem. Explanation and planning Gathering information Avoid jargon: use clear concise language; explain Ask the patient to tell their own story. Listen attentively: do not interrupt; leave the pa- Find out what the patient knows: establish prior tient time and space to think about what they are knowledge; nd out how much they wish to know saying. Encourage the patient to express their feelings: Involvethe patient:share thoughts; reveal rationale actively seek their ideas, concerns and expectations. The way in which these two are understand and which takes their perspectives into used is shown in Table 1. It encourages patient participation and collaboration and facilitates accurate information Closing the session gathering. Building a relationship with the patient in- Closing the interview allows the doctor to summarise volves a number of communication skills that enable and clarify the plans that have been made and what the doctor to establish rapport and trust between thenextstepswillbe.

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