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Glucose Tolerance Test 3 hour

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6581. Assessing Dehydration in Children

). Sunken eyes. Tachycardia. Tachypnoea. Reduced skin turgor. Shock [ ] Arrange emergency transfer to secondary care: Pale or mottled skin. Cold extremities. Decreased level of consciousness. Tachycardia. Tachypnoea. Weak peripheral pulses. Prolonged capillary refill time. Hypotension. Investigations Urine tests: Urinalysis: ketones and glucose in DKA. Urine specific gravity: may be elevated (but diabetes insipidus causes the urine to be dilute). Blood tests: Serum sodium: hyponatraemia (...) chloride with 5% glucose, for fluid deficit replacement and maintenance. Replace the fluid deficit slowly - typically over 48 hours. Monitor the plasma sodium frequently, aiming to reduce it at a rate of less than 0.5 mmol/L per hour. Attempt early and gradual introduction of oral rehydration therapy during intravenous fluid therapy. If tolerated, stop intravenous fluids and complete rehydration with oral rehydration therapy. Fluid management following dehydration [ ] Encourage breast-feeding and other

2008 Mentor

6582. Cellulitis and Erysipelas

. Athlete's foot can be the portal of entry. Malaise, chills and high fever (flu-like symptoms) often precede any skin lesion. Vomiting can occur. Within 48 hours there is a sudden and rapid onset of skin infection with , burning and tenderness. The lesions begin as a small erythematous patch. This then progresses to a fiery-red, indurated, tense and shiny plaque. The margins are raised, sharply demarcated and advancing, with rapid enlargement over 3 to 6 days. There is local oedema, tenderness and warmth (...) with home-based care is high. Outpatient parenteral antibiotics should be used where available. [ ] Consider referral Referral to hospital should be considered if there is: Severe or rapidly worsening infection, especially if there is possible necrotising fasciitis. Systemic illness or vomiting. Evidence of complications or suspected deep infection. Facial infection. Suspected orbital/periorbital cellulitis. Immunocompromise. Diabetes (if blood sugars are unstable). Significant comorbidity. Lymphoedema

2008 Mentor

6583. Cardiovascular History and Examination

an impression. In a bed-bound patient the swelling is likely to be in the sacral area, genitalia and back of the thighs, rather than the ankles. Oedema may also cause pleural effusion, pericardial effusion or ascites. Fundoscopy: Look for the silver wiring effect in hypertension, swollen disc in malignant hypertension, microaneurysms and fluffy deposits. Also, look for Roth's spots in infective endocarditis. Investigations These may include: Blood tests (for fasting glucose and/or glycosylated haemoglobin (...) propped up at night and if so with how may pillows. Establish whether there is any paroxysmal nocturnal dyspnoea or breathlessness at rest. These may last from minutes to hours and be accompanied by wheezing, sweating, distress and cough with frothy or bloodstained sputum. This is commonly termed 'cardiac asthma', although uraemia may cause similar symptoms. Cheyne-Stokes or periodic breathing: this often occurs during sleep, with a long cycle time; it may be found in chronic pulmonary oedema or poor

2008 Mentor

6584. Chronic Renal Failure (CRF)

and often unrecognised because there are no specific symptoms, and it is often not diagnosed, or diagnosed at an advanced stage. [ ] Symptoms It may be discovered by chance following a routine blood or urine test. Specific symptoms usually develop only in severe CKD, and include anorexia, nausea, vomiting, fatigue, weakness, pruritus, lethargy, peripheral oedema, dyspnoea, insomnia, muscle cramps, pulmonary oedema, nocturia, polyuria and headache. Sexual dysfunction is common. Hiccups, pericarditis (...) disease. Urine sediment with red blood cells and red blood cell casts suggests proliferative glomerulonephritis. Pyuria and/or white cell casts suggest interstitial nephritis (especially if eosinophils are present in the urine) or urinary tract infection (UTI). Spot urine collection for total protein:creatinine ratio allows reliable estimation of total 24-hour urinary protein excretion. The degree of proteinuria correlates with the rate of progression of the underlying kidney disease and is the most

2008 Mentor

6585. Chronic Kidney Disease (Chronic Renal Failure)

and often unrecognised because there are no specific symptoms, and it is often not diagnosed, or diagnosed at an advanced stage. [ ] Symptoms It may be discovered by chance following a routine blood or urine test. Specific symptoms usually develop only in severe CKD, and include anorexia, nausea, vomiting, fatigue, weakness, pruritus, lethargy, peripheral oedema, dyspnoea, insomnia, muscle cramps, pulmonary oedema, nocturia, polyuria and headache. Sexual dysfunction is common. Hiccups, pericarditis (...) disease. Urine sediment with red blood cells and red blood cell casts suggests proliferative glomerulonephritis. Pyuria and/or white cell casts suggest interstitial nephritis (especially if eosinophils are present in the urine) or urinary tract infection (UTI). Spot urine collection for total protein:creatinine ratio allows reliable estimation of total 24-hour urinary protein excretion. The degree of proteinuria correlates with the rate of progression of the underlying kidney disease and is the most

2008 Mentor

6586. Acute Myocardial Infarction

increase within 3-12 hours of onset of chest pain, reach peak values within 24 hours and return to baseline after 48-72 hours. Sensitivity and specificity are not as high as for troponin levels. Serial ECGs and continuous ECG monitoring in a coronary care unit (CCU). CXR: to assess the patient's heart size and the presence or absence of heart failure and pulmonary oedema. This may also assist in differential diagnosis. Pulse oximetry and blood gases: monitor oxygen saturation. Cardiac catheterisation (...) increasing age, being male, family history of premature CHD, premature menopause. Modifiable risk factors for atherosclerosis include smoking, diabetes mellitus (and impaired glucose tolerance), metabolic syndrome, hypertension, hyperlipidaemia, obesity and physical inactivity. [ ] Certain ethnic groups have higher risk of CHD. In the UK, the highest recorded rates of coronary artery disease mortality are in people born in India, Pakistan and Bangladesh. [ ] South Asians are thought to have a 40-60

2008 Mentor

6587. Acute Myocardial Infarction Management (Full text)

with GTN sublingual/spray and/or an intravenous opioid 2.5-5 mg diamorphine or 5-10 mg morphine intravenously with an anti-emetic. [ ] Avoid intramuscular injections, as absorption is unreliable and the injection site may bleed if the patient later receives thrombolytic therapy. Aspirin 300 mg orally (dispersible or chewed). Insert a Venflon® for intravenous access and take blood tests for FBC, renal function and electrolytes, glucose, lipids, clotting screen, C-reactive protein (CRP) and cardiac (...) (reteplase or tenecteplase) rather than an infusion for pre-hospital thrombolysis. [ ] Management initiated in hospital If not already done, insert a Venflon® for intravenous access and take blood tests for cardiac enzymes (troponin I or T), FBC, renal function and electrolytes, glucose, lipids, CRP, and clotting screen. See separate article for a more detailed discussion of investigations. Continue close clinical monitoring (including symptoms, pulse, blood pressure, heart rhythm and oxygen saturation

2008 Mentor PubMed abstract

6588. Acute Coronary Syndromes (ACS)

. [ ] Factors to use when assessing risk with an established scoring system include: Full clinical history, including age, previous myocardial infarction, previous percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). Physical examination, including blood pressure and heart rate. 12-lead resting ECG. Blood tests (such as troponin I or T, creatinine, glucose and haemoglobin). The risk of bleeding should be assessed as well as relevant comorbidity before considering treatments (...) and without known diabetes should be tested for HbA1c levels before discharge and fasting blood glucose levels no earlier than four days after the onset of ACS. After stabilisation, secondary risk reduction measures should be implemented. These measures include stopping smoking, continued aspirin therapy, management of hypertension if present, statins, ACE inhibitors and beta-blockers. [ ] If a patient was stabilised with medical treatment then it is likely they will undergo treadmill exercise testing

2008 Mentor

6589. Acromegaly

is also prolactin-secreting [ ] . Hypopituitarism: decreased secretion of anterior pituitary hormones and compression of pituitary stalk. Investigations [ ] See also separate article. Blood glucose; serum phosphate, urinary calcium and serum triglycerides may also be raised. IGF-1 is recommended as the initial screen for suspected acromegaly: It has a correlation with GH levels, long half life of 15 hours and relatively stable serum levels. Highly sensitive, such that a normal level usually excludes (...) acromegaly. False positives may occur in pregnancy and late adolescence. Hepatic disease and chronic kidney disease, malnutrition, hypothyroidism, severe infection and poorly controlled diabetes may affect IGF-1 levels. Levels must be assessed relative to age-appropriate normal levels. There is significant inter-assay variability, so the same laboratory and test should be used for the same patient. Oral glucose tolerance test is used to confirm a raised IGF-1: GH is normally inhibited by glucose

2008 Mentor

6590. Antenatal Examinations

[ , ] Test for asymptomatic bacteriuria early in pregnancy using dipstick testing; send midstream specimen of urine (MSU) if indirect test is positive. Test for proteinuria at each antenatal appointment (along with BP as part of regular surveillance for pre-eclampsia). Check for glycosuria at every visit; if there is glycosuria of more than 2+ on one occasion, or 1+ on two or more occasions, test further to exclude gestational diabetes. An oral two-hour glucose tolerance test is normally used. See (...) options and care in her pregnancy. Information and advice which should be covered in the first appointment is detailed in the separate article. Examination routinely done at the first appointment includes: Measurement of weight and height in order to determine body mass index (BMI). Measurement of baseline blood pressure (BP). Testing of urine for glycosuria/proteinuria. Pelvic examination [ ] Routine antenatal pelvic examination does not accurately assess gestational age, nor does it accurately

2008 Mentor

6591. Angina Pectoris

a diagnosis of angina. Changes on a resting 12-lead ECG that are consistent with CAD include: Pathological Q waves. Left bundle branch block (LBBB). ST-segment and T-wave abnormalities (eg, flattening or inversion). FBC is required to exclude anaemia. Renal function and electrolytes to assess renal function. Fasting blood glucose if diabetes is not known to exist. If diabetes is known and recent figures are not available then glycosylated haemoglobin and microalbuminuria should be checked. Fasting blood (...) despite increasing medical treatment. Refer urgently all people with suspected angina (to be seen within two weeks) to a Rapid Access Chest Pain Clinic for confirmation of the diagnosis and assessment of the severity of coronary heart disease. Further investigations Editor's note April 2018 - Dr Hayley Willacy recommends the latest SIGN guideline on the management of stable angina released this month [ ] . They recommend that in patients with suspected stable angina, the exercise tolerance test should

2008 Mentor

6592. Aminoacidurias

protein intolerance. Metabolism. 2007 Feb56(2):185-9. ; Oral administration of urea cycle intermediates in lysinuric protein intolerance: effect on plasma and urinary arginine and ornithine. Metabolism. 1983 Jan32(1):49-51. ; Lysinuric Protein Intolerance anyone had uti symtoms and blood on dip stick but test comes back negative for infection so confused lisa45174 Health Tools Feeling unwell? Assess your symptoms online with our free symptom checker. Article Information Last Reviewed 19 October 2011 (...) in conditions in which there is hyperaminoacidaemia. Some important aminoacidurias are described below but , , and other are mentioned in detail in separate articles. Fanconi's syndrome is the most frequently studied inherited aminoaciduria. The syndrome is characterised by a generalised aminoaciduria and by other renal tubular defects affecting reabsorption of phosphate and glucose. Frequently, the renal handling of potassium and water, as well as the secretion of hydrogen ions and the manufacture

2008 Mentor

6593. Alcoholism - Recognition and Assessment

-confrontational questions to begin a discussion about alcohol - for example: Do you use alcohol? In what circumstances do you drink - eg, only when socialising? What is the most you have ever drunk? How recent was this? In primary care and hospital settings - use the or questionnaires [ , ] . Often routine blood results may show coincidental macrocytosis or abnormal LFTs which should make you suspicious [ ] . Assessment This involves two main aspects: Is their alcohol intake a problem? Do they have any (...) illnesses relating to their alcohol intake - this encompasses physical, psychological and social aspects? Is their alcohol intake a problem? Amount of consumption. Are they dependent on alcohol? Do they need a drink every day? What time is their first drink? Has anyone expressed concerns about their alcohol intake? Alcohol dependence [ ] : Strong desire to drink. Difficulty controlling alcohol intake. Physiological withdrawal when intake is reduced. Tolerance, such that increasing amounts are required

2008 Mentor

6594. Vaginal and Vulval Candidiasis

-41. ; Genital mycotic infections in patients with diabetes. Postgrad Med. 2013 May125(3):33-46. doi: 10.3810/pgm.2013.05.2650. ; Glucose tolerance in pregnant women with vaginal candidiasis. Ann Saudi Med. 2004 Sep ; Vulvovaginal candidosis. Lancet. 2007 Jun 9369(9577):1961-71. ; Self-taken vaginal swabs versus clinician-taken for detection of candida and bacterial vaginosis: a case-control study in primary care. Br J Gen Pract. 2017 Dec67(665):e824-e829. doi: 10.3399/bjgp17X693629. ; NICE CKS (...) infection [ ] . 10-20% of women have asymptomatic vaginal colonisation with Candida spp. and do not need treatment [ , ] . Risk factors Pregnancy [ ] . Diabetes mellitus (impaired glucose tolerance in pregnancy does not seem to be a statistically significant risk factor) [ , ] . Treatment with broad-spectrum antibiotics (occurs in 28-33%). Chemotherapy. Vaginal foreign body. Contraceptives may predispose to recurrent vaginal and vulval candidiasis - but evidence is conflicting and of poor quality

2008 Mentor

6595. Wilson's Disease

with hypercalciuria and nephrocalcinosis along with renal loss of amino acids, glucose, phosphate and excess uric acid. Rheumatological: Rheumatological features include osteopenia that may be apparent on normal X-rays and osteoarthritis. The spine and large appendicular joints such as the knees, wrists, and hips are most often involved. Osteochondritis dissecans, chondromalacia patellae and chondrocalcinosis have also been described. The chondrocalcinosis and osteoarthritis of Wilson's disease may be due (...) to copper accumulation similar to the arthropathy of haemochromatosis. Myopathy. Cardiac arrhythmias and cardiomyopathy can occur. Hypoparathyroidism. Pancreatitis. Infertility. Azure lunulae of the fingernails have been described and are presumably due to deposition of copper. Investigation [ ] Although the diagnosis of Wilson's disease depends on the evaluation of clinical and laboratory evidence of abnormal copper metabolism, there is no single test that is reliable in isolation. Wilson's disease

2008 Mentor

6596. Von Gierke's Glycogen Storage Disease - Type I

anaemia, neutropenia and proteinuria or at least microalbuminuria. Special tests Ultrasound should be used to assess and monitor the size of liver and kidneys and to detect possible hepatic adenomas and nephrocalcinosis. Glucagon does not cause a rise in glucose levels, but it does raise lactic acid levels. Oral galactose and fructose fail to increase glucose levels but plasma lactic acid levels increase. Glucose tolerance test progressively lowers lactic acid levels over several hours. A bone density (...) immune disturbance. Infections cause significant mortality in GSD type Ib. [ ] Investigations Blood glucose and pH are usually low with elevated lactate, uric acid, triglyceride and cholesterol. Renal function tests: creatinine and urea may be raised if renal function is impaired. FBC: anaemia; patients with GSD type Ib may have neutropenia as a result of frequent bacterial infections. Lactic acidosis may simply be suggested by a high anion gap when electrolytes are measured. Older patients may show

2008 Mentor

6597. High Altitude Illness

to prevent AMS was six. [ ] The most common adverse effect of acetazolamide is paraesthesia; at this lower dose it is more likely to be tolerated. [ ] Dexamethasone has evidence of benefit and the recommended adult doses are 2 mg every six hours or 4 mg every twelve hours. It should not be used for more than ten days to avoid adrenal suppression. There is no robust evidence that ginkgo biloba extract is effective in preventing AMS. Ibuprofen has been studied and found in some trials to be effective (...) term: by increasing red blood cell production (via erythropoietin). Increasing tissue perfusion by increasing cardiac output. Travel to altitudes of 2500 metres (8,000 feet) or greater puts people at risk of developing high-altitude illness. This could be in the form of acute mountain sickness (AMS), high-altitude pulmonary oedema (HAPE or HAPO), and/or high-altitude cerebral oedema (HACE or HACO). AMS: generally a milder and common form of high-altitude illness. It is usually self-limiting

2008 Mentor

6598. Hiccups

% of men and 8% of women. If the history and examination yield no apparent area which should receive particular attention it is not unreasonable to perform simple screening investigations such as: U&Es Serum calcium FBC Blood glucose LFTs Amylase CXR ECG Further investigations may be performed as indicated - for example: Fluoroscopy of diaphragmatic movement Abdominal ultrasound CT/MRI scan Endoscopy Bronchoscopy Colonoscopy Management [ ] Non-drug Most bouts of hiccups will be self-limiting (...) a large meal, drinking during periods of excitement or due to sudden changes in air temperature. Hiccups which recur very frequently, or last for more than 48 hours, may be an indication of an underlying physical problem. Many causes of hiccups have been described; however, often no cause is found. Some of the more common underlying causes of prolonged bouts of hiccups include: Respiratory - eg, bronchial tumour, pneumonia, pleurisy, asthma, pulmonary embolus. [ , ] Cardiovascular - eg, myocardial

2008 Mentor

6599. Hypothermia

transfer to a critical care setting. Assess for and treat any associated disorders - eg, diabetes, sepsis, drug or alcohol ingestion, or occult injuries. Blood investigations: FBC, electrolytes, blood glucose, alcohol, toxin screen, creatinine, amylase and blood cultures. Cardiac monitoring: dysrhythmias, changes of hyperkalaemia; J waves are pathognomonic of hypothermia: Cardiac output falls proportionately to the degree of hypothermia and cardiac irritability begins at about 33°C. Ventricular (...) be deliberate (see below), or accidental. Any patient whose core temperature drops accidentally below 36°C at any stage of the perioperative pathway (from the hour before induction of anaesthesia until 24 hours after entry into the recovery area) should be warmed using a forced air warming device. [ ] Secondary hypothermia This is low body temperature resulting from a medical illness lowering the temperature set-point: Decreased heat production - eg, hypopituitarism, hypoadrenalism, hypothyroidism, severe

2008 Mentor

6600. Hypophosphataemia

. They may also indicate chronic alcoholism. PTH and vitamin D levels. If respiratory alkalosis is considered, arterial blood gases are required. If renal loss is considered, fasting morning urine for phosphate content, along with blood sample. If Fanconi's syndrome is considered, obtain plasma bicarbonate and urate and test urine for glucose and amino acids. A full Fanconi's syndrome consists of renal glycosuria, aminoaciduria, renal tubular acidosis, low blood urate due to high urinary loss (...) is well tolerated although very high doses may cause diarrhoea. Where there is an acute situation or lack of intestinal function, parenteral phosphate may be used but this is much more dangerous and requires monitoring of calcium, phosphate and electrolyte levels every six hours as response is unpredictable. It should only used where serum phosphate levels are under 1.5 mmol/L. The risk is severe hypocalcaemia which may be life-threatening, or over-treatment resulting in hyperphosphataemia

2008 Mentor

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