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X. Sibur-Narad, M.B. B.A.O., M.B.B.Ch., Ph.D.

Vice Chair, Idaho College of Osteopathic Medicine

The method and mode of standardization are variables for the reference interval, particularly for immunologic and enzymatic tests. The selection of the "normal" population is also important because factors such as age, gender, race, diet, personal habits. These multiple variables for determining the reference interval indicate why there are differences among institutions for the same analyte. For convenience, this chapter is divided into the following three sections: clinical chemistry, toxicology, and serology; hematology and coagulation; and drugs-therapeutic and toxic. The list includes reference intervals for the most common tests used in the practice of internal medicine. For more information about the reference interval for a given test or a test not included in the list, a recommended source is Clinical Guide to Laboratory Tests, third edition, edited by Dr. This book contains literature citations for most of the tests listed in this chapter. The pertinent prefixes denoting the decimal factors and abbreviations are listed above. If consideration is interference with or effects of disease on a clinical test, here are two references that are of value. Extraordinary advances in diagnostic and therapeutic modalities, triggered by advances in molecular and cellular biology, are revolutionizing the scientific basis of medicine. One of the highest priorities of this edition is the incorporation of these molecular and cellular advances into a comprehensive yet easily understandable description of the modern pathophysiologic basis of disease. Simultaneously, medicine has seen equally revolutionary advances in the application of methodologies such as the randomized control trial, the measurement of quality-of-life, and an understanding of cost effectiveness as they apply to clinical medicine. This new edition also emphasizes the application of this new information via the concept of evidence-based medicine to clinical decision-making. This dual emphasis-molecular biology and evidence-based medicine-permeates the entire fabric of this work. Increased use of flow diagrams to guide diagnostic and therapeutic decision making is a natural outgrowth of these advances. Just as each edition brings new authors, it also reminds us of our gratitude to past editors and authors. Previous editors of Cecil Textbook of Medicine include Russell Cecil, Paul Beeson, Walsh McDermott, James Wyngaarden, H. Schafer-we also express our appreciation to editors from the previous edition on whose foundation we have built. Special appreciation is due to Fred Plum, who served as consulting editor for the neurology section for eight editions and as co-editor for the 20th edition. We also thank Robert Ockner, who served as consulting editor for gastrointestinal diseases and diseases of the liver, gallbladder, and bile ducts. Smith, who was consulting editor for cardiovascular diseases, respiratory diseases, and critical care medicine. Kokko, continue to make critical contributions to the selection of authors and the review of selected manuscripts. The editors, however, are fully responsible for the book as well as the integration among chapters. The tradition of Cecil Textbook of Medicine is that all chapters are written by distinguished experts in each field. We would also like to take this opportunity to thank several junior physicians who assisted these individuals on specific chapters: Graham Pineo ("Peripheral Venous Disease"), Eric van Sonnenberg and Brian W. Goodacre ("Diagnostic Imaging Procedures in Gastroenterology"), Sergei Kantsevoy ("Acute and Chronic Liver Failure and Hepatic Encephalopathy"), Miguel Arguedas ("Hepatic Tumors"), William Delgado ("Examination of the Skin and an Approach to Diagnosing Skin Disease" and "Skin Diseases of General Importance"), and Robert Sidbury ("Principles of Therapy" and "Skin Diseases of General Importance"). We are also most grateful for the editorial assistance in San Francisco of Stephanie Webb and in Birmingham of Cheryl Dunlap; these individuals have shown extraordinary dedication and equanimity in managing the unending flow of manuscripts, disks, figures, and permissions. Saunders Company, Les Hoeltzel, Lynne Gery, Frank Polizzano, Tom Stringer, Jonel Sofian, and Peg Shaw have been critical to the planning and production process under the direction of Lisette Bralow, to whom we are also most indebted.

Once the amount of water is instilled and you Most people irrigate daily or every other day. I find that feel your colon distending, clamp the tube and hold the irrigation is so effective that no feces is emitted from cone in place for about a minute, then remove the cone my stoma and the stoma cap or pouch only shows a from your stoma. Close the top of the irrigation sleeve and wait tion does not last for the full time. Most is expelled in change of diet or some disturbance of the bacteria in the the first 10-15 minutes, the rest can take another 15-30 gut when taking antibiotics or from food intolerances. During this time, you can fold up the irrigation sleeve and walk around and do other things. Once the returns are completed, remove the Bowel continence is so important to our self-esteem irrigation sleeve, clean your skin or shower, and apply and social life. Those who do not have a colostomy, or a stoma cap or a mini pouch if using a two-piece before you were an ostomate you probably took pooping pouching system. Wash equipment with mild dish soap or vinegar bowels it can have a major impact on his quality of life. It is not necessary to sterilize ostomate Brian McKeown of New Zealand, "but you the equipment. Repeat daily at the same time and your bowels leaky bags or accidents when out in society, and far less should start to become regulated and you feel confident passing wind. When you are confident in a 24-hour interval, this article is not intended to provide medical guidyou may want to try to increase the time between irrigaance or replace the education of your ostomy nurse. Colostomy Care - 45 Beautiful Butte A performer shines brighter and better than ever By B Redner Softly, but firmly, the gastroenterologist spoke, "Your hips will have to wait. Now envision that girl backstage at the fabulous Diplomat Hotel in Miami Beach, where the most famous singing idols of the 1970s performed nightly. Teenage Melissa Marshall stood a mere 20 feet from Frank Sinatra belting out "New York, New York," followed a week later by Sammy Davis, Jr. Melissa not only enjoyed their music, but surreptitiously attended a private master class just by listening and watching how each star practiced their craft and "worked" the audience. She learned how to breathe properly, how to phrase lyrics, when and how to share the stage with an orchestra. She learned what to say when a song tanked and what to do when one blew the roof off. By the time she started at the University of Miami where she majored in jazz-vocal music, she found herself already well prepared for a singing career. Sure enough, shortly after finishing school, Melissa Master Music Classes formed her own band, aptly named, the Marshall Arts Band and launched her career. The seven-piece band played the Sheraton and Marriott circuit between Texas and Illinois. First Signs and Symptoms In 2012 Melissa experienced rectal bleeding, but passed it off as an aging issue. A year later, during an examination prior to hip surgery, she learned the hard fact that she had a tumor. It was an unbenecklace, Melissa incorporated a new charity, the No lievable bonding experience. She had to wait six agonizing weeks to allow her body Melissa muses, "Is it possible to say that cancer and to heal from the first surgical procedure before underthe required surgery became the best thing to have going the next operation. She quickly arrived at her She has gone even further by attending and graduating physical and emotional cellar. Its provisions available at stadium aid stations and in emerbody was a loop of ribbon, the international symbol for gency vehicles. I called a jeweler to craft my design," to bet against her achieving these lofty goals. An innovative pouch develop the confidence to has a built-in cleaning provide your own care.

These are innervated by the mandibular division of the trigeminal nerve and can be tested by having the patient clench the jaw tightly or deviate the jaw from side to side against resistance. Facial Nerve Motor component this nerve supplies motor innervation to the face and has numerous divisions. The patient is then asked to wrinkle the brow, close the eyes firmly, smile and frown. Facial weakness can be due to either lower motor neuron or upper motor neuron lesions. With a lower motor neuron lesion of the facial nerve, ipsilateral weakness of the entire half of the face is observed. Facial weakness can also be seen with an upper motor neuron lesion involving the motor cortex or the corticobulbar tract. In this case, the weakness is contralateral to the lesion and involves only the lower half of the face. This pattern of weakness is seen with upper motor neuron lesions because the upper face receives bilateral cortical innervation and is therefore unaffected in unilateral upper motor neuron lesions. Taste component the facial nerve supplies taste sensation to the anterior 2/3 of the tongue via the chorda tympani nerve. Taste can be checked by applying sugar or salt solutions to the anterior tongue with a cotton applicator. Hearing loss is frequently differentiated into conductive hearing loss and sensori-neural hearing loss. Conductive hearing loss implies a lesion to structures in the outer or middle ear that convert air conduction into bone conduction. Bone conduction is perceived as louder than air conduction in this form of hearing loss. Sensori-neural hearing loss is due to a lesion involving the inner ear (cochlear apparatus) or the eighth cranial nerve. Sensori-neural hearing loss is sometimes further subdivided into cochlear and retro-cochlear. Retrocochlear hearing loss is usually due to a tumor invading the eighth cranial nerve (acoustic Schwannoma). The Weber test and Rinne test are two tests of hearing that help differentiate conductive from sensori-neural hearing loss. In the Rinne test, the base of a vibrating tuning fork (512 Hz) is placed against the mastoid process until the sound is no longer heard. The tines of the tuning fork are then moved adjacent to the external ear where sound should still be appreciated in normal individuals, since air conduction is normally better than bone conduction. If the sound is no longer heard in this second position a conductive hearing loss is suspected. In the Weber test, a vibrating tuning fork (512 Hz) is placed at the vertex of the skull and the patient is asked to localize the sound. Lateralization of the sound to one ear is abnormal, with the sound localizing to the "bad ear" in a conductive hearing loss and to the "good ear" in a sensori-neural hearing loss. The significance of abnormalities in Weber and Rinne testing are listed in table 4. Labyrinthine stimulation can be performed by means of the NylenBarany (Dix-Hallpike) positioning maneuver. If the patient reports vertigo during the maneuver, or if nystagmus develops, vestibular dysfunction may be present. In this test, hot or cold water is introduced into the external auditory meatus and the patient is observed for the development of nystagmus. Both ears are irrigated sequentially and the degree of resultant nystagmus following irrigation of either ear is compared. Nystagmus and vertigo can both be seen following a peripheral lesion involving the vestibular apparatus, or following a central lesion involving the vestibular nuclei in the brain stem. The vertigo and nystagmus that result from either a central or peripheral lesion have different characteristics, and these differences are useful in localizing lesions of the vestibular system. Table 5 lists the different responses seen with central or peripheral lesions for the Nylen-Barany maneuver.

Which of the following amino acids is most likely to be decreased in this patient? Which of the following is required to transport fatty acids across the inner mitochondrial membrane? A 67-year-old man has a restricted diet that includes no fresh citrus fruits or leafy green vegetables. A 45-year-old woman has a uterine leiomyoma that is 5 cm in diameter and is pressing on the urinary bladder, causing urinary frequency. A 5-year-old girl is brought to the emergency department because of fever and severe abdominal pain. In the examination room, she keeps her right hip flexed and resists active extension of the hip. The inflamed structure associated with these symptoms is most likely in contact with which of the following structures? A 61-year-old man comes to the physician because of a 3-month history of episodes of headache, heart palpitations, and excessive sweating. A 6-year-old boy has a large intra-abdominal mass in the midline just above the symphysis pubis. During an operation, a cystic mass is found attached to the umbilicus and the apex of the bladder. A 55-year-old man who has alcoholic cirrhosis is brought to the emergency department because he has been vomiting blood for 2 hours. He has a 2-month history of abdominal distention, dilated veins over the anterior abdominal wall, and internal hemorrhoids. A 3-year-old girl with mild craniofacial dysmorphosis has profound hearing deficits. Further evaluation indicates profound sensory auditory deficits and vestibular problems. Altered development of which of the following is most likely to account for these observations? A 19-year-old woman comes to the physician because of a 5-day history of increasingly severe right lower abdominal pain and bloody vaginal discharge. A 22-year-old man is brought to the emergency department because of a suprahyoid stab wound that extends from one side of the neck to the other. His tongue deviates to the right when protruded; there is no loss of sensory modality on the tongue. Resection of the tumor is scheduled, and the physician also plans to obtain samples of the draining nodes. To find these nodes, a radiotracer is injected adjacent to the tumor and images are obtained. The first draining sentinel node in this patient is most likely found at which of the following locations? This patient most likely has an abnormality of which of the following fetal structures? A 70-year-old man has a 90% blockage at the origin of the inferior mesenteric artery. Which of the following arteries is the most likely additional source of blood to the descending colon? A 30-year-old man comes to the emergency department 1 hour after injuring his left knee in a volleyball game. He says he twisted his left leg when he fell to the floor after he and a teammate accidentally collided. When the patient sits on the edge of the examination table, the left knee can be displaced anteriorly at an abnormal degree. A 70-year-old man is brought to the emergency department because of a 1-week history of increasingly severe left-sided lower abdominal pain and passing gas in his urine. A 60-year-old man has tenderness in the region distally between the tendons of the extensor pollicis longus and extensor pollicis brevis (anatomical snuffbox) after falling on the palm of his right hand. A 20-year-old man is brought to the emergency department 1 hour after he was involved in a motorcycle collision. On auscultation, a harsh continuous murmur is heard at the left of the sternum between the first two ribs.