Learning/Medicine 2021. 8. 20. 15:36

https://www.aafp.org/afp/2010/1101/p1075.html

 

Nongenital Herpes Simplex Virus

Nongenital herpes simplex virus type 1 is a common infection usually transmitted during childhood via nonsexual contact. Most of these infections involve the oral mucosa or lips (herpes labialis). The diagnosis of an infection with herpes simplex virus typ

www.aafp.org

 

 

Nongenital herpes simplex virus type 1 is a common infection usually transmitted during childhood via nonsexual contact. 

 

 Most of these infections involve the oral mucosa or lips (herpes labialis). The diagnosis of an infection with herpes simplex virus type 1 is usually made by the appearance of the lesions (grouped vesicles or ulcers on an erythematous base) and patient history. However, if uncertain, the diagnosis of herpes labialis can be made by viral culture, polymerase chain reaction, serology, direct fluorescent antibody testing, or Tzanck test. The differential diagnosis of nongenital herpes simplex virus infection includes aphthous ulcers, acute paronychia, varicellazoster virus infection, herpangina, herpes gestationis (pemphigoid gestationis), pemphigus vulgaris, and Behçet syndrome. Oral acyclovir suspension is an effective treatment for children with primary herpetic gingivostomatitis. Oral acyclovir, valacyclovir, and famciclovir are effective in treating acute recurrence of herpes labialis (cold sores). Recurrences of herpes labialis may be diminished with daily oral acyclovir or valacyclovir. Topical acyclovir, penciclovir, and docosanol are optional treatments for recurrent herpes labialis, but they are less effective than oral treatment.

 

Pathophysiology

HSV invades and replicates in neurons, as well as in epidermal and dermal cells. The virus travels from the skin during contact to the sensory dorsal root ganglion, where latency is established. Oral HSV-1 infections reactivate from the trigeminal sensory ganglia, affecting the facial, oral, labial, oropharyngeal, and ocular mucosa.

 

Recurrent infections may be precipitated by various stimuli, such as stress, fever, sun exposure, extremes in temperature, ultraviolet radiation, immunosuppression, or trauma. The virus remains dormant for a variable amount of time.

 

Oral HSV-1 usually recurs one to six times per year. The duration of symptoms is shorter and the symptoms are less severe during a recurrence.

 

Clinical Presentation
In primary oral HSV1, symptoms may include a prodrome of fever, followed by mouth lesions with submandibular and cervical lymphadenopathy. The lesions usually heal within 10 to 14 days. 

 

In recurrent herpes labialis, symptoms of tingling, pain, paresthesias, itching, and burning precede the lesions in 60 percent of persons. The lesions then appear as clusters of vesicles on the lip or vermilion border. The vesicles may have an erythematous base. The lesions subsequently ulcerate and form a crust. Healing begins within three to four days, and reepithelization may take seven to eight days.

 

Herpetic keratitis is an HSV infection of the eye. Common symptoms are eye pain, light sensitivity, and discharge with gritty sensation in the eye. Slit lamp need. 

 

Herpetic whitlow is a vesicular lesion found on the hands or digits.  It occurs in children who suck their thumbs or medical and dental workers exposed to HSV-1 while not wearing gloves. Herpes gladiatorum is often seen in athletes who wrestle. Herpetic sycosis is a follicular infection with HSV that causes vesiculopapular lesions in the beard area. It is often caused by autoinoculation from shaving. 

 

HSV infection is one of the most common causes of erythema multiforme.

 

 

Diagnosis

by the appearance of the lesions and the patient's history. if the pattern of the lesions is not specific to HSV, its diagnosis can be made by viral culture, PCR, serology, direct fluorescent antibody testing, or Tzanck test. Viral culture should be obtained from vesicles when possible. The swab should be sent in special viral transport media directly to the laboratory (or placed on ice if transport will be delayed).

 

Management

EPISODIC ORAL TREATMENT FOR PRIMARY HERPETIC GINGIVOSTOMATITIS

Oral acyclovir suspension (Zovirax; 15 mg per kg five times per day for seven days) can be used to treat herpetic gingivostomatitis in young children. Children should be treated symptomatically with oral analgesics and cold, soothing foods such as ice pops and ice cream.

 

EPISODIC ORAL TREATMENT FOR RECURRENT HERPES LABIALIS

table

The patients took oral valacyclovir (2 g twice for one day) and applied clobetasol 0.05% gel (twice per day for three days) at onset of symptoms. - good result 

 

EPISODIC TOPICAL TREATMENT FOR RECURRENT HERPES LABIALIS

Topical treatment for herpes labialis is less effective than oral treatment. 

Treatment with docosanol cream, when applied five times per day and within 12 hours of episode onset, is safe and somewhat effective. OTC

 

ORAL TREATMENT TO PREVENT HERPES LABIALIS RECURRENCES

Oral acyclovir is effective in suppressing herpes labialis in immunocompetent adults with frequent recurrences. 

oral acyclovir (400 mg twice per day)

oral valacyclovir (500 mg per day)

patients receiving treatment for cancer, acyclovir was found to be effective in the prevention of HSV infections.  In another study, daily valacyclovir (500 mg per day) and acyclovir (400 mg twice per day) were equally effective in the prevention of recurrent HSV eye disease.

 

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Learning/Medicine 2021. 8. 19. 21:57

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5165171/

 

Adhesive capsulitis is a common cause of shoulder pain and limited movement. The objectives of this review were to assess the efficacy and safety of corticosteroid injections for adhesive capsulitis and to evaluate the optimum dose and anatomical site of injections. PubMed and CENTRAL databases were searched for randomised trials and a total of ten trials were included. Results revealed that corticosteroid injection is superior to placebo and physiotherapy in the short-term (up to 12 weeks). There was no difference in outcomes between corticosteroid injection and oral nonsteroidal anti-inflammatory drugs at 24 weeks. Dosages of intra-articular triamcinolone 20 mg and 40 mg showed identical outcomes, while subacromial and glenohumeral corticosteroid injections had similar efficacy. The use of corticosteroid injections is also generally safe, with infrequent and minor side effects. Physicians may consider corticosteroid injection to treat adhesive capsulitis, especially in the early stages when pain is the predominant presentation.

 

 

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Learning/Medicine 2021. 8. 19. 18:26

https://www.aafp.org/afp/2014/0201/p180.html

 

The most common etiology is viral gastroenteritis, a self-limited disease.

 

Risk factors and signs of inflammatory diarrhea and/or severe dehydration can direct any needed testing and treatment.

 

Most patients do not require laboratory workup, and routine stool cultures are not recommended. 

 

 Treatment focuses on preventing and treating dehydration.

 

Diagnostic investigation should be reserved for patients with severe dehydration or illness, persistent fever, bloody stool, or immunosuppression, and for cases of suspected nosocomial infection or outbreak.

 

Oral rehydration therapy with early refeeding is the preferred treatment for dehydration. Antimotility agents should be avoided in patients with bloody diarrhea, but loperamide/simethicone may improve symptoms in patients with watery diarrhea.

 

Probiotic use may shorten the duration of illness.

 

When used appropriately, antibiotics are effective in the treatment of shigellosis, campylobacteriosis, Clostridium difficile, traveler's diarrhea, and protozoal infections.

 

Prevention of acute diarrhea is promoted through adequate hand washing, safe food preparation, access to clean water, and vaccinations.

 

Acute diarrhea is defined as stool with increased water content, volume, or frequency that lasts less than 14 days.

 

In patients with acute diarrhea, stool cultures should be reserved for grossly bloody stool, severe dehydration, signs of inflammatory disease, symptoms lasting more than three to seven days, immunosuppression, and suspected nosocomial infections.

 

Routine testing for ova and parasites in acute diarrhea is not necessary in developed countries, unless the patient is in a high-risk group (i.e., diarrhea lasting more than seven days, especially if associated with infants in day care or travel to mountainous regions; diarrhea in patients with AIDS or men who have sex with men; community waterborne outbreaks; or bloody diarrhea with few fecal leukocytes).

 

The first step to treating acute diarrhea is rehydration, preferably oral rehydration.

 

Combination loperamide/simethicone may provide faster and more complete relief of acute nonspecific diarrhea and gas-related discomfort than either medication alone.

 

Antibiotics (usually a quinolone) reduce the duration and severity of traveler's diarrhea.

 

Clinically, acute infectious diarrhea is classified into two pathophysiologic syndromes, commonly referred to as noninflammatory (mostly viral, milder disease) and inflammatory (mostly invasive or with toxin-producing bacteria, more severe disease)

Bacterial infections are more often associated with travel, comorbidities, and foodborne illness

 

Salmonella, Campylobacter, Shigella, and Shiga toxin–producing Escherichia coli (enterohemorrhagic E. coli).

 

HISTORY

The onset, duration, severity, and frequency of diarrhea should be noted, with particular attention to stool character (e.g., watery, bloody, mucus-filled, purulent, bilious).

 

evaluated for signs of dehydration, including decreased urine output, thirst, dizziness, and change in mental status

 

Vomiting is more suggestive of viral illness or illness caused by ingestion of a preformed bacterial toxin.

 

Symptoms more suggestive of invasive bacterial (inflammatory) diarrhea include fever, tenesmus, and grossly bloody stool.

 

A food and travel history is helpful to evaluate potential exposures.

 

Children in day care, nursing home residents, food handlers, and recently hospitalized patients are at high risk of infectious diarrheal illness. Pregnant women have a 12-fold increased risk of listeriosis, which is primarily contracted by consuming cold meats, soft cheeses, and raw milk. 

 

Recent sick contacts and use of antibiotics and other medications should be noted in patients with acute diarrhea. Sexual practices that include receptive anal and oral-anal contact increase the possibility of direct rectal inoculation and fecal-oral transmission.

 

The history should also include gastroenterologic disease or surgery; endocrine disease; radiation to the pelvis; and factors that increase the risk of immunosuppression, including human immunodeficiency virus infection, long-term steroid use, chemotherapy, and immunoglobulin A deficiency.

 

 

 

 

The primary goal of the physical examination is to assess the patient's degree of dehydration. Generally ill appearance, dry mucous membranes, delayed capillary refill time, increased heart rate, and abnormal orthostatic vital signs can be helpful in identifying more severe dehydration. Fever is more suggestive of inflammatory diarrhea.

 

Diagnostic Testing

OCCULT BLOOD

LEUKOCYTES AND LACTOFERRIN
STOOL CULTURES : grossly bloody stool, severe dehydration, signs of inflammatory disease, symptoms lasting more than three to seven days, or immunosuppression. 

CLOSTRIDIUM DIFFICILE TESTING patients who develop unexplained diarrhea while using antibiotics or within three months of discontinuing antibiotics. 

OVA AND PARASITES Indications for ova and parasite testing include persistent diarrhea lasting more than seven days, especially if associated with infants in day care or travel to mountainous regions; diarrhea in persons with AIDS or men who have sex with men; community waterborne outbreaks; or bloody diarrhea with few fecal leukocytes

ENDOSCOPY 

 

Treatment

 

 

REHYDRATION THERAPY

FEEDING BRAT diet (bananas, rice, applesauce, and toast) and the avoidance of dairy are commonly recommended, supporting data for these interventions are limited

ANTIDIARRHEAL MEDICATIONS  loperamide (Imodium) may reduce the duration of diarrhea. loperamide/simethicone combination has demonstrated faster and more complete relief of acute nonspecific diarrhea and gas-related discomfort compared with either medication alone. Loperamide may cause dangerous prolongation of illness in patients with some forms of bloody or inflammatory diarrhea and, therefore, should be restricted to patients with nonbloody stool.

antisecretory drug bismuth subsalicylate (Pepto-Bismol) is a safe alternative in patients with fever and inflammatory diarrhea.

ANTIBIOTIC THERAPY

overuse of antibiotics can lead to resistance (e.g., Campylobacter), harmful eradication of normal flora, prolongation of illness (e.g., superinfection with C. difficile), prolongation of carrier state (e.g., delayed excretion of Salmonella), induction of Shiga toxins (e.g., from Shiga toxin–producing E. coli), and increased cost.

when used appropriately, antibiotics are effective for shigellosis, campylobacteriosis, C. difficile, traveler's diarrhea, and protozoal infections.

Antibiotic treatment of traveler's diarrhea (usually a quinolone) is associated with decreased severity of illness and a two-or three-day reduction in duration of illness. If the patient's clinical presentation suggests the possibility of Shiga toxin–producing E. coli (e.g., bloody diarrhea, history of eating seed sprouts or rare ground beef, proximity to an outbreak), antibiotic use should be avoided because it may increase the risk of hemolytic uremic syndrome. Conservative management without antibiotic treatment is less successful for diarrhea lasting more than 10 to 14 days, and testing and treatment for protozoal infections should be considered.  Antibiotics may be considered in patients who are older than 65 years, immunocompromised, severely ill, or septic. 

 

PROBIOTICS

ZINC SUPPLEMENTATION

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Learning/Medicine 2021. 8. 17. 13:37

 conjugated (direct hyperbilirubinemia) or unconjugated (indirect hyperbilirubinemia)?

 

An increase in unconjugated bilirubin in serum results from overproduction, impairment of uptake, or impaired conjugation of bilirubin. An increase in conjugated bilirubin is due to decreased excretion into the bile ductules or leakage of the pigment from hepatocytes into serum.

 

 

 

 

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Learning/Medicine 2021. 8. 17. 13:32

In patients with cholestasis, the alkaline phosphatase is typically elevated to at least four times the upper limit of normal.

 

The gamma-glutamyl transpeptidase (GGT) may also be elevated in the setting of cholestasis.

 

 Patients with a predominantly cholestatic pattern typically undergo a right upper quadrant ultrasound to further characterize the cholestasis as intrahepatic or extrahepatic; the latter is suggested by biliary tract dilatation.

 

To confirm that an isolated elevation in the alkaline phosphatase is coming from the liver, a GGT level or serum 5'-nucleotidase level should be obtained. These tests are usually elevated in parallel with the alkaline phosphatase in liver disorders but are not increased in bone disorders. An elevated serum alkaline phosphatase with a normal GGT or 5'-nucleotidase should prompt an evaluation for bone diseases.

 

An elevated bone alkaline phosphatase is indicative of high bone turnover, which may be caused by several disorders including healing fractures, osteomalacia, hyperparathyroidism, hyperthyroidism, Paget disease of bone, osteogenic sarcoma, and bone metastases. We generally refer such patients to an endocrinologist for evaluation. Initial testing may include measurement of serum calcium, parathyroid hormone, 25-hydroxy vitamin D, and imaging with bone scintigraphy.

 

Differential diagnosis — If the alkaline phosphatase elevation is isolated (ie, the other routine liver biochemical test levels are normal), is confirmed to be of hepatic origin, and persists over time, chronic cholestatic or infiltrative liver diseases should be considered. The most common causes include partial bile duct obstruction, primary biliary cholangitis (PBC), primary sclerosing cholangitis, and certain drugs, such as androgenic steroids and phenytoin. Infiltrative diseases include sarcoidosis, other granulomatous diseases, amyloidosis, and, less often, unsuspected cancer that is metastatic to the liver.

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Learning/English 2013. 6. 28. 03:36


 


I think your friend Hannah really sexy. 

OH my God

You did not just say that.  how old are you?

What are you, lawyer? 

yeah, little bit

come on

I know

you are? is she?


gonna be

 aren't you think, you are little bit old using be cheesy pick up lines?


Objection, leading the witness
ah, Hen you really wear adress, if do not favor?
That's a line

We're sitting over there past 2 hours, not being able to taking my eyes off you~ It's a fact. I find you very attractive. Do you find me attractive?


she does

I do

You did, she does.

I don't!

Permission to the approach. revenge?

Seriously

just come on , let me closing my argument

sure, proceed.

Hannah we are in the physical world, right?


Ha~

and you are going to be age, right?


Uhm

I guarantee you this, you'll never gonna regret, going home with the guy from the bar one time. It was a total Tom cat in the sec.  But I can guarantee you won't not a regret

or double negative

you are double negative.

OK , you know what, It's time to go home.

really?

Uh hu

It's for you double u but OK I will do it

Ya, his voice is sophry

Stop,  should I get my car or yours? shall I pull the car now? even drinking?

 

 

 

 

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Learning/English 2013. 6. 3. 02:01

발췌.


정확한 발음으로 단 한시간이라도 영어책을 읽어보신 분이 얼마나 있을지 모르겠습니다만 읽어보신 분은 아실 겁니다. 조금만 읽어도 목이 타고, 입이 마르고, 목이 쉬게 됩니다. 영어책을 소리내어 읽다보면 마치 미친사람 처럼 보이기도 합니다. 하지만 처음에는 쉽지 않으나 책을 읽다보면 점점 쉬워집니다. 점점 쉬워지는 이유는 이런 발음이 처음에는 어색하고 혀도 잘 돌아가지 않지만 단어를 수십, 수백번 발음해보면 어느 순간 노력하지 않아도 입이 자연적으로 정확한 발음으로 작동하여 소리내는 법을 깨우치게 되기 때문입니다. 즉 두뇌의 작용과 소리를 내는 기관이 유기적으로 협조해서 그냥 무의식적으로 쉽게 발음해도 정확한 발음이 나오게 되는 것 입니다. 그리고 단어마다 문장의 위치속에서 연음의 관계로 소리가 조금씩 다르게 날 수도 있는데 이런 관계도 읽다보면 자연히 깨우치게 됩니다. 



영문법


영어책 혹은 영화 대사를 소리내어 읽기를 매일 계속하는 가운데 영문법 책을 하루 두페이지 정도씩 다시 읽기 시작. 

영어책을 읽다가 문법적으로 궁금한 내용이 나오면 수시로 문법책 참고. 

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Learning/English 2013. 4. 9. 02:13

뉴스이고 광고가 많이 없고, 음질이 깨끗하다.

http://www.npr.org/ 

 

Voice of America

 

 

차를 살때는

http://www.carbuyingtips.com/

 

 

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Learning/English 2013. 2. 6. 01:03

뉴욕의사의 백신영어에서 발췌


1. 그날 읽을 세 페이지 전체 분량을 책을 보지 않고 전체적으로 세번 정도 듣습니다. (소리에만 집중하는 단계)

 

2. 읽을 한 페이지를 둘로 나누어 반 페이지 분량을 책을 보지 않고서 않고서 세번 정도 다시 듣습니다. (얼마나 들어서 아는지 파악하는 단계)

 

3. 책을 보고 들었던 내용을 확인하고 모르는 단어를 찾아 문장을 해석합니다. 문장의 뜻이 완전히 이해되도록 충분히 공부합니다. (지문을 눈으로 보고 의미를 깨우치는 단계)

 

4. 방금 공부한 반 페이지 부분을 이제 뜻을 다 아는 상태에서 10번 정도 또다시 테이프를 듣습니다. (뭐가 안 들렸는지 복습하는 단계, 발음을 정확히 파악하는 단계)

 

5. 공부한 반 페이지를 25번 읽습니다. (읽으면서 소리를 머리와 입, 귀에 새기는 단계)

 

6. 테이프를 한두 번 듣고 다시 발음과 강세 등을 확인합니다. (제대로 소리를 아는지 복습)

 

7. 교정된 발음과 강세로 다시 반페이지를 25번 읽습니다.

 

8. 이제 첫 페이지의 전반부는 끝났고 후반부 반 페이지로 이동해서 1번에서 7번까지의 과정을 반복하여 공부를 합니다. 이런 식으로 목표로 한 전체 세 페이지까지 끝냅니다.

 

9. 다음날은 전날 읽었던 첫 번째 페이지의 후반부 반절부터 다시 시작합니다. 이런 과정을 통하면 초반부 일부를 제외하고 전체적으로 200번 읽고 테이프는 70번 이상 듣게 됩니다.

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Learning/Medicine 2011. 6. 13. 19:45

1. Medscape +(+는 유니버설 입니다.나머진 폰 전용인듯.)

많이 아실 겁니다. 무조건 다운 받아야 되는 앱

2. Kims mobile lite

별 놈의 약들이 많은데 빠르게 찾고자 할 때 유용합니다. 유료는 10달러쯤..

3. NEJM

예전 것까지 찾는 건 어렵지만 그 주에 나온 논문을 풀로 읽을 수 있습니다.

4. 종양내과 좋아하시면

BioOncology+

5. Lab 정상치 등 궁금하시면

ARUP consult +

6. ClinicalTrials mobile +

최근 clinical trial 확인할 수 있습니다. 병원에서 유용할 듯.

7. MedPage+

요즘 찾은 놈인데 의학계 breaking news 위주로 나옵니다.

8. Medcalc

온갖 계산 식 있어요.

9. Corticonverter

steroid 역가 계산해 줍니다.

10. MedRef

lab 관련 앱

11. ABG

수치 넣으면 ABGA 결과 해석해줘요

12. Insulin DM2

인슐린 계산 앱니다.

13. NCCN guideline

최근 많이 바뀐 cancer stage 관련 앱입니다.


14. Skyscape

특정 출판사에서 나온 앱으로 무료로 쓸 수 있는 프로그램 몇 개 있지만 굳이
받을 필요는 없습니다.

15. iRadiology

제가 초기에 1달러 주고 산 앱. 지금은 무료일 겁니다. normal anatomy of CT scan
에 대해 사진 및 부위 설명이 있습니다. 초반 개념 잡는 데 도움이 될 듯 합니다.

16. Drug trial

이것도 위에 있는 다른 trial 과 비슷합니다. clinical trial 로 못 찾을 때 쓰시면
될 듯 합니다.

17. GI Calc, Heme Calc, Qx Calc

온갖 공식이 다 있는 앱이구요 조금 겹치는 군요. Qx Calc 안에 GI, Heme, cardio 다
있습니다. 그러니 Qx 만 받으셔도 됩니다.

18. 아산 병원엣 나온 앱들

아산 병원이 아이폰하고 가장 친하더군요. 일단 입사하면 하나씩 다 뿌린다능..

1>Toxicology
2>CPCR Drugs
3>약물 정보
요렇게 있습니다. 독성학 전반, CPR 시 사용 가능한 약물, 그리고 일반 환자 대상으
로 한 약물 정보 요렇습니다. 열심히 만든 것 같긴 하더군요.

19. 응급의료 (1339)

보복부에서 만든 허접한 앱입니다. 다만 각 응급의료 센터를 선택하면 그 병원에
남아있는 bed 수를 알 수 있습니다. (엄청나게 중요합니다! ㅋ) 중환 풀 때 유용합
니다. 이걸로 평소 인연 없던 서울 북부 병원에 푼 기억이 새록새록 나는군요...

20. Drugs (Lexicomb에서 만듬) +

약에 관해 상세하게 설명해주는 앱입니다. 패드 전용인지 헤깔리네요. 다만 미국 기
준으로 나와 있어 국내 약들은 없는 게 많습니다.

21. 20번과 비슷한 앱으로 iPharmacyPro +있습니다.

22. 영상의학과 quiz 처럼 풀 수 있는 패드 앱이 더 있습니다.
Radiology 2.0 +
Radiology +
입니다. 심심할 때 풀면 도움이 분명 되더군요.

posted by 차도닥

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