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ABSTRACT: The most useful individual signs for identifying dehydration in children are prolonged capillary refill time, abnormal skin turgor, and abnormal respiratory pattern. However, clinical dehydration scales based on a combination of physical examination findings are better predictors than individual signs. Oral rehydration therapy is the preferred treatment of mild to moderate dehydration caused by diarrhea in children. Appropriate oral rehydration therapy is as effective as intravenous fluid in managing fluid and electrolyte losses and has many advantages. Goals of oral rehydration therapy are restoration of circulating blood volume, restoration of interstitial fluid volume, and maintenance of rehydration. When rehydration is achieved, a normal age-appropriate diet should be initiated.
ABSTRACT: Gastroenteritis in children is a common reason for visits to family physicians. Most cases of gastroenteritis have a viral etiology and are self-limited. However, more severe or prolonged cases of gastroenteritis can result in dehydration with significant morbidity and mortality. This is often the scenario in third-world countries, where gastroenteritis results in 3 million deaths annually. A proper clinical evaluation will allow the physician to estimate the percentage of dehydration and determine appropriate therapy. In some situations, laboratory studies such as determination of blood urea nitrogen and serum electrolytes may be helpful. Stool studies are indicated if a child is having bloody diarrhea or if an unusual etiology is suspected, such as Escherichia coli O157:H7 or Cryptosporidium. Most children with gastroenteritis can be treated with physiologically balanced oral rehydration solutions. In children who are hypovolemic, lethargic and estimated to be more than 5 percent dehydrated, initial treatment with intravenous boluses of isotonic saline or Ringer's lactate may be required. Children with severe diarrhea need nutrition to restore digestive function and, generally, food should not be withheld.
ABSTRACT: Acute gastroenteritis is a common and costly clinical problem in children. It is a largely self-limited disease with many etiologies. The evaluation of the child with acute gastroenteritis requires a careful history and a complete physical examination to uncover other illnesses with similar presentations. Minimal laboratory testing is generally required. Treatment is primarily supportive and is directed at preventing or treating dehydration. When possible, an age-appropriate diet and fluids should be continued. Oral rehydration therapy using a commercial pediatric oral rehydration solution is the preferred approach to mild or moderate dehydration. The traditional approach using "clear liquids" is inadequate. Severe dehydration requires the prompt restoration of intravascular volume through the intravenous administration of fluids followed by oral rehydration therapy. When rehydration is achieved, an age-appropriate diet should be promptly resumed. Antiemetic and antidiarrheal medications are generally not indicated and may contribute to complications. The use of antibiotics remains controversial.
ABSTRACT: Swallowing disorders are common, especially in the elderly, and may cause dehydration, weight loss, aspiration pneumonia and airway obstruction. These disorders may affect the oral preparatory, oral propulsive, pharyngeal and/or esophageal phases of swallowing. Impaired swallowing, or dysphagia, may occur because of a wide variety of structural or functional conditions, including stroke, cancer, neurologic disease and gastroesophageal reflux disease. A thorough history and a careful physical examination are important in the diagnosis and treatment of swallowing disorders. The physical examination should include the neck, mouth, oropharynx and larynx, and a neurologic examination should also be performed. Supplemental studies are usually required. A videofluorographic swallowing study is particularly useful for identifying the pathophysiology of a swallowing disorder and for empirically testing therapeutic and compensatory techniques. Manometry and endoscopy may also be necessary. Disorders of oral and pharyngeal swallowing are usually amenable to rehabilitative measures, which may include dietary modification and training in specific swallowing techniques. Surgery is rarely indicated. In patients with severe disorders, it may be necessary to bypass the oral cavity and pharynx entirely and provide enteral or parenteral nutrition.
ABSTRACT: Proteinuria is a common finding in adults in primary care practice. An algorithmic approach can be used to differentiate benign causes of proteinuria from rarer, more serious disorders. Benign causes include fever, intense activity or exercise, dehydration, emotional stress and acute illness. More serious causes include glomerulonephritis and multiple myeloma. Alkaline, dilute or concentrated urine; gross hematuria; and the presence of mucus, semen or white blood cells can cause a dipstick urinalysis to be falsely positive for protein. Of the three pathophysiologic mechanisms (glomerular, tubular and overflow) that produce proteinuria, glomerular malfunction is the most common and usually corresponds to a urinary protein excretion of more than 2 g per 24 hours. When a quantitative measurement of urinary protein is needed, most physicians prefer a 24-hour urine specimen. However, the urine protein-to-creatinine ratio performed on a random specimen has many advantages over the 24-hour collection, primarily convenience and possibly accuracy. Most patients evaluated for proteinuria have a benign cause. Patients with proteinuria greater than 2 g per day or in whom the underlying etiology remains unclear after a thorough medical evaluation should be referred to a nephrologist.
Acute Diarrhea in Adults - Article
ABSTRACT: Acute diarrhea in adults is a common problem encountered by family physicians. The most common etiology is viral gastroenteritis, a self-limited disease. Increases in travel, comorbidities, and foodborne illness lead to more bacteria-related cases of acute diarrhea. A history and physical examination evaluating for 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.