Acid - Peptic Disease/ Peptic Ulcer Disease

Definition:
Peptic Ulcer disease refers to ulcer in the lower oesophegus, stomach, and duodenum.

Incidence: of peptic ulcer
10% of all adults suffer from peptic ulcer. t is more common in males than females.

What are the mechanisms of acidity?
They are...
1. Strong positive family history.
2. Increased gastric hypersecretion of acid - pepsin juices, which are capable of causing digestion of the stomach mucosa.
3. Decrease of Mucosal resistance of the stomach:

Mucosal resistance of stomach could be decreased due to various reasons
             (a) Infection with Helicopecter Pylori
             (b) Use of Aspirin and other pain killers (NSAID's) for a chronic period. eg. Ibuprofen, Diclofenac, Soadium, Mefenamic acid etc...

NSAIDS are prostaglandin synthesis inhibitors, since prostaglandins are important mediators of pain.

On the other hand, prostaglandins also have an action of increasing the mucosal bloody supply in the stomach and protecting the stomach from acid.  THis is called as Physiological mucosal resistance of the stomach.
Mucosal cells are tightly bounded to each other and so function as a mechanical barrier to protect the stomach from acid damage.  Normally, the epithelial cells of stomach also secrete some bicarbonate in order to neutralize, the acid secretion of the stomach.

This above paragraph is summarized as Mucosal Resistance/ Protecting Mucosal Barriers of Stomach.

CAUSES: of peptic ulcer/ Acid - Peptic
1. Chronic use of  NSAIDS (Non Steroidal Anti Inflammatory Drugs)
2. Severe sepsis
3. Following any surgery (Usually leads to stress ulcers)
4. Following any trauma (Usually leads to stress ulcers)
5. Burns and Shock ( These conditions lead on to ischemia of mucosa which in turn leads to ulcer formation.
7. Infections like typhoid leading on to formation of flask shaped ulcers.
8. Infection with H. Pylori
9. Reflux of bile and other alkaline intestinal contents into the stomach because of poorly functiong pyloric sphincter. (Pyloric sphincter looses its tone) This is because normal physiologic medium of stomach is acidic and not alkaline.

CLINICAL FEATURES: of Peptic Ulcer/ Acid Peptic disease
On and off recurrent pain abdomen there are four characteristics to this pain.
             a). Pain is primarily around the epigestrium.
Patients typically points to this site, locating their pain.  This is, therefore also known as pointing sign.
            b). The pain is typically hanger pain.  i.e. This pain is relieved on taking food/ antacids.  In other words, patient feels much better after taking food/antacids.
            c). This pain is more at night.
            d). Pain is typically episodic each episode lasts about 7 - 10 days, about 4 - 5 times in a year.
2. Water - Brash / Acid- Brash 
This is increased excessive salivation due to increased acidity.

3. Heart - Burn:
Pain in Acid - Peptic disease is burning pain which is mainly retrosternal in location.  This burning retrostrenal chest pain resembles, MI chest pain. (heart attack chest pain.) so, also called as heart- burn.  The diagnosis of MI ( myocardial Infraction) can be confirmed by taking an ECG/ Stress test/ ECHO.  If these all are normal, than cause of burning chest pain is more likely to be ACID - PEPTIC DISEASE.

4. Increased Nausiation and vomiting 

5. Weight loss and loss of Appetite.

TYPES OF PEPTIC ULCER DISEASE:

GASTRIC ULCER

1. More common in more than 40 years of age group.

2. Less frequent episodes.

3. More chances of leading to cancer of stomach later (Gastric ulcer is a pre- malignant lesion)

4. Food irritates the ulcer site, more

5. Heart burn less common

6. Night pains less common

7. Strong positive family history is usually present

8. Most common site is pylorus of stomach.

9. Decreased mucosal resistance is primary cause

10. Since food irritates the ulcer site, though pain is lower in intensity lasts longer.


DEODENAL ULCER:

1. More common in youngers ( 20-40 years of age)

2. More frequent episodes

3. not a premalignant lesion. so does not lead to cancer.

4. food relieves the ulcer site.

5. Heart burn more common

6. Night pains more common.

7. No family history present

8. Most common site is duodenum

9. Increased acidity is the primary cause.

10. Since food relieves ulcer site, though pain is more in intensity lasts for short period.

ALL SYMPTOMS ARE LESS IN GASTRIC THAN DUODENAL BUT GASTRIC ULCER IS PRE-MALIGNANT.


Investigation: of Peptic Ulcer or Acid - Peptic Disease

1. Gastroscopy and Duodenoscopy 

Endoscopy will clearly show the ulcer site.  If it is a gstric ulcer, a biopsy must be taken to rule out carcinoma of stomach.  This is because 10 % of all gastric ulcers are malignant such as gastric ulcers lead on to carcinoma of pylorus and carcinoma of antrum later on.

2. Barrium contrast studies:

It would also reveal the crater of the ulcer.

3. Urea Breath test:

Radioactive labelled urea is ingested.  If H. Pylori is present in the G.I.T it would release urease enzymes.  This enzyme is capable of digesting urea to release ammonia.  Since, urea is radio - active labelled even the ammonia becomes radio - active.  This radio - active ammonia can then be measured in patient's breath by micro- biologist.  If the patient has no H. Pylori in his G.I.T then thre would not be any radio active ammonia in his breath.

TREATMENT: for Peptic Ulcer or Acid Peptic Disease

1. General measures:

• Avoid smoking
• Avoid caffeine 
• Avoid alcohol
• Avoid aspirin and other NSAIDS

All these decreases pyloric sphincter tone.

2. Antacids:

Most commonly used antacids are a combination of aluminium and magnesium compounds.  They act by neutralizing the acid as they are alkaline in nature.  These should not be misused because they can cause constipation (aluminium) and diarrhoe (magnisium) on long term use.

3. H2 receptor antagonists:

Mechanism of Action: These blocks the H2 receptors in the stomach thereby causing inhibition of acid - pepsin secretion symptoms get relieved in a few days and ulcer begins to heal in a few weeks.  Duration of treatment is usually 4- 6 weeks. 

Most commonly ones are

 cimetidine 400 mg BID orally.  

Gynecomestia : Banitidine - 150 mg BID orally, and 50 mg BID IV. 

Famotidine: 20 mg BID (orally)

Nizatidine: 150 mg BID ( orally)

4. Proton Pump Inhibitors: (PPI)

Mechanism of Action: They block the release of HCL from the stomach by completely blocking the proton pump (H+ ATPase enzyme is blocked) in the parietal cells.

Most commonly used Proton Pump Inhibitors are:

Omeprazol: 20 mg OD for 4 weeks

Pentoprazol: 40 mg OD for 4 weeks

Rabeprazol: 20 mg OD for 4 weeks

Proton Pump Inhibitors are more effective then H2 receptros antagonists in treatment of Acid-Peptic diease because they completely block the release of HCL from stomach.

5. Anti-Cholenergics:

These decrease the HCL secretion by blocking muscarinic receptros in the stomach 

eg. Pirenzepine 

not very commonly used, can cause dryness of mouth.  Moreover, there are other better drugs available in the market.

6. Prostaglandin analogues: 

Mechanism of Action: Strengthens the mucosal barrier and protects the stomach from further acid damage. Eg. Mesoprostol.

7. Sucralfate:

Mechanism of Action: This forms a protective coating over the ulcers and protects it from any further acid destruction. 

8. Colloidal Bismuth compounds:

Mechanism of Action: forms a coat at the ulcer base which protects against any further acid - pepsin digestion of mucosa.

9. H. Pylori kits / regimens:

These are regimens which comprise of a combination of a proton - pump inhibitor + an H2 receptor antagonist + an antibiotic.

Proton Pump Inhibitor could be pentoprozol or omperazol or rabeprazol.

H2 receptor antagonist could be Imetidine, ranitidine or famotidine.

Anti-biotic could be (against H. Pylori)

Amoxycillin, tetracyclin, metronidazol

eg of regimen are COA regimen, COM regimen

10. Surgical Management for ACID - PEPTIC DISEASES:

a) For gastric ulcer:

Surgery of choice is partial gastrectomy followed by Billroth's anastomosis.  In this surgery, the affected pylorus with the antrum is removed and subjected to biopsy to rule out any malignancy.  The stump of stomach and intestine is then closed.  In order to establish continuity with G.I.T and to facilitate continous drainage, the rest of intestines are anastomosed with the stomach.  This is called Billroth's anastomosis

2) For Duodenal Ulcer:

Choice of surgery is vegotomy. This is because the fagus is primarily responsible for nerve supply to the acid producing area of stomach by the denervation of vagus.  The acid secretion and release could be brought under control.  THis is called as trunkal vegatomy.  However, in this procedure all branches of vagus are cut resulting in decreased acidity but also resulting in decreased motility of stomach.  This is because the vagus is not only responsible for acid secretion but also for paristalsis of stomach.  so, the side effect of truncal vegotomy is lack of drainage.  So, an additional drainage procedure should be done, The additional drainage procedure could be of two types.

Pyloroplasty - Repairing pylorus and widening the opening to facilitate drainage

Gastro - Enterostomy: Connecting intestines to stomach to faciliate

The other kind of surgery for a duodenal ulcer is HIGHLY SELECTIVE VEGATOMY.  In this procedure, t only that branch of vagus is cut which is responsible for acid production. The other branches of vagus are saved.  Motility of stomach remains intact.  Advantages of HSV is that no additional drainage procedure is required since propulsive movement of the stomach is preserved in HSV.  The current procedure of choice in HSV. 

What's in a myth?

                                    GENERAL KNOWLEDGE!!!





Ancient myth has it that if you stole someone's shadow, they would turn into a vampire!  Crazy ain't it??






In Greek culture, brides carry a lump of sugar in their wedding glove.  It's supposed to bring sweetness to their married life...


The US $ 1 bill is considered unlucky by many folks! it has 13 stars, 13 stripes, 13 steps, 13 arrows and an olive branch with 13 leaves on it!! who has time to check all this??




You can't gift straw sandals in China! Associated with funerals, these footwear bring bad luck!




Medieval farmers looked to their pigs for signs of rain.  If the pigs were to pick up sticks and walk around with them in their mouths, the heavens would surely open up!


If a girl leaves her house early on Valentine's Day and the first person she meets is a man, then they will be married within three months! Now that's a myth that needs no breaking!




DID YOU KNOW WHAT HAPPENED IN THE 14TH CENTURY....


1302- Romeo and Juliet marry in Shakespeare's play! they are 14!




1360 - The Leaning Tower of Pisa is finished!


1314 - Soccer is banned in England because it's too violent!


1350 - The Aztecs brew up the world's first drinking chocolate!


1380 - The Bible is translated into English by John Wycliffe! He works into the next year to finish his hand-written manuscript!


1387 - Chaucer publishes his Centerbury Tales! 


MORE WILL BE UPLOADED TOMORROW!!!  STAY TUNED 

steps to Losing Weight

It's officially ridiculous: Every time we crash in front of our TVs after a long, hard day's work,


we're bombarded by countless infomercials revealing the newest line of fat-burning, abdominal crunching, body-sculpting, miracle-working machines.


Even those Suzanne Somers or Richard Simmons diet plans make us want to shoot ourselves for snacking on popcorn.


Well, we have news for all of you out there: Don't diet, and don't rush off to buy the next gimmick. Here's the real secret to losing weight: Just eat less.






Weight Loss Is About Sensibility

Sensibility is your new mantra. After all, doing everything sensibly in your life is the key to living well. You


don't need to feel trapped behind the prison of your own body anymore. All you need to do is control your portion sizes by eating less and eating sensibly.


You think that's easier said than done? Well, like all things in life, eating less is a learned experience and takes some practice and patience. Our problem nowadays is that we're too lazy to turn this practice into a perfectly balancedmeal plan.


"The problem for most people is that they maintain certain habits that make eating less quite difficult," says Pat Booth, assistant director of the Nutrition Services Department at the University of California San Francisco Medical Center.


Old habits are hard to break, however, tomorrow you'll be looking back at the "old" you and feeling good about the "new" you that's yet to come. Get our point? It also has a lot to do with your self-image. You must first change mentally in order to change physically.

Move over Weight Watchers — an exotic new superfruit called 'African Mango' has quickly become the hottest new way to lose weight. 

 

After one of America's most popular medical doctors and daytime TV talk show hosts calledAfrican Mango (mentioning no specific brand) a"miracle in your medicine cabinet that can help you lose 10 pounds," sales of the supplement have skyrocketed, making it now one of the most popular weight-loss product in America today. 

 

Internet searches reveal countless blog postingsand Facebook messages, calling African Mango, "The hottest new way to lose weight" and "a weight loss supplement without side effects."

 

Study: Reduces 12.3 Pounds of Body Fat Every 28 Days 

 

Beyond the success stories on social networking sites, new clinical research shows African Mango may indeed be the real deal when it comes to causing fast weight loss. 

 

According to a recent study published in the scientific journal Lipids in Health and Disease, African Mango extract helped men and women lose an average of 12.3 pounds of body fat in just 28 days without diet or exercise. 

 

What's more, those taking African Mango lost an average of over 2 inches of dangerous belly — and their bad LDL cholesterol, triglyceride, and glucose levels plummeted. 

 

Test subjects taking African Mango lost an average of 2 inches of dangerous belly fat in 28 days without diet or exercise.

 

 

What Is African Mango, and How Does It Work? 

 

Despite the recent frenzy surrounding African Mango and its weight-loss benefits, the fruit has actually been used as a diet aid for centuries in Cameroon, Africam — the only place in the world where African Mango is grown. 

 

The brightly-colored tropical fruit is found exclusively in Cameroon's west-coastal rainforests. African mango, or bush mango, differs from other mango fruits in that it produces a peculiar seed, which natives of Cameroon refer to as "Dikka nuts." 

 

For hundreds of years, an extract from the seeds called irvingia gabonensis have been used among Cameroon villagers for its wide-ranging medicinal benefits, which range from reducing and preventing obesity to lowering cholestrol to regulating blood sugar to treating infections. 

 

Recommended by Leading Doctors for Safe Weight Loss 

 

While a popular weight-loss treatment in Africa, African Mango only recently became popular in America when on September 13, 2010, the slimming super fruit was featured on one of America's most popular TV shows.

 

On the show, the host, who is also one of America's preeminent medical doctors, called African Mango a "breakthrough supplement" and "a miracle in your medicine cabinet which can help you lose 10 pounds." 

 

Other leading doctors have similar high praise for African Mango. Dr. Judith Ngondi, a physician and professor of biochemistry at Cameroon's University of Yaounde, calls African Mango a highly effective natural alternative for reducing bodyfat and improving overall health. 

 

"Studies have shown supplementation [with African Mango extract] signficiantly reduced bodyweight, total blood cholesterol, LDL cholesterol, and triglycerides," says Dr. Ngondi. "Its use should be further encouraged for the purposes of control of dietary lipids as well as for weight reduction." 

 

Americans Swear by African Mango's Slimming Benefits 

   

Tiffany Waterson, a 30-year-old mother of three from St. Petersburg, Florida, says she's struggled with her weight for years before discovering African Mango.  "I gained 40 pounds with my last child, and I was already 25 pounds overweight," says Waterson. "So when I only lost 20 pounds of weight I had gained with that pregnacy, I then was 55 pounds overweight.
Waterson says she tried several diets and tried to stay away from the foods she loved, but nothing seemed to work. "I might have lost a few pounds," says Waterson, "but it would always come back."
Waterson says her breakthrough came six months ago, when she read an article highlighting the benefits of supplementing with African Mango before meals.
"I have been taking African Mango for six months now, and I am down 33.5 pounds," says Waterson. "All I have done is take the pills like the bottle says and drink plenty of water, and I don't eat past 8 p.m. I still eat what I have always eaten, just smaller portions. And now to tone my body up I'm doing light exercise, and I am loving my new body."

Jeffrey Kennedy, a 36-year-old journalist from Columbia, Missouri, says he's experienced similar weight-loss success with African Mango. 

 

"After just two weeks of using African Mango, I lost 22 pounds of fat, including a lot of fat off my gut," says Kennedy. "I'm amazed at how fast the weight is falling off me. Already my jean size has dropped from 36 to 34." 

 

Jeffrey Kennedy, a 36-year-old journalist from Columbia, Missouri, lost 22 pounds in 14 days while using African Mango.

 

Beware of Low-Quality African Mango from China 

 

With the recent publicity and fanfare surrounding African Mango, it's no surprise that sites are popping up all over the Internet claiming to offer African Mango at bargain-basement prices. 

 

However, according to a recent study published in the scientific journal Food And Chemical Toxicology, upward of 25 percent of the supplements imported from China are tainted with impurities and often have a mere fraction of the active ingredients litsted on their labels.

 

How To Find a Quality African Mango Product 

 

With dozens, if not hundreds, of African Mango products being sold online, selecting one that's worth your money can be a difficult and confusing endeavor. 

According to consumer and Better Business ratings, the 100% Pure African Mango product is considered one of the most effective and trustworthy, with laboratory tests certifying the product's potency and quality.

The website offers a 100% risk-free trial of the product, and the site doesn't try to fool customers into signing up for hidden offers or those controversial "auto-ship" programs.

STRESS!!!

                             What is STRESS???????


This pictures would give you a good idea of stress.
Hopefully this will release some of your stress.....

Stress from work!!

Denial of stress!! Defense mechanism 

Most of the people in stress look like this.  But it has nothing to do with your hair.

Stress from home, work, social life!! 

Please don't try this at home, it will not solve your stress problem, matter of fact it will give you more stress.  Stress of buying a new laptop or computer screen.

Not only humans have stress but animals too.  This poor dog has stress that he/she can't get out of.  Poor dog

Again not only humans. This fellow has stress of looking like donkey now!!

I relate to this, who else does??

Common garden weed can cure cancer

London: A new study conducted by scientists in Australia has revealed a common weed can cure skin cancers.

The sap from a plant known as petty spurge or milkweed — found by roadsides and in woodland — can "kill" certain types of cancer cells when applied to the skin, reports the Daily Mail. It works on non-melanoma skin cancers, which are triggered by sun damage. And, although not usually fatal, can be disfiguring without treatment.

The plant has been used for centuries as a traditional folk medicine to treat conditions such as warts, asthma and several types of cancer. This is the first time the scientists team has carried out a clinical study of sap from Euphorbia peplus. In the study of 36 patients after an average of 15 months following treatment, two thirds of the 48 skin cancer lesions still showed a complete response.


Read more: Common garden weed can cure - The Times of India http://timesofindia.indiatimes.com/home/science/Common-garden-weed-can-cure-/articleshow/7369039.cms#ixzz1CBaZvO6m

Nephrectomy (Kidney removal)

Today we will talk about Surgery.
There are some words used in surgery like ECTOMY or OSTOMY.... people usually confuse this words, but it is very simple.
When the suffix ECTOMY is used it basically means removal of that part like PROSTECTOMY (removal of Prostate Gland), APPENDISECTOMY (removal of Appendix) etc....
When the suffix OSTOMY is used don't mistake it for ECTOMY, because it can give a whole new meaning to it..
OSTOMY means making a incision or just making a hole like THORACOTOMY (means making a incision in your chest (thorax)).

NEPHRECTOMY

     It is removal of kidney along with part of ureter, perinephric pad of fat and enlarged lymph nodes near the hilum.

Types:
Partial nephrectomy
Total Nephrectomy
Radical Nephrectomy

What are the indications:
Stone with gross infected kidney (polynephrosis)
Stone with hydronephrosis with non functional kidney
Multiple stones scattered in the kidney substances and in different calyces.
Renal Tuberculosis
Carcinoma of kidney - WILMS Tumor.
Pyogenic infections
Haemorrhage
Raised Blood Pressure due to renal causes
Hydronephrosis.

Now the Procedure:
Before doing this, must remember that the central arteral kidney must be proved healthy before considering the operation.
Next ask the patient to sleep on the later side.
That way operated kidney is kept on superior side.
Next, arms of the operated side should be supported well.
The legs are extended and fixed.
Antibiotics are given to lower the infection
General anesthesia is given to the patient.

5 Muscles are incised.
Latissmus dorsi
Serratus Anterior
3 oblique muscles of abdomen
Posterior lumbar fascia
and extra peritoneal fat.

Oblique incision on the skin is put to form the angle of 12th rib to spine.
Ligate the renal artery and cut the artery
similarly after ligate the renal vein and cut it.
Than cut the ureter.
Slowly remove the kidney and suture and close back layer by layer with antiseptic solution.

Thus, in the process of total nephrectomy  alnog with kidney, part of ureters surrounding soft tissues, lymph nodes, veins and arteries are also removed.

Complications
Hemorrhage
Infections.

Humidifiers (Humidity Therapy)

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It is adding up of water-vapor and heat to the inspired gas.

Physiology
The primary functions of the upper respiratory tract is heat and moisture exchange and filtration.
The nasal mucosal lining is kept moist by the secretion from mucous glands.
The high vascularity of the mucosa provides heat transfer.
The nasal mucosa is cooled during inhalation and heated during exhalation.
cooled air holds less water vapor and vice versa.


Isothermic Saturation Boundary:
It is the boundary above which temperature and humidity decreases during inspiration and increases during exhalation.
Normally this boundary is 5cm below the carina.
ISB will shift down in cases of:
Breathing cold air, breathing dry air, and bypassed airways etc...

Breathing indications:
To humidify dry medical gases, when upper airways are bypassed.

Secondary
To manage hypothermia in intra-operative.
To treat bronchospasm created by cold air especially after exercise.
If the application of dry medical gas is prolonged there will be structural damage of upper respiratory tract.
Ciliary motility decreases
Airways become irritable
Increased mucous production
Thickening of mucosa
Airway epithelial destruction
leading to Atelectasis.

In cases of endotracheal incubation the heat and moisture exchange capability is lost and hance the danger is high.

Equipments:

Humidifiers:
Is the device that adds molecular water and heat to gas.

Principles of Humidifiers

Temperature
Surface Area
Time of contact

Temperature:
Greater the temperature greater the water vapor it can hold.  So heated humidifier out performs. Normal temp. 40 degree C.

Surface Area
Greater the area of contact, greater the humidification.

Time of Contact
Greater the contact time, greater the evaporation.

Types of Humidifiers
3 primary types of humidifiers
   Bubble
   Pass over (wick type, membrane type)
  Heat and moisture exchange (artificial nose)
      Simple condenser humidifier
      Hygroscopic condenser humidifier
      Hydrophobic condenser humidifier
It can be classified as heated and non heated humidifier

Bubble Humidifier
Breaks an under water gas stream into small bubbles













Pass over
  Wick humidifiers
It is a cylinder of absorbant material.  The wick will absorb water from reservoir and heat itself moistened.
The dry gas passes over this and takes up the moisture.

   Membrane Humidifier
In this a hydrophobic membrane separates water from gas stream through which water molecule can pass but not liquid water.
Heat and moisture exchange (artificial nose)
It is mainly used with endo tracheal and tracheostomy tubes.
Simple condensor humidifiers
It contains an element with high thermal conductivity like in metalic gauze, parallel metal tubes etc...
Hygroscopic condenser humidifier
Uses an element of low thermal conductivity like paper, wool, foam etc..
This element is impregnated with hygroscopic salts like Ca++ or lithium chlorides.
This salt helps to capture the extra moisture
Efficiency 70%.

Hydrophobic Condenser Humidifiers:
It uses water repellent element with large surface area and low thermal conductivity.
Some provide bacterial filtration efficiency 70%.
Contraindication:
Thick copious and bloody secretions.
Patients with high spontaneous minute volume.
Body temp <32 C.

Incentive Spirometry

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Incentive Spirometry
It is one of the ways to deliver lung expansion.
It helps to increase the trans-pulmonary pressure.
It mimics the natural sighing.
It is performed using devices that provides visual feedback.
The basic maneuverer of incentive spirometry is Sustained Maximal Inspiration (SMI.
SMI is a slow deep inspiration from Functional Residual Capacity (FRC) upto
Total Lung Capacity (TLC)followed by a 5-10 second breath hold.
So as the trans pulmonary pressure increases, lung expansion increases.

Indication

Presence of atelectasis
Presence of condition predisposing to atelectasis like upper abdominal surgeries, Thoracic surgeries etc..
In case of restrictive lung disease associated with quadriplegia, diaphragmatic dysfunction etc...
In post-operative period to monitor lung function.

Contraindication
Unconscious or uncooperative patient.
Patient unable to take deep breaths.

Complications
Acute respiratory alkalosis due to two rapid respiration
Signs of dizziness and numbness around the mouth
Pulmonary baro-trauma
Exacerbation of bronchospasm
Fatigue
Hyperventilation

Equipments used
They are simple, portable, and inexpensive.
they are categorized into 2.

Flow oriented
  It measures and visually indicates the inspiratory flow.  The vloume can be indirectly measured as
Volume = Flow X Time


Volume oriented
Measures and visually indicates the volume achieved. It uses bellows that rises according to inspired volume.

Administering the Incentive Spirometry
The application involves 3 phases

Planning
Implementation
Follow up

Planning:
It involves the assessment therapeutic outcomes selected at this phase.

Implementation:
The patient teaching has to be effective. the patient is positioned in a comfortable manner.  The patient is instructed to inspire slowly and deeply.  Initially the good set should be moderate.
The shoulders and upper chest should be relaxed and diaphragmatic breathing should be encouraged.
At the end of maximal inspiration, ask the patient to sustain it for 5-10 seconds.
A normal exhalation follows.
Give rest as long as needed.
Repetition 5-10 SMI/hour

Follow Up:
It includes re-assessment
Supervised till the patient masters the correct technique
Establish new and increasing inspiration volume each day.

Outcomes of Incentive Spirometry:
Absence or improvement of signs of atelectasis
Decrease in Respiratory rate (if it is increased)
normal pulse rate
Resolution of abnormal breath sounds
Improved chest radiography
Increased PaO2 and decrease PaCO2.
Increase SpO2
increased vital capacity and PEFR (Peak Expiratory flow rate)
Improved cough
Increased FVC

Examination of Peripheral Vascular Disease (PVD)

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History
Obtain a complete and detailed history of the patient.
Concentrate on past medical history with emphasis on diabetes mallitus, hypertension or any other cardiac diseases.
Obtain the medications and perior treatment for the current problem.
History of relevant surgical or medical.
treatment involving vascular system should be collected.
Social history should concentrate on lifestyle pattern such as use of tobacco, dietary habits, and use of alcohol, etc...

Collect details of onset of symptoms mechanism of injury, work environment, job skills.

Subjective examinations
This includes the current symptoms.
factors increasing or decreasing the symptoms
about intermittent claudication, rest pain, how positioning of
lower limb affects pain etc..

Objective Examination
On observation
check for evidence of cellulites, edema, discoloration of skin, cyanosis or pallor, loss of hair, wound, etc...

Motor Examination
Should be done to access Range Of Motion and Muscle strength.

Sensory Examination
This is done mainly for light touch and pressure, includes Semmes Weinstein monofilaments to check sensation.

Temperature
Using palpation, thermistor, test tubes etc... and compare to the other side.
Usually the temperature decreases in arterial disorders.

Girth Measurement
done for edema
measurements should be taken in reference to bony prominences, volumetric is a quantitative system to measure edema.

Vascular Examination
Palpate for the pulses especially distal pulses.
Auscultation: Auscultate for identifying turbulent blood flow called bruit.