By B. Frillock. Alliant International University.

For instance safe 100mg amantadine, Canada prohibits already from buying better basic care generic 100mg amantadine amex, independently of one s ability to pay cheap amantadine 100 mg. The basis for a universal coverage and the notion of the right to health care seems then rather difficult to support. Not only does Miles fail to demonstrate how a universal coverage and the notion of the right to health care would be possible but he also did not rec- ognize the politically charged tone of this arguments for a universal health care system. Curiously Miles ignores his political assumptions but is eager to stress that Today, all economically developed nations whose healers claim descent from the Hippocratic tradition view universal access to affordable health care as a moral obligation of their health care system every developed nation except the United States. I believe that physicians could embrace a commitment to working for affordable universal health care as exemplifying the principle from what is to their harm or injustice I will keep them. His claim that the legal and ethical norms for these [medical] activi- ties and many other are governed by an implicit or explicit pact between physicians and society (Miles, 2004, p. The difficulty is that Miles does not develop the moral arguments needed to show that 114 F. Instead of a moral argument, he substitutes the dubious historical claim that the Hippocratic Oath and the professional tradition it supports requires such provision. Medicine as a Profession The Oath ends with the sanction that follows if the physician is not faithful of the covenant: If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite to all this be my lot. Oaths imply not only the requirement to keep personal promises but like- wise are a social institution which establish the rules for social interaction between individuals (i. Many scholars, Miles included, recognize that a position supporting the view that certain values and obligations are intrinsic to the practice of med- 12 icine (called the internal morality of medicine ) is problematic due the various moral visions inherent of our pluralistic society. Miles adopts a mid- dle way position arguing that the Oath reflects a blended position in which society s time-tested moral views are the proper measure of the ethics of medicine (Miles, 2004, p. Thus, Miles accepts that the moral standards The Hippocratic Oath and Contem porary Medicine 115 of medicine must be reevaluated in the light the historical development of society but likewise suggests that the Oath ought not to be regarded as an old relic relevant for past medical practitioners of Ancient Greece. The Oath, he claims, can still teach us one medical ethic among competing moral systems. It is only insofar as one is able to understand (thus, the necessity to study the Oath) how the Oath might have spoken to its own culture that one will be able to see how relevant it is for his or her own. This begs the question as to know whether everyone will recognize the moral values and obligations described in the Oath as relevant for contem- porary medicine. As I have emphasized, scholars such as Miles who regard the Hippo- cratic Oath simply as symbolic discount the full force of its power as a doc- ument to direct professional conduct. Thus although Greek medicine recognized and emphasized the idea of a guild/profession, it appears that it does not correspond to today s model of medical practice. Gone too are the simple certainties of an ethic based entirely on what the doctor thinks is good for the patient, and with it also any acquaintance with Hippocratic morality outside the Oath and a few phrases such as primum non nocere... Professors of medical history are giving way to medical ethicists as the keepers of the medical con- science, or are themselves turning to history of ethics as a way to ensure the relevance of their own discipline in a modern medical school. The reasons are multiple and they deserve a more careful examination than what I will be able to accomplish in this article. However, it is crucial to locate the development of medicine in its proper context, par- ticularly how American medicine went from the status of guild power between 1930 and 1965 to its decline in power from 1970 to 1990 (Krause, 1996). The turning point, Krause argued, is the introduction of the Medicare- Medicaid Act (1965 1966) during the Kennedy and Johnson administrations (1961 1969). These two programs forced the federal government, through Congress, to seek to control the increasing costs of health care. First, the medical profession could not maintain the independent professional and moral identity necessary to sustain a particular tradition, that is, the Hippocratic tradition. The reflection on the moral dimension of medical practice came to occur mostly outside the medical profession as bioethics gained respectability as an academic field. Cost containment appeared suddenly as a moral obligation imposed on the physician. This means that the physicians are no longer exclusively committed to their patients but also dependent on and controlled by the social institutions that structure health care, in particular its economic aspects. These two factors contributed to the deprofessionalisation and the transformation of medicine into a vast industry, in which physicians lost their authority as professionals and became dependent on managed care 16 organizations for their economic survival. Current Efforts to Reconsider Medical Professionalism Some critics see in this transformation of medicine (Miles included, see for instance p. In response to these concerns, various efforts to reconsider and examine the concept of medical professionalism have taken place. Interestingly and in rela- tion to Miles analysis of the Hippocratic Oath, Jay Johansen wonders whether such a charter on medical professionalism will replace the Hippo- cratic Oath (Johansen, 2002). It is too early to say at this stage, but, as occurred when the Hippocratic Oath was formulated, the charter s publica- tion is an attem pt to (re)affirm som e of the fundam ental principles neces- sary for the practice of medicine. This document (The Charter on Medical Professionalism ) calls for a renewed sense of professionalism and responds to physicians frustrated by how health care is provided in society, which, it is argued, threaten the 17 very nature and values of medical professionalism. As is the case for the Hippocratic tradition, it is difficult to assess to what extent this charter built on the moral traditions of physicians has cur- rent moral significance for the medical profession. One of the main prob- lems is that the terminology of the document appears too vague and imprecise to count as a medical morality for the medical profession.

Wegener granulomatosis in a 61-year-old man who presented with chronic cough order amantadine 100 mg without a prescription, malaise generic 100mg amantadine mastercard, and weight loss safe 100mg amantadine. Computed tomography demonstrates bilateral irregular masses (arrows) and nodules in the mid-lung (arrowhead). These areas usually represent pulmonary hemorrhage, and present as bilateral air space opacities. Involvement of the trachea or bronchial walls usually consists of mucosal or submucosal granulomatosis thickening. If the thickening becomes severe, narrowing of the lumen and eventually calcification also may occur ( 1,2). The diagnosis is even more likely if the bronchial dilatation is moderate to severe, affects three or more lobes, and involves the central bronchi ( Fig. Allergic bronchopulmonary aspergillosis in a 44-year-old man with asthma and eosinophilia. High-resolution computed tomography demonstrates extensive central bronchiectasis ( arrow) and tubular densities ( arrowhead) consistent with mucoid impaction. Asthma Asthma is a disease of the airways that is characterized by an increased responsiveness of the tracheobronchial tree to a multiplicity of stimuli ( 17). Expiratory high resolution computed tomography demonstrates areas of air trapping ( arrows). Hypersensitivity Pneumonitis Hypersensitivity pneumonitis, also known as extrinsic allergic alveolitis, is an inflammatory lung disease caused by inhalation of airborne organic particulate matter (10,13). Acute hypersensitivity pneumonitis in a 30-year-old woman with acute dyspnea, hypoxemia, and chills after cleaning her attic. High-resolution computed tomography shows numerous centrilobular nodules (arrows). The radiologic and clinical findings resolved 5 days after starting corticosteroid therapy. Chronic hypersensitivity pneumonitis occurs after long-standing exposure to an offending antigen and can result in chronic pulmonary fibrosis ( Fig. In chronic hypersensitivity pneumonitis the chest radiograph most commonly reveals mild middle to upper lobe fibrosis ( 10,21). Chronic hypersensitivity pneumonitis in a 52-year-old man with progressive dyspnea. Computed tomography shows nodules, linear opacities, centrilobular nodules (arrowheads), and bronchiectasis (arrows). Acute Eosinophilic Pneumonia Acute eosinophilic pneumonia is idiopathic disease in which acute upper respiratory failure is accompanied by markedly elevated levels of eosinophilia in fluid recovered from bronchoalveolar lavage ( 13,21). Patients with acute eosinophilic pneumonia present with fever and acute respiratory failure, and have radiographic signs consistent with pulmonary edema ( 22). These findings are in contrast to those of chronic eosinophilic pneumonia in which pulmonary infiltrates are peripheral in distribution. Chronic Eosinophilic Pneumonia Chronic eosinophilic pneumonia is an idiopathic condition characterized histologically by filling of the air spaces with eosinophils and macrophages and associated mild interstitial pneumonia. The classic radiographic findings of chronic eosinophilic pneumonia consist of peripheral, nonsegmental areas of consolidation involving mainly the upper lobes. The remaining cases show radiographic findings that are nonspecific and consist of unilateral or patchy bilateral consolidation. The combination of peripheral consolidation and peripheral blood eosinophilia is virtually diagnostic of chronic eosinophilic pneumonia ( 23). Transverse thin-section computed tomography demonstrates extensive areas of air space consolidation (arrows) and ground-glass attenuation ( arrowhead) involving mainly the peripheral lung region. Drug-induced Lung Disease Pulmonary drug hypersensitivity is increasingly being diagnosed as a cause of acute and chronic lung disease ( 24). Numerous agents including cytotoxic and noncytotoxic drugs have the potential to cause pulmonary disturbances. The clinical and radiologic manifestation of these drugs generally reflect the underlying histopathologic processes. The prevalence of drug-induced pulmonary hypersensitivity or toxicity is increasing, and more than 100 drugs are now known to cause injury. The diagnosis of pulmonary drug toxicity should be considered in any patient with drug therapy who presents with new progressive respiratory complaints. Idiopathic Hypereosinophilic Syndrome The idiopathic hypereosinophilic syndrome is a rare and often fatal disorder characterized by elevated blood eosinophil levels (>1,500/ L) for more than 6 months. This syndrome is characterized by the absence of parasitic or other causes of secondary hypereosinophilia ( 13).

Histopathologic studies of sinus mucosa taken from patients with chronic sinusitis do not generally demonstrate bacterial tissue invasion generic amantadine 100 mg amex. A pronounced inflammatory response with a dense lymphocytic infiltrate is typically seen discount 100mg amantadine, at least in part as a response to the bacteria purchase amantadine 100 mg online. The symptomatology associated with chronic sinusitis is probably a result of this inflammatory reaction. Rhinitis The exact incidence of allergy in patients with chronic rhinosinusitis is unclear. In susceptible individuals, provocation by airborne inhalant allergens triggers the release of mediators from mast cells that reside in the nasal mucosa. Immunoglobulin E (IgE) nonallergic mediated inflammation may lead to osteomeatal obstruction and secondary sinusitis. The early phase is primarily mediated by histamine and leukotrienes, whereas late-phase reactions result from cytokines and cellular responses. Nonallergic rhinitis, including vasomotor rhinitis, also can result in osteomeatal obstruction and secondary sinusitis. They are associated with high-grade chronic sinonasal inflammation in susceptible individuals. Polyps also can be associated with specific disorders, such as aspirin-sensitive asthma and cystic fibrosis. The latter diagnosis must be excluded by chloride sweat test in the pediatric patient with polyps ( 2). Some individuals with recurrent acute or chronic sinusitis may have an immune deficiency. Antibody defects predispose the patient to infection with encapsulated gram-positive and some gram-negative organisms. This is in contrast to T-cell deficiencies, which render the patient more susceptible to viral, fungal, and protozoal infections. Thus, the particular type of immune deficiency dictates the nature of the infectious organisms ( 9). These observations are particularly important in this era of widespread acquired immunodeficiency in which sinusitis can be more atypical than in the general population. Rhinoscopically directed cultures may be useful in the diagnosis and management of atypical infections. Allergic Fungal Sinusitis Allergic fungal sinusitis is a pathologic entity distinct from invasive fungal sinusitis. The latter is a fulminant infectious process with tissue invasion; chronicity is rare. Histologic examination of this allergic mucin reveals embedded eosinophils, Charcot-Leydin crystals (eosinophil breakdown products), and extramucosal fungal hyphae. Although bone destruction and expansion may occur, the disease most often follows a slow, progressive course and thus represents a unique form of chronic sinusitis. The incidence of nasal polyposis in this disorder is high and, by some definitions, is required for diagnosis. Polyps, in combination with allergic mucin, often lead to secondary osteomeatal obstruction. Any combination of the previously discussed inflammatory and anatomic factors can result in the histopathologic picture of chronic sinusitis, a proliferative process associated with fibrosis of the lamina propria and an inflammatory infiltrate of eosinophils, lymphocytes, and plasma cells. Chronic mucosal inflammation also may induce osteitic changes of the ethmoid bone ( 5). Although the precipitating and potentiating causes for chronic rhinosinusitis are multifactorial, the common outcome is a cycle by which ostial obstruction leads to stasis of secretions, microbial colonization, and further inflammatory changes and polyp formation in susceptible individuals. This group also identified clinical factors that are associated with the diagnosis of sinusitis. These are grouped into two categories: major factors and minor factors ( Table 40. The presence of two or more major factors or one major and two minor factors is considered a strong history for sinusitis. A stream purulent of mucus may be apparent draining from beneath the middle turbinate. Endoscopically directed cultures of this drainage may be of particular value in guiding antibiotic therapy ( 5). Major and minor factors in the diagnosis of sinusitis Classification of sinusitis as acute, subacute, recurrent acute, or chronic is dependent on temporal patterns. A diagnosis of chronic sinusitis requires that signs and symptoms consistent with a strong history for sinusitis persist for longer than 12 weeks. Patients also may have acute exacerbations of chronic sinusitis in which they experience worsening of the chronic baseline signs and symptoms or the development of new ones.

In older patients lead to a deliberate suppression of the urge to defe- colonoscopy with ileoscopy should be performed with cate and therefore the accumulation of large amantadine 100mg cheap, dry generic amantadine 100 mg with visa, hard biopsy and histological examination of any suspicious stools and constipation amantadine 100 mg on-line. Bright red blood on the toilet paper after wip- by defecation, is commonly due to a functional bowel ing is usually due to haemorrhoids. Rectal blood with other conditions including depression and any ma- may occur with infection or inammation of the bowel lignancy. It is important to consider gastrointestinal ma- together with weight loss, this suggests either malab- lignancy in any case of rectal bleeding. The history should establish the du- Constipation ration and severity of weight loss. Hard, dif- The acute abdomen introduction culttopassstoolsarealsoconsideredconstipation,even if frequent. The patient is often generally unwell and may be shocked due to dehydration and loss of uid into extravascular Management spaces such as the lumen of the bowel and the abdominal Patients may require resuscitation, and general manage- cavity. Investigations r If shocked, a uid balance chart should be started and r Full blood count (often normal, but leucocytosis may where appropriate urinary catheterisation to monitor be present). Gallbladder Acute cholecystitis Colon Diverticulitis Fallopian tube Pelvic inammatory disease Prevalence Pancreas Acute pancreatitis Dyspepsia has a prevalence of between 23 and 41% in Obstruction Western populations. Intestine Intestinal obstruction Biliary system Biliary colic Aetiology/pathophysiology Urinary system Ureteric obstruction/colic. Acute urinary retention Diagnosesmadeatendoscopyincludegastritis,duodeni- Ischaemia tis or hiatus hernia (30%); oesophagitis (10 17%); duo- Small/large bowel Strangulated hernia denal ulcers (10 15%); gastric ulcers (5 10%) and oe- Volvulus sophageal or gastric cancer (2%); however, in 30% the Mesenteric ischaemia endoscopy is normal. Functional dyspepsia describes the Perforation/rupture Duodenum/ Perforation of peptic ulcer or presence of symptoms in the absence of mucosal abnor- stomach eroding tumour mality, hiatus hernia, erosive duodenitis or gastritis. Epigastric mass Suspicious barium meal Previous gastric ulcer Clinical features Peritonitis presents with pain, tenderness, rebound ten- derness and excessive guarding. Antise- the pain, so patients often lie very still and have a rigid cretorydrugs(i. At endoscopy, biopsy and urease tests should be Infection may spread to the blood stream (septicaemia) performed. In patients under the age of 55 years with signicant symptoms but without any alarm symptoms or signs antisecretory agents may be commenced. It is recom- Microscopy mended that such patients should undergo Helicobac- An acute inammatory exudate is seen with cellular in- ter pylori testing and where appropriate, eradication ltration of the peritoneum. Investigations The diagnosis is clinical, further investigation depends on the possible underlying cause. Peritonitis Denition Management Peritonitis is inammation of the peritoneal lining of the Managementinsecondaryperitonitisisaimedatprompt abdomen. Peritonitis may be acute or chronic, primary surgical treatment of the underlying cause (after ag- or secondary. Primary or postoperative peri- tonitis, which is non-surgical in origin, is managed medically. Patients undergo- Intestinal obstruction ing peritoneal dialysis are at particular risk of recur- Denition rent acute peritonitis, which may result in brosis and Intestinal obstruction results from any disease or process scarring preventing further use of this type of dialysis. It may be Chronic liver disease patients with ascites are at risk acute, subacute, chronic or acute on chronic. Aetiology r Chronic infective peritonitis occurs from tuberculous The common causes vary according to age. Childrendevelopintestinalobstructionfromex- lae conniventes) whereas large bowel markings (haus- ternal hernia, intussusception or surgical adhesions. Erect adults external hernia, large bowel cancer, adhesions, di- abdominal X-ray may demonstrate uid levels and any verticular disease and Crohn s disease may all cause ob- co-existent perforation. Management Pathophysiology Following resuscitation, prompt diagnosis and opera- r The bowel may obstruct from an intraluminal mass, tion are essential to avoid strangulation. Theremaybecompressionofblood r Hernias are reduced and repaired, adhesions and vessels and a consequent ischaemia. As the ex- r Gallstones or food bolus causing intraluminal ob- tracellular pressure rises arteries become obstructed struction are milked into the colon. Clinical features Right colonic obstruction: Patients present with pain, vomiting and a failure to pass r Obstructive lesions of the right colon are managed by faeces or atus. The site of pain is dependent on the righthemicolectomy and end-to-end ileocolic anas- embryological gut: tomosis. Left colonic obstruction:Surgery is often a two-stage r Hind gut (down to the dentate line of the rectum). Auscultation reveals exaggerated with closure of the distal stump, which is returned to bowel sounds and high pitched tinkling sounds when the abdominal cavity). Sim- Denition ilarly in proximal colonic obstruction the ileocaecal Acessation of the peristaltic movement of the gastroin- valve forms a second point of obstruction. Aetiology/pathophysiology Causesofparalyticileusincludeabdominalsurgery,peri- Investigations tonitis, pancreatitis, metabolic disturbance (including Abdominal X-ray reveals the distension and allows as- hypokalaemia) or retroperitoneal bleeding.