*Important Notice : Guided tours to the Parliament Chamber are suspended until further notice as a preventative measure in response to Covid-19


David I. Silverman, MD

  • Professor of Medicine
  • University of Connecticut School of Medicine
  • Director, Echocardiography Laboratory
  • Hartford Hospital
  • Hartford, Connecticut

A "Bell palsy" with hearing loss and an aural discharge should prompt consideration of mastoiditis and petrositis purchase pregabalin 75mg line. If there is hearing loss without a discharge buy cheap pregabalin 150mg, the possibility of an acoustic neuroma or cholesteatoma must be entertained order discount pregabalin line. The association of a central facial palsy with hemiplegia brings up a host of possibilities including subdural hematoma buy pregabalin now, brain abscess discount 150 mg pregabalin with visa, brain tumor, and cerebrovascular accident. If the patient has clinical Bell palsy, one could start a therapy without a workup, but it is wise to get an x-ray of the skull and mastoids to rule out mastoiditis and petrositis and a glucose tolerance test to rule out diabetes. An acetylcholine receptor antibody titer or Tensilon test would only be ordered if the palsy were intermittent or there were other cranial nerve signs. Examination revealed weakness of the right facial muscles and inability to close his right eye. Utilizing the methods presented above, what would you consider in the differential diagnosis at this point A neurologist is consulted and his examination shows weakness of the left facial muscles as well. Furthermore, there is mild weakness and loss of sensation in all four extremities and diminished deep tendon reflexes. Endocrine system: this would bring to mind the coarse facial features of myxedema and cretinism, the proptosis of hyperthyroidism, the moon face of Cushing syndrome, and the square protruding jaw of acromegaly. Cardiovascular system: this should prompt the recall of the malar flush in mitral stenosis and the cyanosis of congenital heart disease. Nervous system: this should suggest the masked face of Parkinsonism, the hatchet-shaped face of myotonic dystrophy, the snarl of myasthenia gravis, and the drawing of the face to one side in Bell palsy with flattening of the nasolabial fold. It should also suggest the expressionless face and often drooling mouth of bulbar and pseudobulbar palsy and sarcastic smile of patients with tetanus. Skeletal system: this would bring to mind the protruding forehead of Paget disease and the wide separation of the eyes in hypertelorism. Approach to the Diagnosis Obviously, the workup of abnormal facies will depend on what disease is suggested by the facial appearance combined with other abnormalities of the physical and neurologic examination. The physiologic model of intake, absorption, transport, and utilization will help develop a differential diagnosis. Intake: Intake of food may be impaired by social conditions of poverty, malnutrition, and child abuse. It may also be impaired by chronic anxiety and depression or other psychiatric disorders. Finally, the patient may not eat because of a neurologic disorder such as microcephaly, hydrocephalus, cerebral palsy, or other disorders associated with mental retardation. Absorption: Absorption of food may be impaired by malabsorption syndrome and fibrocystic disease. Transport: this topic brings to mind chronic anemia and congenital heart disease especially when associated with hypoxemia. Utilization: Utilization of food is impaired in diabetes mellitus, hypothyroidism, pituitary insufficiency, galactosemia, and uremia. The child may also come from an abnormal gestation where the mother suffered alcoholism, drug abuse, or chronic illness. At this point, it is helpful to consult a pediatrician before ordering expensive diagnostic tests. It may occur, however, in certain cases of peripheral neuropathy, in electrolyte disturbances, and in myasthenia gravis, especially under treatment. It is also found in healthy states, most commonly in the twitching of the orbicularis oculi muscle from nervous tension or eyestrain. V-Vascular conditions include anterior spinal artery occlusion and intermittent claudication from peripheral vascular disease. I-Inflammatory diseases include poliomyelitis, viral encephalomyelitis, tetanus, syphilis, and diphtheria. N-Neoplasm suggests intramedullary tumors of the cord such as ependymomas, and extramedullary tumors such as meningioma, Hodgkin lymphoma, metastatic carcinoma, and multiple myeloma must be considered. T-Trauma suggests herniated discs and fractures that compress the anterior horn or roots. Approach to the Diagnosis Deciding on the cause of fasciculations will usually be based on other neurologic symptoms and signs. Muscular atrophy without sensory changes suggests progressive muscular atrophy, whereas atrophy and fasciculations with sensory changes suggest syringomyelia, peripheral neuropathy, and root compression. Serum electrolytes, calcium, phosphorus, and magnesium levels are useful in selected disorders. Physiology: Increased heat in the body is caused by increased production or decreased elimination or dysfunction of the thermoregulatory system in the brain. Increased production of heat occurs in conditions with increased metabolic rate such as hyperthyroidism, pheochromocytomas, and malignant neoplasms. Most cases of fever are caused by the effect of toxins on the thermoregulatory centers in the brain. These toxins may be exogenous from drugs, bacteria (endotoxins), parasites, fungi, rickettsiae, and virus particles, or they may be endogenous from tissue injury (trauma) and breakdown (carcinomas, leukemia, infarctions, and autoimmune disease). Also, when the physician attempts to recall the specific infections, he or she can group them into six categories beginning with the smallest organism and working up to the largest as follows: viruses, rickettsiae, bacteria, spirochetes, fungi, and parasites. Endogenous toxins released by infarctions of various organs form another convenient group. Finally, the 351 most common neoplasms to cause fever (by tissue breakdown) are illustrated on page 172. Approach to the Diagnosis There are certain things to remember when a patient with fever is approached. Second, one should rule out malingering by the patient or incorrect recording by hospital personnel. If possible, a careful chart of the fever should be made with the patient off all drugs (especially aspirin and steroids). Conditions with intermittent or relapsing fever such as brucellosis, malaria, and Mediterranean fever will be elucidated in this fashion (see Table 28). Fever, right upper quadrant pain, and jaundice suggest cholecystitis or cholangitis, whereas fever with right-sided flank pain suggests pyelonephritis. After taking a few moments to jot down the differential diagnosis before launching into the history and physical examination, one can question and examine the patient more appropriately. The differential diagnosis will also lead to more appropriate use of laboratory testing. A serum procalcitonin will distinguish bacterial infections from viral infections. Case Presentation #27 A 16-year-old white boy is referred to you with a history of sore throat and intermittent fever for 10 days. He was treated with penicillin by his family physician 1 week ago but failed to respond. Utilizing the methods discussed above, what is your list of possibilities at this point However, if the clinician immediately focuses on the kidney, he or she may be sadly mistaken because one forgets the other significant organs in the area. Looking at the adrenal gland, one need only recall the tumors of this gland such as a neuroblastoma, adrenocortical carcinoma, or pheochromocytoma. Surprisingly, other organs located near the flank may be palpated as a flank mass. As in the right upper quadrant, a carcinoma or collection of stool can be palpated in the flank. Moving into the retroperitoneal area, we again may find hematomas of the wall of the flank, bony tumors, and retroperitoneal sarcomas. Approach to the Diagnosis the history of trauma will be helpful in narrowing the diagnosis. Obviously, if there is fever a perinephric abscess, pyonephrosis, or tuberculosis is more likely. It is wise to consult an urologist before ordering any x-ray procedure to help decide which is the most cost-effective approach. Visualizing the anatomy of the right flank and crossindexing each structure with the etiology classification, what would be your list of possible causes at this point Further history reveals the patient has noted painless hematuria on a couple of occasions but is otherwise asymptomatic. Physical examination is unremarkable aside from the large nontender mass in the right flank. As is shown in Table 29, however, jumping to that conclusion in any given case may be hazardous. In addition to the kidney (pyelonephritis and perinephric abscess), inflammation of the skin (herpes zoster), the colon (diverticulitis and colitis), the gallbladder (cholecystitis), and the spine (epidural abscess and Pott disease) may also cause flank pain. Neoplasms of the kidney and colon are less likely to produce pain unless they are complicated by infection. However, trauma of the kidney and spine and renal calculi-whether due to hyperparathyroidism, idiopathic etiologies, or hyperuricemia-are important causes. If these are negative, bone scans, arteriogram, and other tests listed below may be 362 required. Utilizing the methods discovered above, what would be your list of possibilities at this point Physical examination is unremarkable except for hyperesthesia and hyperalgesia in the distribution of T12 dermatome on the left. Retina: Conditions of the retina to be considered in this symptom are exudative choroiditis, retinal detachment, venous thrombosis, and embolism. Optic cortex: Transient ischemic attacks in the posterior cerebral circulation and epileptic auras may cause this symptom. Arterial circulation to the eye and brain: Migraine, cerebral thrombosis, and emboli present with this symptom. Approach to the Diagnosis this is similar to the workup of blurred vision (see page 76). The increase of gas in the intestinal tract depends on three physiologic mechanisms: 1. Increased intake of air: this is probably one of the most frequent causes of flatulence and borborygmi. However, compulsive eating, compulsive drinking, excessive smoking, or excessive talking may produce the same effect. When we overeat, however, or when we drink too much, the amount of gas taken in may exceed our ability to absorb it. Salesmen and public speakers have an additional problem because talking increases salivation and swallowing, and frequently air is swallowed between sentences. Some people have a particular beverage they are fond of, such as cola, coffee, or alcohol. In addition, some of these beverages release gas after ingestion (carbonated beverages especially), which causes flatulence. Increased production of gas in the intestinal tract: In acute bacterial gastroenteritis. The diarrhea or vomiting associated with these disorders usually makes 364 the diagnosis easy. A more obscure cause of increased production of gas is chronic mild intestinal obstruction leading to excessive bacterial overgrowth. Adhesions, intestinal polyps, regional ileitis, and the various causes of paralytic ileus. Gas production is also increased when bacteria are allowed to accumulate in large numbers in chronic intestinal disorders. The blind loop syndrome, diverticulitis, and Meckel diverticulum fall into this category. Some types of irritation in the intestinal tract cause a mild paralytic ileus and allow bacteria to multiply and ferment: Esophagitis and hiatal hernia, chronic gastritis, ulcers, regional ileitis, and ulcerative and mucous colitis may cause mild paralytic ileus on this basis. When the amount of digestive juices is insufficient to digest food, more food is available for bacterial fermentation. Thus, in chronic atrophic gastritis, the reduced level of hydrochloric acid leaves undigested food for bacterial action. In cholecystitis and partial bile duct obstruction or liver disease, there are insufficient bile acids for digestion and more food is left for bacterial fermentation. In chronic pancreatitis, the reduction in pancreatic enzymes causes the same problem. In celiac disease, the atrophied villi cannot pick up food and gas, and these are passed through the intestines. Intestinal parasites may preempt food from absorption and produce excessive gas in their own digestive processes. Approach to the Diagnosis If excessive food, beverages, or air swallowing from nervous tension or talking can be excluded, reflux esophagitis and diverticulitis must be considered. If these findings are questionable, a more definitive diagnosis may be made with endoscopy. When the outcome is still 365 uncertain, evaluation of the adequacy of the intestinal digestive secretions is worthwhile. Gastric analysis with Histalog and duodenal analysis for bicarbonate, bile, and pancreatic enzymes is done. If the digestive secretions are adequate, a small-bowel biopsy may be necessary to exclude a malabsorption syndrome. Therapeutic trial of proton pump inhibitors (reflux esophagitis) Case Presentation #31 A 46-year-old white woman complained that for the past year she has had increasing episodes of flushing of the face and neck, especially during exercise or stress. What diagnosis should you entertain considering the physiology involved in this symptom Further history reveals that she has had chronic diarrhea for a couple of years as well. Physical examination revealed telangiectasias of the face and neck and mild hepatomegaly. A flushed face may result from an increased amount of circulating blood (polycythemia) or from any factor that may dilate the blood vessels in the face.

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Manifestations are cessation of mitotic activity discount pregabalin line, cellular swelling purchase pregabalin 75 mg with visa, tissue edema discount pregabalin 75mg with amex, and tissue necrosis order pregabalin mastercard. Early problems associated with irradiation of gynecologic cancers include enteritis buy 75mg pregabalin with amex, acute cystitis, vulvitis, proctosigmoiditis, topical skin desquamation, and, occasionally, bone marrow depression. Chronic complications occur months to years after completion of radiation therapy. These include obliteration of small blood vessels or thickening of the vessel wall, fibrosis, and reductions in epithelial and parenchymal cell populations. Several drugs are currently available that target specific molecules or proteins in cancer cells. Additionally, bevacizumab is a monoclonal antibody designed to target the vascular endothelial growth factor protein and inhibit angiogenesis in tumors. It is currently approved for treatment of a variety of tumors, including cervical and epithelial ovarian cancer. Tumor vaccines are also currently being investigated for the treatment of ovarian cancer. Inactivated virus strains have also been studied as a vector for the vaccines in hopes of creating higher immunogenicity. Currently, the response to this type of therapy has been modest, but studies are ongoing. For instance, because half of ovarian cancers exhibit deleterious mutations in the p53 gene, research has focused on delivering a normal p53 gene product to the tumor using a variety of viral vectors. The hope is that the wild-type gene product would then be expressed by the tumor, and the growth would then be inhibited. The potential benefits of these novel therapeutic concepts are manifold, whether considered as primary or adjunct therapy. Work in this area is in the experimental stage, but eliminating cancer cells with minimal toxicity remains the goal of cancer therapeutics. She is now prepared to undergo chemotherapy with a better 907 understanding of what she might expect. You perform an ultrasound, which demonstrates a snowstorm pattern and no fetus in the uterus. There are two varieties of molar pregnancies, complete mole (no fetus) and incomplete mole (fetal parts in addition to molar degeneration). Persistent or malignant disease will develop in approximately 20% of patients with molar pregnancy. Complete moles are associated with low dietary carotene consumption and vitamin A deficiency. Both complete and partial moles are associated with a history of infertility and spontaneous abortion. Partial moles are characterized by focal trophoblastic proliferation, degeneration of the placenta, and identifiable fetal or embryonic structures. The genetic constitutions of the two types of molar pregnancy are different (Table 45. Complete moles have chromosomes entirely of paternal origin as the result of the fertilization of a blighted ovum by a haploid sperm that reduplicates or, rarely, fertilization of a blighted ovum with two sperm. This consists of one haploid set of maternal chromosomes and two haploid sets of paternal chromosomes, the consequence of dispermic fertilization of a normal ovum. Complete moles are more common than partial moles and are more likely to undergo malignant transformation. Clinical Presentation Patients with molar pregnancy have findings consistent with a confirmed pregnancy as well as uterine size and date discrepancy, exaggerated subjective symptoms of pregnancy, and painless second-trimester bleeding. With the increased early prevalence of first-trimester ultrasound, moles are now frequently diagnosed in the first trimester of pregnancy before symptoms are present. Abnormal bleeding is the most characteristic presenting symptom which prompts evaluation for threatened abortion. Lack of fetal heart tones detected at the first obstetric appointment can also prompt evaluation (depending on the estimated gestational age). Rarely, patients experience tachycardia and shortness of breath, arising from intense hemodynamic changes associated with acute 913 hypertensive crisis. In these patients, physical examination reveals not only the date and size discrepancy of the uterine fundus and absent fetal heart tones but also changes associated with developing severe hypertension such as hyperreflexia. With earlier diagnosis, the medical complications of molar pregnancy are becoming less common. In any woman who presents with findings suggestive of severe hypertension prior to 20 weeks in pregnancy, a molar pregnancy should be immediately suspected. Twin pregnancies with a normal fetus coexisting with a complete or partial mole are exceedingly rare. Women with these pregnancies should be treated in a tertiary hospital center with specialized care. Medical complications in molar twin gestations rarely allow these pregnancies to reach term. Whereas both partial and complete molar pregnancies present as abnormal pregnancies, partial mole most often presents as a missed abortion. Vaginal bleeding is less common in partial molar pregnancy than in complete molar pregnancy. Uterine growth is less than expected for the gestational age in partial molar pregnancy. Ultrasound reveals molar degeneration of the placenta and a grossly abnormal fetus or embryo. Medical complications, theca lutein cysts, and subsequent malignancies are rare (see Table 45. Uterine evacuation is done most often by dilation of the cervix and suction curettage followed by gentle sharp curettage. Because the evacuation of larger moles is sometimes associated with uterine atony and excessive blood loss, appropriate preparations should be made for uterotonic administration and blood transfusion, if needed. In rare cases of a late presenting partial molar pregnancy, there may be an additional need for larger grasping instruments to remove the abnormal fetus. In general, the larger the uterus, the greater the risk of pulmonary complications associated with trophoblastic emboli, fluid overload, and anemia. This is particularly true in patients with associated severe gestational hypertension, who may experience concomitant hemoconcentration and alteration in vascular hemodynamics (see the section on preeclampsia in Chapter 22). Hysterectomy or induction of labor with prostaglandins is not usually recommended, because of the increased risk of blood loss and other sequelae. The theca lutein cysts invariably regress within a few months of evacuation and, therefore, do not require surgical removal. Patients who have no interest in further childbearing or have other indications for hysterectomy may be treated by hysterectomy with ovarian preservation. Postevacuation Management Because of the predisposition for recurrence, patients should be monitored closely for 6 to 12 months after the evacuation of a molar pregnancy. Follow-up consists of periodic physical examination to check for vaginal metastasis and appropriate involution of pelvic structures. During the first year, the patient should be provided with a reliable contraceptive method to prevent an intercurrent pregnancy. Multiple studies have proven the safety of oral contraceptive use after a molar pregnancy. There is no increase in congenital anomalies or complications in future pregnancies. An invasive mole, a localized form, is histologically identical to a complete mole. It invades the myometrium without any intervening endometrial stroma seen on histologic sample. Occasionally, it may be diagnosed on curettage at the time of initial molar evacuation. Although invasive moles are histologically identical to antecedent molar pregnancies while invading the myometrium, choriocarcinomas are a malignant transformation of trophoblastic tissue. Instead of hydropic chorionic villi, the tumor has a red, granular appearance on cut section and consists of intermingled syncytiotrophoblastic and cytotrophoblastic elements with many abnormal cellular forms. Clinically, choriocarcinomas are characterized by rapid myometrial and uterine vessel invasion and systemic metastases resulting from hematogenous embolization. Lung, vagina, central nervous system, kidney, and liver are common metastatic locations. Choriocarcinoma may follow a molar pregnancy, normal-term pregnancy, abortion, or ectopic pregnancy. Identified metastatic sites should not be biopsied to avoid bleeding complications. Prior chemotherapy Poor prognosis 917 From the American College of Obstetricians and Gynecologists. Adjunctive radiotherapy is sometimes performed with patients who have brain or liver metastasis. Surgery may be necessary to control hemorrhage, remove chemotherapy-resistant disease, and treat other complications to 918 stabilize high-risk patients during intensive chemotherapy. The 5-year survival rate for nonmetastatic and good-prognosis disease approaches 100%. Placental Site Tumors Placental site tumor is a rare form of trophoblastic disease. The tumor is composed of monomorphic populations of intermediate cytotrophoblastic cells that are locally invasive at the site of placental implantation. She recovers well from this procedure and sees you regularly for quantitative beta human chorionic gonadotropin levels for a full 12 months. She is carefully monitored throughout the pregnancy and ultimately delivers a healthy baby at term. She reports that it has been going on for about 5 months and she has tried over-the-counter vaginal preparations for yeast, but these have not helped. She even went to an urgent care clinic and obtained a prescription for metronidazole for bacterial vaginosis, but that too did not help. On examination, you notice some erythema with a keyhole lesion on the perineal body. The major symptoms of vulvar disease are pruritus, burning, nonspecific irritation, and/or appreciation of a mass. The vulvar region is particularly sensitive to irritants, more so than other regions of the body. Noninflammatory vulvar pathology is found in women of all ages but is especially significant in perimenopausal and postmenopausal women because of concern regarding the possibility of vulvar neoplasia. Diagnostic aids for the assessment of noninflammatory conditions are relatively limited in number and include careful history, inspection, and 920 biopsy. Because vulvar lesions are often difficult to diagnose, use of vulvar biopsy is central to good care. Punch biopsies of vulvar abnormalities are most helpful to determine if cancer is present or to histologically determine the specific cause of a perceived abnormality of the vulva. Cytologic evaluation of the vulva is of limited value, insofar as the vulvar skin is keratinized and epithelium shedding does not occur as readily as that of the cervix. Colposcopy is useful for evaluating known vulvar atypia and intraepithelial neoplasia. Currently, these diseases are classified into three categories: squamous cell hyperplasia, lichen sclerosus, and other dermatoses. Typically, the vulva is diffusely involved, with very thin, whitish epithelial areas, termed "onion skin" epithelium. The lesion may extend to include a perianal "halo" of atrophic, whitish epithelium, forming a figure-8 or keyhole configuration with the vulvar changes. In severe cases, many normal anatomic landmarks are lost, including obliteration of the labial and periclitoral architecture, sometimes resulting in fusion of the normal labial and periclitoral folds, as well as severe stenosis of the vaginal introitus. Some patients have areas of cracked skin, which are prone to bleeding with minimal trauma. Patients with these severe anatomic changes complain of difficulty in having normal coital function. However, the response to topical steroids further indicates the underlying inflammatory process and the role of prostaglandins and leukotrienes in 923 the hallmark symptom of pruritus. Histologic evaluation for confirmation of lichen sclerosis is often necessary and useful because it allows specific therapy. The histologic features of the lichenoid pattern include a band of chronic inflammatory cells, consisting mostly of lymphocytes, in the upper dermis with a zone of homogeneous, pink-staining, collagenous-like material beneath the epidermis due to cell death. The obliteration of boundaries between collagen bundles gives the dermis a "hyalinized" or "glassy" appearance. In 27% to 35% of patients, there are associated areas of acanthosis characterized by hyperkeratosis-an increase in the number of epithelial cells (keratinocytes) with flattening of the rete pegs. In patients with this mixed pattern, both components need to be treated to effect resolution of symptoms. Patients in whom a large acanthotic component has been histologically confirmed should be treated initially with wellpenetrating corticosteroid creams. Treatment for lichen sclerosis includes the use of topical high-dose steroid (clobetasol) preparations in an effort to ameliorate symptoms.

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Refer to orthopedic surgeon for manipulation under general anesthesia or other surgical procedure buy 150 mg pregabalin free shipping. If the lesions are pointed and have a white center perform I&D and get material for culture and sensitivity generic 150 mg pregabalin visa. If it is on the dorsum of the wrist buy pregabalin 150 mg cheap, pick up a heavy book and strike the flexed wrist with a moderate and sharp blow purchase pregabalin 150mg on line. If above unsuccessful order 75 mg pregabalin amex, aspirate the material in the cyst with a #18 needle and syringe under sterile procedure. Intravenous fluids if there is clear evidence of dehydration (coated tongue, mushy eyeballs or tenting of the skin). Alternatively, administer loperamide (Imodium): 4 mg stat and 2 mg after each stool. Avoid caffeinated beverages, chocolate, alcohol, nicotine, and milk and milk products. If patient needs more than 6 weeks of therapy, then they are not following orders 1, 2, and 3. If proton pump inhibitors unsuccessful, try cimetidine 800 mg bid or ranitidine 150 mg bid. If all above measures fail, consider referral to an abdominal surgeon for fundal plication and other surgical procedures. Alternatively, may give a single 2 g dose of tinidazole (Tindamax) in adults and 50 mg/kg in children to maximum of 2 g. Regular cleaning of teeth and gums every 3 to 6 months by a dental hygienist is recommended. Brushing and flushing teeth with a water pick twice a day will often prevent this condition. Gonococcal Infections, Acute (Includes urethritis, vaginitis, cervicitis, pharyngitis, and proctitis) 1. However, citrus fruits, meats cured with nitrates, and caffeinated beverages are not uncommon causes of migraine. Cervical traction over-the-door beginning with 7 lb for one-half hour twice a day and increasing gradually to 15 lb for 1 hour twice a day. If there is clear evidence of myelopathy clinically or radiographically, refer to a neurosurgeon for laminectomy or other 918 surgical procedures. Patients with clinical evidence of radiculopathy but no evidence of weakness or atrophy of the muscles of the upper extremity, may be treated conservatively, but should be offered the option of referral to a neurosurgeon for evaluation for surgery. Patients with clinical evidence of radiculopathy including atrophy of the muscles of the upper extremity should be referred to a neurosurgeon. Conservative treatment of cervical pain and radiculopathy includes one or more of the following: a. Except in cases of acute neck pain or radiculopathy use narcotic analgesics only as last resort and then only until more definitive treatment can be instituted. Patients with no clinical evidence of radiculopathy or a neurogenic bladder may be treated conservatively. Patients with evidence of a neurogenic bladder or cauda equina syndrome should be referred to a neurosurgeon without delay. Patients with clinical evidence of radiculopathy and weakness or 919 atrophy of one or both lower extremities need neurosurgical or orthopedic Consult. Patients with clinical evidence of radiculopathy without muscle atrophy of the lower extremities may be treated conservatively, but should be given the option of an orthopedic or neurosurgical consult. Gabapentin (Neurontin) or other medications for neuropathic pain: 11, 90, 111, 260 (Appendix 2A). Exercise to strengthen the anterior spinal muscles including pelvic tilts and sit-ups. If the clinician is unable to demonstrate these to the patients, consult a physiotherapist. Except in acute low back pain and radiculopathy, narcotic analgesic should be used as last resort and then only until more definitive treatment can be initiated. May use prednisone 60 mg daily for severe neuralgia, but must not use for extended period of time (more than 1 week) and cover with antiviral therapy during each use. Bacitracin + neomycin + polymyxin B, and hydrocortisone (Cortisporin) ophthalmic ointment: apply qid to eyelids. Look for the cause and treat: hypothyroidism, diabetes mellitus, nephrosis, biliary cirrhosis, etc. If patient is overweight, the first thing to do is prescribe a reducing diet and an exercise program. If weight is normal, prescribe a low cholesterol diet preferably with the help of a dietician. Reduce the fats to 30% or less of total calories and saturated fats to less than 10% of total calories. Cut fat off meat, restrict pork, gravy, and greasy foods and increase intake of fruits and vegetables. A fibrate such as gemfibrozil (Lopid) 600 mg bid or Fenofibrate (TriCor) 160 mg daily may be tried next. If patient is obese, place on a weight reducing diet with plenty of fresh fruits and vegetables and salt restriction (which is an appetite suppressant). If the above drugs are unsuccessful in lowering the blood pressure, a thorough re-evaluation for renal and adrenal causes of hypertension should be done and a nephrologist consulted. Monitor patients regularly for renal, ocular, and cardiac complications of hypertension. Treat mild elevations in obese patients with weight reduction, avoidance of free sugar, and regular exercise. Avoid or give lower doses of drugs that increase triglycerides such as -blockers, diuretics, and corticosteroids. If only the triglycerides are elevated, gemfibrozil (Lopid) 600 mg bid or fenofibrate (TriCor) 160 mg daily may be effective. Patients with triglycerides over 500 mg/dL should be treated aggressively to avoid pancreatitis. If patient is conscious, give orange juice with added sugar or 50% glucose solution by mouth. Monitor blood sugar for several hours especially in patients on oral hypoglycemic. Faced with mild hypokalemia in a patient on diuretics in the clinic setting simply prescribe slow K 10 mEq bid p. Hydrocortisone 20 mg daily or bid may be tried but be sure adrenal insufficiency is ruled out. Children and obese patients may need up to 4 g/kg/day while the elderly require less than average doses. The substitution of triiodothyronine (Cytomel) up to 125 g daily for 50 g of levothyroxine has helped some patients with this disease. Launder bedding and clothes that might have been exposed to the bacteria before treatment was begun. For mild cases, take a fingernail file and make 2 or 3 V-shape grooves in the end of the nail so the nail will grow medially instead of laterally. Alternatively, remove one-half or all the nail under sterile prep and local anesthesia. Yearly influenza virus vaccine for people at high risk for pulmonary or cardiovascular disease. Follow patients with tick bites for Lyme disease, Rocky Mountain spotted fever, etc. If stool is loose, be sure and do a thorough workup for infection and other causes of diarrhea. Refer patients with incontinence refractory to above medications to an urologist for surgical treatment. Intermittent use of a catheter or Urisheath (in men) may save a lot of trouble for caretakers. Prescribe a combination of valerian root, tryptophan, and melatonin (Alteril), an over-the-counter preparation. Avoid benzodiazepines at all cost because, they accumulate in the body for long periods. Look for gastrointestinal diseases which may masquerade as this syndrome such as, giardiasis, amebiasis, neoplasm, lactose intolerance, and malabsorption syndrome. Alternatively, begin with a clear liquid diet and add solid items one at a time over a period of several weeks. Look for other causes of vertigo (cerebrovascular disease, benign positional vertigo, toxic labyrinthitis from drugs, etc. This not only includes milk and ice cream but yogurt, cheese, butter, and milk chocolate. Lactose eliminating tablets (Lactaid) may be taken prior to ingesting milk and milk products, but this is not really necessary with all the commercially available substitutes. If a viral etiology is suspected, treat with rest of the voice, humidifier, and pseudoephedrine (Sudafed) 60 mg q6hrs or the extended release form, 240 mg once daily.

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For severe flare-ups prescribe prednisone 60 to 80 mg a day and taper once inflammation under control pregabalin 75 mg sale. Avoid alcoholic beverages purchase 150mg pregabalin otc, skin irritants buy pregabalin overnight delivery, carbonated beverages buy cheapest pregabalin, frequent baths discount pregabalin 75 mg with amex, or use of soaps. Once patient is able to ambulate, apply ace bandages over dressing or fit with compression stockings if the inflammation has subsided. Annual checks for retinopathy, nephropathy, and neuropathy as outlined under Type 1 Diabetes Mellitus should be made. Brittle diabetics may benefit from low dose corticosteroids or estrogen replacement therapy (in menopausal women) or testosterone replacement therapy (in men with possible male climacteric). Consult surgeon or gastroenterologist for resistant cases or if you suspect perforation, abscess, significant obstruction, or bleeding. Thorough pelvic examination and Pap smear to rule out serious causes of vaginal bleeding. It is the goal of therapy for regular periods (with normal menses) to be established once the exogenous hormones wear off. If the above techniques are unsuccessful, look for anemia (especially iron-deficiency anemia), hypothyroidism or hyperthyroidism or refer the patient to a gynecologist for a D&C or other procedures (ultrasonogram, etc. Medical D&C with Medroxyprogesterone (Provera): 10 mg daily for 21 days beginning 7 days after period began. Test all recent sexual partners (within past 30 days) for gonorrhea and Chlamydia. If bleeding persists, pack anterior nasal compartment with oxidized cellulose (Surgicel) or absorbable gelatin foam (Gelfoam). In persistent cases, consult a neurologist to verify the diagnosis and suggest other forms of treatment. Bacitracin and Polymyxin B topical ointment (Polysporin): Apply tid to affected area. At the same time the patient is receiving anti-inflammatory drugs and muscle relaxants begin an exercise program including pelvic tilts, sit-ups, and knee bends. If necessary enlist the help of a physiotherapist to school the patient on these exercises. In persistent cases, refer the patient to a physiotherapist for evaluation and treatment. For obese patients a reducing diet is prescribed along with an appetite suppressant if necessary. These patients should also be given the benefit of evaluation by on orthopedic or neurologic surgeon. Avoid narcotic analgesics unless the patient has a consult with a pain management specialist. Never give up hope for these patients until they have had the benefit of a psychiatric consult or psychometric testing. A physiotherapist may be consulted for evaluation and treatment especially in persistent cases. Other muscle relaxants may be substituted for cyclobenzaprine: 29, 53, 69, 207 (Appendix 2A). The patient should be educated by a physiotherapist on how to avoid a recurrence before returning to work. For complications such as the acute bubonic stage enlist the service of a general surgeon. Supportive care including humidification, bed rest, forced fluids, antipyretics, and antitussive agents. Prophylaxis: Immunize people who have been exposed (within 72 hours of exposure) or are at risk of being exposed and cannot be sure they have ever been vaccinated, especially unimmunized school children. Children who are unable to be vaccinated within 72 hours of exposure, must be excluded from school, child care, and so forth until a period of 2 weeks has elapsed from the onset of the last case of measles. Patients with a hysterectomy and no history of breast cancer in themselves or their family: 1. Some patients do better with esterified estrogen + methyltestosterone (Estratest): 1 tablet daily 25 days a month. If patient is smoking less than 10 cigarettes a day begin with 14 mg patch daily for 6 weeks and then 7 mg patch for 2 weeks. Study patients for hypothyroidism, Cushing disease, and complications of obesity, such as, coronary insufficiency, hypertension, gallstones, and diabetes. Set a goal of a certain weight the patient should achieve by the end of dieting, including how much to lose each week. Take a one a day multivitamin such as unicaps but beware of high potency vitamins as they may put on weight and increase appetite. Beware of drugs like antidepressants or birth control pills that might put on weight while you are dieting. Plan with your spouse, friend, or a family member for a special reward (cruise, new clothes, etc. Patients who fail to lose weight on a reducing diet should be referred for bariatric surgery. Careful workup to rule out rheumatic fever, gout, pseudogout, septic arthritis, and rheumatoid arthritis. A nonsteroid anti-inflammatory drug such as naproxen (Naprosyn) 500 mg bid or tid is tried first. Non-narcotic analgesics such as acetaminophen may be useful to control acute exacerbations. If the above medical treatments are unsuccessful, referral to an orthopedic surgeon for intra-articular hyaluronic acid injections, joint irrigation, or arthroscopic debridement is done. Then apply bacitracin + neomycin + polymyxin-B, and hydrocortisone (Cortisporin) suspension: 5 drops in affected ear applied to the cotton wick q4hrs. May have the patient return for reinsertion of a fresh cotton wick every 2 days in severe cases. Refer to an otolaryngologist if poor progress or increasing pain and hearing loss. Consult a psychiatrist or psychologist for evaluation and recommendations for treatment. Alternatively, apply lindane 1% (Kwell) shampoo for 4 minutes and rinse out of hair. Lansoprazole + amoxicillin + clarithromycin (Prevpac-triple therapy): 1 bid for 14 days. Alternatively bismuth subcitrate + metronidazole + tetracycline (Helidac): 3 capsules qid plus + 20 mg omeprazole for 10 days. Consult vascular surgeon for consideration of percutaneous transluminal angioplasty or arterial bypass surgery if symptoms and objective findings indicate severe arterial insufficiency. Mebendazole (Vermox): chewable 100 mg single dose for each member of family and repeat in 2 weeks. Alternatively, may prescribe albendazole (Albenza): 400 mg as a single oral dose to all members of the family. If possible get a smear, culture, and sensitivity of sputum before beginning therapy. Alternatively may use other macrolides: 76, 119 or tetracycline 109 (Appendix 2A). Children over 5 years of age may be given azithromycin 10 mg/kg/day or (a maximum of 500 mg) orally followed by 5 mg/kg/day for 4 days. Watch for temporal arteritis and be ready to treat this with much larger doses of corticosteroids. In persistent cases, make a referral to a psychiatrist, neurologist, or pain management specialist. If above treatment suggestions are ineffective, a referral to a gynecologist would be wise. A consult with an urologist may be wise at the outset, but is necessary if the above drugs are ineffective. For severely ill patients and those not responding to above treatment, consult an urologist. Unless smear and cultures of prostatic secretions yield positive results there is no specific treatment. At the same time administer metronidazole (Flagyl) 500 mg bid to avoid Clostridia difficile. Patients who cannot tolerate quinolones may be given cefuroxime (Ceftin) 500 mg bid. More specific antibiotic therapy can be given once cultures and sensitivities are back. Consult an urologist to evaluate for obstructive uropathy and other lesions that may contribute to pyelonephritis. Treat nausea and vomiting with trimethobenzamide (Tigan) suppositories 200 mg q8hrs. Use narcotics as a last resort but it is wise to consult a neurologist or psychiatrist before initiating these drugs. Once diagnosis is firmly established, consult a rheumatologist for disease modifying drug therapy such as methotrexate, sulfasalazine, etc. Perhaps an antihistamine nasal spray like azelastine (Astelin) 2 sprays in each nostril bid may be effective. If the above are not successful, prescribe fluticasone (Flonase) nasal spray, 2 sprays in each nostril daily. In persistent cases, order blood tests for allergens or consult an allergist for skin testing or immunosuppressive therapy. If the above measures fail, referral to an orthopedic surgeon or a course of physiotherapy is in order. Alternatively, apply crotamiton (Eurax) 10% cream from neck to toes and wash off in 24 hours.

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Each year in the spring the child develops a runny nose; itchy discount 75mg pregabalin with mastercard, watery eyes; and sneezing order pregabalin without a prescription. Degranulation occurs when immunoglobulin E (IgE) fixates to mast cells buy pregabalin no prescription, and there is a subsequent exposure to a specific antigen discount pregabalin 150mg fast delivery. When released cheap pregabalin 150 mg with amex, histamine becomes bound to specific membrane-bound histamine receptors. The therapeutic uses of antihistamine medications primarily involve the H1-and H2-receptor subtypes. Their activation increases phospholipase C activity, causing increases in diacylglycerol and intracellular calcium. H1-receptor antagonists are frequently used for the treatment of allergic rhinitis, urticaria, and hives. Older, first-generation, antihistamines cross the blood-brain barrier, contributing to their potentially use-limiting side effect of sedation and can also have significant anticholinergic effects (dry mouth, dry eyes, blurred vision, urinary retention). They must be used with caution in the elderly and in combination with other sedating medications, because the effects can be additive. This results in a lower incidence of sedation and fewer anticholinergic side effects. Activation of H2 receptors in gastric parietal cells causes an increase in gastric acid production. Medications that are competitive antagonists of H2 receptors are used to reduce gastric acid secretion. These are used clinically in the management of peptic ulcer disease, gastroesophageal reflux disease, heartburn, and acid hypersecretory syndromes. Know the mechanism of action, uses, and adverse effects of antihistamine medications. Mast cells and basophils are the principal histamine-containing cells in most tissues. Histamine is stored in vesicles in a complex with heparin and is released by either an immunologic trigger or following a mechanical or chemical stimulus. Once released, histamine produces a number of responses including local vasodilation, transudation of fluid through endothelial cells, and stimulation of nerve endings, producing pain and itching. In the lung, histamine is a bronchoconstrictor, and this action is magnified in patients with asthma. The actions of histamine are mediated by four distinct membrane receptors that are coupled to G-proteins. The H1 receptor, located in smooth muscle cells, endothelium, and brain, is coupled to increased diacylglycerol and Ca2+ release. There is no clinical pharmacology yet for H3 (located in the brain and peripheral neurons) or H4 (found on eosinophils and neutrophils) receptors, but both of these receptors are targets for therapeutic agents and are under intense investigation. Histamine itself has a variety of untoward effects and is useful only diagnostically to assess bronchial hyperreactivity. Antihistamines Compounds that block the active state of histamine H1 receptors have been used for years and are widely marketed both as prescription and overthe-counter medications. The current group of available drugs can be divided into first-generation and second-generation agents. All of these drugs block the action of H1 receptors, and they do not possess significant affinity for the H2 receptor. However, many of the first-generation agents have significant anticholinergic activity, and this is responsible for a significant degree of their central effects. Second-generation agents are less lipid soluble and do not penetrate the blood-brain barrier and hence have many fewer central adverse effects. Histamine is released by IgE-sensitized cells, especially mast cells, and antihistamines can reduce the rhinitis, conjunctivitis, sneezing, and urticaria associated with this reaction. They are most effective in acute allergic reactions with a relatively low antigen burden, and effectiveness diminishes in chronic disorders. Antihistamines are marketed for treatment of the common cold, but they have very limited effectiveness in this application and their adverse effects (eg, sedation) outweigh their benefit. Some of the first-generation agents, especially dimenhydrinate, meclizine, cyclizine, and promethazine, are useful for the prophylaxis of motion sickness and vertigo. Promethazine is the most potent in this regard but has pronounced sedative activity that limits its usefulness. The sedating action of some antihistamines has been exploited in their use as sleeping aids. The anticholinergic activity produces atropine-like effects including dry mouth, urinary retention, and cough. Topical application of diphenhydramine is useful in the treatment of minor allergic dermatologic reactions. H2-Receptor Antagonists Histamine is a potent gastric acid secretagogue and this action is mediated by histamine H2 receptors. Cimetidine, ranitidine, nizatidine, and famotidine are H2-specific antagonists and are used to treat gastroesophageal reflux disease and peptic ulcers. Cimetidine inhibits many P450 enzymes and by this mechanism causes drug interactions. Antihistamine agents used for allergic rhinitis have antagonistic activity against both H1 and H2 receptors. Second-generation antihistamines have fewer anticholinergic effects than first-generation antihistamines. First-generation agents that cause sedation have been used as sleeping aids, and some have antiemetic effects. Second-generation antihistamines have less sedating and anticholinergic side effects than first-generation agents. Allergic rhinitis: selective comparisons of the pharmaceutical options for management. She reports that approximately once a month she has a severe, unilateral headache associated with nausea and extreme photophobia. She has had success in reducing the severity of the headaches with opioid pain medications, but usually she is too nauseous to take them. When she is able to tolerate them, she will have to sleep for several hours afterward. She has no other significant medical history and takes no medications on a regular basis. You decide to prescribe sumatriptan for her to try with her next migraine headache. Stimulation of these receptors results in vasoconstriction in the carotid circulation that may directly oppose the vasodilation and the release of vasodilating peptides thought to be involved in migraine. At prejunctional sites, activation of these receptors results in decreased transmission of nociceptive signals in the trigeminal nerve. While being fairly specific for the carotid circulation, there can be activity at other vascular sites. Cerebrovascular, peripheral vascular, mesenteric arterial, or coronary artery diseases are all contraindications to its use. List the agents that act as serotonin agonists and describe their mechanisms of action and uses. List the agents that act as serotonin antagonists and describe their mechanisms of action and therapeutic uses. Partial agonists can competitively inhibit the response to a full agonist, including the physiologic response to endogenously released hormones and neurotransmitters. The ergot alkaloids (ergotamine [the prototype], dihydroergotamine, ergonovine, methylergonovine) act through the same mechanisms as the triptans and are effective clinically during the prodrome of a migraine attack. Diarrhea, nausea and vomiting, and drowsiness are their most common adverse effects. Prolonged vasospasm resulting from smooth muscle stimulation is a serious consequence of overdose that may result in gangrene and amputation of arms, legs, or digits. It promotes release of acetylcholine from the myenteric plexus and may be used to treat gastroesophageal reflux and motility disease. The major clinical use of selective serotonin receptor antagonists is as first-line drugs for treatment of nausea and vomiting, resulting from vagal stimulation that is associated with surgery and cancer chemotherapy. It is only approved for treatment of women because efficacy has not been documented for men. Its major adverse effects are constipation that may be severe and require discontinuation of therapy. Their antagonist and agonist and partial agonist activity at -adrenergic receptors and dopamine receptors is responsible for some adverse actions. Administration Sumatriptan may be administered orally, as a subcutaneous injection, or as a nasal spray, making it particularly valuable for migraine patients with nausea and vomiting as symptoms. Ergotamines are available for oral, sublingual rectal, parenteral, and inhaler administration. Ergotamine tartrate may be administered combined with caffeine, which facilitates its absorption. Prolonged vasospasm caused by smooth muscle stimulation is a serious consequence of overdose with ergotamine. Ergot alkaloid agents can cause vasoconstriction and should not be used in patients with occlusive vascular disease. The effects of selective serotonin receptor antagonists like ondansetron seem to be enhanced with concomitant administration of dexamethasone. The nurse is concerned that the patient is continuing to bleed more than would be expected, and that her uterine fundus does not feel firm. Examination of the patient reveals her to be comfortable and cooperative but she is mildly tachycardic. Vaginal examination shows no cervical or vaginal lacerations, but there is a steady flow of blood from the still-dilated cervix. Ergot alkaloids are structurally similar to norepinephrine, dopamine, and serotonin. They can have agonist or antagonist effects on -adrenoceptors, dopamine receptors, and serotonin receptors. This provides its therapeutic benefit in the treatment of postpartum hemorrhage because of uterine atony. This drug can have other effects mediated by -adrenoceptors, including acute hypertensive reactions and vasospasm. Migraine: A familial disorder marked by periodic, usually unilateral, pulsatile headaches that begin in childhood or early adult life and tend to recur with diminishing frequency in later life. They are classic migraine (migraine with aura) and common migraine (migraine without aura). There are two major families of ergots: the peptide ergots and the amine ergots, all contain the tetracyclic ergoline nucleus. The peptide ergots include ergotamine, -ergocryptine and bromocriptine; the amine ergots include lysergic acid, lysergic acid diethylamide, ergonovine, and methysergide. The ergots have agonist, partial agonist, and antagonist actions at -adrenergic receptors and serotonin receptors, and agonist or partial agonist actions at central dopamine receptors. Postpartum Hemorrhage Ergonovine and its semisynthetic derivative, methylergonovine, cause powerful contractions of smooth muscle; the gravid uterus is especially sensitive to this drug. In circumstances where oxytocin is not effective, methylergonovine causes forceful contractions of uterine smooth muscle that effectively stops the bleeding. Migraine Headache Dihydroergotamine is useful in the prophylactic management of migraines. It is effective in preventing or reducing the frequency of migraines in approximately 60 percent of patients. Chronic use of methysergide is associated with retroperitoneal fibroplasia and subendocardial fibrosis. Endocrine Abnormalities Bromocriptine is very effective in reducing the high levels of prolactin production that occur with certain pituitary tumors. Echocardiography identifies a restrictive cardiomyopathy with decreased flexibility of the heart. Although methylergonovine does cause vasoconstriction, its action in postpartum hemorrhage is mediated by forceful clamping of the myometrium, which restricts blood flow. Bromocriptine is a dopamine receptor agonist that is used to treat prolactinsecreting pituitary adenomas. Methysergide can induce a fibroelastosis of the heart, which leads to a restrictive cardiomyopathy. Bromocriptine is a dopamine receptor agonist and is used to treat prolactinsecreting pituitary adenomas. Methylergonovine is used to treat postpartum hemorrhage caused by uterine atony and causes contraction of the uterine smooth muscle. Rescue therapy for acute migraine, part 1: triptans, dihydroergotamine, and magnesium. Her heart rate remains mildly tachycardic, but her blood pressure has gone up in response to the methylergonovine. They typically have short plasma half-lives (seconds) and are catabolized mainly in the lung. Specific cell surface receptors mediate activities of each class of eicosanoid and many different second messenger pathways are involved. This effect mediates its primary therapeutic use, the treatment of postpartum hemorrhage. Know the therapeutic uses, adverse effects, and contraindications to the use of eicosanoids.


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