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Iodine deficiency is exceed- ingly uncommon in the Unit ed St at es because of iodized salt cheap inderal online master card zantac blood pressure medication. Several different autoantibodies directed toward components of the thyroid gland will be present in t he pat ient’s serum; however inderal 80mg on line hypertension levels, of these buy inderal 80 mg low cost hypertension from stress, ant i- T P O ant ibody almost always is detectable. O n thyroid biopsy, lymphocytic infiltration and fibrosis of the gland are pathognomonic. The presence of these autoantibodies pre- dicts progressive gland failure and the need for hormone replacement. In a young woman with oligomenorrhea, pregnancy should always be the fir st d iagn osis con sid er ed. Ur in e pr egn an cy t est s are easily p er for med in the clinic and are highly sensitive. In t his pat ient, t he next most likely diagnosis is hypot halamic hypogonadism, secondary to her strenuous exercise regimen. These young women are at risk for ost eoporosis and sh ould be counseled on adequat e nutrition and offered combined oral contraceptives if the amenorrhea per- sist s. The amount of hormone batch to batch and the patient dose response are believed to be more predictable than with other forms of hormone replace- ment, such as thyroid extract, which is made from desiccated beef or pork thyroid glands. There is no evidence that the natural hormone replacement is superior t o t he synt het ic form. Other medica- tions, especially iron-containing vitamins, should be taken at different times than levothyroxine because they may interfere with absorption. Hyp e rp ro la c t in e m ia fro m a n y ca u se in d u ce s h yp o t h a la m ic d ysfu n ct io n, le a d in g t o m e n st ru a l irre g u la rit ie s in wo m e n, a n d d im in ish e d lib id o a n d in fe rt ilit y in m e n. Guidelines for the treatment of hypothyroidism: prepared by the American Thyroid Association task force on thyroid hormone replacement. She spent the rest of the day lying down with mild, diffuse, abdominal pain and nausea. She reports several months of wors- ening fatigue, mild, intermittent, generalized abdominal pain, and loss of appetite with a 10- to 15-lb unintentional weight loss. Her medical history is significant for hypothyroidism for which she takes levothyroxine. She does become light-headed, and her heart rate rises to 125 bpm upon standing with a drop in systolic blood pressure to 70 mm Hg. He r c h e s t is c le a r, a n d h e r h e a r t rh yt h m is t a c h yc a rd ic b u t re g u la r. On a b d o m in a l examination, she has normal bowel sounds and mild diffuse tenderness without guarding. Initial la b o ra t o ry st u d ie s a re sig n ifica n t fo r Na 121 m Eq / L, K 5. All of this patient’s clinical features are consistent with acute adrenal insufficiency. The most common cause of adrenal insufficiency is idiopat hic aut o- immune dest ruct ion. Next step: After drawing a cortisol level, immediate administration of intrave- nous saline with glucose and stress doses of corticosteroids. Know the present ation of primary and secondary adrenal insufficiency and of adrenal crisis. Co n s i d e r a t i o n s This patient has a low-grade fever, which may be a feature of adrenal insufficiency, or it may signify infection, which can precipitate an adrenal crisis or produce a simi- lar clin ical pict ure. Becau se of the ad r en al in su fficien cy an d the ald ost er on e d eficien cy, sh e h as volu m e depletion, hypoglycemia, and hypotension. Thus, immediate intravenous replace- ment with normal saline with 5% glucose is critical. A low serum cortisol level wit h t he pat ient’s clinical present at ion and wit hout other explanat ion confirms t he diagnosis of adrenal insufficiency. The most common cause in the United States is autoimmune destruction of the adrenal glands. In primary adrenal insufficiency, the glands themselves are destroyed so that the patient becomes deficient in cor- t isol and aldosterone. Primary adrenal insufficiency is a relat ively uncommon dis- ease seen in clinical pract ice. A high level of suspicion, par t icu larly in in dividuals wh o have suggest ive signs or sympt oms, or wh o are suscept ible by virtue of associ- ated autoimmune disorders or malignancies must be maint ained. The nonspecific sympt oms might be ot herwise missed for many years unt il a st ressful event leads to crisis and death. It can be caused by an aut oimmune, infil- trative, metastatic disease of the pituitary. The most common reason, however, is chronic exogenous administration of corticosteroids, wh ich can suppr ess the ent ir e hypothalamic-pituitary-adrenal axis. Because of the widespread use of corticoste- roids, secondary adrenal insufficiency is relatively common. In secondary adrenal insufficiency, the renin-angiotensin system usually is able to maint ain near-normal levels of aldost erone so that the pat ient is deficient only in cort isol. Acute adre- nal insufficiency, or ad dison ian cr isis, m ay pr esent wit h weakness, nausea, vomit- ing, abdominal pain, fever, hypotension, and tachycardia. Laborat or y fin dings may include hyponatremia, hyperkalemia, metabolic acidosis, azotemia as a consequence of aldosterone deficiency, and hypoglycemia and eosinophilia as a consequence of cort isol deficiency. Patients with adrenal insufficiency may go into crisis when st ressed by infect ion, t rauma, or surgery. The clinical features may appear identical to those of septic shock; the on ly clues that the cause is adrenal disease may be the hypoglycemia (blood sugar is often elevated in sepsis) and profound hypotension, which may be refractory to administration of pressors but is reversed almost imme- diately when steroids are given. A pat ient may h ave h ypoglycemia an d post ur al h ypot en sion as a result of volume depletion. It is typically seen as generalized hyperpigmentation of skin and mucous membranes. It is increased in sun-exposed areas or over pressure areas, such as elbows and knees, and may be noted in skin folds. Therefore, volume depletion and hyperkalemia are not present and the patient will not manifest the typical hyperpigmentation. Cortisol levels are high in the morning and low as the day progresses, and levels should be elevated in st ressful situat ions such as acut e medical illness, surgery, or t rauma. A morning plasma cortisol level less than or equal to 5 µg/ dL in an acutely ill patient is definitive evidence of adrenal insufficiency. Conver sely, a ran dom cor t isol level mor e t h an 20 µg/ dL u sually is interpreted as evidence of int act adrenal funct ion. As in ot h er endocrine deficiency st at es, t he diagnost ic t est in t his case is a st imulat ion t est (conversely, in endocrine excess st at es, t he diagnost ic t est is oft en a suppression t est ). An increase in t he cort isol level of 7 µg/ dL or a maximal stimulated level more than 18 µg/ dL is considered normal and indicates int act adrenal funct ion. The insulin-glucose tolerance test is the gold standard for testing the entire hypothalamic-pituitary axis. Tr e a t m e n t Treatment of addisonian crisis includes intravenous 5%glucose with normal saline to correct volume depletion and hypoglycemia and administration of corticosteroid therapy.
Optimal treatment consists of a fairly high dose of metronidazole (2 g orally) as a one-t ime dose purchase discount inderal arteria 2013, with the part ner t reated as well generic inderal 40 mg on-line arteria humana de mayor calibre. A newer antiprotozoal agent buy inderal without prescription blood pressure level chart, Tinidazole, has a similar dosing, side-effect profile, and cont raindicat ion for concurrent alcohol; due to its expense, it s main role is for met ronidazole-resistant cases. Treatment usually does not include vaginal metronidazole because of low therapeutic levels in the ure- thra or Skene’s glands where trichomonads may reside. Candidal vaginitis is usually caused by the fungus, Candida albicans, although other species may be causative. Diabetes mellitus, which suppresses immune function, may also predispose patients to these infections. The patient usually presents with intense vulvar or vaginal burning, irrit at ion, and swelling. The discharge usually appears curdy or like cottage cheese, in con- trast to the homogenous discharge of bacterial vaginosis. The microscopic diagnosis is confirmed by ident ification of the hyphae or pseudohyphae after the discharge is mixed with potassium hydroxide. Treatment includes oral fluconazole (D iflucan) or topical imidazoles, such as terconazole (Terazol), miconazole (Monistat), and clot r imazole ( Lot r im in ). Sh e complains of a 1-day h ist ory of it ch ing, burning, and a yellow- ish vaginal discharge. The speculum examination reveals an erythematous vagina and punctuations of the cervix. Frothy discharge, normal to acidic pH, and flagellated organ- isms are more t ypical of t richomoniasis. After antibiotic therapy, candidal organisms often proliferate and may induce an overt infect ion. T h e mechanism is likely t hat t he lact obacilli are eliminat ed by t he ant ibiot ic, allowing overgrowt h of yeast. Pat ient s sh ou ld be in st r u ct ed t o avoid alco- hol while taking metronidazole to avoid a disulfiram reaction. Erythromycin may be used in the treatment of syphilis in nonpregnant women allergic to penicillin. Clindamycin is typically used in conjunction with gentamicin in the t reatment of infections requiring broad-spect rum antibiot ics, necessit at - ing anaerobic coverage (ie, postpartum endomyomet rit is). Trichomonas vaginalis is a hardy organism and may be isolated from a wet surface up t o 6 hours aft er inoculat ion. T h e organism’s difficult y t o eradicat e is the reason t hat t herapy requires high t issue levels, met ronidazole 2 g orally all at once, to be able t o obt ain sufficient ly high t issue levels to be effect ive. Not uncommonly, a single course is not effective, and a 2- or 3-day course of metronidazole of high dose orally is needed. T h e pat ient t akes 2 g of m et r on idazole as a sin gle d ose t o at t ain sufficient tissue levels to eradicate the trichomonads. Erythematous vagina and punctuations of the cervix (strawberry cervix) are classic findings of the inflammatory effect s induced by t richomoniasis. T h e most common side effect s from met ron idazole are gast roint est in al including nausea, abdominal discomfort, bloat ing or diarrhea. A disulfi- ram (Antabuse) effect that can be seen with metronidazole includes facial flu sh in g, h ead ach e, h yp ot en sion, t ach ycar d ia, d izzin ess, an d n au sea an d vo m it in g. Vulvovaginitis, sexually transmitted infections, and pelvic inflammatory dis- ease. Diagnostic value of Amsel’s clinical criteria for diagnosis of bact erial vaginosis. Sh e d e n ie s h a vin g b e e n t re a t e d fo r s e xu a lly t ra n s m it t e d d is e a s e s. Examination of the external genitalia reveals a nontender, firm, ulcerated le sio n a p p ro xim a t e ly 1 cm in d ia m e t e r, wit h ra ise d b o rd e rs a n d a n in d u ra t e d b a se lo ca t e d o n the rig h t la b ia m a jo ra. Bila t e ra l in g u in a l lym p h n o d e s a re a lso n o t e d that are nontender. Know the classic appearance and presentation of the chancre lesion of primary syphilis. Co n s i d e r a t i o n s This 31-year-old woman came in for a well-woman examination. N evertheless, she has t he classic lesion of pri- mary syphilis, the painless chancre. It is typically a nontender reddish ulcer wit h clean-appearing edges, often accompanied by painless inguinal adenopat hy. Occasionally,the patient willhave a negative nontreponemaltest in t he sett ing of primary syphilis. Primary syphilis usually manifest s it self wit h in 2 to 6 weeks after inoculation. The treatment for syphilis, that is less than 1-year duration, is one injection of long-acting penicillin. If this patient were older, for inst ance, in her post menopausal years, squamous cell carcinoma of the vulva would be considered. Systemic diseases such as Behcet’s disease, Candida infec- tion, or vulvar neoplasms should also be considered. Step 4: If negative, then reassess based on the wide differential diagnosis; biopsy may be helpful. T his organism is highly cont agiou s, an d it is t h ou gh t that 20% of wom en in t h eir ch ild bear in g year s are infected. The primary episode is usually a syst emic as well as local disease, wit h t he woman oft en complaining of fever or general malaise. Local infect ion t ypically induces paresthesias before vesicles erupt on a red base. After the primary episode, the recurrent disease is local, with less severe symptoms. The gold standard diagnostic test is viral culture, but polymerase ch ain r eact ion t est s are in cr easin gly u sed becau se they are m or e sen sit ive. Infec- tions occur rarely in the United States and tend to be concentrated in southern regions. The organism is extremely tightly wound, and too thin to be seen on light microscopy. T h e u lcer u sually ar ises 3 weeks aft er exposure and disappears spont aneously aft er 2 t o 6 weeks wit hout t herapy. Darkfield m icr oscopy is an accept ed diagn ost ic t ool, but is limited in availability. Secondary syphilis is usually syst emic, occurring about 9 weeks after the primary chancre. The classic macular papular rash may occur any- wh ere on the body, but usually on the palms and soles of the feet. Flat moist lesions called con dylomat alat a m ay be seen on the vu lva ( Figu r e 39– 1), an d h ave a h igh con cen t r at ion of spir och et es. T r ep on em al an d n on t r ep on em al ser ologic t est s are positive at this stage.
P a t i e n t E d u c a t i o n Raltegravir Inform patients about signs of a hypersensitivity reaction (e buy inderal 40 mg with visa blood pressure yahoo. Raltegravir can cause potentially fatal hypersensitivity reactions discount inderal 40mg with visa arrhythmia graphs, including Stevens-Johnson syndrome and toxic epidermal necrolysis purchase inderal 40 mg overnight delivery prehypertension occurs when. The treatment recommendations presented in this chapter reflect those guidelines, which are available at http://www. Infection is frequently asymptomatic in women and may also be asymptomatic in men. Treatment Adults and Adolescents For uncomplicated urethral, cervical, or rectal infections in adults or adolescents, treatment with either azithromycin [Zithromax] or doxycycline [Vibramycin, others] is recommended. Patients who are unable to take these medications may take erythromycin, levofloxacin [Levaquin], or ofloxacin [generic]. If the patient cannot take azithromycin, the approved alternatives are amoxicillin, erythromycin base, or erythromycin ethylsuccinate. Conjunctivitis does not result in blindness and spontaneously resolves in 6 months. The preferred treatment for both infections is oral erythromycin base or erythromycin ethylsuccinate. Although topical erythromycin, tetracycline, or silver nitrate may be given to prevent conjunctivitis, these drugs are not completely effective—and they have no effect on pneumonia. Preadolescent Children Although infection in preadolescent children can result from perinatal transmission, sexual abuse is the more likely cause, especially in children older than 2 years. For children who weigh less than 45 kg, the preferred treatment is oral erythromycin base or erythromycin ethylsuccinate. For children who weigh 45 kg or more, but are younger than 8 years, the preferred treatment is azithromycin. For children at least 8 years old, the preferred treatments are azithromycin or doxycycline. From this site, the organism migrates to regional lymph nodes, causing swelling, tenderness, and blockage of lymphatic flow. Erythromycin base serves as an alternative for those who cannot take tetracycline antibiotics. Gonococcal Infections Characteristics Gonorrhea is caused by Neisseria gonorrhoeae, a gram-negative diplococcus, often referred to as the gonococcus. In men, the main symptoms are a burning sensation during urination and a pus-like discharge from the penis. In contrast, gonorrhea in women is often asymptomatic or may present as mild cervicitis. However, serious infection of female reproductive structures (vagina, urethra, cervix, ovaries, fallopian tubes) can occur, ultimately resulting in sterility. Among people who engage in oral sex, the mouth and throat can become infected, causing sore throat and tonsillitis. Among people who engage in receptive anal sex, the rectum can become infected, causing a purulent discharge and constant urge to move the bowels (tenesmus). Bacteremia can develop in males and females, causing cutaneous lesions, arthritis, and, rarely, meningitis and endocarditis. Treatment Owing to antibiotic resistance, treatment of gonorrhea has changed over the years—and undoubtedly will continue to evolve. In the 1930s, virtually all strains of the gonococcus were sensitive to sulfonamides. Fortunately, by that time penicillin had become available, and the drug was active against all gonococcal strains. This recommendation was changed yet again in 2012, also triggered by antimicrobial resistance—this time to oral cephalosporins. If a patient is allergic to azithromycin, a 7-day course of doxycycline may be substituted. Spectinomycin, an aminoglycoside, has also been suggested; however, it is not currently available in the United States. Pharyngeal Infection Gonococcal infection of the pharynx is more difficult to treat than infection of the urethra, cervix, or rectum; therefore, parenteral therapy is recommended for all patients. Azithromycin is preferred over doxycycline because patients are more likely to adhere to a single-dose regimen of azithromycin than the full-week regimen of doxycycline taken twice a day. Conjunctivitis Gonococcal conjunctivitis can be reliably eradicated with ceftriaxone plus azithromycin. Symptoms include petechial or pustular skin lesions, arthritis, arthralgia, and tenosynovitis. Neonatal Infection Neonatal gonococcal infection is acquired through contact with infected cervical exudates during delivery. To protect against neonatal ophthalmia, a topical antibiotic should be instilled into both eyes immediately postpartum—as required by law in most states. If this antimicrobial is not available, parenteral therapy with ceftriaxone is to be used. Possible manifestations include sepsis, arthritis, meningitis, and scalp abscesses. Preadolescent Children Among preadolescent children, the most common cause of gonococcal infection is sexual abuse. For children with localized infection who weigh more than 45 kg, treatment is the same as for adults. Other likely agents are Ureaplasma urealyticum, Trichomonas vaginalis, and Mycoplasma genitalium. The recommended treatment is either azithromycin [Zithromax] or doxycycline [Vibramycin]. Alternative regimens are erythromycin base, erythromycin ethylsuccinate, levofloxacin, or ofloxacin. Azithromycin should be added to the regimen if it had not been used during initial therapy. Unfortunately, we have no easy tests for this bacterium, and hence definitive diagnosis may not be possible. However, Mycoplasma hominis, as well as assorted anaerobic and facultative bacteria, may also be present. This may be attributable to intensified patient education efforts, increased and improved screening practices, or improved adherence to single- dose treatment. Because multiple organisms are likely to be involved, drug therapy must provide broad coverage. For the hospitalized patient, treatment can be initiated with either cefoxitin or cefotetan, combined with doxycycline. The syndrome occurs primarily in young adults (under 35 years old) and may be associated with urethritis.
You should appreciate that nausea and vomiting associated with chemotherapy are much more severe than with other medications buy inderal blood pressure issues. Whereas these reactions are generally unremarkable with most drugs 40mg inderal fast delivery blood pressure 200 100, they must be considered major and characteristic toxicities of cytotoxic drugs buy discount inderal 40mg online pulse pressure emt. These drugs offer three benefits: (1) reduction of anticipatory nausea and vomiting, (2) prevention of dehydration and malnutrition secondary to frequent nausea and vomiting, and (3) promotion of compliance with chemotherapy by reducing discomfort. The regimen of choice for patients taking highly emetogenic drugs consists of aprepitant [Emend], dexamethasone, and a serotonin antagonist, such as ondansetron [Zofran]. The use of antiemetics for chemotherapy-induced nausea and vomiting is discussed in Chapter 64. Other Important Toxicities Alopecia Reversible alopecia (hair loss) results from injury to hair follicles. Hair loss begins 7 to 10 days after the onset of treatment and reaches maximal loss in 1 to 2 months. In fact, for many cancer patients, alopecia is second only to vomiting as their greatest treatment-related fear. For patients who choose to wear a hairpiece or wig, one should be selected before hair loss occurs. Hairpieces are tax deductible as medical expenses and are covered by some insurance plans. To some degree, hair loss can be prevented by cooling the scalp while chemotherapy is being administered. Cooling causes vasoconstriction and thereby reduces drug delivery to hair follicles. Unfortunately, scalp cooling is uncomfortable, causes headache, and creates a small risk for cancer recurrence in the scalp (because drug delivery is reduced). Reproductive Toxicity The developing fetus and the germinal epithelium of the testes have high growth fractions. As a result, both are highly susceptible to injury by cytotoxic drugs, especially the alkylating agents. Risk is highest during the first trimester, and hence chemotherapy should generally be avoided during this time. However, after 18 weeks of gestation, risk appears to be very low: according to a 2012 report in Lancet, exposure during this time does not cause neurologic, cardiac, or any other fetal abnormalities. Drug effects on the ovaries may result in amenorrhea, menopausal symptoms, and atrophy of the vaginal epithelium. Hyperuricemia Hyperuricemia is defined as an excessive level of uric acid in the blood. Hyperuricemia is especially common after treatment for leukemias and lymphomas (because therapy results in massive cell kill). The major concern with hyperuricemia is injury to the kidneys secondary to deposition of uric acid crystals in renal tubules. In patients with leukemias and lymphomas, in whom hyperuricemia is likely, prophylaxis with allopurinol is the standard of care. Local Injury From Extravasation of Vesicants Certain anticancer drugs, known as vesicants, are highly chemically reactive. These drugs can cause severe local injury if they make direct contact with tissues. Vesicants are administered intravenously, usually into a central line (because rapid dilution in venous blood minimizes the risk for injury). Extreme care must be exercised to prevent extravasation because leakage can produce high local concentrations, resulting in prolonged pain, infection, and loss of mobility. Severe injury can lead to necrosis and sloughing, requiring surgical débridement and skin grafting. Because of the potential for severe tissue damage, vesicants should be administered only by clinicians specially trained to handle them safely. Unique Toxicities In addition to the toxicities discussed previously, which generally apply to the cytotoxic drugs as a group, some agents produce unique toxicities. For example, a number of drugs can cause peripheral sensory neuropathy, manifesting as numbness or tingling in the fingers and toes and around the mouth and throat. Neuropathy may impede activities of daily living, such as buttoning clothing, writing, or just holding things. Anthracyclines such as daunorubicin and doxorubicin can cause serious injury to the heart. Carcinogenesis Along with their other adverse actions, anticancer drugs have one final and ironic toxicity: these drugs, which are used to treat cancer, have caused cancer in some patients. Cancers caused by anticancer drugs may take many years to appear and are hard to treat. Making the Decision to Treat From the preceding discussion of toxicities, it is clear that cytotoxic anticancer drugs can cause great harm. Given the known dangers of these drugs, we must ask why such toxic substances are given to sick people at all. The answer lies with the primary rule of therapeutics, which states that the benefits of treatment must outweigh the risks. That is, although the toxicities of the anticancer drugs can be significant, the potential benefits (cure, prolonged life, palliation) justify the risks. There are patients whose chances of being helped by chemotherapy are remote, whereas the risk for serious toxicity is high. Because the potential benefits for some patients are small and the risks are large, the decision to institute chemotherapy must be made with care. Before a decision to treat can be made, the patient must be given some idea of the benefits the proposed therapy might offer. For treatment to be justified, there should be reason to believe that at least one of these benefits will be forthcoming. If a patient cannot be offered some reasonable hope of cure, prolonged life, or palliation, it would be difficult to justify treatment. The most important factors for predicting the outcome of chemotherapy are (1) the general health of the patient and (2) the responsiveness of the type of cancer the patient has. General health status is assessed by measuring performance status, frequently using the Karnofsky Performance Scale (Table 82. A Karnofsky score of less than 40 indicates the patient is debilitated and not likely to tolerate the additional stress of chemotherapy. Accordingly, patients with a low Karnofsky rating should not receive anticancer drugs—unless their cancer is known to be especially responsive. Nonetheless, we should still try to assess whether treatment is likely to produce cure, palliation, or prolonged life. If a positive outcome is deemed likely, the patient should almost always be treated, even if his or her Karnofsky score is low. In contrast, if a positive outcome is deemed highly unlikely, the patient should be treated only after careful consideration, so as to avoid the discomforts of a course of treatment that has little to offer. An important requirement for deciding in favor of chemotherapy is that the effect of treatment be measurable.
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