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Social Anxiety Disorder Most common phobia: Fear or avoidance of objects or situations other than those involved in agoraphobia heart attack 21 year old female buy discount triamterene 75mg line. She reports that she fell 3 months ago at a national ballet competition and since then suffers extreme anxiety, trembling, diaphoresis, and breathlessness when she has to go on stage. Acute stress disorder Adjustment disorder with anxious mood Panic disorder Social phobia Answer: C. It often coexists with major depression, specific phobia, social phobia, and panic disorder. Treatment Treatment consists of supportive psychotherapy, including relaxation training and biofeedback. The case must also describe that the individual recognizes that the behavior is unreasonable and excessive. Obsessions are anxiety provoking; thoughts are intrusive and are commonly related to contamination, doubt, guilt, aggression, and sex. Compulsions are peculiar behaviors that reduce the anxiety and are most commonly habitual hand washing, organizing, checking, counting, and praying. Re-experiencing of the traumatic event: Dreams, flashbacks, or intrusive recollections 2. Avoidance of stimuli associated with the trauma or numbing of general responsiveness 3. Increased arousal: Anxiety, sleep disturbances, hypervigilance, emotional lability, or impulsiveness Treatment Give benzodiazepines acutely for anxiety symptoms. Diazepam Fluoxetine Group counseling Haloperidol Individual psychotherapy Answer: C. Mood Disorders Major Depressive Disorder this disorder is characterized by depressed mood or anhedonia and depressive symptoms lasting at least 2 weeks. However the question may describe superimposed acute major depression, which is common in these patients. Treatment Long-term individual, insight-oriented psychotherapy is the best treatment. Seasonal Affective Disorder the diagnosis is seasonal affective disorder when the case describes depressive symptoms in the winter months (shorter daylight hours) and absence of depressive symptoms during summer months (longer daylight hours). Bipolar Disorder Bipolar disorder is the diagnosis when the case describes episodes of depression, mania, or mixed symptoms for at least 1 week that cause distress or impaired functioning. The questions will describe a history of both manic symptoms and depressive symptoms, as well as periods of normal mood.
Long-term use of meperidine for analgesia is avoided because the accumulation of a metabolite blood pressure 200 over 100 triamterene 75mg low price, normeperidine, is associated with risk of (A) Constipation (B) Dependence (C) Neutropenia (D) Renal impairment (E) Seizures 79. Protamine can be used to partially reverse the anticoagulant effect of which of the following A 31-year-old premenopausal woman has been using a combined oral contraceptive for 10 yr. As a result of this contraceptive use, she has a reduced risk of which of the following Hypercoagulability and dermal vascular necrosis resulting from protein C deficiency is known to be an early-appearing adverse effect of treatment with which of the following drugs A 24-year-old man with a history of partial seizures has been treated with standard anticonvulsants for several years. He is currently taking valproic acid, which is not fully effective, and his neurologist prescribes another drug approved for adjunctive use in partial seizures. The second drug prescribed was (A) Diazepam (B) Ethosuximide (C) Felbamate (D) Lamotrigine (E) Phenobarbital 86. A 29-year-old accountant has recurrent episodes of tachycardia that sometimes convert to sinus rhythm spontaneously but more often require medical treatment. Which of the following toxic compounds is correctly paired with an antidote that is used in the treatment of a patient poisoned with the toxic compound A 64-year-old recipient of a kidney transplant was being treated with immunosuppressants. After several episodes of gout, the decision was made to treat his gout with the xanthine oxidase inhibitor allopurinol. The dose of which of the following of his immunosuppressant drugs should be reduced to avoid excessive bone marrow suppression due to a drugdrug interaction Examination of synovial fluid removed from the joint revealed crystals of uric acid. Which of the following is the most appropriate drug for immediate treatment of this acute attack of gout Lab tests reveal macrocytic anemia, an increased serum concentration of transferrin, and a normal serum concentration of vitamin B12. What deficiency is the most likely cause of her anemia and what effect does this deficiency have on her child A 42-year-old woman developed a syndrome of polyuria, thirst, and hypernatremia after surgical removal of part of her pituitary gland. Following her surgery, she was treated with a drug that prevents the conversion of testosterone to estradiol. Which of the following drugs is most likely to cause hypoglycemia when used as monotherapy in the treatment of a patient with type 2 diabetes
If the tests point to a pituitary source but the scanning is indeterminant blood pressure medication equivalents purchase 75 mg triamterene visa, inferior petrosal sinus sampling is used to confirm it. Petrosal sinus sampling is also used to localize the lesion, as well to see which half of a pituitary should be removed. It presents with the following: Fatigue, anorexia, weight loss, weakness with hypotension Thin patient with hyperpigmented skin Diagnostic Testing Laboratory abnormalities are as follows: Hyperkalemia with a mild metabolic acidosis from the inability to excrete either H+ or K+ because of the loss of aldosterone. Basic Science Correlate Glucocorticoids increase glucose by blocking the uptake at peripheral tissues such as muscle, fat, and lymph. Glucocorticoids also have a permissive effect on glucagon, increasing its ability to break down glycogen from the liver. Glucocorticoids increase gluconeogenesis and break down protein for amino acid substrate. Steroid replacement: For acute addisonian (hypoadrenal) crisis, draw a cortisol level and give fluids and hydrocortisone. Fludrocortisone is used for patients with adrenal insufficiency who are still hypotensive after initial replacement with prednisone. Hydrocortisone provides both glucorticoid and mineralocorticoid effects on the kidney. Hence, the case may feature "polyuria and polydipsia"; however, in primary hyperaldosteronism, the glucose level will be normal. Treatment Solitary adenoma: Surgical resection Hyperplasia: Spironolactone Pheochromocytoma the patient presents with headache, palpitations, tremors, anxiety, and flushing. Blood pressure that goes up in episodes is as close a clue as we get to knowing the diagnosis prior to testing. Because 11- and 17-hydroxylase deficiencies involve an increased level of 11-deoxycorticosterone, there is hypertension. It presents differently in men and women: Men - Presents with impotence, decreased libido, and occasionally gynecomastia. Prolactinoma should only be investigated under the following conditions: Pregnancy has been excluded. Treatment Best initial therapy: Dopamine agonist agents, such as bromocriptine or cabergoline. It presents with enlargement of the head (hat size), fingers (ring size), feet (shoe size), nose, and jaw. It also causes the following: Joint abnormalities: these arise from unusual growth of the articular cartilage Amenorrhea: Growth hormone is frequently cosecreted with prolactin Cardiomegaly and hypertension Colonic polyps Diabetes is common because growth hormone acts as an anti-insulin. Treatment Surgical resection with transphenoidal removal cures 70 percent of cases. Testicular feminization: this is a genetically male patient who looks, feels, and acts as a woman. The girl has breasts but no cervix, tubes, or ovaries, and she is missing the top third of the vagina.
Vancomycin is not absorbed after oral administration and is used by this route in the treatment of colitis caused by C difficile and staphylococci blood pressure medication that doesn't cause cough buy triamterene 75mg with visa. Vancomycin is commonly considered the drug of first choice for parenteral use against methicillinresistant staphylococci. Describe 3 mechanisms underlying the resistance of bacteria to beta-lactam antibiotics. Identify the prototype drugs in each subclass of penicillins, and describe their antibacterial activity and clinical uses. Identify the 4 subclasses of cephalosporins, and describe their antibacterial activities List the major adverse effects of the penicillins and the cephalosporins. Chloramphenicol, Tetracyclines, Macrolides, Clindamycin, Streptogramins, & Linezolid the antimicrobial drugs reviewed in this chapter selectively inhibit bacterial protein synthesis. The mechanisms of protein synthesis in microorganisms are not identical to those of mammalian cells. Such differences form the basis for the selective toxicity of these drugs against microorganisms without causing major effects on protein synthesis in mammalian cells. Chloramphenicol, tetracyclines, and the aminoglycosides (see Chapter 45) were the first inhibitors of bacterial protein synthesis to be discovered. Because they had a broad spectrum of antibacterial activity and were thought to have low toxicities, they were overused. Many once highly susceptible bacterial species have become resistant, and most of these drugs are now used for more selected targets. Erythromycin, an older macrolide antibiotic, has a narrower spectrum of action but continues to be active against several important pathogens. Azithromycin and clarithromycin, semisynthetic macrolides, have some distinctive properties compared with erythromycin, as does clindamycin. Newer inhibitors of microbial protein synthesis, which include streptogramins, linezolid, telithromycin, and tigecycline (a tetracycline analog) have activity against certain bacteria that have developed resistance to older antibiotics. With the exception of tetracyclines, the binding sites for these antibiotics are on the 50S ribosomal subunit. Thus, the peptide at the donor site cannot be transferred to its amino acid acceptor. Macrolides, telithromycin, and clindamycin, which share a common binding site on the 50S ribosome, also block transpeptidation. They bind to the 50S ribosomal subunit, constricting the exit channel on the ribosome through which nascent polypeptides are extruded.
Per orming a negative endoscopy is much better than neglecting an occult oreign body blood pressure medication edema buy 75mg triamterene visa. Removal requires teamwork and communication, with all equipment available, assembled, and working. General anesthesia is required, with spontaneous ventilation, may be supplemented by topical anesthesia. Pulmonary insuf ciency that bene ts rom reduction o upper airway resistance and dead space v. It is best to intervene early rather than wait or late signs o upper airway obstruction. Secure tube tightly, pre erably with direct sutures, to prevent accidental dislodgement. Immediate: bleeding, pneumothorax, pneumomediastinum, subcutaneous emphysema, dislodged or obstructed tube, alse passage with tube outside trachea, postobstructive pulmonary edema, apnea due to loss o hypoxic drive, tube too short or inappropriate shape (especially in morbidly obese patients) ii. Delayed: granulation tissue, stomal in ection, subglottic or tracheal stenosis, tracheomalacia, tracheoesophageal stula, displacement o tube, tracheoinnominate stula, persisting tracheocutaneous stula a er decannulation Cha pter 44: the La rynx 799 Swallowing and Management o Dysphagia Stages o Swallowing A. Muscle is under tonic contracted to prevent air ingestion with inhalation and re ux rom esophagus ii. Signs and symptoms: coughing, choking, recurrent pneumonia, malnutrition, dehydration, weight loss, regurgitation, globus sensation, ood impaction B. Patient questionnaire indicating the severity o dysphagia and e ect on quality o li e b. Screening tool used to assess whether patient needs urther testing or is cleared or oral intake b. Uses trial with water and various consistencies monitoring outcomes o oxygen saturation or coughing to pass or ail patient c. Probes with graded pressure sensors placed in of ce and patient observed with numerous swallows b. Good or detection o penetration, aspiration, pooling, retained secretions, e ectiveness o cough d. Start with pharyngeal squeeze (high pitched strained phonation in rising crescendo) 2.
Syndromes
C (41) Glipizide is the only agent in this list that can stimulate insulin secretion arrhythmia jobs discount 75 mg triamterene with visa, potentially leading to hypoglycemia. A (34) Deep vein thromboses tend to be fibrin-rich and platelet-poor, making them less responsive to the antiplatelet agents (eptifibatide, clopidogrel). Unfractionated heparin carries the risk of triggering more heparin-induced thrombocytopenia. Argatroban (direct thrombin inhibitor) is the drug of choice for fast anticoagulation in patients with heparin-induced thrombocytopenia. Drug 1 evokes a strong pressor effect and a bradycardia that is probably a reflex compensatory response. However, the effect of Drug 2 unmasks a tachycardia produced by Drug 1, so this agonist must be norepinephrine; phenylephrine does not have agonist action. I (10) See answers to the preceding question and to questions 95 and 96 in Examination 1. Broken down into three categories, there is osteopetrosis with precocious mani estations, osteopetrosis with delayed mani estations, and pyknodysostosis. In the mandible long-term antibiotic therapy, multiple debridements, sequestrectomies, or even resection are possible treatments. Frequently, there is an elevation o serum alkaline phosphatase as well as endocrine abnormalities. Aldrich Syndrome T rombocytopenia, eczema, and recurrent in ections occur during the rst year o li. The bleeding time is prolonged, the platelet count is decreased, and the bone marrow megakaryocytes are normal in number. Amalric Syndrome Granular macular pigment epitheliopathy (oveal dystrophy) is associated with sensorineural hearing loss. Amalric syndrome may be a genetic disorder, or it may be the result o an intrauterine rubella in ection. Apert Syndrome Apert syndrome is not to be con used with P ei er syndrome, which has di erent types o hand mal ormations. Ascher Syndrome Ascher syndrome is a combination o blepharochalasis, double lip, and goiter. Auriculotemporal Syndrome (Frey Syndrome) Auriculotemporal syndrome is characterized by localized ushing and sweating o the ear and cheek region in response to eating. It is assumed that the parasympathetic bers o the ninth nerve innervate the sweat glands a er parotidectomy. It has been estimated that 20% o the parotidectomies in children result in this disorder. Avellis Syndrome Unilateral paralysis o the larynx and velum palati, with contralateral loss o pain and temperature sensitivity in the parts below the larynx characterize Avellis syndrome. The syndrome is caused by involvement o the nucleus ambiguus or the vagus nerve along with the cranial portion o the ninth nerve.
Anterior Spinal Artery Infarction All sensation is lost except position and vibratory sense hypertension images discount triamterene 75mg otc, which travel down the posterior column. The patient loses ipsilateral position, vibratory sense, contralateral pain, and temperature. Amyotrophic Lateral Sclerosis this is an idiopathic disorder of both upper and lower motor neurons; signs are listed in the table below. It is treated with riluzole, a unique agent that blocks the accumulation of glutamate. Upper Motor Neuron Signs Hyperreflexia Upgoingtoesonplantarreflex Spasticity Weakness Lower Motor Neuron Signs Wasting Fasciculations Weakness Peripheral Neuropathies Diabetes the most common cause of peripheral neuropathy by far is diabetes. A specific test, such as an electromyogram or nerve conduction study, is not necessary in the majority of cases. Carpal Tunnel Syndrome Look for pain and weakness of the first 3 digits of the hand. Radial Nerve Palsy Also known as "Saturday night palsy," this results from falling asleep or passing out with pressure on the arms underneath the body or outstretched, perhaps draped over the back of a chair. Peroneal Nerve Palsy this results from high boots pressing at the back of the knee. There is also loss of taste on the anterior two thirds of the tongue, hyperacusis, and the inability to close the eye at night. Hyperacusis results in the inability to control the stapedius muscle of the middle ear, which acts as a kind of "shock absorber" for sounds. Reflex Sympathetic Dystrophy Also called chronic regional pain syndrome, reflex sympathetic dystrophy happens in a patient with previous injury to the extremity. Light touch, such as from a sheet touching the foot, results in extreme pain that is "burning" in quality. The patient experiences an uncomfortable feeling in the legs, which is relieved by movement. A man comes to the emergency department with weakness in his legs that has been getting markedly worse over the last few days. Peak inspiratory pressure predicts who will have respiratory failure before it happens. Myasthenia Gravis Myasthenia gravis presents with weakness of the muscles of mastication, making it hard to finish meals. Blurry vision from diplopia results from the inability to focus the eyes on a single target. Treatment Best initial therapy: Pyridostigmine or neostigmine Thymectomy: Use in patients < 60 if pyridostigmine or neostigmine do not work. They decrease the function of T-cells, which control cellular immunity such as organ transplant rejection. Treatment Treatment of prerenal azotemia is entirely based on the underlying cause. Toxin-Induced Renal Insufficiency In these cases, there is no single test to prove that a particular toxin caused the renal failure.
Depth o tumor invasion greater than 2-4 mm correlated with higher rates o regional metastasis blood pressure for heart attack discount 75 mg triamterene fast delivery, recurrence, and mortality. Perineural invasion at the primary site is another indicator o recurrence and increased mortality. In this young population, no clinical eatures or risk actors (age, substance abuse) have been clearly identi ed and an increased genetic susceptibility to carcinogenesis has been postulated. T orough oral cavity examination by dentists, oral surgeons, otolaryngologists, and primary care physicians especially in patients with risk actors is critical or early detection. Late symptoms include tongue xation, decreased tongue sensation, alteration in speech and swallowing, and cervical lymphadenopathy. Screening methods include vital staining, spectral analysis, ViziLite (chemiluminescence), and brush biopsies. Incidence o nodal metastases depends on size o primary tumor and depth o invasion with 25% to 33% clinically detectable and 20% to 25% occult. Risk o bilateral cervical lymph node metastases with midline dorsum or ventral surace o tongue. External beam radiation with or without brachytherapy may be used in patients with 1- 2 lesions that are not suitable or or re use surgery. The approach may be transcervical a er raising the so tissue ap over the bone or translabial (lip splitting incision) with a lateral mandibulotomy.
Used in transient ischemic attacks and to prevent strokes and restenosis after placement of coronary stents prehypertension stage 1 stage 2 triamterene 75 mg line. Other direct thrombin inhibitors are lepirudin, a recombinant form of a medicinal leech protein, and bivalirudin-both used parenterally. Used in muscle spasm (cerebral palsy, multiple sclerosis, cord injury) and in emergency treatment of malignant hyperthermia. Conivaptan, an antagonist at V1a and V2 receptors and tolvaptan, an antagonist at V2 receptors, are used for hyponatremia. Uses: anxiety states, ethanol detoxification, muscle spasticity, status epilepticus. Unlike other tetracyclines, it is eliminated mainly in the feces and has longer half-life. Used in diagnosis of myasthenia gravis and to distinguish myasthenic crisis from cholinergic crisis. In botanicals (eg, ma huang) and products for weight loss that are banned in the United States. Drug of choice in anaphylaxis; used as hemostatic and as adjunct with local anesthetics; cardiac stimulant; traditional use in asthma. Tox: cholestatic jaundice (avoid estolate in pregnancy), inhibits liver drug-metabolizing enzymes, interactions with cisapride, theophylline, warfarin. Other macrolide antibiotics include azithromycin (no effect on P450 drug metabolism) and clarithromycin. Used in anemia associated with renal failure and anemias secondary to cancer chemotherapy. Tox: injection site reactions include erythema, itching, and swelling; possible increased rates of infection and malignancy. Chronic use leads to dependence and dysfunction of multiple organ systems; fetal alcohol syndrome. Used in esophageal and vaginal candidiasis, in coccidioidomycosis, and in the prophylaxis and treatment of fungal meningitis. Ethacrynic acid is similar and can be used in case of sulfa allergy and causes less hyperuricemia. Tox: renal dysfunction, ototoxicity; once-daily dosing is effective (postantibiotic effect) and less toxic. Blocks K+ channels in pancreatic B cells, causing depolarization and release of insulin. Related drugs: glyburide and older sulfonylureas such as chlorpropamide and tolbutamide; short-acting secretagogues include repaglinide and nateglinide. Tox: cardiovascular and respiratory depression and relaxation of skeletal and smooth muscle.
Occasionally blood pressure 150 90 buy triamterene 75mg lowest price, folliculitis can occur from Pseudomonas in those who contract it in a whirlpool or hot tub. When several furuncles become confluent into a single lesion, it becomes known as a carbuncle, essentially a localized skin abscess that must be drained. Folliculitis is rarely tender, while furuncles and carbuncles are often extremely tender. Necrotizing Fasciitis this is an extremely severe, life-threatening infection of the skin. Streptococcus and Clostridia are the most common organisms involved, because they produce a toxin that worsens the damage to the fascia. All of these laboratory methods of establishing a diagnosis lack both sensitivity and specificity. Surgical debridement is both the best way to confirm the diagnosis, as well as being the mainstay of therapy. Treatment Treat with beta lactam/beta lactamase combination medications: Ampicillin/sulbactam (Unasyn) Ticarcillin/clavulanate (Timentin) Piperacillin/tazobactam (Zosyn) If there is a definite diagnosis of group A Streptococcus (pyogenes), then the treatment is with clindamycin and penicillin. It is generally treated with a small incision to allow drainage and antistaphylococcal antibiotics as previously described. Viral Infections Herpes Simplex Herpes simplex infections of the genitals are characterized by multiple, painful vesicles. They are usually obvious by examination, and you should proceed directly to therapy with acyclovir, famciclovir, or valacyclovir. Diagnostic Testing Best initial test: In the event that the diagnosis is not clear or the lesions have become confluent into an ulcer, then the best initial test is a Tzanck smear. The Tzanck smear is somewhat nonspecific in that it will only determine that the infection is in the herpes virus family. Tzanck smears detect multinucleated giant cells and are similar in technique to a Pap smear. A scraping of the lesion is immediately placed on a slide and sprayed with fixative. Treatment Oral acyclovir, famciclovir, or valacyclovir Topical acyclovir has extremely little efficacy. If the child is immunocompromised or the primary infection occurs in an adult, then acyclovir, valacyclovir, or famciclovir should be given. Diagnostic Testing Although Tzanck prep and viral culture are the best initial and most accurate diagnostic tests, they are generally not necessary, because little else will produce a band of vesicles in a dermatomal distribution besides herpes zoster. Treatment Treat with the following: Steroid use is still not clearly beneficial, although the best evidence for its efficacy is in elderly patients with severe pain. There is no benefit to routine subtyping of the specific strain of papillomavirus.
Sulfock, 38 years: Orbital hemorrhage: caused by damage to the anterior or posterior ethmoidal arteries; may be subperiosteal or extend into orbital so tissue i periosteum is disrupted D. Otolithic crisis o umarkin = sudden unexplained alls without loss o consciousness or associated vertigo C. Of all the antimetabolites, cytarabine is the most specific for the S phase of the cell cycle.
Ali, 64 years: Still Disease Rheumatoid arthritis in children is sometimes called Still disease (see a pediatric textbook or more details). Azithromycin is eliminated slowly (half-life 24 d), mainly in the urine as unchanged drug. Plane o Dissection-Subcutaneous Surgical technique-The standard procedure involves elevation o anterior (temporal and preauricular) and posterior (postauricular and cervical) skin aps.
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