Tinea Corporis

Tinea corporis is a superficial dermatophyte infection of the cornified layers of skin on the trunk and extremities. Lesions are typically annular with central clearing and a scaling border and may be pruritic (Fig. 33-42). Infection may be transmitted from person to person, by animals such as household pets or farm animals, and through fomites. Because the cornified layer of skin is involved, topical therapy is usually sufficient for localized cases. A topical antifungal should be applied to...

Manifestations

In seasonal allergic rhinitis, exposure is followed by complaints of paroxysmal sneezing, a watery nasal discharge with congestion, and nasal pruritus. Conjunctival and pharyngeal itching often occurs. Less specific symptoms are postnasal drainage or fullness or aching in the frontal areas. The patient might exhibit an allergic salute, an upward thrust of the palm against the nares to relieve itching and open the nasal airways and a gaping expression from mouth breathing. Allergic shiners or...

Maternal Biochemical Screening

Low-risk women can be offered screening for genetic abnormalities of the fetus by biochemical testing in the first or second trimester and ultrasound nuchal translucency screening (first trimester) and targeted ultrasound evaluation of fetal anatomy, best done at 18 to 20 weeks' gestation. The general consensus is that women of any age should have access to any screening or diagnostic testing (as previously described) if they choose to accept the underlying risks. Biochemical testing is the...

Measles

In 2008, more measles cases were reported than in any other year since 1997 (CDC, 2010). Measles is the first disease of childhood from the history of medicine. In adults, measles infection may be acquired in the face of waning immunity from remote immunization. A booster dose of MMR vaccine is recommended before college entry. Clinically, measles presents with cough, coryza (nasal irritation and congestion), and conjunctivitis. Fever is common several days before the onset of the rash. The...

Measles Rubeola and Rubella

Rubeola presents as maculopapular (morbilliform) eruption. It starts on the face and spreads centrifugally. It is associated with cough, coryza, conjunctivitis, fever, and Koplik spots (red-white-blue macules in mouth). As with varicella, rubeola is now uncommon because of vaccinations. The exanthem of rubeola (measles) begins around the fourth febrile day, with discrete lesions that become confluent as they spread from the hairline downward, sparing the palms and soles. The exanthem typically...

Measuring Physical Parameters of Growth

Measure height and weight at all well-child visits. Measure head circumference in children up to 24 months of age and blood pressure in children 3 years and older. Plot measurements on NCHS growth charts to demonstrate normal growth. Investigate significant deviations if the child's growth crosses multiple percentile lines on the growth chart. Weight, length, and head circumference are the most useful routine measurements in infants. Total body length in children up to age 2 is obtained most...

Mechanisms of Arrhythmias

Two main mechanisms for the initiation and perpetuation of arrhythmias have been proposed. Putative mechanisms include disorders of impulse formation and disorders of impulse conduction. These may occur alone or in combination and result in isolated electrical events and sustained arrhythmias. Alterations in automaticity or triggered activity are two main areas of disordered impulse formation. Clinical examples of abnormal automaticity include inappropriate sinus tachycardia, multifocal atrial...

Medical Disorders in Pregnancy

Many medical disorders can be seen in the pregnant woman few are incompatible with pregnancy. In the management and care of the pregnant woman with a medical illness, it is important to understand the normal physiology of pregnancy and the effect of the disorder on the pregnancy, and vice versa. Common medical problems in pregnancy include anemia, asthma, hypertension, diabetes, and pyelonephritis. Women with moderate to severe preexisting medical illness should be referred for evaluation to a...

Medical Eligibility Criteria

The World Health Organization (WHO) periodically convenes an Expert Working Group to make evidence-based recommendations for who can safely use a Table 26-2 Preferred Contraceptive Options for Select Patient Groups Table 26-2 Preferred Contraceptive Options for Select Patient Groups DMPA, implant, COC, or IUC plus condoms IUCs are excellent option currently underused in adolescents. Condom plus any other form of contraception DMPA, implant, POP, IUC, LAM up to 6 months if specific criteria met...

Medications for Acute Relapses

Glucocorticoids are still widely used for the treatment of acute exacerbations of MS. The principal effects of cortico-steroids appear to be related to their anti-inflammatory and The complete reference list is available online at www.expertconsult.com. Washington University Neuromuscular Disease Center comprehensive resource for disorders affecting peripheral nerve, muscle, and neuromuscular junction. Centers for Disease Control and Prevention recommended immunization schedule. www.aan.com...

Menopause

Vasomotor symptoms are the most common menopausal sign. The Women's Health Initiative showed that hormone replacement therapy did not prevent cardiovascular disease in postmenopausal women and in fact increased the risk of breast cancer. Menopause is defined as the cessation of menstruation. It is a retrospective diagnosis that comes after a woman has not menstruated for 12 months. The menopausal transition occurs over several years as the number of ovarian...

Metatarsal Fractures

Nondisplaced fractures of the midshaft and distal portions of the metatarsals are treated with immobilization. Short-leg casting and immobilizer boots can lead to adequate healing in 6 to 8 weeks in most cases. Postoperative shoe use without formal immobilization can also lead to adequate healing of metatarsal fractures, although the risk of adverse outcome is higher. Displaced, angulated, and rotated fractures may require operative fixation. Fractures of the proximal portion of the metatarsal...

Methamphetamine

Methamphetamine is a highly addictive stimulant that can cause increased alertness and increased physical activity with small doses by causing the release of high levels of the neu-rotransmitter dopamine in the brain. Abusers of metham-phetamine experience a brief rush by smoking or injecting methamphetamine. Oral ingestion or snorting methamphet-amine can produce a high that can last approximately half a day. Due to tolerance, chronic users of methamphetamine may take higher doses of the drug...

Mitral Valve Prolapse

Mitral valve prolapse (MVP) is described as bulging of one or more of the mitral leaflets into the left atrium in systole (see Fig. 27-21). Although the most common cause of significant MR (Cheng and Barlow., 1989), it can be isolated without valvular insufficiency. MVP with MR is a strong indication for prophylaxis against bacterial endocarditis during dental, GI, and genitourinary procedures. MVP carries a benign course (Freed et al., 2002). On rare occasions it may be associated with...

Molluscum Contagiosum

Molluscum contagiosum is a common, self-limited viral infection seen most frequently in children and can occur anywhere on the body most often on the trunk, face, and extremities. In adults, mollusca are considered sexually transmitted and occur in the genital region or lower abdomen. Infection occurs through direct skin-to-skin contact or indirect contact with fomites. The typical molluscum lesion is a pink to flesh-colored, firm, smooth, dome-shaped papule with central umbilication (Fig....

Morbilliform Maculopapular Exanthemlike Reaction

Morbilliform eruption is by far the most common type of drug eruption, reported in response to almost every drug. Small, pink to red papules and macules usually start on the face or upper chest and can extend to limbs resembling measles (Fig. 33-66). The rash may be relatively asymptomatic or extremely pruritic. The typical course begins 7 to 14 days after drug initiation if the first exposure. On reexposure to the same medicine, the eruption will occur much more quickly, within 1 to 3 days....

Motivational Enhancement Therapy

Motivational enhancement therapy (MET) engages patients in increasing their internal motivations for making healthy changes in their drug use, building on a patient's strengths and resources in making prior behavioral changes. Goals are set by the patient, although the counselor may advise specific goals when appropriate. This approach is noncon-frontational. The counselor seeks to have the patient talk about the pros and cons of the substance use, reflecting and summarizing as an active...

Narcolepsy

Although rare, narcolepsy is an important cause of daytime sleepiness because it can affect personal safety and school performance but is readily treatable. Normally, REM sleep only occurs when a person has been asleep for 60 to 90 minutes and follows all four stages of non-REM sleep. Narcolep-tic patients, on the other hand, experience sudden episodes of REM sleep in the middle of a wakeful state or immediately after falling asleep. The key feature of narcolepsy is recurrent sleep attacks...

Nasal Obstruction

The sensation of unilateral or bilateral nasal obstruction is relatively common and can range from mildly annoying to extremely frustrating to the patient. Nasal obstruction may be associated with other symptoms such as rhinorrhea, lost or altered sense of smell, or facial discomfort. Nasal obstruction may result from pathology of the nasal cavity or nasopharynx. (eTable 19-4 online summarizes the most common causes, associated signs and symptoms, and treatment for nasal obstruction). See the...

Natriuretic Peptides BNP and Nterminal proBNP

Blood levels of natriuretic peptides are used in the evaluation of heart failure. Cardiac cells release natriuretic peptides, in response to stretch and wall tension. Ventricular myocytes release a pro-B-type natriuretic peptide (pro-BNP), which is cleaved into the active B-type natriuretic peptide (BNP) and the inactive N-terminal pro-BNP (NT-pro-BNP). Levels of both BNP and NT-pro-BNP increase with age and in renal insufficiency and are reduced in women and obese patients. Some medications,...

Natural History of Delirium

Delirium is usually of acute onset and transient duration. Delirium often resolves a few days to a few weeks after etio-logic insults are corrected. In some patients, however, delirium may persist. When chronic, delirium may result in permanent cognitive deficits, meeting the criteria for dementia (Fong et al., 2009). Hastening the progression of an existing dementia might explain this clinical observation. Delirium is persistent at hospital discharge in almost one third of patients, with...

Nausea and Vomiting

In patients with nausea and vomiting, the physician should first look for a reversible cause such as constipation or gastritis from NSAIDs. If increased intracranial pressure is the cause, the patient may require steroids. Overfeeding may be the problem if a nasogastric or gastrostomy tube is in place. Metoclopramide (Reglan) is the agent of choice when an enormous liver limits gastric emptying or slow motility is causing early satiety. Many patients whose nausea and vomiting have not responded...

NCCAM Strategic Plan 2010

Now in its third cycle of 5-year strategic planning, NCCAM continues to explore CAM healing practices in the context of science, train CAM researchers, and disseminate authoritative information to public and professional communities. Thought Conventional conventional medical medicine would professional not help suggested it Thought it would be interesting to try Thought CAM combined with conventional medicine would help Figure 11-5 Reasons people use complementary and alternative medicine (CAM)...

Neonatal Resuscitation

The successful transition to extrauterine life depends heavily on the ability of the neonatal pulmonary system to adapt quickly and provide oxygen to the infant. Any illness or injury Box 22-2 Neonatal Resuscitation Supplies and Equipment for Delivery of a Term Infant Mechanical suction and tubing Suction catheters 8-F feeding tube and 20-mL syringe Meconium aspirator Neonatal resuscitation bag with a pressure-release valve or pressure manometer Face masks, newborn and premature sizes Oxygen...

Neoplastic

Anaplastic carcinoma Follicular carcinoma Lymphoma Medullary carcinoma Papillary carcinoma of hyperthyroidism and is more common in women age 20 to 50. Treatment modalities include antithyroid medications, radioactive iodine ablation, or surgical excision when medical treatment fails. Thyroiditis can cause nodular enlargement of the thyroid gland. Subacute thyroiditis may be a cause of intermittent hyperthyroidism from the release of stored thyroid hormone. Chronic lymphocytic (Hashimoto's)...

Neoplastic Disorders

Most salivary gland neoplasms arise in the parotid gland, and most are benign. Approximately 80 of parotid gland tumors are benign, with pleomorphic adenoma (mixed tumor) being the most common in adults. Hemangiomas are the most common benign tumor in children, but malignancy in children is more likely than in adults when a solid mass is found in the salivary gland. Other benign tumors include Warthin's tumors (papillary cystadenoma lymphomatosum) and oncocytomas. The most common malignancy in...

Neurochemical Hypothesis

Cholinergic transmission in the CNS has a major role in cognition and attention, and an acute cholinergic deficit exists in delirium. Dopaminergic transmission is increased in delirium, and this or the imbalance between cholinergic and dopaminergic systems may be etiologic. Disturbances in other neurotransmitters are hypothesized, perhaps explaining subtypes or variations in presentations of delirium. Serotonin may be increased in delirium associated with serotonin syndrome and in hepatic...

Neurologic Examination and Newborn Reflexes

The neurologic examination of the newborn begins with the general appearance of the infant. The newborn should have a strong cry and exhibit symmetric movements a high-pitched or weak cry can be associated with current illness or neurologic deficits. Asymmetric movements can indicate musculoskeletal or focal neurologic injury. Complete absence or asymmetry of any newborn reflex can indicate neurologic deficit or injury. The following developmental reflexes are present at birth in the normal...

Neutropenia

Neutropenia is defined as ANC less than 1800 cells L, approximately 2 SD below the mean, and includes both mature PMN and band forms. Some ethnic populations, such as those of African descent or Yemenite Jews, may have a lower total WBC count and ANC that can be normal at 1000 neutrophils . The primary concern with neutropenia is the risk of infection. Severe infection does not usually occur unless ANC is less than 500 cells L (Table 39-5). When severe neutropenia occurs, patients are at risk...

Nocturia

Nocturia describes waking at night to urinate. It is more common in older adults, but no population data define a normal range for any group therefore the complaint implies a deviation from a perceived norm. Furthermore, the primary complaint often centers on the sleep disturbance rather than on urination. It may represent frequent nocturnal urination or excessive nocturnal urine production (nocturnal polyuria). Although often thought of as a prostatic symptom, it is common in both men and...

Nodules and Cysts

Thyroid nodules come in a variety of sizes and types. The incidence of malignancy in nodules less than 1.0 cm, which are found incidentally during nonthyroid-related diagnostic procedures (e.g., head and neck ultrasonography), is less than 0.5 . Current recommendations for evaluation of inci-dentalomas include a sTSH and FT4 and careful palpation of the thyroid gland (Cooper et al., 2009). If tests and palpation are normal, only annual follow-up with palpation by the physician is recommended....

Nonhealing Wounds

Patients underlying healing status may be affected by nutritional status and underlying medical conditions such diabetes, cancer, and anemia. Healing may be slowed by smoking as well as age. Surgical repairs with too much tension on skin closure increase the chance of dehiscence and nonheal-ing. In the United States, chronic wounds affect 6.5 million patients. More than 25 billion is spent annually on treatment of chronic wounds, and the burden is rapidly growing because of increasing health...

Nonpharmacologic Interventions

Therapeutic lifestyle change (TLC) is first-line therapy for patients at risk for cardiovascular events. Patients who smoke should stop. The amount of daily consumed cholesterol should be less than 200 mg. Table 27-2 summarizes the distribution of calories from nutrients. Reduced saturated fat and increased consumption of mono- and polyunsaturated fats promote serum LDL-C reduction. The ingestion of viscous fiber and plant stanols decrease cholesterol absorption. Ideally, patients should...

Nonstress Test

Most often the nonstress test (NST) is used as the primary tool in antepartum fetal surveillance. It has been used to document second-trimester and third-trimester fetal well-being for the past 40 years. It serves as a surrogate measure of the developing fetal autonomic nervous system and the adequacy of the uteroplacental function (Myrick and Harper, 1996). The NST is more specific than sensitive and thus a better indicator of fetal health than fetal illness. The test itself is read as...

Nontraditional Therapy

Interest in complementary and alternative medicine (CAM) for health disorders has been growing steadily in the last several decades. As a result, a greater number of alternative or complementary agents are being tested in more methodologically rigorous ways, allowing greater scientific assessment of such treatments. Survey evidence suggests that as many as 40 to 60 of patients may be taking CAM therapies, although patients often do not disclose such use to their physicians (Elkins et al.,...

Normal Equilibrium State and Stressors

Under normal circumstances, a person has a sense of internal psychological equilibrium and environmental support that generally permits activities of daily living (ADLs), working, and experiencing pleasure. A delicate balance among the person's internal wishes and fears, skills and capacities, and values and ideals determines psychological equilibrium. Environmental equilibrium refers to a stable balance among basic needs for food, water, shelter, physical comfort, and the integrity of...

Normal Labor and Delivery

Labor, whether preterm or term, is defined as the presence of sufficient uterine contractions in frequency, intensity, and duration to bring about effacement and dilation of the cervix. Control of normal labor is complex and, despite advances in medical science, poorly understood. Evidence supports prostaglandin (PG) involvement, in particular PGE2 and PGF2a, as well as other mediators (Ulmsten, 1997). Before the onset of labor, the fetal head may descend into the pelvis, and the height of the...

Ocular Changes with Aging

Arcus senilis, or corneal arcus, is a hazy, white or yellow arc or deposit in the peripheral cornea. It has many causes and is more common in older adults. The deposit is composed of cholesterol and other lipids and does not generally indicate an underlying systemic abnormality. It does not interfere with vision or eye function. In white patients, this finding may indicate lipid abnormalities and an increased propensity for cardiovascular disease. No such clear correlation has been identified...

Ocular Medications

Ocular medications may have significant systemic side effects, such as many of the glaucoma medications. Glaucoma medications can generally be classified into p-blockers, prostaglandins and prostamides, carbonic anhydrase inhibitors, a-blockers, and older medications, such as epinephrine and pilocarpine. Systemic absorption of beta-adrenergic blockers, such as timolol (Timoptic), may exacerbate asthma. p-Blockers may also cause problems with breathing, bradycardia, and hypotension. These...

Office Business and Management Functions

In addition to scheduling and billing functions, information technology must facilitate intraoffice communications and workflow. Automating repetitive tasks saves time, improves efficiency, and enhances other patient care. Systems should record and analyze a broad set of demographics to enhance the care of diverse populations. Electronic monitoring of information allows data-driven decision making about staffing and resource allocation. Well-developed information systems have long been...

Operative Vaginal Deliveries

Indications for operative vaginal delivery in a low-risk mother are nonreassuring FHR, maternal exhaustion, and prolonged second stage, which is generally 3 hours for a nul-liparous woman and 2 hours for a parous woman. Essential for safe operative vaginal delivery is optimal readiness. The laboring woman should understand the reasons why operative delivery has been chosen, with documentation in the chart. She should then be placed in a position in which her legs are maximally open, preferably...

Ophthalmia Neonatorum

Ophthalmia neonatorum is an infection or inflammation of the conjunctiva that occurs during the first 4 weeks of life. Possible causes include chemical conjunctivitis, Neisseria gonorrhoeae, and chlamydial infection. The increased incidence of venereal disease and shortcomings in silver nitrate prophylaxis are significant factors in the constantly evolving clinical picture. Ophthalmia neonatorum frequently is a manifestation of a systemic infection, requiring determination of the exact cause in...

Opiates

Intoxication with opiates causes miotic pupils, euphoria, altered level of consciousness, constipation, and respiratory depression. Treatment of opiate overdose involves providing respiratory support and administering naloxone, a pure opiate antagonist. Naloxone is typically administered IV but may also be administered SC, intramuscularly (IM), via endotracheal tube, or intranasally until IV access is established (Barton et al., 2005). The initial dose is typically 0.4 to 0.8 mg, with a...

Organizing Information for Pointof Care Decision Making

Most EHR systems can be configured to organize needed information for a particular patient or condition so that it is presented in a clear and concise way. Some templates actually integrate treatment goals or guidelines and provide highlights or reminders when the patient's parameters are out of range. For example, if you are seeing a diabetic patient whose BMI or blood pressure is high or whose LDL level is above the recommended target, you would get a prompt to modify the treatment plan. When...

Orthopedic Disorders

Overweight children have an increased risk of slipped femoral capital epiphysis, genu valga, pes planus, and scoliosis (Speiser et al., 2005). In adults, an association between obesity and degenerative joint disease (DJD), particularly of the knee, is related in part to mechanical factors resulting in increased compressive forces on the knee. Obesity-related cytokine production has been associated with a chronic inflammatory state promoting osteoarthritis. Obesity is associated with knee...

Orthopedic Hardware Infections

Infections secondary to orthopedic hardware devices have become common problems with the increasing incidence of hip, knee, and shoulder replacement surgeries. Also, patients with traumatic injury resulting in a fracture often have hardware implanted to stabilize the bone. These patients present in one of the three following ways 1. Early Symptoms develop less than 3 months after surgery and have an acute presentation with pain, erythema, and warmth, usually caused by S. aureus and...

Osteoarthritis

Osteoarthritis affects 20 of the U.S. population 44 of OA patients are not active. Primary and secondary OA must be differentiated. NSAIDs, not COX-2 inhibitors, are still the pharmacologic treatment of choice for OA. Osteoarthritis, also known as degenerative joint disease, is the most common form of arthritis and causes more work disability in the United States (17 ) than any other disease. Arthritis affects 20 of the U.S. population, about half of whom primarily have OA. Long thought to...

Other Causes of Strabismus

Acute strabismus may be brought on by a viral upper respiratory tract infection, which can cause acute cranial nerve VI palsy. With the advent of antibiotics, middle ear infections with associated petrositis and cranial nerve VI palsies are relatively uncommon. Sudden-onset strabismus may also indicate underlying neurologic disease. Another cause is spasm of the near reflex. A hallmark of spasm of convergence is a constricted pupil. Paralytic or mechanical causes of strabismus occur with trauma...

Other Chronic Bronchial Diseases Bronchiectasis

Bronchiectasis is both a chronic airway infection and a disease of chronic lung inflammation. Bronchiectasis might be more common outside the United States (Tsang and Tipoe, 2004). Clinical course can be progressive or indolent. Cough is the predominant symptom, and some patients have significant hemoptysis or shortness of breath, or both. Malodorous (fetid) breath is a characteristic symptom. Bronchiectasis not associated with a genetic disorder is designated non-cystic fibrosis...

Other Drugs

Table 51-6 lists the signs and symptoms of intoxication and withdrawal of other drugs. There are no specific antidotes or reversal agents for the remaining drug classes. Care of the overdose patient is largely supportive and aimed at treating the medical effects of the particular overdose, such as treatment of myocardial ischemia resulting from cocaine overdose. Currently, no FDA-approved medications are available for stimulant (including cocaine and methamphetamine), marijuana, hallucinogen...

Other Infectious Arthritides

Although mycobacteria, parasites, and fungi rarely cause arthritis, incidence has increased with increasing numbers of HIV AIDS and other immunosuppressed patients. Mycobacterium tuberculosis arthritis occurs by hematogenous spread from the lung and is diagnosed by synovial fluid culture. The classic tuberculosis infection involves the spine and is known as Pott's disease. Thoracic vertebrae are most often involved, but a monoarticular arthritis can also occur in large, weight-bearing joints....

Other Keys to Interpreting Clinical Evidence

Use a personal digital assistant (PDA) or computer online, with bookmarks for helpful EBM sources, to apply evidence at the point of care. Although full access to the Cochrane Database can be expensive, helpful summaries are available for free. Attend an information mastery or EBM workshop to solidify your grasp of basic concepts and application of this information to daily practice. Becoming a reviewer of Clinical Inquiries, HelpDesk Answers, or PURLs can consolidate your skills in EBM. Make...

Other Medications Used in Alcohol Treatment Anticonvulsants Topiramate

Anticonvulsants likely exert beneficial effects on y-aminobutyric acid (GABA) receptors. Placebo-controlled studies included carbamazepine (Mueller et al., 1997), divalproex (Brady et al., 2002), and topiramate (Johnson et al., 2003), with a multicenter study confirming the efficacy of topiramate and anticonvulsants for treatment of alcohol use disorders (Johnson et al., 2007). Topiramate was shown to decrease (1) drinks day, (2) drinks drinking day, (3) drinking days, (4) heavy-drinking days,...

Other Pulmonary Diseases of the Pulmonary Vasculature

Wegener's granulomatosis is a vasculitis (inflammatory condition) of the vascular bed that can manifest either with shortness of breath or hemoptysis or with progressive pulmonary fibrosis caused by repeated small hemorrhages at the alveolar level. It is now categorized as a systemic antineutrophil cytoplasmic antibody (ANCA)-associated small-vessel vasculitis, and it usually combines pulmonary features with glomeru-lonephritis. Tissue biopsy of either the lung or the kidney may be diagnostic....

Other Syndromes

Syndromes involving chromosomes (Down, Klinefelter's), fat and muscle metabolism (Prader-Willi, myotonic dystrophy), and autoimmune mechanisms (stiff man syndrome) can affect insulin secretion or sensitivity. Aging, 1 IR or 2 excess nutrient storage Figure 34-1 How normal or genetically impaired beta cells can be affected by inflammation and overnutrition, resulting in absolute or relative loss of insulin secretory reserve and the activation of the common mechanism leading to diabetic crisis. 1...

Other Treatments Electroconvulsive Therapy

Electroconvulsive therapy (ECT) involves a brief electrical stimulation of the brain while the patient is anesthetized, inducing a seizure. ECT remains the most effective treatment for depression (UK ECT Group, 2003), although the stigma surrounding the treatment, misinformation about its practice, side effects, and cost have often made it a treatment of last resort. Although occasionally used as first-line therapy for severe depression, ECT is often used for multitreatment-refractory patients,...

Ovarian and Testicular Disorders

Sexual development in both males and females is driven by the hypothalamic-pituitary axis. The normal process is the result of pulsatile release of GnRH from the hypothalamus, which stimulates the pituitary to release FSH and LH (GHRH and GH also play a role). Release of FSH and LH activates the ovary and testis to produce estrogen and testosterone and is responsible for stimulation of gametogenesis. This process is assisted by conversion of adrenal androgens from the adrenal cortex into...

Overview

Tobacco use is the leading cause of death in the United States. Toxins from cigarette smoke cause disease in most organs of the body. Smokers die an average of 13 or 14 years earlier than nonsmokers, and 50 of continuing smokers will die of a tobacco-related disease. Smoking is responsible for 40 of all deaths from cancer and 21 of deaths from cardiovascular disease. Almost 10 of deaths attributable to smoking occur in nonsmokers exposed to secondhand smoke. The power of nicotine addiction...

Pap Smear Guidelines Key Points

Pap screening should begin at age 21. Women should have Pap smears every 2 years. Women who have had a hysterectomy for benign disease should not have Pap smear screening. Women are not required to have a Pap smear before starting hormonal contraception. Women do not need a pap smear over age 65 if they have had normal results in the past. Although the Pap smear is still the mainstay of cervical cancer screening, recent advances in the understanding of human papillomavirus (HPV) have...

Paradoxical Vocal Cord Motion

Paradoxical vocal cord motion is defined by an inappropriate adduction of the true vocal cords on inspiration and adduction on expiration. The functional airway obstruction results in marked inspiratory stridor and wheezing, and the symptoms are similar to asthma. Often misdiagnosed as refractory asthma, paradoxical vocal cord motion appears to be psychogenic and occurs most often in young women with a history of prior psychiatric illnesses (e.g., depression, personality disorder, posttraumatic...

Paralanguage

Paralanguage is the voice effect that accompanies or modifies talking and often communicates meaning. It includes velocity of speech (e.g., fast, slow, hesitant), tone and volume of voice, sighs and grunts, pauses, and inflections. Urgency, sincerity, confidence, hesitation, thoughtfulness, gaiety, sadness, and apprehension all are conveyed by qualities of voice. McCaskey (1979) believes that the literal interpretation (i.e., definition) of words accounts for only 10 of communication between...

Parental Education and Anticipatory Guidance before Discharge

Parental education before discharge should include infant feeding, safety at home, tobacco exposure, and recognizing neonatal illness. Breastfeeding support should be provided throughout hospitalization and continuing after discharge. All infants should be secured in a rear-facing car seat, with accessibility of the car seat verified before hospital discharge. Parents should be encouraged to place their children in the supine position while sleeping to prevent sudden infant death syndrome....

Partial Lens Opacities

The evaluation of partial lens opacities is related to the location of the cataract. Anterior cataracts include anterior lenticonus, polar cataracts, persistent pupillary membrane opacities, and those occurring with anterior segment dys-genesis. Posterior cataracts include posterior polar, posterior lenticonus, persistent hyperplastic primary vitreous, and posterior subcapsular lens opacities. Posterior subcapsular cataracts are typically associated with corticosteroid use, atopic dermatitis,...

Pathologic coping styles

Deceptive, antisocial Use of dishonesty, lying, cheating, or stealing to resolve crisis Suicidal Using threat of suicide or suicide attempts to coerce someone or to solve problem Violent Using threat or actual violence to establish control and solve problem Avoidance, denial Failure to confront or acknowledge problems Somatization Displaying physical symptoms as a method of expressing emotions Impulsive Unpredictable or impulsive responses without anticipation of possible outcomes Random,...

Pathophysiologic Classification

Based on the primary site of involvement, peripheral neuropathies can be classified as neuronopathies, axonal neuropathies, and myelinopathies. Electrodiagnostic studies can help define this in a clinical setting. Neuronopathies result from damage to the sensory cell bodies in the dorsal root ganglia or motor neuron cell bodies in the spinal cord. Their location in the CNS usually results in a degenerative process that produces incomplete recovery. Diseases that specifically affect the motor...

Pathophysiology

The hemodynamic model of CHF has been largely abandoned and replaced by the concept of left ventricular remodeling (Francis, 2001). Remodeling of the left ventricle indicates stretching and dilation with subsequent reduction in left ventricular function. The remodeling process can be triggered by a multitude of potential injuries (Levy et al., 1996 Kannel et al., 1994), including CAD, MI, hypertension, valvular heart disease, diabetes, congenital heart defects, anemia, and alcoholism....

Patient Centered Medical Home

The patient-centered medical home ((PCMH see Chapter 2) has been proposed as an enhanced model of primary care by four medical organizations (family medicine, pediatrics, The pace of medical progress may result in tomorrow's innovations exceeding today's fantasies. Family medicine in the future will be different as a result of technology. Every patient and physician will be computer literate, with patients having access to the same sources of information as the physician. Patients are likely to...

Pattern Recognition of Arrhythmias Atrial Rhythms

Treatment of asymptomatic or minimally symptomatic, non-life-threatening atrial rhythms should be less risky than no treatment at all. The proarrhythmic side effects of drug therapy, including ventricular fibrillation, should be carefully weighed before initiation of drug therapy. Sinus rhythm is a regular, organized atrial rhythm between 60 and 100 beats min at rest in healthy individuals. Slower rates as low as 40 to 50 beats min may be normal in some individuals. Originating high in the...

Pediatric Cataracts

Approximately 40 of acquired pediatric cataracts are secondary to trauma, and as many as approximately one third of pediatric cataracts are inherited. The basic approach to the patient with pediatric cataracts is to determine whether the cataract is an isolated finding, part of a systemic abnormality, or associated with ocular disease. When several members of the same family are affected by congenital cataracts, a hereditary origin may be assumed. Autosomal dominant hereditary patterns are the...

Pediculosis Corporis Body Lice

Body lice are most frequently seen in patients who live in environments that prevent regular changing of clothing and bedding, such as the homeless. Diagnosis should be suspected in patients with generalized itching and excoriations and poor hygiene. Body lice are more likely to be found in the seams of clothing than on the patient (Fig. 33-65). Initial treatment of body lice entails washing the entire body surface and wearing clean clothing. In severe infestations, topical use of permethrin,...

Pelvic Inflammatory Disease

Pelvic inflammatory disease can be caused by a number of organisms, including Chlamydia, and presents with pelvic pain and discharge. Findings that contribute to the diagnosis of PID include fever greater than 101 F, cervical or vaginal mucopurulent discharge, abundant WBCs on saline preparation of vaginal discharge, elevated erythrocyte sedimentation rate (ESR), elevated C-reactive protein (CRP), and evidence of N. gonorrhoeae or C. trachomatis infection. Hospitaliza-tion with parenteral...

Perimenopausal Women

Abnormal bleeding in the 5 to 10 years before menopause is very common. The most common pathology is anovula-tion caused by declining numbers of ovarian follicles and decreasing inhibin B levels (Jain and Santoro, 2005). Peri-menopausal women may also bleed from structural lesions (most often uterine fibroid tumors) or bleeding disorders. Evaluation of a perimenopausal woman with abnormal Unstable women with acute heavy vaginal bleeding should be admitted to hospital for IV estrogen therapy or...

Peripheral Arterial Disease

Patients must be encouraged and supported to stop smoking and to avoid secondhand smoke (Smith et al., 2001) (SOR A). Nicotine replacement therapies to prevent withdrawal symptoms (bupropion, varenicline) are useful aids for tobacco cessation (SOR A). Patients should participate in regular aerobic exercise for at least 30 minutes a day three or four times weekly. Walking improves claudication (SOR A). Patients should receive dietary counseling and be encouraged to achieve an ideal body weight...

Peripheral Vascular Disease

Smoking is strongly associated with other forms of cardiovascular disease, including abdominal aortic aneurysm (AAA) and peripheral vascular disease in both men and women. Smoking causes as much as half of all peripheral artery disease, and significantly increases the failure rates after lower-limb bypass surgery. The risk of AAA rises in proportion to duration and intensity of smoking and is up to sevenfold greater at 20 pack-years (US Surgeon General, 2004). The U.S. Preventive Services Task...

Peritonsillar Abscess

A peritonsillar abscess is the accumulation of pus in the peritonsillar space that surrounds the tonsil. The same organisms responsible for common tonsillar infections Streptococcus and Staphylococcus species and anaerobes are also found in peritonsillar abscesses. The typical signs and symptoms of peritonsillar abscess include fever, sore throat for 3 to 5 days, dysphagia, odynophagia, and a muffled, hot potato voice. Trismus is extremely common. Examination confirms asymmetric tonsils and...

Personal Control

An individual's perception of the extent of his or her control in a stressful circumstance is a critical component of the appraisal process in coping. This includes control over the stressor or circumstances as well as control over one's responses, whether problem focused or emotion focused. How a person deals with the loss of control precipitated by stressful life events can affect health outcomes. Personal control can be defined as the feeling that one can make decisions and take effective...

Personality Style vs Personality Disorder

A personality style is the lifelong habitual way that a person thinks, feels, and behaves. Styles are determined by genetics and are often called temperament. Temperamental aspects, such as the ability to filter external stimuli or shyness, are often observable at birth. Other personality traits are determined by upbringing from early parent-child interactions, such as mentalization, which is the ability to empathize with another's emotions or perspective and utilize this to read the intentions...

Pharmacokinetics and Pharmacodynamics

Knowledge of the physiologic changes that occur with aging is essential when prescribing medications to the elderly patient. Changes in pharmacokinetics and pharmacodynam-ics can result in increased or decreased amounts of medication and drug-drug interactions (Table 4-11). Pharmacokinetics refers to the body's response to the drug and includes absorption, distribution, metabolism, and elimination (excretion). Age-related gastrointestinal and skin changes have minimal effect on drug absorption,...

Pharmacologic Therapies

Various medications have been used to treat the different forms of urinary incontinence. However, most current medications are used for urge or mixed incontinence, because there is little evidence that adrenergic agonists help stress incontinence (Alhasso et al., 2005) (Table 4-18). The anti-cholinergic, antimuscarinic medications prescribed for urge incontinence work by blocking cholinergic receptors in the bladder, which in turn diminishes bladder contractility. This class of medications is...

Pharmacologic Therapy

Published studies to date overwhelmingly support the ability of aspirin to reduce stroke incidence and death in patients who present with TIA or CVA. Aspirin and other agents that affect platelet function are frequently used for long-term secondary stroke prevention. It therefore seems reasonable, after hemorrhage has been excluded by CT, to begin aspirin therapy in the setting of acute stroke, provided the patient does not have a contraindication to aspirin therapy. Aspirin doses between 50...

Phosphorus

The usual serum phosphorus level is approximately 2.5 to 4.8 mg dL in adults and 4.0 to 6.0 mg dL in children. Disorders of phosphorus metabolism are caused by variations in dietary intake, phosphorus excretion, and transcellular shifts. Because postprandial phosphorylation of glucose can decrease serum phosphorus levels, fasting specimens are more accurate. Hyperphosphatemia most often occurs in the setting of reduced renal excretion from renal insufficiency. Other causes of hyperphosphatemia...

Physical Activity and Exercise

Physical activity is a key component of a healthy lifestyle for reasons ranging from stress reduction to decreased risk of cardiovascular disease. It is also an important component of preventing and treating obesity. Everyone should include physical activity in their daily routine whenever possible (e.g., walk over lunch hour, using stairs) as well as a more formal exercise program. An advantage of exercise is that more calories can be expended in a given period. The choice of exercise depends...

Physical Examination

The neck examination includes inspection for any neck lesions, masses, or scars as well as posture and normal cervical lordosis, characterized by a slight anterior curvature (Fig. 31-5). The neck is palpated for points of tenderness. Figure 31-1 Typical cervical vertebra. S, Spinous process L, lamina A, articular facet P, pedicle T, transverse process B, body. (Redrawn from MercierL. Practical Orthopedics, 5th ed. St Louis, Mosby, 2000, p 27) Figure 31-3 Ligaments of the cervical spine. A,...

Physician Reactions to Difficult Patients

Although DSM-IV-TR is a useful aid for making a diagnosis, family physicians often recognize a patient with a personality trait or unexplained physical complaint by their own reaction to the patient. Physicians working with difficult patients seem to have specific and characteristic reactions to these patients that need to be recognized, understood, and used for the patient's benefit. Patient-generated feelings provoked in the physician are created through the interpersonal interaction between...

Pilonidal Cyst and Abscess

Pilonidal disease may manifest itself as a chronically draining sinus or fistula at the base of the spine in the interglu-teal crease 5 to 10 cm from the anus. Pilonidal cysts can also become infected and may lead to extensive presacral abscess formation. Multiple hair shafts may be seen within the cyst. Incision and drainage or an elliptic incision under local anesthesia over the sinus track is performed. Drainage is the preferred office management technique and is similar to standard abscess...

Platelet Function Disorders

Impaired platelet function may be acquired or inherited. Certain drugs are designed to interfere with platelet function and have proved useful in preventing recurrent strokes or other cardiovascular events, such as transient ischemic attacks (TIAs), in patients with established vascular disease. Particularly useful are drugs such as aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). An important distinction between aspirin and NSAIDs is that aspirin irreversibly inactivates...

Platelet Functions

The primary role of the platelet is to maintain the integrity of the endothelial lining of small vessels. This process is not completely understood but most likely indicates that platelets are constantly being recruited to repair submicroscopic rents between endothelial lining cells in small arterioles and venules. Thus, when the platelet count falls below a certain level, petechiae begin to appear, particularly in the dependent portions of the body such as the ankles and lower legs. Minor...

Pneumonia

The infant with pneumonia generally presents with respiratory symptoms, particularly with tachypnea. Pneumonia has various causes, including aspiration and infection. Meconium aspiration syndrome can lead to severe pneumonia, with subsequent development of persistent pulmonary hypertension. It becomes difficult to oxygenate Vaginal and rectal GBS screening cultures at 35-37 weeks' gestation for all pregnant women (unless patient had GBS bacteriuria during the current pregnancy or a previous...

Polycythemia

Polycythemia (or erythrocytosis) is the overproduction of red blood cells (erythrocytes). The mechanism of action resulting in polycythemia may be primary or secondary. Primary polycythemia indicates that the disorder arises at the level of the hematopoietic stem cells (see later), whereas secondary polycythemia represents the overproduction of RBCs caused by the increased stimulation of the bone marrow by EPO. Polycythemia is typically identified initially in the laboratory by Hb and Hct...

Posterior Pituitary Disorders

Arginine vasopressin (AVP) and oxytocin are the principal hormones secreted from the posterior pituitary. The two major stimuli of oxytocin secretion are suckling during lactation and dilation of the cervix during labor. Although not essential for initiation of labor, oxytocin can be used pharmacologically to initiate labor or control postpartum hemorrhage and uterine atony. Rarely, it has been used to induce milk ejection. The physiologic role of oxytocin in males is not known. AVP differs...

Postoperative Care

Intensive insulinization should be maintained in the postoperative ICU, especially in patients with increased risk of ketoacidosis. Problems can occur when ICU patients transfer to step-down units, where tight control to achieve 120 to 180 mg dL values depends on SC insulin delivery, which is inherently more unstable. The principles of adequate basal coverage and reactive bolus insulin apply, although frequent adjustments remain necessary because of altered insulin pharmacokinetics associated...

Postpartum Hemorrhage

Traditionally, postpartum hemorrhage (PPH) was defined as blood loss greater than 500 mL in a vaginal delivery and greater than 1000 mL in a cesarean delivery. However, studies have revealed that an uncomplicated delivery often results in blood loss of more than 500 mL without any compromise of the mother's condition (Pritchard et al., 1962). Clinically, these findings led some authors to adopt a broader definition for PPH. Any bleeding that results in signs and symptoms of hemodynamic...

Potassium

Potassium is the most abundant cation in the body and has a much higher concentration in the intracellular space than in extracellular fluids. Normal potassium levels are maintained despite fluctuating potassium intake by adjustments in renal secretion of potassium. Hyperkalemia is defined as a serum potassium level greater than 5.1 mmol L. Occasionally, hyperkalemia can be an artifact (pseudohyperkalemia) of phlebotomy, associated with thrombocytosis, leukocy-tosis, or hemolysis during...

Precipitating Factors

All patients suspected of having asthma should be questioned about early warning signs and precipitating factors. Early warning signs of an attack include symptoms such as cough, scratchy throat, and nasal stuffiness, especially if an attack follows an upper respiratory tract infection. Many other precipitating factors can provoke asthma symptoms or an acute attack (Box 20-3). Identification of these precipitating factors can help patients manage their asthma by learning their early warning...

Pregnant Women

Approximately 5.1 of pregnant women age 15 to 44 were current users of illicit substances in 2008. Compared with nonpregnant women, the rate of drug use is significantly lower for all age groups, with the exception of adolescent women 15 to 17 years old. The rate of illicit substance use was higher among pregnant adolescents age 15 to 17 compared to same-age nonpregnant adolescents (21.6 vs. 12.9 ). Use of cocaine, heroin, methamphetamine, marijuana, MDMA, inhalants, and nicotine during...

Prenatal Genetic Diagnostic Testing

If specific risk factors for fetal abnormalities are identified in the mother, appropriate counseling and specific diagnostic testing should be offered. The most common reason to offer prenatal genetic diagnosis is advanced maternal age a somewhat linear increase in nondisjunction in meiosis increases the risk of a conception with aneuploidy (abnormal chromosome number). This is one reason why older women have a higher rate of spontaneous first-trimester miscarriage. It is also why older women...

Presentation

Tuberculosis is most frequently manifested clinically as pulmonary disease, but it can involve any organ. Extrapulmonary TB accounts for about 20 of disease in HIV-seronegative persons but is more common in HIV-seropositive persons. Pulmonary TB typically manifest with fever, night sweats, chronic cough, sputum production, hemoptysis, anorexia, and weight loss. Chest radiographs in patients with pulmonary TB typically reveal upper-lobe cavitary lesions and can reveal infiltrates or nodular...

Preterm Labor

Preterm labor is defined as uterine contractions occurring before 37 weeks of gestation that cause cervical change. Cervical change can be diagnosed if an initial examination reveals a cervix that is at least 2 cm dilated or 80 effaced, or if interval cervical examinations document progression of effacement or dilation. Preterm contractions without cervical advancement can also occur these do not require intervention. The distinction may be difficult, in particular at the onset of contractions....

Prevalence

Prevalence of diabetes has increased worldwide. In 1990 the prevalence of self-reported diabetes was 2.9 in the United States, increasing to almost 8 in the first decade of the 21st century. Because self-report misses persons with undiagnosed diabetes, the Centers for Disease Control and Prevention (CDC) estimates total prevalence of diabetes in adults 20 or older approaches 11 of the U.S. population, and those with impaired fasting glucose (prediabetes), about 26 (2003-2006). In both men and...

Prevention

The USPSTF recommends high-intensity behavioral counseling to at-risk adults and adolescents to prevent STIs. High-intensity counseling involves multiple sessions and often is delivered to groups of patients. Unfortunately, this type of intervention has limitations in its practicality for population-based delivery. No risk of harm was discovered in the delivery of counseling for STI prevention. Vaccination is the most important form of primary prevention of common infectious diseases. Two...