Nonpharmacologic Therapy

Nonpharmacologic treatment of GERD includes patient-specific lifestyle modifications, antireflux surgery, or endoscopic therapies. Although most patients do not respond to lifestyle changes alone, the importance of maintaining these lifestyle changes throughout the course of GERD therapy should be stressed to selected patients on a routine basis. The most common lifestyle changes that a patient should be educated about include (a) losing weight and (b) elevating the head of the bed if symptoms...

Pulmonary Function Tests

Postbronchodilator FEV1 1.70 L (13.3 increase) FEV1 after exercise 1.23 L (23.1 decrease) Given this additional information, what is your assessment of the patient's asthma severity Identify your treatment goals for this patient. What nonpharmacologic and pharmacologic alternatives are feasible for this patient Outline a treatment plan for this patient that includes nonpharmacologic therapy, pharmacologic therapy, and a monitoring plan. Justify your therapeutic selections. Children Up to 4...

Patient Encounter 2 Part 2 Medical History Physical Examination Diagnostic Tests and Creating a Care Plan

All developmental milestones within normal limits. Two episodes of AOM treated with no sequelae. Current on all immunizations ROS (+) nocturnal incontinence 5 nights week or more (-) vaginal itching, UTIs, urgency, frequency, dysuria, lower abdominal fullness VS BP_ _mm Hg, P_bpm, RR min, T 37.0 C (98.6 F) Resp Within normal limits CV Within normal limits Abd Soft, nontender, nondistended (+) bowel sounds bladder not palpable Neuro Within normal limits...

Treatment Goals of Therapy

The introduction of antibiotic therapy and vaccines has reduced dramatically the mortality associated with bacterial meningitis.19 Prior to these advances, bacterial meningitis was almost universally fatal, and those few patients who survived often suffered from debilitating residual neurologic deficits, such as permanent hearing loss. Although significant improvements have been made, the fatality rate of pneumococ-cal meningitis remains above 20 likely due to its occurrence in debilitated...

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common disorder that is often unrecognized, affecting 4 of middle-aged white men and 2 of middle-aged white women.15 In women, the frequency of OSA increases after menopause. OSA is as common or more common in African Americans and less common in Asian populations. The risk of OSA increases with age and obesity. Individuals with OSA experience repetitive upper airway collapse during sleep, which decreases or stops airflow, with subsequent arousal from sleep to...

Restless Legs Syndrome

RLS treatment involves suppression of abnormal sensations and leg movements and consolidation of sleep. Dopaminergic and sedative-hypnotic medications are prescribed commonly. In the last few years, dopamine agonists (DAs) have become the therapy of choice for the treatment of RLS, replacing levodopa carbidopa as first-line agents. The DAs offer many advantages over levodopa carbidopa, including longer half-lives to cover overnight symptoms, flexible dosing, and a reduced incidence of symptom...

Patient Encounter Part 3 Modifying Treatment Plan

CH returns to the clinic 3 months later. The physician previously diagnosed him with OSA and RLS. He received a prescription for CPAPs for OSA and ropinirole 0.5 mg at bedtime for RLS at his last visit. Via phone calls, his ropinirole dose has been increased to 3 mg at bedtime. He has received moderate relief of his RLS symptoms, but on occasion, he still awakens and cannot fall back asleep. His sleepiness and RLS symptoms are improved ESS 13 24. Based on the information presented, recommend...

Acromegaly Patient Care and Monitoring

Assess patient's clinical signs and symptoms to determine severity of acromegaly. 2. Review the biochemical disease markers to assess severity of acromegaly. 3. Review the available diagnostic data to determine pituitary tumor size and location. Determine if the patient has a coexisting prolactin secreting tumor. Determine if the tumor extends toward the optic chiasm or if it is continuous on the optic tracts. 4. Assess presence of acromegaly complications. Identify any significant...

Clinical presentation and diagnosis

Any interaction between a patient and a healthcare provider presents an opportunity to evaluate the patient's height and weight. From these parameters, the BMI should be determined as well as waist circumference and the presence of comorbidities or associated risks. BMI, waist circumference, comorbidities, and readiness to lose weight are used in the assessment of the overweight or obese patient. The BMI is calculated using the measured weight in kilograms divided by the height in meters...

General Approach to Treatment

Since the goals for obesity management in the adult population are multifactorial, it should be considered a chronic illness where treatment is maintained for life. Any implemented therapy promoting weight loss should focus on behavior modification directed toward both dietary restriction and increased activity in conjunction with the selective use of pharmacologic or surgical intervention. Before initiating therapy, secondary causes of obesity (e.g., hypothyroidism and Cushing syndrome) must...

Outcome evaluation

Successful management of overweight and obesity is determined by the ability the treatment plan has to (a) prevent weight gain, (b) reduce and maintain a lower body weight, and (c) decrease the risk of obesity-related comorbidities. Since weight is necessary to calculate the BMI, it, as well as waist circumference, should be determined. Obesity management may encompass more than weight loss or maintenance in the presence of other conditions other pertinent parameters should be assessed at...

Pathophysiology Ischemic Stroke

In ischemic stroke, there is an interruption of the blood supply to an area of the brain either due to thrombus formation or an embolism. Loss of cerebral blood flow results in tissue hypoperfusion, tissue hypoxia, and cell death. Tipid deposits in the vessel wall cause turbulent blood flow and lead to vessel injury, exposing vessel collagen to blood. This vessel injury initiates the platelet aggregation process due to the exposed subendothelium. Platelets release adenosine diphosphate (ADP),...

Treatment Of Acute Hemorrhagic Stroke Supportive Measures

Acute hemorrhagic stroke is considered to be an acute medical emergency. Initially, patients experiencing a hemorrhagic stroke should be transported to a neurointensive care unit. There is no proven treatment for ICH. Management is based on neurointensive care treatment and prevention of complications. Treatment should be provided to manage the needs of the critically ill patient including management of increased ICP, seizures, infections, and prevention of rebleeding and delayed cerebral...

Hemorrhagic Stroke

The pathophysiology of hemorrhagic stroke is not as well studied as that of ischemic stroke however, it is more complex than previously thought. Much of the process is related to the presence of blood in the brain tissue and or surrounding spaces resulting in compression. The hematoma that forms may continue to grow and enlarge after the initial bleed and early growth of the hematoma is associated with a poor outcome. Brain tissue swelling and injury is a result of inflammation caused by...

General Signs and Symptoms

Hypoperfusion of skeletal muscles leads to fatigue, weakness, and exercise intolerance. Decreased perfusion of the CNS is related to confusion, hallucinations, insomnia, and lethargy. Peripheral vasoconstriction due to SNS activity causes pallor, cool extremities, and cyanosis of the digits. Tachycardia is also common in these patients and may reflect increased SNS activity. Patients will often exhibit polyuria and nocturia. Polyuria is a result of increased release of natriuretic peptides...

Mghr on for 1214 hours off for 101 hours

Common adverse effects of nitrates include postural hypotension, flushing, and headache secondary to venodilation. Headache often resolves with continued therapy and may be treated with acetaminophen. Hypotension is generally of no serious consequence. However, in patients with hypertrophic obstructive cardiomyopathy or severe aortic valve stenosis, nitroglycerin may cause serious hypotension and syn- cope. Therefore, long-acting nitrates are relatively contraindicated in these conditions....

Gastrointestinal System

GI involvement may present initially as small bowel obstruction shortly after birth due to abnormally thick meconium that cannot be passed (meconium ileus). Older CF patients may develop distal intestinal obstruction syndrome (DIOS), formerly called meconium ileus equivalent, which occurs due to fecal impaction in the terminal ileum and cecum. Maldigestion due to pancreatic enzyme insufficiency is present in about 85 to 90 of CF patients.5 Thick pancreatic secretions and cellular debris...

Upon completion of the chapter the reader will be able to

Identify the causes of constipation. 2. Compare the features of functional constipation with those of irritable bowel syndrome (IBS) with constipation (IBS-C). 3. Recommend general and dietary modifications and therapeutic interventions for the treatment of functional constipation. 4. Distinguish between acute and chronic diarrhea. 5. Compare and contrast diarrhea caused by different infectious agents. 6. Explain how medication use can lead to diarrhea. 7. Discuss nonpharmacologic strategies...

Alosetron Lotronex11 5HT4 Raptor Agonist

0-t50 mg po daily 10-t 50 mg po daily Trig po then 2 mg po after each loose stool daily maximum 16 mg Withdrawn from general use available only under special circumstances. Bulk producers may improve stool passage in IBS-C but are unlikely to have a fa- vorable effect on pain or global IBS symptoms. Psyllium may increase flatulence, which may worsen discomfort in some patients. Methylcellulose products are less likely to increase gas production. Although fiber-based supplements are more likely...

Patient Encounter Part 2

CN begins to improve after 2 days of methylprednisolone 1 g IV daily. The treatment team wants to begin a disease-modifying treatment. Do you agree that she should be on a disease-modifying treatment Why If so, which treatment would you choose Recommend a dosing regimen. How should the patient be counseled on the chosen treatment MS patients usually have upper motor neuron spasticity this type of spasticity cannot be treated with muscle relaxants (i.e., carisoprodol). MS patients must be...

Autonomic and Other Problems

Drooling may be accompanied by speech problems and dysphagia. Anticholinergics, botulinum toxin injections, and sublingual atropine can decrease drooling. Speech therapists perform swallowing studies to assess the risk of aspiration, and nutritionists optimize diet. Patients at high risk of aspiration or poor nutrition may require placement of a percutaneous endoscopic gastrostomy tube. Nausea improves if patients take their PD medications with meals or pharmacologic therapy (domperidone in...

NSAIDs nonsteroidal antiinflammatory drugs SNRIs serotonlnnorepinephrine reuptake inhibitors SSRls selective serotonin

AX, a 27-year-old African American woman, presents to your clinic with GI complaints (e.g., constipation, bloating, and cramping) and fatigue. She is a single mother of three (ages 2, 3, and 6 years) and is a full-time college student. She states that she worries about everything her grades, finances, the 6-year-old riding the school bus, etc. She states that even if it's not important, I still worry. She has difficulty sleeping and says that she often feels like she might jump out of her skin....

Patient Encounter 1 Part 1

HT, a 34-year-old woman, comes to the clinic complaining of fatigue, lethargy, and having a fuzzy head for the past 6 months. She thought it was because she was working too hard, but the symptoms have not improved despite a better work schedule. She has noticed a 2.3-kg (5-lb) weight gain over the past 6 months, her menses have become heavier, she feels cold all the time, and her skin is drier. She takes no medications other than occasional acetaminophen for headache and milk of magnesia for...

Relative Contraindications

Smoking (less than 15 cigarettes per day) at any age History of migraine headache disorder Women stop their oral contraceptives owing to side effects such as headaches, nausea, vomiting, or weight gain that occur during oral contraceptive use. Package labeling reports a higher incidence of these side effects, although it cannot be determined if they occurred because of the pill or just happened when the women were on the pill.1 One double-blind trial compared women taking oral contraceptives...

Patient Care and Monitoring UI

Assess the patient's symptoms to determine if patient-directed therapy is appropriate or whether or not the patient should be evaluated by a physician. Assessment includes the types and severities of symptoms and the presence or absence of exacerbating factors. Does the patient have any UI-related complications 2. Review any available diagnostic data to determine disease status. 3. Obtain a thorough medication history, including use of prescription, nonprescription, and complementary and...

Patient Encounter 1 Part

The patient is diagnosed with IDA and is started on ferrous sulfate 325 mg orally three times daily to be taken on an empty stomach. Follow-up CBC 1 month later reveals a Hgb of 10 g dL (100 g L or 6.2 mmol L), previously 9.3 g dL (93 g L or 5.77 mmol L). The patient complains of shortness of breath on exertion and constipation. She also admits to taking only one tablet a day because of nausea. What Hgb level would constitute a therapeutic response in this patient How can nausea secondary to...

Patient Encounter 2

A 36-year-old female who has been in good health presents to your clinic complaining of constipation and abdominal pain. She explains to you that she has been feeling stressed lately because her 40-year-old sister is undergoing chemotherapy for breast cancer and they just lost their mother to ovarian cancer a few years ago. Does she have a hereditary risk factor What screening tools could be used to monitor this patient Identify the treatment options for prevention of ovarian cancer available...

Clinical Presentation And Diagnosis Cancer

Palliative care is most commonly associated with patients who have cancer. Regardless of whether or not the cancer is curable, most patients have various degrees of physical, psychological, social, and spiritual symptoms which arise once a diagnosis is confirmed. The primary site of solid tumor and hematologic cancers associated with limited life include, but are not limited to, lung, bronchus, breast, colon, rectum, pancreas, prostate, ovaries, uterus, brain, esophagus, liver, kidneys,...

Nonsmall Cell Lung Cancer

The first step in treatment of NSCLC involves confirmation of the clinical stage and determination of resectability of the tumor. This decision should always be made by a thoracic surgeon who routinely performs lung cancer surgery. Treatment options depend on the advancement of disease (i.e., local, locally advanced, or metastatic), PS, and eligibility for resection. Local Disease (Stages 1A, 1B, and II A) Local disease encompasses stages IA through IIA and is associated with a favorable...

Colorectal Cancer Prevention

Strategies to prevent colorectal cancer can be done with pharmacologic or surgical interventions and involve either preventing the initial development of colorectal cancer (primary prevention) or preventing cancer in patients that demonstrate early signs of colorectal cancer (secondary prevention). The most widely studied agents for the chemoprevention of colorectal cancer are agents that inhibit COX-2 (aspirin, NSAIDs, and selective COX-2 inhibitors) and calcium supplementation.19 COX-2...

Extraintestinal Manifestations and Complications of IBD

Patients may manifest signs and symptoms of disease in areas outside the GI tract. These extraintestinal manifestations may occur in various body regions.5,13 Painful joint complications associated with IBD include sacroiliitis and ankylosing spondylitis. Ocular involvement with episcleritis, uveitis, or iritis may manifest as blurred vision, eye pain, and photophobia. Associated skin findings include pyoderma gan-grenosum (involving papules and vesicles that develop into painful ulcerations)...

Patient Care and Monitoring

Assess the patient's symptoms to determine the time of attack onset, which joints are affected, the level of pain, and other symptoms. 2. Review the patient history for contributing lifestyle factors and other disease states that may help guide therapy. 3. Obtain a thorough medication history for prescription drug, nonprescription drug, and dietary supplement use. Determine if any of these products may be contributing to hyperuricemia. 4. Educate the patient on lifestyle modifications that will...

Treatment Desired Outcomes

O The primary goals of management of TLS are (a) prevention of renal failure (b) prevention of electrolyte imbalances. Thus, the best treatment for TLS is prophylaxis to enable delivery of cytotoxic therapy for the underlying malignancy. For patients that present with or develop TLS despite prophylaxis, treatment goals include (a) decreasing uric acid levels (b) correcting electrolyte imbalances (c) preventing compromised renal function. These goals should be achieved in a cost-effective...

Insulin

Insulin is one of a very few medications which is itself a whole protein, and can induce IgE sensitivity directly. This can result in anaphylaxis. Adverse reactions to insulin also include erythema, pruritis, and indurations, which are usually transient and may be injection site-related. For the sensitivity reactions, treatment options include dexa-methasone or desensitization. If the reaction is injection site-related, a change in delivery system (i.e., insulin pump or inhaled insulin) may be...

Patient Encounter Part

BB is now 3 days old and presents with body temperature fluctuations and hypotension. A workup to rule out sepsis was initiated with collection of blood cultures. He was empirically started on ampicillin 50 mg (50 mg kg dose) IV every 8 hours and gentamicin 4 mg (4 mg kg dose) IV daily. (1 0.2 x IOVL Bands 0 Segs41 Lymphs 49 Monocytes 6 SO 0.4 mg dL (35.4 pmol L) Less than or equal to 0.6 rng dL 53 imol L) Using the most appropriate method, calculate a creatinine clearance for BB. The mg kg...

Common Errors in Pediatric Drug Therapy

Prevention of errors in pediatric drug therapy begins with identification of possible sources. Reports have shown that nearly 50 of medication errors in the United States in neonatal and pediatric critical care units are attributable to prescribing and transcribing errors.2 Up to 69.5 of overall calculation errors affect pediatric patients.29 As pediatric drug therapy is based on weight, body surface area, and age, it is crucial to verify accurate weight, height, and age for dosing calculations...

Other Contributing Processes and Factors

Many other processes are proposed to contribute to the development of hypertension, including obesity, physical inactivity, insulin resistance, potassium and magnesium depletion, chronic moderate alcohol consumption, and transient effects of cigarette smoking and caffeine intake.9 The assessment of global cardiovascular risk in all hypertensive patients should be part of the management plan while also pursuing target BPs through nonpharmacologic and pharmacologic means. Regardless of the...

Angiotensin Receptor Blockers

ARBs are another key class of agents whose role in managing patients with hypertension has been further defined by recently completed studies. ARBs are inhibitors of the angiotensin-1 (ATI) receptors (Fig. 5-3). ATI receptor stimulation evokes a pressor response via a host of accompanying effects on catecholamines, aldosterone, and thirst. Consequently, inhibition of ATI receptors directly prevents this pressor response and results in up-regulation of the RAAS. Up-regulation of the RAAS results...

Epidemiology And Etiology Epidemiology

HF is a major public health concern affecting approximately 5 million people in the United States. An additional 550,000 new cases are diagnosed each year. HF manifests most commonly in adults over the age of 60. The growing prevalence of HF corresponds to (a) better treatment of patients with acute myocardial infarctions (MIs) who will survive to develop HF later in life, and (b) the increasing proportion of older adults due to the aging Baby Boomer population. The relative incidence of HF is...

Unique Oral Contraceptives

Along with varying doses of ethinyl estradiol and different progestins, there are also formulation modifications that may benefit various patient situations. In the United States, these formulations include products such as Loestrin-24 Fe, Seasonale, Seaso-nique, Ortho Tri-Cyclen, Estrostep Fe, Yasmin, Yaz, Mircette, Ovcon 35, and Lybrel. Each of these products may show benefit in certain women owing to their unique characteristics. Loestrin-24 Fe (norethindrone ethinyl estradiol) is an...

Epidemiology and etiology

Rates of dysmenorrhea range from 20 to 90 . ' Dysmenorrhea can be associated with significant interference in attendance at work and school for 15 of women affected by the most severe form.25 Risk factors for dysmenorrhea include young age, heavy menses, and nulliparity.11 Causes of secondary dysmenorrhea may include cervical stenosis, endometriosis, pelvic infections, pelvic congestion syndrome, uterine or cervical polyps, and uterine fibroids.26

Abbreviations Introduced in This Chapter

ARDS AST CSF CYP ELISA FISH HAART HRCT IA IRIS NIAID A la li int.1 aminotransferase Acute respiratory distress syndrome Aspartate aminotransferase Cerebrospinal fluid Cytochrome P45 isoenzyme Enzyme-linked immunosorbent assay Highly active antiretroviral therapy High-resolution computed tomography Invasive aspergillosis Immune reconslitulion syndrome National Institute of Allergy and Infectious Diseases Pneumocystis jiroveci (carinii) pneumonia Polymerase chain reaction Self-assessment...

ABlockers

Generally, ai-blockers are considered as inferior agents and should not be used as monotherapy. The ALLHAT trial had an ai-blocker arm that was discontinued early as terazosin was associated with an increase in cardiovascular events. aiBlockers may be considered as add-on therapy to other agents (i.e., 3rd or 4th line) when hypertension is not adequately controlled. In addition, they may have a specific role in the antihypertensive regimen for elderly males with prostatism however, their use is...

About The Editors

Chisholm-Burns, BPharm, PharmD, MPH, FCCP, FASHP, is professor and head of the Department of Pharmacy Practice and Science at The University of Arizona College of Pharmacy. She received her BS and PharmD degrees from The University of Georgia and completed a residency at Mercer University Southern School of Pharmacy and at Piedmont Hospital in Atlanta, Georgia. She is the founder and executive director of the Medication Access Program. She has also served in elected positions in...

Acetaminophen

Acetaminophen is a centrally acting analgesic that produces analgesia by inhibiting prostaglandin production in the brain and spinal cord. It is an effective and inexpensive analgesic with a favorable risk-benefit profile.12 For treatment of mild to moderate pain, acetaminophen should be tried initially at an adequate dose and dur- ation before considering an NSAID J Acetaminophen is generally considered to be as effective as NSAIDs for mild to moderate joint pain with a superior safety...

Acute Adrenal Insufficiency

During an acute adrenal crisis, the immediate treatment goals are to correct volume depletion, manage hypoglycemia, and provide glucocorticoid replacement. V lume depletion and hypoglycemia can be corrected by giving2large volumes (approximately 2-3 L) of IV normal saline and 5 dextrose solution. Glucocorticoid replacement can be accomplished by administering IV hydrocortisone, starting at a dose of 100 mg every 6 to 8 hours for 24 hours, increasing to 200 mg to 400 mg day if complications...

Adapted from Ref 5

An additional consideration when stopping or changing therapy is a staggered discontinuation of antiretrovirals with different half-lives. For example, in patients taking Atripla (tenofovir, emtricitabine, and efavirenz) tenofovir and emtricitabine should be continued for at least 4 days after discontinuation of efavirenz due to the much prolonged half-life of efavirenz as compared to tenofovir and emtricitabine. Otherwise, the potential for monotherapy with efavirenz exists. If new...

ADH Alcolioi dehydrogenase ALT Alanine aminotransferase AST Aspartate aminotransferase

Model for lilt J Stage Liver Pist-asc Nonsleroidi 1 anl Nnfla m mat ory ru g Ren i n-abgiotef si 11-aldosterone system Serum-aKil G Allixi 11 lin gradient TrdtajuguJar intrahepatic porla& ystcniicshunt Self-assessment questions and answers are available at ht-tp www. mhpharmacotherapy. com pp.html.

Adult Outpatient With Comorbid Conditions

The comorbid conditions that can impact therapy and outcomes in patients with CAP include diabetes mellitus, COPD, chronic heart, liver, or renal disease, alcoholism, malignancy, asplenia, and immunosuppressive condition or use of immunosuppress-ive drugs. 8 If the patient did not receive antibiotics in the last 3 months then either a respiratory fluoroquinolone alone or a combination of an oral -lactam agent plus a macrolide or azalide is recommended. If the patient received an antibiotic in...

AF atrial fibrillation

These studies have found no significant differences in mortality in patients who received rhythm control therapy versus those who received rate control therapy.29-32 Howevei patients assigned to the rhythm control strategy were more likely to be hospitalized -31-32 and were more likely to experience adverse effects associated with drug therapy. Therefore, drug therapy for the purpose of maintaining sinus rhythm or reducing the frequency of episodes of AF should be initiated only in those...

Agerelated Changes

In basic terms, pharmacokinetics is what the body does to the drug, whereas pharmacodynamics is what the drug does to the body. All four components of pharmacokinetics absorption, distribution, metabolism, and excretion are affected by aging, the most clinically important and consistent being the reduction of renal elimination of drugs12 As people age, they become frailer and are more likely to experience altered and variable drug pharmacokinetics and pharmacodynamics than younger patients....

Airway Obstruction

Symptoms of airway obstruction include chest tightness, cough, and wheezing. Airway obstruction can be caused by multiple factors including airway smooth muscle constriction, airway edema, mucus hypersecretion, and airway remodeling. Airway smooth muscle tone is maintained by an interaction between sympathetic, parasym-pathetic, and nonadrenergic mechanisms. Acute bronchoconstriction usually results from mediators such as histamine, cysteinyl leukotrienes, prostaglandins, and tryptase released...

ALL in the Elderly

The proportion of ALL in patients older than age 60 years constitutes between 16 and 31 of all adult leukemias. Treatment of adults largely has followed the conventional chemotherapeutic regimes used in childhood ALL. However, the intensification regimens common in childhood are not suitable for this population because of their associated toxicities in older patients. The adverse prognostic factor, the Ph+, occurs in 15 to 30 of adults and thus is more common in the over 60 age group.21 Based...

Allergic conjunctivitis Etiology

Ocular allergy is a broad term that includes several diseases with the hallmark symptom of itching, often accompanied by tearing, conjunctival swelling, and nasal congestion.14 Seasonal ocular allergy is the most common type of allergic conjunctivitis. This is an IgE-mediated hypersensitivity to pollen or other airborne allergens.11 Often, the patient's history is positive for atopic conditions such as allergic rhinitis, asthma, or eczema.14 Perennial allergic conjunctivitis has similar but...

Aloe vera

Lactose intolerance is responsible for many cases of acute diarrhea, especially in patients of African descent, Asians, and Native Americans. Possible food-related causes include fat substitutes, dairy products, and products containing nonabsorbable carbohydrates. The diarrhea of IBS is sudden and perhaps watery but likely loose, usually accompanied by urgency, bloating, and abdominal pain occurring upon arising in the morning or immediately following a meal. Inflammatory bowel disease is...

Amenorrhea in adolescents

Amenorrhea in the adolescent population is of great importance because this is the time in the female life cycle when peak bone mass is achieved. The cause of amenor-rhea and appropriate treatment must be identified promptly in this population because hypoestrogenism contributes negatively to bone development. Estrogen replacement, typically via an OC, is important. In addition, ensuring that the patient is receiving adequate amounts of calcium and vitamin D is imperative. Table 49-2...

Anger

Low self-confidence or morale Full inability to achieve erections Ability to achieve partial erections, but not suitable for intercourse Erections sufficient for intercourse, but early detumescence The problem may have a slow or acute onset, or may wax and wane Diagnosis ED may be the presenting symptom of other chronic disease states. Full medical, social, and medication histories should be taken to determine areas that can cause or exacerbate ED and to assess the patient's ability to safely...

Anovulatory bleeding in adolescents

Anovulatory cycles are not unusual in the perimenarchal reproductive years. Ovulation typically is established a year or more following menarche. When anovulatory bleeding occurs in this population, it may be excessive. If the bleeding is excessive, the patient should be evaluated for blood dyscrasias. The prevalence of blood dys-crasias, including von Willebrand's disease and prothrombin deficiency, and the prevalence of idiopathic thrombocytopenia purpura in this population ranges from 5 to...

Anticonvulsants

A life-threatening syndrome can occur following a few weeks of therapy with anticonvulsants, such as phenytoin, phenobarbital, and carbamazepine. Symptoms include fever, a maculopapular rash, generalized lymphadenopathy and varying degrees of internal organ dysfunction. The rash may be mild at first but can progress to exfoliative dermatitis, erythema multiforme, Stevens-Johnson syndrome, or toxic epidermal necrolysis. The causative agent should be withdrawn immediately. Valproic acid,...

Antimicrobial Considerations in Selecting Therapy

Drug-specific considerations in antimicrobial selection include spectrum of activity, effects on nontargeted microbial flora, appropriate dose, pharmacokinetic and pharmacodynamic properties, adverse-effect and drug-interaction profile, and cost (Table 69-2). Spectrum of Activity and Effects on Nontargeted Flora Most initial antimicrobial therapy is empirical because cultures usually have not had sufficient time to identify a pathogen. Empirical therapy should be based on patient-and...

Application of Ophthalmic Solutions or Suspensions

Avoid touching the dropper tip with your fingers or against your eye to maintain sterility of product shake dropper bottle if product is a suspension. 3. Tilt head back pull down the lower eye lid with index finger. 4. Hold the dropper bottle with other hand as close as possible without touching the eye. The dropper should be pointing toward the eye with remaining fingers bracing against the face. 5. Gently squeeze the bottle so that one drop is placed into...

Assessment of Adverse Effects

Adverse effects cause more nonadherence to prescribed therapy than any other factor. Monitor patients regularly for adverse effects and health status, especially since mood stabilizing drugs and antipsychotic drugs commonly cause metabolic side effects such as weight gain. Repeat laboratory tests for renal and thyroid function for patients taking lithium and hematology and liver function for patients taking carbamazepine or DVP. Annual measurement of serum lipase may be advisable for patients...

Behavioral considerations

The correlation between risky sexual behavior and STIs is well documented. Inconsistent and incorrect condom use has been recognized to increase the incidence of new STIs. Assuming that patients, especially adolescents, consistently use and understand how to use condoms, spermicides, or diaphragms can be detrimental and may contribute to nonpharmacologic mismanagement. Health care providers who manage persons at risk for STIs should counsel women concerning the option for emergency...

BiPAP Pi level posit i ve airway pressure

BZ DRA Bt1 nzod i aiepiHC reccptO r agon 1st CPA P Cont i nuo us posit ive a i rway pressu re HiitofismpniiN ily leukocyte antigen Stmlonin and norepinephrine reuptake inhibitor Selective serotonin reuptake inhibitor Self-assessment questions and answers are available at ht-tp www. mhpharmacotherapy. com pp.html.

Bisphosphonates

Bisphosphonates are first-line therapy for osteoporosis due to established efficacy in preventing hip and vertebralfractures. They are also the most commonly prescribed therapy for osteoporosis. They decrease bone resorption by binding to the bone matrix and inhibiting osteoclast activity. They remain in the bone for a prolonged period and are released very slowly. These effects increase bone mineral density. Although sever- al bisphosphonates are currently available, only alendronate,...

Bursitis and Tendonitis

Bursitis is an inflammation of the bursa, the fluid-filled sac near the joint where the tendons and muscles pass over the bone. The bursa assists with movement by reducing friction between joints. Tendonitis (also known as tendinitis) is an inflammation of the tendon or, more specifically, the fibrous sheath that attaches muscle to bone. Tenosynovitis is an inflammation of the tendon sheath. Repetitive overuse of a tendon can cause cellular changes in the tissues. Specifically, collagenous...

Cardiac Output

CO is an important determinant of BP. Factors which elevate CO may, in theory, contribute to the development of primary hypertension. Increases in CO and subsequently BP may arise from factors that increase preload (fluid volume) or myocardi-al contractility. Nonetheless, even if increased CO may be involved in the development of primary hypertension, these increases do not appear to persist over time. As a consequence, elevated CO is not considered a hemodynamic hallmark of established primary...

Case Study

The final patient is a 23-year-old woman who was admitted 6 hours ago for diabetic ketoacidosis. With appropriate therapy, her hyperglycemia has improved and her serum ketones are improving. Because she continues to feel poorly, repeat blood work is obtained. Studies show a pH of 7.15, PaCC> 2 of 15 mm Hg (2 kPa), HCO3 of 5 mEq L (mmol L), sodium concentration of 140 mEq L (mmol L), and chloride concentration of 110 mEq L (mmol L). What is the primary acid-base disorder Given the clinical...

Causes of Thyrotoxicosis Hyperthyroidism

Thyrotoxicosis is any syndrome caused by excess thyroid hormone. Hyperthyroidism is related to excess thyroid hormone secreted by the thyroid gland. Thyrotoxicosis can be related to the presence or absence of excess hormone production (hyperthyroid-ism). The common causes of thyrotoxicosis are shown in Table 44-6 ' disease is the most common cause of hyperthyroidism. Thyrotoxicosis in the elderly is more likely due to toxic thyroid nodules or multinodular goiter than to Graves' disease....

Cellulitis and erysipelas epidemiology and etiology

Cellulitis and erysipelas are bacterial infections involving the skin. OG Cellulitis is an infection of the dermis and subcutaneous tissue, whereas erysipelas is a more superficial infection of the upper dermis and superficial lymphatics. Although both can occur on any part of the body, about 90 of infections involve the leg.12, 3 These infections develop after a break in skin integrity, resulting from trauma, surgery, ulceration, burns, tinea infection, or other skin disorder. However, they...

Cerebral Ischemic Events

'O' There are two main classifications of cerebral ischemic events transient ischemic attack (TIA) and cerebral infarction. A TIA is a temporary reduction in perfusion to a focal region of the brain causing a short-lived disturbance of function. TIAs have a rapid onset (5 minutes) and short duration (2-15 minutes, up to 24 hours). The symptoms vary depending on the area of the brain affected however, no deficit remains after the attack. The classic definition of TIA is based on symptom duration...

Cetuximab and Panitumumab

Cetuximab (Erbitux) and panitumumab (Vectibix) are monoclonal antibodies directed against the EGFR. Cetuximab is a chimeric antibody, whereas panitumumab is a fully human monoclonal antibody. The EGFR receptor is overexpressed in colorectal can- cers and leads to an increase in tumor proliferation and growth. ' ' Cetuximab received FDA approval for use in EGFR-expressing meta-static colorectal cancer in irinotecan relapsed or refractory patients. Cetuximab should be administered in combination...

Chemoprevention

Chemoprevention refers to the use of prophylactic medications to prevent the development of cancer. Many studies of potential chemopreventatives, including nonster- oidal anti-inflammatory drugs, retinoids, inhaled glucocorticoids, vitamin E, selenium, and green tea extracts, have been conducted, but none has been successful. Large randomized clinical trials have evaluated P-carotene and vitamin E as lung cancer che-mopreventative agents in high-risk patients (older smokers). Although vitamin E...

Choice of Contraceptives Important Considerations

When helping a patient decide on a contraceptive, the most important goal is to find an option that the patient is comfortable with and that the clinician feels will be beneficial for the patient. It is imperative to explain the side effects, safety concerns, and noncontraceptive benefits of each alternative to the patient so that she may make an informed decision. Fertility goals vary for each patient. It must be determined if the goal is to postpone contraception, space out the next...

Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) has a prolonged and variable course. Patients with COPD have a high number of physician visits and hospital admissions. Palliative care treatment is directed at reducing symptoms, reducing the rate of decline in lung function, preventing and treating exacerbations, and maintaining quality of life. In end-stage COPD, bronchodilators and anti-inflammatory agents become less effective. Symptoms of late-stage disease include wheezing, chronic sputum...

CKCreatine kinase

CK-MB Creatine kinase myocardial band CPR Cardiopulmonary resuscitation rtiplii utahlc cardioverter defibrillator National Cholesterol Education Program Pc rcu la n coui to ro n a ry i n ter vc n t io n Thrombolysis io myocardial infarction Self-assessment questions and answers are available at ht-tp www. mhpharmacotherapy. com pp.html.

Clinical Assessment and Diagnosis

It is important for the clinician to identify the cause(s) of AHF in order to maximize treatment efficacy and reduce future disease exacerbations. Cardiovascular, metabolic, and lifestyle factors can all precipitate AHF. The most common precipitating factors for acute decompensation and how they contribute pathophysiologically are listed in Table 6-3. Routine laboratory testing of patients with AHF includes electrolytes and blood glucose, as well as serum creatinine and blood urea nitrogen to...

Clinical Course

The clinical course of MS has four basic patterns Relapsing remitting, secondary progressive, primary progressive, and progressive relapsing (Fig. 29-3). Relapsing remitting MS develops into secondary progressive MS in 50 of patients within 10 years and in 75 within 25 years of diagnosis.1 Rating scales are used clinically (Table 29-2). MS reduces overall life expectancy 6 to 7 years. Suicide is disproportionately high in MS patients, accounting for about 15 of MS-related deaths. r Desired...

Clinical Course O

Patients with POAG typically have a slow, insidious loss of vision. This is contrasted by the course of acute PACG which can lead to rapid vision loss that develops over hours to days. For POAG, only 4 to 8 of patients may progress to legal blindness. It may take 13 to 16 years for a patient to go blind from glaucoma. A patient's quality of life may not be affected until significant visual field loss is present and the patient can no longer perform the activities of daily living. Vision loss...

Clinical presentation and diagnosis Diagnosis

Osteoporosis has been defined by the WHO as a disease characterized by low bone density and weakening of bone tissue associated with an increase in fragility and vulnerability to fracture.1 Because bone strength cannot be measured directly, an assessment of bone mineral density is used, which represents 70 of bone strength. Low bone mineral density has been associated with an increased risk of fractures. X-rays are useful only in identifying patients suspected of sustaining a fracture and are...

Clinical Presentation And Diagnosis Of Chronic Hf

In low-output HF, symptoms are generally related to either congestion behind the failing ventricle(s), hypoperfusion (decreased tissue blood supply), or both. Congestion is the most common symptom in HF, followed by symptoms related to decreased perfusion to peripheral tissues including decreased renal output, mental confusion, and cold extremities. Activation of the compensatory mechanisms occurs in an effort to increase CO and preserve blood flow to vital organs. However, the increase in...

Clinical Presentation and Diagnosis of Diaper Dermatitis Typical Symptoms

Erythema is the most common symptom presented with a diaper rash. The rash may begin as light to medium pink with poorly defined edges, but when further developed may become dark red and raised lesions with distinct edges. Rashes generally appear in the folds of the skin around the diaper area, thighs, genitals, and buttocks. Other typical symptoms include irritation and pruritus. Atypical symptoms Patients presenting with the following symptoms may indicate the need for more aggressive...

Clinical Presentation and Diagnosis of Rotavirus Infection40

Incubation period of 2 days 2- to 3-day prodrome of fever and vomiting Profuse diarrhea without blood or leukocytes (up to 10-20 stools per day) Presentation in adults may vary from asymptomatic to nonspecific symptoms of headache, malaise, and chills to severe diarrhea, nausea, and vomiting. Diagnosis can be made by polymerase chain reaction (PCR) of the stool. Table 76-4 Agents Responsible for Acute Viral Gastroenteritis and Diarrhea Viml PrakAgE PukTimr Duntinn Tiinimiuinii Symptoms...

Clinical Presentation and Diagnosis Pediatric Enuresis

Proper assessment of the child or adolescent with enuresis should explore every aspect of UI, especially the genitourinary and nervous systems. The minimum assessment should include34,35 Interview of child and parent(s), being sensitive to the emotional consequences of the enuresis Direct physical examination, looking for enlarged adenoids tonsils, bladder disten-tion, fecal impaction, abnormal genitalia, spinal cord anomalies, and abnormal neurologic signs (look for an organic cause amenable...

Clinical Presentation of MS1016

O MS symptoms are a function of the location of lesions within the CNS. Because myelin increases the speed of nerve impulse transmission, demyelination slows the speed of transmission. No impulses can be transmitted if the axon is transected. The primary symptoms of MS are caused by this delay or cessation of impulses. Secondary symptoms of MS result from the primary symptoms. Urinary Symptom . IjK Ora iriCrXfl Urinary retention Soawiciiy visual symptoms Optic neuritis Diplopia Rowel syrnplcmi...

Clinical Presentation of NMSC Five Warning Signs of BCC

The appearance of some BCCs is similar to plaque, psoriasis, or eczema, and these benign disorders are included in the differential diagnosis. An open sore that bleeds, oozes, or crusts and remains open for 3 or more weeks A reddish patch or irritated area that may crust, itch, hurt, or persist with no noticeable discomfort A shiny bump or nodule that is pearly or translucent and may be pink, red, or white. In dark-haired people, it may be tan, black, or brown and can be confused with a mole A...

Clinical Presentation of Trichomoniasis

Prostatitis or epididymitis (men) Symptoms Excessive yellow-green discharge Urethral discharge or irritation Vaginal pH greater than 4.5 Metronidazole may be administered orally as a single 2-g dose or 500 mg twice daily for 7 days. Pregnant women should be prescribed the single dose of metronidazole. Cure rates are greater than 90 when metronidazole is administered as either a single 2-g dose or a 7-day regimen. Possible adverse effects include an unpleasant metallic taste, reversible...

Compensatory Mechanisms

In the setting of a sustained loss of myocardium, a number of mechanisms aid the heart when faced with an increased hemodynamic burden and reduced CO. They include the Frank-Starling mechanism, tachycardia and increased afterload, and cardiac hypertrophy and remodeling (Table 6-2). ,7 Table 6-2 Beneficial and Detrimental Effects of the Compensatory Responses in Heart Failure Dfltri mvnti I Fllnli 1 in in icjimtion intreased piofcail ( hioujh sodium and wiler reiention OfuidndlVvIa FiartiiariHig...

Complications of brain metastases introduction

Brain metastases are among the most feared complications of cancer and generally carry a poor prognosis. One serious consequence of brain metastases is elevated ICP, which can rapidly lead to fatal intracranial herniation and death. Rapid identification of the signs and symptoms of brain metastases is critical to improve long-term outcome and avoid mortality. The signs and symptoms of brain metastasis can be confused with common psychological distress or other neurologic problems (such as...

Conditions prevalent in pregnancy and lactation Nausea and Vomiting

As many as 80 of pregnant women suffer from nausea or vomiting.16 Nonpharmacologic measures, such as lifestyle (rest, avoidance of nausea triggers such as strong odors) and dietary changes (small and frequent meals, fluid restriction during meals) should be used as first-line management. Acupuncture and acupressure can be also helpful.16 The combination of pyridoxine (vitamin B6) and doxylamine is well studied during pregnancy and is the first-line pharmacologic treatment of nausea and vomiting...

Consequences Of Ckd And Eskd Impaired Sodium and Water Homeostasis

Sodium and water balance are primarily regulated by the kidney. Reductions in the number of functioning nephrons decrease glomerular filtration and subsequent reabsorption of sodium and water, leading to edema. Sodium and water balance can be maintained despite wide variations in intake with normal kidney function. The fractional excretion of sodium (FENa) is approximately 1 to 3 with normal kidney function, allowing sodium balance to be maintained with a sodium intake of 120 to 150 mEq...

Consolidation

After completion ofinduction and restoration ofnormal hematopoiesis, patients begin consolidation. The goal of consolidation is to administer dose-intensive chemotherapy in an effort to further reduce the burden of residual leukemic cells. It is in this and subsequent treatment phases that the presence of MRD is reduced by increasing the aggressiveness of the drug regimen. Several regimens use agents and schedules designed to minimize the development of drug cross-resistance. Studies have...

Contrasting Bacterial Virulence and Resistance

Virulence refers to the pathogenicity or disease severity produced by an organism. Many bacteria may produce toxins or possess growth characteristics that contribute to their pathogenicity. Some virulence factors allow the organism to avoid the immune response of the host and cause significant disease. Virulence and resistance are different microbial characteristics. For example, Streptococcus pyogenes, a common cause of skin infections, produces toxins that can cause severe disease, yet it is...

Conversion factors SI Units

SI (le Syst me International d'Unit s) units are used in many countries to express clinical laboratory and serum drug concentration data. Instead of employing units of mass (such as micrograms), the SI system uses moles (mol) to represent the amount of a substance. A molar solution contains 1 mole (the molecular weight of the substance in grams) of the solute in 1 L of solution. The following formula is used to convert units of mass to moles (mcg mL to imol L or, by substitution of terms, mg mL...

Creactive protein Microbiologic Studies

Culture and susceptibility testing FIGURE 69-2. Important bacterial pathogens classified according to Gram stain and morphologic characteristics. (From Rybak MJ, Aeschlimann JR. Laboratory tests to direct antimicrobial pharma- FIGURE 69-2. Important bacterial pathogens classified according to Gram stain and morphologic characteristics. (From Rybak MJ, Aeschlimann JR. Laboratory tests to direct antimicrobial pharma- cotherapy. In In DiPiro JT, Talbert RL, Yee GC, et al., eds. Pharmacotherapy A...

Cryptococcosis epidemiology

Cryptococcus neoformans is an encapsulated yeast that can infect apparently normal hosts but is more frequently associated with severe infections in immunocompromised patients. C. neoformans is divided into two varieties based on serotype C. neoformans var. neoformans (serotypes a and d) and C. neoformans var. gatti (serotypes b and c). C. neoformans var. gatti is found predominantly in tropical and subtropical climates associated with eucalyptus trees, whereas C. neoformans var. neoformans is...

Daunorubicin

Daunorubicin is an anthracycline that is sometimes referred to as an antitumor antibiotic. Daunorubicin inserts between base pairs of DNA to cause structural changes in DNA however, the primary mechanism of cytotoxicity is the inhibition of topoi-somerase II. The pharmacokinetics are best described by a two-compartment model, with a terminal half-life of about 20 hours. The predominant route of elimination of daunorubicin and hydroxylated metabolites is hepatobiliary secretion. Daunorubi-cin...

Desired Outcomes

ED is not a life-threatening condition, but left untreated it can be associated with de- pression, loss of self-esteem, poor self-image, and marital discord. The primary goal of therapy is achievement of erections suitable for intercourse and improvement in patient quality of life. Additionally, the ideal therapy should have minimal side effects, be convenient to administer, have a quick onset of action, and have few or no drug interactions.10 In addition to a physical exam, a thorough medical,...

Desired Therapeutic Outcomes

The goal of VTE treatment is to prevent short-and long-term complications of the disease. In the short term (i.e., the first few days to 6 months), the aim of therapy is to prevent propagation or local extension of the clot, embolization, and death. In the long term (i.e., more than 6 months after the first event), the aim of therapy is to prevent complications, such as PTS, pulmonary hypertension, and recurrent VTE. ' General Treatment Principles Anticoagulant drugs are considered the mainstay...

Developed by K R rower and M Karanvl I a ye

Table 36-9 Sample Regimen of Clonidine for Withdrawal From Methadone (Up to 20-30 mg Day) or Equivalent Fentanyl (Duragesic) Patches Table 36-9 Sample Regimen of Clonidine for Withdrawal From Methadone (Up to 20-30 mg Day) or Equivalent Fentanyl (Duragesic) Patches 0,1 mg 4 x daily o 0,2 rng 3 x daily Decrease by 0J mq d ay reduce nighttime dose last