Treatment of Acute Severe Asthma

The optimal treatment of acute severe asthma depends on the severity of the exacerbation. The patient's condition usually deteriorates over several hours, days, or weeks. Gradual deterioration may indicate failure of long-term controller therapy. However, rapid deterioration can occur in some patients these patients usually respond well to bronchodilator therapy.41 Severity at the time of the evaluation can be estimated by signs and symptoms or presenting PEF or FEV1 but patient response 30...

Therapy of COPD Exacerbations

An exacerbation is a sustained worsening of the patient's symptoms from his or her usual stable state that is beyond normal day-to-day variations. It is acute in onset and sufficient to warrant a change in management. Commonly reported symptoms are worsening of dyspnea, increased sputum production, and change in sputum color. The most common causes of an exacerbation are respiratory infection and air pollution, but the cause cannot be identified in about one-third of severe exacerbations....

Patient Encounter 1 Part 2 Converting to Different Drugs and Adjusting Doses

Two years following his diagnosis of lung cancer, BA has been diagnosed as having bone metastases. Pain has been controlled with the following medications hydro-morphone (Dilaudid) 10 mg IV every hour and levorphanol (Levo-Dromoran) 10 mg orally every 4 hours. He is currently receiving hydrochlorothiazide 25 mg daily, senna 2 tablets twice daily, and docusate sodium 100 mg twice daily. As the home care pharmacist, you are asked to convert this patient's pain medications to a morphine infusion....

Nonpharmacologic Therapy

To reduce nocturia, patients should be instructed to stop drinking fluids several hours before going to bed, and then voiding before going to sleep. During the day, patients should avoid excessive caffeine and alcohol intake, as these may cause urinary frequency. Patients should avoid taking nonprescription medications that can worsen obstructive voiding symptoms (e.g., antihistamines or decongestants) (Table 52-4). In addition, toilet mapping (knowing the location of toilets on the way to and...

Diuretics

Many authorities recognize the value of diuretics as first-line agents for the majority of patients with hypertension. Among others, the basis for endorsement of diuretics as choice initial drug therapy for a variety of patient types includes their practical attributes (acquisition cost and availability as combination agents), extent of experience and favorable outcomes in placebo-controlled trials. ' These virtues are further sup- ported by results of studies such as ALLHAT. Table 5-4 Commonly...

Pathophysiology Types of Pain

Several distinct types of pain have been described, for example, nociceptive, inflam- matory, neuropathic, and functional. Nociceptive pain is a transient pain in response to a noxious stimulus at nociceptors that are located in cutaneous tissue, bone, muscle, connective tissue, vessels, and viscera. Nociceptors are classified as thermal, chemical, or mechanical. The nociceptive system extends from the receptors in the periphery to the spinal cord, brain stem, to the cerebral cortex where pain...

A

Adverse effects of, 1427,1428 , 1437 -1440 dosage of, 1427 , 1428 drug interactions of, 1427 , 1428 in HIV infection, 1425, 1427 , 1428 , 1433 mechanism of action of, 1421f Abarelix in cancer therapy, 1468 dosage of, 1545 mechanism of action of, 1468 in prostate cancer, 1544 Abatacept adverse effects of, 991 dosage of, 991 in rheumatoid arthritis, 991 ABCD acronym, for melanoma, 1616-1617, 1616f Abciximab in acute coronary syndromes, 141 , 141, 145 adverse effects of, 141, 145 contraindications...

Pathophysiology

The body's main fuel source is glucose. Cells metabolize glucose completely through glycolysis and the Kreb cycle, producing adenosine triphosphate (ATP) as energy. Glucose is stored in the liver and muscles as glycogen. When energy is required, gly-cogenolysis converts stored glycogen back to glucose. Excess glucose also may be converted to triglycerides and stored in fat cells. Triglycerides subsequently undergo lipolysis, yielding glycerol and free fatty acids. While usually reserved for...

T

Tablets, administration through feeding tubes, 1714 Tacalcitol, in psoriasis, 1084 Tachyarrhythmia, 160 Tachycardia in heart failure, 81, 81 , 82 in sepsis, 1349 Tachyphylaxis, to calcitonin, 1673 Tachypnea in asthma, 268 in sepsis, 1349 TAC regimen, in breast cancer, 1482 Tacrine, in Alzheimer's disease, 598, 601 Tacrolimus adverse effects of, 54 , 946 , 951 arrhythmia with, 179 comparative efficacy of calcineurin inhibitors, 949 nephrotoxicity of, 432, 440, 441-442 in transplant recipient,...

Esophageal Clearance

Many patients with GERD produce normal amounts of acid, but the acid produced spends too much time in contact with the esophageal mucosa. The contact time is dependent on the rate at which the esophagus clears the noxious material, as well as the frequency of reflux. The esophagus is cleared by primary peristalsis in response to swallowing, or by secondary peristalsis in response to esophageal distention and gravitational effects. Table 17-1 Foods and Medications That May Worsen GERD Symptoms...

Endocrine System

CF-related diabetes (CFRD) shares characteristics of both type 1 and type 2 diabetes mellitus, but CFRD is categorized separately. Reduced functional pancreatic islet cells and increased islet amyloid deposition results in insulin deficiency, the primary cause of CFRD. Insulin secretion is delayed in response to glucose challenge, and absolute insulin secretion over time is reduced. Some insulin resistance may also be present in CFRD however, sensitivity maybe increased in CF patients without...

Patient Care and Monitoring Acne

Assess patient symptoms and the presence of acne lesions. Determine severity of acne mild, moderate or severe. 2. Review patient history to determine treatment regimens that have been used in the past, including nonprescription, prescription, and herbal medications. 3. Obtain patient's allergy status. 4. Develop a treatment plan appropriate for improvement of acne. 5. Discuss any monitoring parameters that may be necessary throughout the course of therapy. 6. Provide patient education on acne...

Race and Ethnicity

The incidence of clinical prostate cancer varies across geographic regions. Scandinavian countries and the United States report the highest incidence of prostate cancer, while the disease is relatively rare in Japan and other Asian countries.4 African American men have the highest rate of prostate cancer in the world, and in the United States, prostate cancer mortality in African Americans is more than twice that seen in Caucasian populations.1 Hormonal, dietary, and genetic differences, as...

Cycling PN

PN should be administered over 24 hours in most hospitalized patients to minimize glucose, fluid, and electrolyte abnormalities. However, administering PN via a cyclic infusion over less than 24 hours, or cycling PN, may be advantageous in certain patients and situations. Cycling PN typically involves administering the same PN volume to a goal infusion time usually over 12 hours rather than over 24 hours. Taper PN to the goal cycle over 2 to 4 days (e.g., 24 hours, then 18 hours the next day,...

Pharmacologic Therapy

Nonprescription cough and cold preparations are used frequently to manage cold symptoms despite the lack of evidence to support their safety and efficacy. Over 10 of children per week receive nonprescription cough and cold remedies with highest use among children under 5 years of age.46 Reports of serious adverse events and deaths have led to efforts to eliminate use of nonprescription cough and cold medica- tions in young children. Manufacturers have removed product labeling for children under...

Patient Encounter 1 Part 1 Patient History

A 74-year-old Caucasian woman with a history of chronic obstructive pulmonary disease (COPD) and gastroesophageal reflux disease (GERD) presents to the clinic for follow-up. She reports intermittent daytime and nighttime sweating that comes on suddenly. She reports soaking her bed sheets when this occurs. She had a hysterectomy at age 20 and has never taken estrogen replacement. She reports good relief of reflux symptoms on her current regimen. She started taking a calcium supplement...

Secondary Hyperparathyroidism and Bone and Mineral Metabolism Disorders

Increases in parathyroid hormone (PTH) occur early as kidney function begins to decline. The actions of PTH on bone turnover lead to bone and mineral metabolism disorders (BMMD). As many as 75 to 100 of patients with stage 3 CKD have BMMD.52 The type of bone disease can vary based on the degree of bone turnover. High bone turnover is the most common cause of bone abnormalities in patients with CKD, present in as many as 75 of patients receiving dialysis,52 and is generally mediated by high...

Small Cell Lung Cancer

SCLC typically presents as extensive disease (approximately 60-70 of new cases) and progresses very quickly. Small cell carcinomas are very responsive to chemotherapy and radiation, but have a short duration of response. Radiotherapy became the standard in 1969, when a randomized trial showed that it offered the potential for cure, whereas surgery did not. In the vast majority of patients, chemotherapy with or without radiotherapy is the treatment of choice. Even after a complete response to...

Epidemiology and etiology

While it is widely known that chemotherapy causes nausea and vomiting, the rate of emesis varies depending on individual patient risk factors and drug therapy regimen. Therefore, cancer treatments are stratified into varying risk levels high, moderate, low, and minimal. Agents with a high emetic risk cause emesis in greater than 90 of cases if not given any prophylaxis. The rates of emesis for moderate, low, and minimal are 30 to 90 , 10 to 30 , and less than 10 , respectively. Table 99-1 lists...

Vaccinations

Several HPV genotypes have been linked to the development of cervical cancer. HPV vaccine (Gardasil), developed to protect against HPV genotypes 6, 11, 16, and 18, is the first employed to prevent cervical cancer, precancerous genital lesions, and genital warts due to HPV. The CDC recommends the HPV vaccine for all 11- and 12- year-old females. Vaccination is also recommended for females aged 13 through 26 years who have not been previously vaccinated or who have not completed the full series...

Have been reported with PD pathophysiology

Amygdala Pathophysiology

The thalamus and amygdala are important in the generation of a normal fear response and play a central role in most anxiety disorders. The thalamus provides the first real processing region to organize sensory data obtained from the environment. It passes information to higher cortical centers for finer processing and to the amygdala for rapid assessment of highly charged emotional information. The amygdala provides the emotional importance of the information. This helps the organism to act...

End Stage Renal Disease

Chronic kidney disease is progressive and leads to renal failure. In end-stage renal disease (ESRD) the only life-sustaining treatments are dialysis or renal transplant. Without treatment, kidney failure causes uremia, oliguria, hyperkalemia and other electrolyte disorders, fluid overload and hypertension unresponsive to treatment, anemia, hepatorenal syndrome, and uremic pericarditis. Symptoms associated with chronic kidney disease (stage 5) include fatigue, pruritus, nausea, vomiting,...

Patient Encounter Part 1

GR is a 68-year-old, 64 kg African American male who presents to the emergency department with dizziness and loss of speech that began 1 hour ago. His past medical history is significant for hypertension, diabetes mellitus, dyslipidemia, and benign pro-static hypertrophy (BPH). Social history is significant for smoking one pack per day for the last 38 years. Current medications include metoprolol 50 mg twice daily, insulin NPH 20 units twice daily, and simvastatin 20 mg daily. What signs and...

Patient Care and Monitoring

Patient monitoring should involve a regular systematic evaluation ofefficacy and adverse events, referral to appropriate specialists, and patient education. 1. Determine type of symptoms, frequency, and exacerbating factors. Assess for PD treatment-related complications Assess the patient's symptoms to determine if therapy should be adjusted or maintained, or if referral for more extensive evaluation is needed. 2. Review any available diagnostic data to determine status, motor ability,...

Clinical Staging

Once the diagnosis of lung cancer is confirmed through visualization and biopsy, the extent of disease must be determined. NSCLC is staged using the American Joint Committee on Cancer tumor, node, and metastasis (TNM) staging system. SCLC is typically staged using the Veterans Administration Lung Cancer Study Group method. Clinical staging serves two primary purposes predicting prognosis and guiding therapy. Clinical staging of NSCLC with the TNM system evaluates the size of the tumor (T),...

Clinical Presentation and Diagnosis of Sleep Disorders

Patients with sleep disorders may complain about daytime symptoms. A bed partner may witness hallmark characteristics of the sleep disorder. Patients with sleep complaints should have a careful sleep history performed to assess their possible sleep disorder in order to guide diagnostic and therapeutic decisions. Daytime Symptoms and Associated Characteristics EDS is the primary symptom described by patients with sleep disorders. It is usually described as not waking up refreshed in the morning,...

Key concepts

Common symptoms of menopause include hot flashes, night sweats, vulvova-ginal atrophy, and vaginal dryness. Women less commonly may experience mood swings, depression, insomnia, arthralgia, myalgia, and urinary frequency. Hormone therapy (HT) remains the most effective treatment for vasomotor symptoms and vulvovaginal atrophy and should be considered for women experiencing these symptoms. Women should receive a thorough history and physical examination, including assessing for coronary heart...

Physiology anatomy and biochemistry of the adrenal gland

Adrenal Glands Anatomy

The adrenal gland is located on the upper segment of the kidney (Fig. 45-1).1 It consists of an outer cortex and an inner medulla. The adrenal medulla secretes the catecholamines epinephrine (also called adrenaline) and norepinephrine (also called noradrenaline), which are involved in the regulation of the sympathetic nervous system. The adrenal cortex consists of three histologically distinct zones the zona glom-erulosa, zona fasciculata, and an innermost layer called the zona reticularis....

Renin AngiotensinAldosterone System

Since the discovery of renin over 100 years ago, the renin-angiotensin-aldosterone system (RAAS) has been extensively studied as a prime target or site of action for many effective antihypertensives.16 Renin is produced and stored in the juxtaglomerular cells of the kidney, and its release is stimulated by impaired renal perfusion, salt depletion, Pi-adrenergic stimulation. The release of renin is the rate-limiting step in the eventual formation of angiotensin II, which is primarily responsible...

Chemotherapy safety

One of the first Institute of Medicine reports starts out with a patient who died from an overdose of chemotherapy the patient did not have an immediately life-threatening cancer, so her death was hastened by a medication error. Chemotherapy agents may cause harm to patients, health care workers, and the environment if not handled correctly. Because of the severe toxicities associated with many of the chemotherapy agents, safety precautions must be in place to prevent chemotherapy errors,...

Etiology and epidemiology

Obesity is a multifactorial, complex disease that occurs following an interaction between genotype and the environment. While the etiology is not known completely, it involves overlapping silos of social, behavioral, and cultural influence patho- physiology metabolism and genetic composition. The majority of overweight or obese individuals are adults, but these diseases are also prevalent in children between 2 and 19 years of age. Thirty-two percent of adults 20 years of age and older are...

Clinical Manifestations of Thyrotoxicosis

Many of the signs and symptoms seem to be related to autonomic hyperactivity. As with hypothyroidism, the clinical manifestations may be subtle initially and slowly progressive. Screening of patients for thyroid disease may identify patients with sub-clinical or mild thyrotoxicosis. Patients may seek medical attention only after a long period of thyrotoxicosis or owing to an acute complication such as atrial fibrillation. The clinical manifestations of thyrotoxicosis in the elderly may be...

Pathophysiology Lipid and Lipoprotein Metabolism

Cholesterol is an essential substance manufactured by most cells in the body. Cholesterol is used to maintain cell wall integrity and for the biosynthesis of bile acids and steroid hormones. Other major lipids in our body are triglycerides and phospholip-ids. Since cholesterol is a relatively water-insoluble molecule, it is unable to circulate through the blood alone. Cholesterol along with triglycerides and phospholipids are packaged in a large carrier-protein called a lipoprotein (Fig. 12-1)....

Impaired Potassium Homeostasis

Potassium balance is also primarily regulated by the kidney via the distal tubular cells. Reduction in the number of functioning nephrons decreases the overall tubular secretion of potassium, leading to hyperkalemia. Hyperkalemia is estimated to affect more than 50 of patients with stage 5 CKD. Pathophysiology The distal tubules secrete 90 to 95 of the daily dietary intake of potassium. The fractional excretion of potassium (FEk) is approximately 25 with normal kidney function.40 The GI tract...

Gell and Coombs

Type I reactions occur when the drug or its bound hapten incites an IgE antibody response. IgE binds to high-affinity receptors on mast cells and basophils. When the original antigen cross-links cell-bound IgE, the effector cell releases enormous amounts of preformed mediators, producing the well-known symptoms of immediate hyper-sensitivity urticaria, rhinitis, bronchoconstriction, and anaphylaxis. Type II reactions are produced by IgG (or IgM) antibody. The drug or hapten that elicited the...

Poliovirus Vaccine

Poliomyelitis is a highly contagious disease that is often asymptomatic however, approximately 1 in every 100 to 1,000 cases will develop a rapidly progressive paralytic disease. Polio is caused by poliovirus which has three serotypes type 1 is most frequently associated with paralytic disease. Poliovirus replicates in the oropharynx and intestinal tract and is excreted in oral secretions and feces, which can infect others. As a result, more than 90 of unvaccinated individuals will become...

Pathogenesis and clinical presentation

Invasive candidiasis is not a single syndrome, rather a spectrum of infections that differ in terms of clinical presentation and course depending on the type of host immune immunosuppression. Many forms of invasive candidiasis are potentially severe, however, with high (30-60 ) rates of crude morbidity and mortality.19 The most common form of invasive candidiasis is seen in non-neutropenic patients with disruption of the GI, skin or microbiologic barriers giving rise to a bloodstream infection...

Relapsed ALL

Relapse is the recurrence of leukemic cells at any site after remission has been achieved. Relapse is a major complication for 15 to 20 of patients with ALL. Current research suggests that this is the result of residual leukemic cells at diagnosis. Thus the importance ofMRD. Bone marrow relapse is the principal form of treatment failure in patients with ALL. Extramedullary sites of relapse include the CNS and the testicles. Extramedullary relapse while once common, has decreased to 5 or less...

Varicella Vaccine

Varicella zoster virus is a herpes virus that infects nearly all humans. Primary infection with Varicella zoster causes chickenpox (varicella), which is one of the most common childhood diseases. Chickenpox has always been thought to be a benign disease causing few serious complications in children. The rate of chickenpox prior to the vaccine becoming available was thought to approximate the birth rate with 3 to 4 million cases annually resulting in 11,000 hospitalizations and 100 deaths....

Migraine Headache in Children and Adolescents

Migraine headaches are common in children and their prevalence increases in the ad- olescent years. The diagnosis and evaluation of headaches is especially difficult in children, given their decreased ability to articulate symptoms. Treatment presents another challenge to the practitioner, because medications used for headache management in adults have not been fully evaluated for efficacy and safety in children. Consensus panel recommendations identify ibuprofen as effective and acetaminophen...

Pharmacologic Treatment Fig 561

The NOF recommends that all men and women over age 50 be considered for pharmacologic treatment if they meet any of the following criteria history of hip or vertebral fracture, T-score less than or equal to -2.5 at femoral neck or spine, or osteopenia and at least a 3 10-year probability of hip fracture or at least a 20 10-year probability of major osteoporosis-related fracture as determined by FRAX.1 'Major nsk factors low body we ght. personal history of fracture as an adult (alter age 45...

Control risk factors

Hypertension Dyslipidem.a Obesity Metabolic syndrome Cigarette smoking FIGURE 7-4. General treatment strategies for angina follow in clockwise fashion from the top center. (ACE-I, angiotensin-converting enzyme inhibitor ARB, angiotensin receptor blocker.) Therapies to alleviate and prevent angina are aimed at improving the balance between myocardial oxygen demand and supply. Since angina usually results from increased myocardial oxygen demand in the face of a relatively fixed reduction in...

Appendix B Common Laboratory Tests

The following table is an alphabetical listing of some common laboratory tests and their reference ranges for adults as measured in plasma or serum (unless otherwise indicated). Reference values differ among laboratories, so readers should refer to the published reference ranges used in each institution. For some tests, both the Syst me International Units and Conventional Units are reported. Ar 1 iV l piiitiiil ttllQfrtoOptetfn TH loPT I) Adrenocorticotropic ly mane (ACTH Wainini amiivKraniitr...

Patient Encounter 2 Part 3 ITP Creating a Care Plan for ITP patient

Based on the information presented, create a care plan for this patient's ITP. For most patients, the initial dose of eltrombopag is 50 mg once daily. The daily dose is subsequently adjusted to a maximum dose of 75 mg daily, in order to achieve and maintain a platelet count greater than or equal to 50 x 103 mm3 (50 x 109 L) in order to reduce the risk for bleeding. Romiplostim and eltrombopag are effective in increasing platelet counts in patients with ITP and can be used in combination with...

P

See Cardiac pacemaker Packed red blood cells, in hypovolemic shock, 256a, 259 Paclitaxel adverse effects of, 1458, 1483t, 1484, 1491-1493 albumin-bound, 1458 in breast cancer, 1482, 1483t, 1484 in cancer therapy, 1458 dosage of, 1458, 1483t, 1491, 1507t, 1572t, 1573, 1574t drug interactions of, 955t, 1458 drug-eluting vascular stents, 118 extravasation of, 1677, 1677t, 1678t in lung cancer, 15071, 1510-1511 mechanism of action of, 1458 in ovarian cancer, 1569, 1571, 1571t,...

Clinical Presentation and Diagnosis of Anovulatory Bleeding

May or may not be in acute distress Symptoms Irregular, heavy, or prolonged vaginal bleeding, perimenopausal symptoms (hot flashes, etc.) Acne, hirsutism, obesity Laboratory Tests If suspect PCOS, consider free or total testosterone, fasting glucose, fasting lipid panel If suspect perimenopause, FSH Other Diagnostic Tests Pelvic ultrasound to evaluate for polycystic ovaries Patient Encounter 2, Part 1 TP, a 22-year-old woman, presents to your office for a routine gynecologic examination. She...

Adverse Effects

Therapy with estrogen with or without a progestogen should be initiated at the lowest dose in order to minimize adverse effects. Because the adverse effects of these preparations can be similar, it may be difficult to assess whether the estrogen or the progestogen is the cause. Changing preparations, particularly the progestogen, or changing the method of administration may help to alleviate adverse effects. Table 50-2 lists the adverse effects that may be associated with estrogen and...

Treatment Desired Outcomes

Once extravasation occurs, the primary goals of treatment are to (a) avoid further tissue damage by using appropriate nonpharmacologic and pharmacologic strategies (b) promptly refer patients for surgery if required. Optimal pharmacologic and nonphar-macologic treatment of the extravasation will allow the cancer patient to continue with their chemotherapy (Table 99-19). If extravasation occurs, the infusion should be stopped immediately with aspiration of fluid from the site, needle, and tubing...

Patient Encounter 2

A 40-year-old woman presents with right elbow pain. On questioning, you determine that she works in a factory performing repetitive tasks with her right arm. She reports the gradual onset of pain over the last few months. When she wakes in the morning, she has minimal pain after rest, but the pain intensifies after a few hours at work. She tends to have less pain on weekends. She reports decreased range of motion compared with the left side. She is a nonsmoker and does not drink. She has no...

Epidemiology

Dry eye is a frequent cause of eye irritation. A lack of a single diagnostic test for the condition limits the available epidemiologic data. One study estimated the prevalence of dry eye in the U.S. population age 65 and older at 14.6 , which is approximately FIGURE 63-4. Amsler's grid distortions in the lines of the grid may be caused by subtle changes in central vision due to fluid in the subretinal space. This is the Amsler's grid as it appears to someone with normal vision. (From the...

Cancer Chemotherapy and Treatment

Upon completion of the chapter, the reader will be able to 1. Describe the etiology of cancer. 2. Define the tumor, nodes, metastases (TNM) system of cancer staging. 3. Classify each drug used in the treatment of cancer, and compare and contrast the mechanisms of action, uses, and side effects. 4. Outline actions for all health care providers to prevent medication errors with cancer treatments. 5. Describe the role of the health care practitioner in the care of cancer patients. The word cancer...

Amyloidosis

Systemic lupus erythematosus Scleroderma SFeep apnea Drugs Adenosine Amiodarone Blockers Buplvicaine Carbamazepine Chbroquine DigoKtn Dillia em Drbnedarone Hecainide AV, atrioventricular, from Refs. 12,13,15. Clinical Presentation and Diagnosis of AV Nodal Blockade Symptoms Hyd rox y c h tor o q uine Paclitaxel First-degree AV nodal blockade is rarely symptomatic, because it rarely results in bradycardia Second-degree AV nodal blockade may cause bradycardia, as not all impulses generated by the...

Patient Encounter 2 Part 2 Selecting Antifungal Therapy

The patient is started on fluconazole 400 mg day, but 3 days later has persistent fever and develops hypotension and decreased urine output. Blood cultures reveal a germ tube-negative yeast growing in the blood. Laboratory studies revealed a WBC of 12.3 x 103 mm3 (12.3 x 10 L), aspartate aminotransferase 68 IU L (1.13 Kat L), alanine aminotransferase 75 IU L (1.25 Kat L), alkaline phosphatase 168 IU L (2.8 Kat L), and normal bilirubin. Serum creatinine is 1.8 mg dL (159 p,mol L). What factors...

General Approach to Treatment

Hypercalcemia Related Malignancy

Therapeutic options for the treatment of hypercalcemia should be directed toward the level of corrected serum calcium and the presence of symptoms (Fig. 99-5). Hypercalcemia may be classified as mild (corrected calcium equal to 10.5-11.9 g dL 2.6-3 mmol L ), moderate (12-13.9 g dL 3-3.5 mmol L ), and severe (greater than 14 g dL 3.5 mmol L ). Adequate treatment of mild or asymptomatic hypercalcemia may be achieved on an outpatient basis with nonpharmacologic measures. Moderate to severe or...

Pharmacologic Systemic Therapy Endocrine Therapy

The pharmacologic goals of endocrine therapy for breast cancer are either to decrease circulating levels of estrogen and or to prevent the effects of estrogen on the breast cancer cell (targeted therapy) through blocking the hormone receptors or downregu-lating the presence of those receptors. Achievement of the first goal depends on the menopausal status of the patient, but achievement of the second goal is independent of menopausal status. Many endocrine therapies are available to target...

Oral Analgesics

Nonopioid analgesics, including acetaminophen, aspirin, and NSAIDs, are used commonly for musculoskeletal disorders. All these agents provide analgesia, but aspirin and NSAIDs also work peripherally to decrease production of the principal mediator of acute inflammation, PGE2.19 NSAIDs and aspirin inhibit the enzyme COX. While the mechanism of action of acetaminophen is less clear, it appears that acetaminophen acts as a weak inhibitor of PG production. In contrast to aspirin and NSAIDs that...

PLactam Allergy

Penicillin allergy is one of the most common reported drug allergies. Concerns over cross-reactivity may limit the use of -lactams for surgical prophylaxis. A thorough drugallergy history should be taken to discern true allergy (e.g., anaphylaxis) from adverse event (e.g., stomach upset). Allergy testing may be helpful in confirming a patient's penicillin allergy and could spare vancomycin. However, practitioners should be aware allergy testing may be difficult to perform due to the removal of...

Patient Encounter

A 78-year-old Caucasian man presents to the emergency department with complaints of a headache persisting over the last 3 days. Repeated BP measurements average 200 110 mm Hg. He reports no other symptoms physical examination and laboratory tests are unremarkable as is his past medical history with exception of hypertension diagnosed in his early 60s. He reports he is struggling on a fixed retirement income with no prescription coverage and takes what I can afford. BP medications are...

Treatment Desired Outcome

Locally advanced breast cancer generally refers to breast carcinomas with significant primary tumor and nodal disease but in which distant metastases cannot be documented. A wide variety of clinical scenarios can be seen within this group of patients, including neglected tumors that have spread locally and inflammatory breast cancers that are a unique clinical entity. Many locally advanced breast cancers are diagnosed in patients who have had symptoms for months to years and have neglected to...

Upon completion of the chapter the reader will be able to

Identify the structures of the male reproductive system and describe the physiology of a penile erection. 2. Differentiate between organic and psychogenic erectile dysfunction (ED) and describe the etiology and pathophysiology of each. 3. Identify the drug classes most likely to contribute to ED. 4. Define the essential components of history, physical examination, and laboratory data needed to evaluate the patient presenting with ED. 5. Describe current nonpharmacologic and pharmacologic...

Immunosuppressive Therapies Induction Therapy

The goal of induction therapy is to provide a high level of immunosuppression in the critical early post-transplant period, when the risk of acute rejection is highest.2,8,10-12 This stage of immunosuppression is often initiated intraoperatively or immediately postoperatively and is generally concluded within the first 7 to 10 days after transplantation. Induction therapy is not a mandatory stage of recipient immuno-suppression. However, since acute rejection is a major concern in solid organ...

Vaccine administration schedules

Most vaccines are administered in two- to four-shot series in order to elicit the best protection. Childhood and adult immunization schedules are revised frequently and published annually by the CDC Advisory Committee on Immunization Practices. Current immunization schedules can be found at www.cdc.gov. The childhood schedule is published in January and the adult schedule in October of each year. Recommendations will be published throughout the year in the Morbidity and Mortality Weekly Report...

Composition of Refluxate

The composition, pH, and volume of the refluxate are other factors associated with gastroesophageal reflux. Duodeno-gastric reflux esophagitis or alkaline esophagitis refers to esophagitis induced by the reflux of bilious and pancreatic fluid. Although bile acids have both a direct irritant effect on the esophageal mucosa and an indirect effect of increasing hydrogen ion permeability of the mucosa, symptoms are more often related to acid reflux than to bile reflux. The percentage of time that...

Treatment Of Acute Ischemic Stroke

Acute ischemic stroke is a medical emergency. Identification of the time and manner of stroke onset is an important determinant in treatment. The time the patient was last without symptoms is used as the time of stroke onset. Because patients typically do not experience pain, determining the onset time can be difficult. It is also important to document risk factors and the previous functional status of the patient to assess current disability due to stroke. FIGURE 11-2. Acute stroke treatment...

Treatment Of Headache Disorders Desired Outcomes

The primary short-term treatment goal of migraine is to achieve rapid pain relief allowing the patient to resume normal activities21 The long-term goal of therapy is to prevent headache recurrences and to diminish headache severity. Similarly, the goal of TTH is to lessen headache pain, while the long-term goal is to avoid analges-22 ic dependence. The short-term goal in cluster headache therapy is to achieve rapid pain relief. Prophylactic therapy may be necessary to obtain the...

Desired Outcomes

Health care providers use a multimodality approach including surgery and chemotherapy in initial treatment of ovarian cancer with a curative intent, or restoring a normal life span. Although majority of patients will initially achieve a CR more than 50 will recur within the first 2 years. '31 CR to treatment is defined as no evidence of disease can be detected by physical examination or diagnostic tests and patient has a normalized CA-125. The stage of disease at the time of diagnosis is the...

Abbreviations Introduced in This Chapter

AUC Area under the curve BRCA1 Breast cancer activator gene 1 International Federation of Gynecology and Hereditary breast and ovarian cancer Hereditary nonpolyposis colorectal cancer National Comprehensive Cancer Network Self-assessment questions and answers are available at ht-tp www. mhpharmacotherapy. com pp.html.

Hypoproliferative or Decreased Production Anemias Nutritional

Deficiencies in nutrients such as folic acid and vitamin B12 may hinder the process of erythrocyte maturation.4,5 Folic acid and vitamin B12 are required for the formation of DNA. When these nutrients are decreased, DNA synthesis is inhibited, and consequently, erythrocyte maturation also is inhibited.4,5 Poor diet can be a contributor to the deficiencies in these nutrients. Similarly, patients with a condition called pernicious anemia are unable to absorb B12 via their GI tract due to a lack...

Pharmacologic Systemic Adjuvant Therapy

Unfortunately, breast cancer cells often spread by contiguity, lymph channels, and through the blood to distant sites. This often occurs early in the breast cancer growth, and deposits of tumor cells form in distant sites that cannot be detected with current diagnostic methods and equipment (micrometastases). Systemic adjuvant therapy is defined as the administration of systemic therapy following definitive local therapy (i.e., surgery, radiation, or a combination of these) when there is no...

Bronchodilators

'O' Bronchodilators are the mainstay of treatment for symptomatic COPD. They reduce symptoms and improve exercise tolerance and quality of life.2 They can be used as needed for symptoms or on a scheduled basis to prevent or reduce symptoms. Bron-chodilator drugs commonly used in COPD include P2-agonists, anticholinergics, and theophylline. The choice depends on availability, individual response, and preferences. The inhaled route is preferred, but attention must be paid to proper inhaler...

Patient Encounter 1 Part 1

A 48-year-old man with a history of hypertension, peptic ulcer disease (gastric ulcer 1 year ago), and morbid obesity presents to the emergency department complaining of excruciating pain in his left big toe and both ankles. This is similar to a painful episode he had with his left toe and ankle 6 months ago. On examination, his left great toe and both ankles are red, swollen, and warm to the touch. He describes the pain as throbbing and rates it as a 10 10 (where 10 is the worst pain he has...

Patient Encounter 2 Part 2 Medical History Physical Examination and Diagnostic Tests

The 52-year-old man who developed complications after abdominal surgery was intubated 6 days ago. The nurses note an increase in the amount and the purulence of his sputum. Attempts yesterday and today to wean the patient off the ventilator have failed. He is sedated, but he does respond to commands. PMH Small bowel obstruction, surgery 8 days ago hypertension for 15 years, currently controlled FH Father died of acute MI at the age of 68 years mother, age 72 years is alive, with hypertension...

Patient Encounter 1

HPI A 72-year-old man with a history of congestive heart failure, diabetes, hypertension, and hyperlipidemia presents to the local emergency room with complaints of increasing shortness of breath, cough productive of yellow-green sputum, chest pain, fever, and malaise. He was hospitalized 12 days ago for urosepsis, for which he received 10 days of levofloxacin. PMH Congestive heart failure, diabetes mellitus x 22 years, hypertension, hyperlip-idemia Chronic renal insufficiency baseline SCr 1.8...

Hepatitis B Vaccine

Hepatitis B virus is a blood-borne or sexually transmitted virus. Most acute infections occur in adults, while chronic infections usually occur in individuals infected as infants or children. However, about 10 of adults who contract hepatitis B virus will fail to clear their infection and develop chronic hepatitis B infection. Individuals with chronic hepatitis B infection are at risk for cirrhosis or hepatocellular carcinoma. Vaccination with hepatitis B vaccine is the most effective way to...

Geriatric Assessment

The term geriatric assessment is used to describe the interdisciplinary team evaluation of the frail, complex elderly patient. Such a team may include but is not limited to a geriatrician, nurse, pharmacist, case manager social worker, physical therapist, oc cupational therapist, speech therapist, psychologist, nutritionist, dentist, optometrist, and audiologist. Assessment may be performed in a centralized geriatric clinic, or by a series of evaluations performed in separate settings. The team...

Introduction

Despite efforts to promote awareness, treatment, and the means available to aggressively manage high blood pressure (BP), trends over the past 15 years demonstrate only modest improvements in its treatment and control. National and international organizations continually refine their recommendations of how clinicians should approach the management of patients with high BP, and although approaches vary to some degree, there are clear themes that emerge regardless of which national or...

Gh somatotropin

Acromegaly Pictures Before After

Somatotropin or GH is the most abundant hormone produced by the anterior pituitary lobe. The GH-secreting somatotropes account for 50 of hormone-secreting cells in the anterior pituitary. GH is regulated primarily by the hypothalamic-pituitary axis. The hypothalamus releases growth hormone-releasing hormone (GHRH) to stimulate GH synthesis and secretion, whereas somatostatin inhibits it.1 Upon stimulation by GHRH, somatotropes release GH into the circulation, thereby stimulating the liver and...

Patient Encounter Part 3 Creating a Care Plan

Based on the information presented, create a care plan for this patient's colon cancer. Your plan should include (a) the patient's drug-and nondrug-related needs and problems, (c) a treatment plan specific to GW that includes strategies to prevent adverse effects of chemotherapy, (d) a follow-up plan to determine whether the goals have been achieved and the adverse effects of chemotherapy have been minimized, and (e) a plan for treatment options when the initial therapy is no longer achieving...

Preparative Regimens for HSCT

Examples of commonly used preparative regimens are included in Table 98-2. The nonhematologic toxicity differs based on the preparative regimen administered. Myeloablative Preparative Regimens In both autologous and allogeneic HSCT, infusion of stem cells circumvents dose-limiting myelosuppression, maximizing the potential value of the steep dose-response curve to alkylating agents and radiation, suppressing the host immune system, and creating space in the marrow compartment to facilitate...

Clinical Presentation and Diagnosis of Allergic and Pseudoallergic Drug Reactions

The clinical presentation of a patient experiencing an allergic reaction varies greatly. The primary reactions are described below Anaphylaxis Anaphylaxis is an acute life-threatening allergic reaction. Signs and symptoms involve the skin (e.g., pruritis, urticaria), respiratory tract (e.g., dyspnea, wheezing), gastrointestinal tract (e.g., nausea, cramping), and cardiovascular system (e.g., hypotension, tachycardia). Onset is usually within 30 minutes, but can be as long as 2 hours. Treatment...

Toxicities and Management of Preparative Regimens

Myelosuppression is a frequent dose-limiting toxicity for antineoplastics when administered in the conventional doses used to treat cancer. However, because myelosuppression is circumvented with hematopoietic rescue in the case of patients receiving HSCT, the dose-limiting toxicities of these myeloablative preparative regimens are nonhematologic and vary with the preparative regimen used. Most patients undergoing HSCT experience toxicities commonly associated with chemotherapy (e.g., alopecia,...

Treatment Desired Outcomes and Goals

While eliminating existing lesions and preventing the development of new lesions are primary goals of acne therapy, secondary goals include relieving pain or discomfort and preventing permanent scarring.8 In addition, acne can cause patients a significant amount of stress, anxiety, frustration, embarrassment, and even depression. 0 Because of these psychological symptoms, treatment compliance and patient education on both physical and psychological aspects of this skin disorder are also...

Nausea and Vomiting

Platinum agents are the most active lung cancer agents and historically have very high rates of nausea and vomiting. This is particularly true of high-dose cisplatin, which is used in many regimens. Understanding how to prevent and treat chemotherapy-induced nausea and vomiting (CINV) in lung cancer patients is crucial because nearly all the regimens are highly emetogenic. Although the pathology of CINV is not fully understood, there are three classifications of CINV based on the time of...

Patient Care and Monitoring of Streptococcal Pharyngitis

Assess the patient's signs and symptoms. Are they consistent with streptococcal pharyngitis Are symptoms of viral infection present 2. Perform laboratory testing to confirm the presence of group A streptococci. 3. Does the patient require antibiotic therapy Avoid antibiotic use in viral disease. 4. Obtain a complete medication history, including prescription drugs, nonprescrip-tion drugs, and natural product use, as well as allergies and adverse effects. 5. Recommend antipyretic or analgesic...

Parasitic Diseases

Upon completion of the chapter, the reader will be able to 1. Identify the primary reasons why some parasitic diseases may be more prevalent in the U.S. population. 2. Describe the treatment algorithm for giardiasis and amebiasis. 3. List one effective therapy for nematodes and select the drugs of choice for strongyloidiasis and tapeworms. 4. List three major reasons why travelers are infected with malaria. 5. Describe the presenting signs and symptoms of malaria. 6. List some specific...

References

Young AS, Klap R, Sherbourne CD, Wells KB. The quality of care for depressive and anxiety disorders in the United States. Arch Gen Psychiatry 2001 58 55-61. 2. Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text revision. Washington, DC American Psychiatric Association, 2000 429-484. 3. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of the DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005a 62...

Trior to matinib therapy Epidemiology And Etiology

It was estimated that 5,050 new cases of CML were diagnosed in 2009, accounting for 15 of all adult leukemias. The incidence of CML increases with age, with the median age of diagnosis in the fifth decade of life.1 In most newly diagnosed cases, the etiology cannot be determined but high doses of ionizing radiation and exposure to solvents such as benzene are recognized risk factors. CML arises from a defect in an early progenitor cell. The pluripotent (noncommitted) stem cell is implicated as...

Primary Angle Closure Glaucoma

Therapeutic modalities for PACG are targeted at decreasing IOP. The goals of therapy are to preserve visual function by controlling the elevation in IOP manage an acute attack of angle closure reverse or prevent angle closure using a laser and or surgical intervention educate and involve the patient in the management of the disease.10 The treatment of choice for PACG is laser iridotomy. Medical therapy is used to lower IOP, reduce pain, and reverse corneal edema before the iridotomy. Laser...

PAdrenergic Antagonists

Topical B-adrenergic antagonists (B-blockers) are generally considered first-line agents for the treatment of POAG unless contraindications are present. ' Topical B-blockers decrease IOP by reducing the formation of aqueous humor made by the ciliary body which results in 20 to 35 reduction in IOP.1113 34 Timolol, levobunolol, metipranolol and carteolol are nonselective for ft- and B2-adrenergic receptors, while betaxolol has ft1-selective properties. All of the topical B-blockers have similar...

Patient Encounter 1 Part 1 Risk Factor Evaluation and Recommended Frequency of Eye Care

A 65-year-old African American female with a history of type 2 diabetes, mild intermittent asthma, and hypertension presents to your clinic for her yearly checkup. She states that she is concerned about losing her eyesight because her sister has started losing her vision from glaucoma. She denies any changes in her vision. Meds Metformin 1,000 mg orally twice a day, albuterol two puffs every 6 hours as needed for wheezing, lisinopril 10 mg orally daily What risk factors does this patient have...

BRM other agents Can also consider BRM earlier even as first line bul costly

Treatment algorithm for moderate to severe psoriasis. Pharmacologic Treatment Pharmacologic alternatives for psoriasis include topical agents, phototherapy, and systemic agents including the use ofBRMs. See Figures 64-1 and 64-2 for treatment algorithms. Topical Therapy for Psoriasis Topical therapy is the initial drug treatment strategy for patients with mild to moderate psoriasis. It is estimated that approximately 70 to 80 of all patients with psoriasis can be treated adequately...

Bariler Migraine

Cancer statistics, 2008. CA Cancer J Clin 2008 58 71-96. 2. Blagosklonny MV. Molecular theory of cancer. Cancer Biol Ther 2005 Jun 4(6) 621-627. 3. Folkman J. Angiogenesis. Annu Rev Med 2006 57 1-18. 4. Mountford CE, Doran S, Lean CL, Russell P. Cancer pathology in the year 2000. Biophys Chem 1997 Oct 68(1-3) 127. 5. Paolo A, Danesi R, Vannozzi F, et al. Limited sampling model for the analysis of 5-fluorouracil pharmacokinetics in adjuvant chemotherapy for...

Allergies NKDA

Meds Diltiazem CD 240 mg once daily nitroglycerin 0.4 mg sublingual (SL) as needed (last use yesterday after showering) glipizide 10 mg twice daily for diabetes ibuprofen 600 mg twice daily for arthritis pain vitamin B12 once daily multivitamin daily aspirin 325 mg once daily FH Significant for early heart disease in father (MI at age 53) SH Disabled from a previous accident married, has six children, and runs her own business she does not drink alcohol and smokes one to two packs of cigarettes...

H

HACEK group, in infective endocarditis, 1236t, 1241, 1248 Haemophilus aphrophilus, in infective endocarditis, 1241 Haemophilus ducreyi, 1333-1334. See also Chancroid Haemophilus influenzae, 1407 in bite wound infections, 1232t in conjunctivitis, 1065 in COPD exacerbations, 298, 299t in cystic fibrosis, 304, 309 in immune thrombocytopenic purpura, 1134 in infective endocarditis, 1241 in meningitis, 1170, 1171t, 1176t, 1179, 1181-1182, 1184 in otitis media, 1204 in pneumonia, 1190, 1190t, 1193,...

Levocarnitinein Libido

Adverse effects of, 71 in arrhythmias, 162 dosage of, 71 , 124 in heart failure, 97 in hypertension, 61 , 67, 70, 71 , 72 in hypertensive emergency, 71 in ischemic heart disease, 124 mechanism of action of, 162 in pregnancy, 72 in stroke, 220 Labor, preterm, 826, 832 , 835-836 Labyrinthitis, nausea and vomiting with, 358t Lacrimation, in opioid withdrawal, 619 Lactase deficiency, 376 Lactase tablets, 380 Lactated Ringer's solution, 482, 482t in dehydration, 1268t in hypovolemic shock, 256a, 257...

Prevention And Treatment Of Viral Hepatitis Desired Outcomes

General desired outcomes for treating hepatitis are to (a) prevent the spread of the disease (b) prevent and treat symptoms (c) suppress viral replication (d) normalize hepatic aminotransferases (e) improve histology on liver biopsy and (f) decrease morbidity and mortality by preventing cirrhosis, HCC, and ESLD. For hepatitis B, additional treatment goals include (a) seroconversion or loss of HBsAg (b) seroconversion or loss of HBeAg and (c) achieving undetectable HBV DNA levels. Additional...

Urinary Tract Infections

Septic patients with a community-acquired urinary tract infection should be treated with a third-generation cephalosporin (ceftriaxone or cefotaxime) or a fluoro-quino- lone (ciprofloxacin or levofloxacin). The causative pathogen is commonly an enteric gram-negative bacilli (i.e., Escherichia coli). Nosocomially-acquired urinary tract infections are often related to catheters and are caused by fermenting and nonfermenting (Pseudomonas) gramnegatives, and enterococci (see Table 82-3). -Lactam...

SF Sexual ly t ra ns m ittcd i n fee t ion WSW Women who have sex with women

Self-assessment questions and answers are available at ht-tp www. mhpharmacotherapy. com pp.html. 1. Birley H, Duerden B, Hart C. Sexually transmitted diseases Microbiology and management. J Med Microbiol 2002 51 793-807. 2. Aral S. Sexually risky behaviour and infection Epidemiological considerations. Sex Transm Infect 2004 80(Suppl II) ii8-ii12. 3. Biddlecom A. Trends in sexual behaviours and infections among young people in the United States. Sex Transm Infect 2004 80(Suppl II) ii74-ii79. 4....

Alcohol Withdrawal

There are four different alcohol withdrawal syndromes, which differ in terms of their pharmacologic treatment and need for hospitalization. This is the most commonly observed syndrome, and as the name denotes, is not complicated by seizures, delirium tremens (DTs), or hallucinosis. Symptoms are typically rated using a validated scale such as the Clinical Institute Withdrawal Assessment Scale for Alcohol Revised (CIWA-Ar, Table 36-5).16 The recommended CIWA-Ar threshold score for treating...

Fluid Management Strategies

Classic indications for IV fluid include maintenance of BP, restoring the ICF volume, replacing ongoing renal or insensible losses when oral intake is inadequate, and the need for glucose as a fuel for the brain. Although large volumes of fluid are given during the resuscitation of most trauma patients, a recent analysis reported uncertainty about the use of early large volume fluid replacement in patients with active bleeding, calling into question our understanding of the need for fluids in...