By I. Hassan. Pacific Union College. 2018.

Treatment Patients may appear asymptomatic even in the pres- is based on plasma salicylate levels (>500 mg/L (3 20mg female cialis amex women's health clinic brighton. Gastrointesti- Activated charcoal may be considered in conscious pa- nal haemorrhage may require blood replacement and tientswithin1hourofingestionandconsumptionabove metabolic acidosis should be corrected generic female cialis 10 mg free shipping pregnancy diarrhea. Symptomatic patients with moderate (3–5 mg/L or Haemodialysis is used if plasma salicylate level is 700 55–90 µmol/L) or severe (>5 mg/L or 90 µmol/L) mg/L (5. Patients who have not developed symptoms by 6 hours following ingestion are unlikely to have had a significant overdose and do not require further Iron overdose monitoring. Aetiology Iron poisoning is usually seen in childhood and results Tricyclic antidepressant overdose from accidental ingestion of iron-containing medica- Definition tions such as vitamin preparations mistaken for sweets. Patients may de- Incidence/prevalence velop nausea, vomiting, abdominal pain and diarrhoea. Late signs in severe overdose include hypotension, coma, hy- Pathophysiology poglycaemia and hepatocellular necrosis. Tricyclic antidepressants have anticholinergic, alpha- adrenergic blocking, and adrenergic uptake inhibiting Investigations properties. They also have a quinidine like effect on the Aserum iron level (ideally at 4 hours after ingestion) is myocardium. Clinical features Araised neutrophil count and serum glucose suggests r Common features include hot, dry skin, dry mouth, toxicity. There may r In severe poisoning (unconscious or hypotension) be increased tone, increased deep tendon reflexes and intravenous fluids and desferrioxamine (a chelating extensor plantar responses. If the patient is comatose, agent for iron) should be commenced immediately all reflexes may be absent. Lithium overdose r Confusion, agitation and visual hallucinations may Definition occur during recovery. Lithium poisoning usually results from chronic drug ac- cumulation, accidental or deliberate overdose of lithium Complications carbonate. Aetiology/pathophysiology Investigations Lithium has a narrow therapeutic index (the levels at Arterial blood gases to check both pH and bicarbonate which it becomes toxic are only marginally higher than levels. U&Es and urine output duce toxicity, as may concomitant use of nonsteroidal should be monitored. Management Clinical features r Patients should be stabilised with management of air- Thereisgoodcorrelationbetweensymptomsandplasma way, breathing and circulation as required. Intravenous lidocaine may be Investigations of benefit in treatment of cardiac arrhythmias; how- Serum lithium levels should be measured if chronic toxi- ever, it may precipitate seizures. Refractory should be taken 6 hours post-ingestion and 6–12 hourly seizures require intubation, ventilation, paralysis and thereafter. Persisting hypotension may require intravenous flu- ids, glucagon bolus and infusion (corrects myocardial depression) and in severe cases inotropes. Management In chronic accumulation, stopping lithium is often all Prognosis that is needed to alleviate symptoms; however, patients Tricyclic antidepressant overdose carries a high mor- may require other treatments for bipolar disorder. All patients should be surviving patients most cardiac complications resolve observed for a minimum of 24 hours post-ingestion. In refractory hypotension, inotropes may 532 Chapter 15: Overdose, poisoning and addiction be required.

Admission should be considered for patients with renal dysfunction female cialis 20mg on-line menstruation vertigo, a serious infection purchase 20mg female cialis with mastercard women's health center rockford il, or volume overload and for those who are unable to care for themselves. She is afebrile with a blood pressure of 130/64 mm Hg, pulse of 74 beats per minute, and respiratory rate of 20 breaths per minute. She reports a history of increased fatigue with exertion and intermittent paresthesias but denies any history of diabetes, hypertension, or recurrent urinary infections. One year ago, she had some difficulty with double vision that had resolved spontaneously. This patient needs to be hospitalized because of a concomitant urinary tract infection and renal dysfunction. Decompression of the bladder with a urethral catheter should be performed before examination of the prostate. Percutaneous bladder aspiration is not indicated unless other attempts to decompress the bladder have failed. This is likely caused by herpes simplex virus with associated urethral irrita- tion and urinary retention. Bladder decompression should be performed as quickly as possible to prevent further damage to the urinary system. Consultation with a urologist may be necessary if urethral catheterization cannot be accomplished with a Foley or coudé catheter. Admission should be considered for patients with renal dysfunction, a serious infection, or volume overload and for those who are unable to care for themselves. Renal calculi (kidney stones) In: Principles and Practice of Emergency Medi- cine. She tells you that she and her friends recently returned from spring break vacation in Mexico, and she has noticed a constant ache that is worse on her right side. The patient’s mother is worried because her daughter has been unable to eat or drink anything for 2 days and thinks she may have become sick from drinking the water while on vacation. After asking the mother to step out of the room while you examine the patient, she tells you that she has had five sexual partners, occasionally uses condom for birth control, and has never been pregnant. On physical examination, her blood pressure was 100/70, pulse 110 beats per minute, respirations 22 breaths per minute, and temperature 38. The abdominal examination reveals a diffusely tender lower abdomen, greater on the right than left and the patient exhibits voluntary guarding. Examination of the pelvis reveals a greenish, foul-smelling discharge with a red, friable-appearing cervix. Bimanual examination reveals an exquisitely tender cervix with fullness and pain in the right adnexal area. She displays cervical motion tenderness and her right adnexa appear to have some fullness and tenderness on examination. Know the criteria and treatments for both outpatient and inpatient pelvic inflam- matory disease. Know the common differential diagnoses for lower abdominal pain and be able to consult the appropriate specialties based on the physical examination and labora- tory studies. Considerations This nulliparous adolescent woman has lower abdominal pain, fever, abnormal vaginal discharge, adnexal tenderness/fullness, and cervical motion tenderness. Although the etiology may be poly- microbial, sexually transmitted organisms such as Neisseria gonorrhoeae or Chla- mydia trachomatis are implicated in many cases. Because the disease may mimic other common conditions, meticulous physical examination, clinical examination, and use of transvaginal ultrasound must be performed in conjunction to correctly diagnose a gynecologic disease from that of a general surgery process. This patient is admitted to the hospital due to inability to tolerate oral medication (nausea and vomiting) and also height of the temperature (37.

A cannula is placed in the right atrium in order fected coronary artery buy cheap female cialis 10 mg on-line menstruation in animals, the balloon is inflated to dilate to divert blood away from the heart discount female cialis 20 mg on-line breast cancer x ray images. The blood is then the stenosis, compressing the atheromatous plaque and oxygenated by one of two methods: stretching the layers of the vessel wall to the sides. A stent r Bubble oxygenators work by bubbling 95% oxygen is often used to reduce recurrence. If the myocardium is to be opened, cross-clamping the Complications aorta gives a bloodless field; the heart is protected from The main immediate complication of balloon angio- ischaemia by cooling to between 20 and 30˚C. Systemic plasty is intimal/medial dissection leading to abrupt ves- cooling also lowers metabolic requirements of other or- sel occlusion. Beatingheartbypassgraftingisnow has been largely resolved with the routine implantation possible using a mechanical device to stabilise the target of a stent. There is a risk of complications, including surface area of the heart, but access to the posterior sur- emergency coronary artery bypass surgery, myocardial face of the heart can be difficult. More commonly, local The internal mammary artery is the graft of choice haematoma at the site of arterial puncture may occur. The coronary arteries are opened distal to the obstruction and the grafts are placed. If the saphenous Prognosis vein is used, its proximal end is sewn to the ascend- Depending on the anatomy of the lesion, significant ing aorta. Ventricular fibrillation is deliberately induced during 30 Chapter 2: Cardiovascular system cardiopulmonary bypass to reduce heart movement and r Open valvotomy and valve repair is performed under avoid additional ischaemia and internal defibrillating cardiopulmonary bypass. Valvular regurgitation when due to dilation of the valve Complications ring may be treated by sewing a rigid or semi-rigid Aspirin is usually continued for the procedure, but other ring around the valve annulus to maintain size (annulo- antiplatelet drugs such as clopidogrel are stopped up to plasty). During the procedure patients are due to infective endocarditis or chordal rupture, part of heparinised to prevent thrombosis. Antibiotic cover is the leaflet may be resected or even repaired with a piece provided using a broad spectrum antibiotic to prevent of pericardium to restore valve competence. Operative mortality depends on many fac- Valve replacement: Using cardiopulmonary bypass the tors including age and concomitant disease, it usually diseased valve is excised and a replacement is sutured varies from 1 to 5%. Current designs all have Approximately 90% of patients have no angina postop- some form of tilting disc such as the single disc Bjork–¨ eratively, with almost all patients experiencing a signifi- Shiley valve or the double disc St Jude valve. Over time symptoms may gradually durable, but require lifelong anticoagulation therapy return due to progression of atheroma in the arteries or to prevent thrombosis of the valve and risk of em- occlusion of vein grafts. Outcome is improved by risk factor modifi- r Biological valves may be xenografts (from animals) cation(stoppingsmoking,loweringhighbloodpressure, or homografts (cadaveric). They are treated with glutaraldehyde to possible if medication is insufficient to control symp- prevent rejection and are used to replace aortic or mi- toms; however, repeat surgery has a higher mortality. They do not require anticoagulation unless Angioplastyusingstentimplantationissuitableforgrafts the patient is in atrial fibrillation but have a durabil- or native vessels. Valve failure may result from leaflet shrinkage or weakening of the valve com- petence causing regurgitation, or calcification causing Valve surgery valve stenosis. Valvesurgery is used to treat stenosed or regurgitant Valve replacements are prone to infective endocarditis, valves, which cause compromise of cardiac function. The aortic valve is not usually amenable to conservative Valve replacement provides marked symptomatic re- surgery and usually requires replacement if significantly lief and improvement in survival. A stenosed mitral valve may be treated by fol- is approximately 2%, but this is increased in patients lowing procedures: with ischaemic heart disease (when it is usually com- r Percutaneous mitral balloon valvuloplasty in which a bined with coronary artery bypass grafting), lung dis- balloon is used to separate the mitral valve leaflets. Perioperative complications include This is now the preferred technique unless there is haemorrhage and infection. All r Closed valvotomy uses a dilator that is passed through prosthetic valves require antibiotic prophylaxis against aleft sub-mammary incision into the left atrial ap- infectiveendocarditisduringnon-sterileprocedures,e.

Subtotal thyroidectomy results in normali- Primary Idiopathic/autoimmune thyroid atrophy sation of thyroid function in 70% purchase 10mg female cialis with mastercard women's health clinic bowling green ky. The patient must be made Iatrogenic: radioactive iodine buy female cialis 10mg visa women's health clinic ucla, surgery, drugs euthyroid before surgery with antithyroid drugs and β- Iodine deficiency (common in Nepal, Bangladesh) blockers (see page 436). Inborn errors of hormone synthesis Secondary Panhypopituitarism due to pituitary adenoma Iatrogenic: pituitary ablative therapy/surgery Prognosis Tertiary Hypothalamic dysfunction (rare) Thirty to fifty per cent of patients used to undergo spon- Peripheral resistance to thyroid hormone (rare) taneous remission without treatment. Hypothyroidism (myxoedema) Thyrotoxic crisis (storm) Definition Definition Hypothyroidism is a clinical syndrome resulting from a Arare syndrome of severe acute thyrotoxicosis, which deficiency of thyroid hormones. Pathophysiology Congenital hypothyroidism causes permanent develop- Pathophysiology mental retardation. In children it causes reversible de- Levels of thyroid-binding protein in the serum fall and layedgrowthandpuberty,anddevelopmentaldelay. This results in increased cocious puberty may occur in juveniles, due to pituitary free T3 and T4, coupled to increased sensitivity of the hypertrophy. In adults it causes decreased removal of heart and nerves due to the presence of catecholamines. The symptoms include life-threatening coma, heart fail- ure and cardiogenic shock. There is a high fever (38– Clinical features 41◦C), flushing and sweating, tachycardia, often with Usually insidious onset. Central nervous creasing lethargy, forgetfulness, intolerance to cold, symptoms include agitation, restlessness, delirium and weight gain, constipation and depression (see also coma. Hypercholesterolaemia increases the incidence of tithyroid drugs and corticosteroids. Chapter 11: Thyroid axis 433 r Respiratory system: Respiration may be slow and shal- Aetiology low. Patients have detectable anti-microsomal antibody and r Gastrointestinal system: Reduced peristalsis, leading antithyroglobulin antibodies in most cases. The patient, typically a postmenopausal female, presents r Other signs include a cool rough dry skin, hair loss, with a diffuse goitre. Although most patients are euthy- puffy face and hands, a hoarse husky voice and slowed roid, thyrotoxicosis can occur and if presentation is late, reflexes. The thyroid is diffusely enlarged and has a fleshy white cut surface due to lymphocytic infiltration, which is seen Investigations on microscopy around the destroyed follicles. Thyroid autoantibodies are High titres of circulating antithyroid antibodies, associ- present in patients with autoimmune disease. Large goitres require subtotal thyroidectomy if causing com- Management pression of local structures such as the oesophagus or Thyroxine replacement starting with a low dose is re- trachea. Treatment of elderly patients should be recurrent laryngeal nerves or parathyroids. Post-surgery undertaken with care, as any subclinical ischaemic heart or following significant thyroid destruction patients be- disease may be unmasked. Thyroxine dosing is titrated come hypothyroid requiring treatment with thyroxine according to thyroid function tests. Hashimoto’s disease (autoimmune Myxoedema coma thyroiditis) Definition Definition This is the end-stage of untreated hypothyroidism, lead- Organ-specific autoimmune disease causing thyroiditis ing to progressive weakness, hypothermia, respiratory and later hypothyroidism. Myxoedema coma may be precipitated by inter- Malignant tumours of the thyroid current illness or disorder, such as heart failure, perhaps Papillary adenocarcinoma following a myocardial infarction, stroke, pneumonia; iatrogenic causes include water overload and sedative or Definition opiate drugs.

We found that patients with the chronic fatigue syndrome have a lower exercise tolerance than normal subjects buy 20 mg female cialis otc menstrual flow. Previous studies have shown biochemical and structural abnormalities of muscle in patients with the chronic fatigue syndrome” (Aerobic work capacity in patients with chronic fatigue syndrome purchase 20 mg female cialis mastercard menopause question and answers. This study was done on a fairly homogeneous population and 80% of the biopsies showed structural damage to the mitochondria (Acta Neuropathol 1991:83:61‐65). Magnetic resonance scans of the brain showed punctate, subcortical areas of high signal intensity consistent with oedema or demyelination in 78% of patients. Dedra Buchwald, Paul Cheney, Robert Gallo, Anthony L Komaroff et al Ann Intern Med 1992:116:2:103‐113). A few patients have more dramatic neurologic events such as seizures, periods of severe visual impairment, and periods of paresis. Most investigators believe that reactivation of these viruses is probably secondary to some immunologic challenge. At worst, it is a nightmare of increasing disability with both physical and neurocognitive components. As for the symptoms that accompany the fatigue, it is striking that these symptoms are experienced not just occasionally but are present virtually all the time. We examined venous blood lactate responses to exercise at a work rate below the anaerobic threshold in relation to psychiatric disorder. All specimens showed hypotrophy, fibres fragmentation, red ragged fibres, and fatty and fibrous degeneration. Electron microscopy confirmed these alterations, showing degenerative changes, and allowed us to detect poly/pleomorphism and cristae thickening of the mitochondria. The histochemical and quantitative determination of the enzymatic activity showed important reduction, in particular of the cytochrome‐ oxidase and citrate‐synthetase. In 1999, Paul et al provided irrefutable evidence of delayed muscle recovery after exercise. In 2000, a Belgian / Australian collaborative study entitled “Exercise Capacity in Chronic Fatigue Syndrome” was unequivocal: “Comparing the exercise capacity in our patients with data from other studies shows a functionality similar to that of individuals with chronic heart failure, patients with chronic obstructive pulmonary disease, and those with skeletal muscle disorder”. Specific findings included (i) the resting heart rate of patients was higher than controls but patients’ maximal heart rate at exhaustion was lower than controls (ii) the maximal workload achieved by patients was almost half that achieved by controls (iii) the maximal oxygen uptake was almost half that achieved by controls. Sports Exerc: 2002:34:1:51‐56) and the authors stated: “The fatigue is often present at rest and exacerbated by the simplest of physical tasks. The purpose of the present study was to employ ‘gold standard’ maximal exercise testing methodology. The present findings indicate that physical deconditioning (is not) a critical factor in the fatigue that (patients) experience. Although the recommendation or imposition of exercise‐training programmes may have benefit in terms of social interaction, such programmes could well be based on a false premise if the intention is to improve well‐ being by correcting the effects of deconditioning”. These scores tended to be below the published norm for patients with cancer, congestive heart failure and myocardial infarction” (J Nerv Ment Dis 2003:191:324‐331). The aerobic system depends on a constant supply of oxygen being delivered to active muscles. In the absence of an adequate supply of oxygen, energy production shifts to anaerobic (without oxygen) process, leading to oxygen debt. Oxygen debt equals fatigue and before normalcy can return (that debt) must be repaid. Elevation of thalamic choline was also demonstrated, suggesting the presence of neuronal damage.