Vice Chair, Oregon Health & Science University School of Medicine
Conditions where pain may be absent Spinal conditions are not always associated with pain acne keloidalis cure buy antibiotrex 30mg otc. Occasionally skin care 70 purchase antibiotrex with mastercard, a child may present with back deformity or neurological symptoms in the legs alone: the history may be non-specific and skin care must haves order antibiotrex online now, for example acne 40 year old woman antibiotrex 20 mg mastercard, in a very young child, nothing more than a refusal to walk. Pain is more likely to be present if the chondritis is thoracolumbar, rather than thoracic. Past developmental, medical, family, and social history Ask about milestones in musculoskeletal development. It can be a sign of an underlying neurological or inflammatory lesion or occurs because of an underlying structural anomaly. Joint dislocation and multiple soft-tissue musculoskeletal injury (especially over-use) in family members raises the possibility of general hypermobility (joint hypermobility syndrome or other heritable connective tissue disease. Nevertheless, in children with nonspecific spinal pain or fibromyalgia, social conflict resulting in stress and anxiety may be very important in generating symptoms. Examination It is best, and certainly ultimately more informative, to undertake the examination only when the child is comfortable with the situation, with their modesty and dignity preserved, and with consent to go ahead after a reassurance that the examination will be stopped if it is painful. Observing the young child while playing is a considerate way of starting the examination. Age-related variations in biomechanical development and gait patterns Walking while holding a hand or furniture develops by 12 months and normally independent walking by 18 months. Observation Observe children unclothed to underwear if possible; initially at play then look from behind. Also, limp may be the only feature of a serious underlying neurological or bony deformity. Spinal examination with the child standing Examine the whole spine while the child is standing. Examine the sitting patient Examine the child who is sitting on the couch, legs hanging over the side: this is the best way to elicit pain from posterior vertebral structure pathology in thoracic or lumbar segments. Look for leg length discrepancy, lower leg asymmetry, and do a neurological examination: Measure and determine actual or apparent leg length discrepancy. Apparent leg length discrepancy/pelvic tilts can occur to compensate for scoliosis caused by spinal lesions. Examine the prone patient Palpate over the spinous processes, interspinous spaces, paracentrally between spinous processes (over facet joints), and in the sacroiliac area. Where there are isolated areas of tenderness feel for skin warmth, as this may be a site of infection. Investigations Radiographs Radiographs have a characteristic appearance in certain cases of bone tumour but may also, in some cases, be normal (Table 2. Lytic lesion can cause solitary vertebral collapse, even collapse of adjacent bones. Up to 50% have abnormal films: widened spinal canal, pedicle erosions, scalloping of vertebral bodies. The management of various spinal disorders in adults and children is included in b Chapter 20, p 525. The femoral head is stabilized in the acetabulum by the acetabular labrum and strong pericapsular ligaments. Anatomy of pelvic musculature Three groups of muscles move the hip joint: the gluteals, the flexor muscles, and the adductor group. It extends and externally rotates the hip (the hamstrings also extend the hip); gluteus medius (L4/5, S1): lies deeper and more lateral. It inserts into the lateral greater trochanter and abducts and internally rotates the hip; piriformis, obturator internus, and quadratus femoris arise deep in the pelvis and insert into the posterior greater trochanter. It runs anteriorly over the iliac rim, across the pelvis, under the inguinal ligament, and inserts into the lesser trochanter. Retroperitoneal or spinal infections that track along soft tissue planes sometimes involves the psoas sheath and can cause inflammation in the psoas bursa, which separates the muscle from the hip joint. The adductor magnus (L4/5) is the largest of the deeper adductors; it inserts into the medial femoral shaft. Body weight is transferred onto one leg during this action and, therefore, adductors need to be strong, especially for running. Tibial torsion can compensate but this and hip anteversion results in a toe-in gait. Femoral neck retroversion (if the angle is posterior to the femoral intercondylar plane) allows greater external rotation of the hip, usually resulting in a toe-out gait. This is at a foramen formed by the ilium (above and lateral), sacrum (medial), sacrospinous ligament (below), and sacrotuberous ligament (posteromedial). Nerve entrapment and trauma at this site may give rise to piriformis syndrome, and may benefit from physical therapy. Distribution and type of bone and soft tissue pain All mechanical lesions of the lumbar spine can result in referred pain around the pelvis and thighs. Tendonitis of the adductor longus, osteitis pubis, a femoral neck stress fracture (4% of all stress fractures), osteoid osteoma, or psoas bursitis can give similar symptoms. When it does occur, it is unlikely to be confined to pelvic musculature or to be unilateral, but should be considered where acute or subacute onset diffuse pelvic girdle/thigh pain accompanies weakness. Quality and distribution of nerve pain Nerve root pain is often clearly defined and sharp. It may be burning in quality and is often accompanied by numbness or paraesthesias.
The nature of the presentation acne face buy cheap antibiotrex on-line, sequence of events acne 2 weeks pregnant antibiotrex 5mg cheap, and constellation of signs and symptoms suggests a differential diagnosis skin care educator jobs cheap 30 mg antibiotrex mastercard. Starting from the presentation acne xlr buy antibiotrex 5mg amex, the physician must select diagnostic tests and procedures and then, once a diagnosis is made, initiate treatment. The differential diagnosis may be altered by pregnancy and diagnostic procedures employed may be different from those one would use for nonpregnant patients. We will consider the following presentations: headache, seizures, altered state of consciousness, and motor or sensory changes. This signs and symptoms approach was chosen because patients do not usually come to the physician with a diagnosis but with a change in their condition, appearance of symptoms, and the need for care. Patients who report having had the same problem for some time prior to pregnancy do not usually have a neurological emergency. Chronic and recurrent headaches may be due to tension, migraine, sinusitis, pseudotumor cerebri or in many cases be unexplained. Migraine headaches are relatively common during reproductive age of women and often become less frequent and severe in pregnancy. In a minority of migraine sufferers, however, they may present for the first time or become more severe in pregnancy. Many patients who think they have migraines do not have the classical pattern of aura, headache, and nausea. Headaches which, aside from frequency, are similar to those the patient has experienced in the past can generally be considered to not represent a neurological emergency and can be managed symptomatically. If headaches become more frequent and severe or have accompanying neurologic manifestations, then they require further evaluation. Onset of a new headache or the occurrence of a headache with a different location, quality, or accompanying neurologic symptoms demands further evaluation. Figure 16-1 and Table 16-2 outline an approach to the evaluation of headache in pregnancy. The sudden onset of headache requires immediate evaluation and perhaps admission to the hospital. Headache is a common feature of preeclampsia which must be considered in any patient in the second half of pregnancy. Since preeclampsia consists of a constellation of clinical and laboratory abnormalities, appropriate clinical and laboratory evaluation should be able to determine if it is a likely diagnosis in a specific patient (see Chap 5). The differential diagnosis of sudden, severe headache in pregnancy is the same as that for the nonpregnant patient with the addition of preeclampsia. It includes subarachnoid hemorrhage, intracerebral hemorrhage, cortical vein thrombosis, meningitis, and mass lesions (tumors or abscesses). Cerebral aneurysms usually occur on the vessels of the circle of Willis or the proximal portions of the vessels arising from it. These saccular or berry aneurysms can be found in any patient but are more common in patients with Marfan syndrome or familial polycystic kidneys. These patients all present with sudden onset of severe headache, nausea and vomiting, and meningeal signs. They may have focal neurological deficits, altered state of consciousness, seizures, and hypertension. The condition of the patient at presentation is the most important prognostic feature (see Table 16-3). The diagnosis of possible subarachnoid hemorrhage in pregnancy starts with a high index of suspicion raised by the presentation. Clinical and laboratory evaluation for possible preeclampsia/eclampsia must be accomplished, since it is the more common diagnosis and if confirmed requires specific therapy and possible delivery as the definitive treatment. The American College of Radiology recommends against their use "unless absolutely necessary. Contrast dyes used in x-ray angiography pose no significant risk to the fetus beyond the radiation exposure. Spinal tap will serve to confirm the presence of subarachnoid blood and rule out meningitis as the cause of the headache. Simultaneously, with the initiation of the diagnostic workup, neurological and neurosurgical consultation should be obtained. Surgery under hypotensive anesthesia or hypothermia can be well tolerated by the fetus. Anesthetic medications generally suppress fetal heart rate variability and can make monitor interpretations more difficult. If fetal bradycardia occurs, it is desirable to raise the maternal blood pressure to improve utero-placental perfusion. The second question to ask oneself is whether this represents eclampsia (Fig 16-2). There appears to be an increase in seizure frequency in pregnancy, but it is unclear how much of this increase is due to increased susceptibility to seizures and how much is due to declining blood drug levels. Both the volume of distribution and hepatic clearance of anticonvulsant drugs are increased in pregnancy. These physiologic changes result in falling anticonvulsant levels while the patient is maintained on a constant dose. A woman who, when not pregnant, experienced at least one convulsion per month can expect an increase in seizure frequency during pregnancy.
These effusions are generally asymptomatic acne zapper zeno order antibiotrex paypal, and are found in the setting of active disease acne on buttocks order antibiotrex 10 mg amex. Radiographically skin care store purchase antibiotrex with mastercard, the lesions take on the appearance of ground glass infiltrates that gradually lead to honeycombing and fibrosis acne zip back jeans buy antibiotrex with paypal. Many conditions affect the kidneys directly, and a careful examination may yield important clues to the correct diagnosis. For other patients, the kidneys must be considered because many treatments have renal toxicity or are renal cleared. Diseases involving the renal artery (such as renal artery stenosis, polyarteritis nodosa affecting the renal artery, or renal artery thrombosis) may cause pre-renal azotaemia. Post-renal azotaemia Nephrolithiasis is not a common cause of post-renal azotemia, but should be considered in a patient with gout. Glomerular deposits of amyloid lead to proteinuria (which can be nephrotic range) and progressive renal failure. Scleroderma renal crisis Scleroderma renal crisis is a rheumatologic emergency characterized by acute renal failure and malignant hypertension (b Chapter 24, p 609). Some are specific for certain disorders; others are non-specific, but occur with greater frequency among patients with endocrine disease. Musculoskeletal manifestations occur either as a result of metabolic disturbances or are influenced by a common link through their autoimmune pathophysiology. These scleroderma-like skin changes are more prevalent among patients with type I diabetes. It presents acutely with pain, weakness, and wasting of the proximal lower limb muscles. Differential diagnosis includes myositis (b Chapter 14, p 385) and polymyalgia rheumatica (b Chapter 15, p 405). Osteomyelitis is usually disclosed by prominent blood flow in the dynamic (first) phase and increased uptake of tracer by soft tissue and bone in later stages. Cellulitis is associated with minimal uptake of tracer in bone in the delayed (third) phase. Neuropathic joints display minimal first-phase abnormalities but prominent tracer uptake in the third phase. Often mistaken for thrombophlebitis, myositis or vasculitis, this is a late complication of diabetes. It is characterized by pain, stiffness, effusions, and synovial thickening due to glycosaminoglycan deposition. Calcium pyrophosphate deposition may contribute to this arthropathy (b Chapter 7, p 269). Treated hypothyroidism then requires review of the need for uric acid-lowering therapy. The presentation can mimic polymyositis with elevation of muscle enzymes, but muscle biopsy typically shows no inflammatory cell infiltrate. Improvement with thyroxine replacement is sometimes complicated by muscle cramps, but these should resolve in a few weeks. Muscle mass increase is sometimes striking and can take many months to resolve on treatment. Thyrotoxicosis Hyperthyroidism can cause a proximal myopathy (70%), shoulder peri-arthritis (7%), acropachy (thickening of extremities), and osteoporosis (b Chapter 16, p 431). It consists of clubbing, painful soft tissue swelling of hands and feet, and periosteal new bone on the radial aspect of the second and third metacarpals. Clinically, this occurs most frequently in patients who have the opthalmopathy or dermopathy associated with autoimmune thyroid disease. Hyperparathyroidism (b Chapter 16, p 431) the following points refer to both primary and secondary disease: Musculoskeletal symptoms are the initial manifestation in up to 16% of patients with primary hyperparathyroidism. An erosive polyarthritis favoring the large joints can occur with renal osteodystrophy in patients with chronic renal failure on dialysis. Hyperparathyroidism is associated with a specific shoulder arthropathy characterized by intra/peri-articular erosions of the humeral head. Fragility fracture is common and often precedes a diagnosis of primary hyperparathyroidism. Although significant and fast accretion of bone occurs after surgery, bone mass often remains low long term. Severity of rheumatologic manifestations Optimal surveillance strategies for the musculoskeletal manifestations of gut or biliary disease are not known in many instances. Hepatitis B is associated with polyarteritis nodosa, and hepatitis C may lead to cryoglobulinaemic vasculitis. Peptic lesions may be clinically silent and may present with dropping haemoglobin levels or an acute bleed. Biopsies of the upper gastrointestinal tract will demonstrate amyloid deposits in 13% of patients. There are numerous gastrointestinal manifestations of amyloidosis, including gastrointestinal haemorrhage, malabsorption, obstruction, and hepatosplenomegaly. Sacroiliitis 15% Migratory arthritis in >60% Polyarticular symptoms 50% in scleroderma Arthritis is rare Rare (<0.
Also skin care over 40 order antibiotrex 40mg otc, strenuous activity that generates excessive body heat on a hot day or inadequate replacement of the fluid and salt lost in perspiration may lead to hyperthermia acne on forehead purchase antibiotrex cheap. Because of less effective physiologic compensation mechanisms acne glycolic acid buy antibiotrex 5 mg without a prescription, older people skin care 30 anti aging buy antibiotrex 40mg on line, infants, and cardiac patients are most at risk for overheating, as demonstrated in a severe heat wave in Chicago during the summer of 1995 that resulted in more than 100 fatalities. Syndromes associated with hyperthermia include: Heat cramps with skeletal muscle spasms caused by loss of electrolytes Heat exhaustion, with sweating, headache, nausea, and dizziness or syncope (fainting), the most common problem, resulting from loss of water and sodium leading to hypovolemia Heat stroke, with shock, coma, and very high core body temperature, the most serious complication. It is caused by general vasodilation, a marked decrease in circulating blood volume, and damage to the heart. Prompt cooling and fluid and electrolyte replacement in persons with these syndromes are essential to prevent brain damage or cardiac failure. Carbon monoxide remains bound to hemoglobin for significant periods of time and can lead to a fatal decrease in oxygen supply if exposure is prolonged. Carbon monoxide monitors are available to warn of the presence of the colorless and tasteless gas. Cigarette smoking predisposes the smoker to lung disease, including emphysema, bronchitis, and lung cancer, and also to bladder cancer, peptic ulcers, and cardiovascular disease. Smoking impairs fertility, and during pregnancy it also affects fetal development, leading to stillbirth or low birth weight infants and an increased risk of complications. These concerns have led to social and political action concerning cigarette smoking and second-hand smoke exposure. Many areas across the country now have laws banning smoking in the work place and any indoor place other than the home. There has been an increase in serious cases of hypothermia in colder climates as the number of homeless individuals in these areas has escalated. Localized frostbite usually affects the fingers, toes, ears, or exposed parts of the face. In these areas, vascular occlusion occurs quickly and may lead to necrosis and gangrene. Usually sensation is lost early, and the individual may not be aware of the danger. Close observation of exposed areas for color changes, particularly whitish or bluish spots, is important. Explain why chronic lung disease such as bronchitis occurs more frequently in highly industrialized regions. Describe two possible effects of chemical toxicity in the body, giving an example of each. Explain why young children are at greater risk of pathologic changes resulting from exposure to hazardous chemicals. Low temperatures can affect many body tissues, depending on the length of time of the exposure and the actual temperature. Shivering occurs initially in an effort to generate more body heat, and then the body feels numb. Reflex vasoconstriction and increased blood viscosity lead to ischemia and reduced metabolism. When the core body temperature drops, the capillaries and cell membranes are damaged. This leads to abnormal shifts of fluid and sodium and ultimately to hypovolemic shock (low blood pressure), and cell necrosis ensues. Rewarming must be done slowly and cautiously and must be accompanied by fluid replacement to maintain adequate circulation and minimize cell damage. Often the brain is protected against edema by the administration of corticosteroid drugs during the return to normal body temperature. Suggest some reasons why it would be difficult for a person submerged in an icy lake to continue swimming. The amount of radiation absorbed by the body is measured in rads, or "radiation-absorbed doses. The effects of repeated small doses of radiation have not been well studied and there is far less information about the resulting pathology than for massive exposure, such as occurred when atomic bombs were used against cities in Japan in 1945 and in the 1986 nuclear meltdown of the Chernobyl nuclear reactor in Ukraine. Cumulative damage is manifested by the development of skin cancers resulting from ultraviolet rays related to sun exposure, as seen frequently in older individuals. Radiation primarily affects cells that undergo rapid mitosis, such as epithelial tissue, bone marrow, and the gonads (ovaries and testes). Exposure to large amounts of radiation leads to radiation sickness, resulting in damage to the bone marrow, digestive tract, and central nervous system. Without intensive care and bone marrow replacement, most victims of radiation sickness die within a few days. Health care workers who are at risk of exposure to radiation must use lead shields and wear monitoring devices to check individual exposure. Ionizing radiation includes x-rays and gamma rays as well as particles such as protons and neutrons. These rays and particles differ both in energy levels and their ability to penetrate body tissue, clothing, or lead. Increased distance from the source lessens the amount of radiation to which a person is exposed. List specific structures that include epithelial tissue likely to be damaged by radiation. Give several specific examples of radiation sources in your community and workplace. A sudden, extremely loud noise may rupture the tym panic membrane (eardrum) or damage the nerve cells in the inner ear.
Infusing normal saline may produce a hyperchloremic metabolic acidosis; however acne extraction dermatologist order 20mg antibiotrex, this occurrence is rare acne 60 year old woman safe antibiotrex 40mg. Ringer lactate is an isotonic fluid that may be used interchangeably with normal saline in the treatment of hypovolemia or shock acne jeans review order cheap antibiotrex on-line. Ringer lactate is a balanced electrolyte solution that substitutes potassium and calcium for some of the sodium acne zits generic 40 mg antibiotrex with amex. The concern that acidosis may be worsened by the installation of Ringer lactate during shock is unfounded; however, it is recommended that extreme caution should be taken while using the fluid in patients with diabetes or renal failure. Hypertonic sodium-containing solutions (600-2400 mOsm/L) may be used in patients in whom a large volume load is contraindicated. Some studies have noted that the infusion of a hypertonic solution may reduce interstitial edema as well as create a positive inotropic effect. Care should be taken to use a slow infusion rate and to monitor sodium regularly to avoid hypernatremia. Although theoretically its adjusted pH may be preferential to saline or Ringer lactate, there are no definitive studies that show a great difference in its effects on vascular volume. Colloid Colloids are large molecular weight substances that do not pass readily across capillary walls. The rationale for the use of colloids is to expand the vascular volume and to decrease the amount of fluid that leaves the intravascular space A recent review in the Cochrane database does not support the routine use of colloid for volume resuscitation. Human Serum Albumin Albumin, which is synthesized in the liver, is the major oncotic protein of plasma. Responsible for about 80% of the colloid osmotic pressure of plasma, it also serves as the major transport protein for drugs and ions. The preparation is available as 5% (50 g/L) and 25% solution (250 g/L) in isotonic saline. An infusion of 100 mL of 25% albumin will expand the plasma volume to about 500 mL. Contrary to popular belief, albumin will eventually pass into the interstitial space. Caution should also be exercised when using large volumes since dilutional coagulopathy can occur. Hydroxyethyl Starch (Hespan) Hetastarch is a synthetic colloid that closely resembles glycogen. Hetastarch has a longer half-life than albumin with 50% of the osmotic effect persisting for 24 hours. The clinician should be aware that serum amylase may be elevated in patients receiving hetastarch as amylase is used to cleave polymers in order to facilitate renal excretion. Dextrose-Containing Solutions Dextrose, 5% in water, is isotonic; but unlike normal saline, it penetrates the cell leaving behind the infused water. One liter of a 5% solution contains approximately 170 kcal and a 10% solution contains 340 kcal. When dextrose is added to normal saline or to Ringer lactate, it raises the osmolality of the fluid to roughly twice that of plasma. This can promote significant changes in serum osmolality when large volumes of fluid are infused. Dextran the dextrans are another group of synthetic colloids that are polysaccharides derived from the juice of sugar beets. The available preparations are dextran-40 (mean molecular weight-40,000) and dextran-70 (mean molecular weight-70,000). Dextrans may inhibit platelet aggregation, decrease platelet factor 3, and produce an anticoagulation effect. Dextrans coat the surface of red blood cells and interfere with the ability to crossmatch blood. Dextraninduced renal failure or an osmotic diuresis may interfere with the overall fluid status (Tables 25-4 and 25-5). Figure 25-2 offers a simple algorithm for the treatment of hypernatremia due to this cause. Hypotonic Fluid Loss Hypotonic fluid loss is the most common cause of hypernatremia. It is usually caused by dehydration due to gastroenteritis or an osmotic diuresis. Crystalloid or Colloid Much debate has raged over the use of cystalloid versus colloid solution. Colloids are much more expensive and associated with an increased risk of side effects. Champions of colloid use maintain that the cost and the side effects are outweighed by the benefit of colloid use. Proponents of crystalloid use point out that the infusion of crystalloid increases intravascular volume and that the shift in interstitial fluid is a result of the underlying pathological process. Pulmonary edema may occur with both types of fluid, although the edema associated with colloid use may be delayed. While judicious use of colloid may be useful in some clinical situations, it is the opinion of the author that crystalloid resuscitation is preferred in the obstetrical population. It is usually seen only when hypertonic saline- or bicarbonatecontaining solutions are being infused. Hyponatremia Hyponatremia is defined as a serum sodium level of 135 mEq/L or less.
