Ibuprofen

By V. Rocko. New England School of Communications. 2018.

External pacing plays no role in the management of hypotension in a patient with sinus tachycardia generic 600mg ibuprofen amex pain medication for shingles nerves. Hemodialysis has a role in the management of theo- phylline toxicity discount 600 mg ibuprofen with visa pain management and shingles, especially if seizures develop or levels are greater than 100 mg/L; how- ever, hemodialysis would likely worsen the existing hypotension acutely, and the hypotension would have to be improved before dialysis could be implemented. A 70-year-old woman with chronic atrial fibrillation who is on warfarin therapy was prescribed erythro- mycin 10 days ago for a community-acquired pneumonia. A CT scan of the head reveals a large intracranial hemorrhage, and her prothrombin time (international normalized ratio [INR]) is 20. Overanticoagulation may have been avoided if, instead of erythromycin, this patient had been pre- scribed which of the following? None of the above Key Concept/Objective: To know that warfarin interacts with a vast number of commonly pre- scribed drugs Drugs that interact with warfarin include many antibiotics that are frequently used to treat community-acquired pneumonia (cephalosporins, quinolones, macrolides, tetra- cyclines, and long-acting sulfonamides). Use of these antibiotics in patients on warfarin requires vigilant monitoring of their anticoagulation status. Among the available newer-generation quinolone antibiotics, trovafloxacin and sparfloxacin do not seem to interact with warfarin. A 33-year-old man who suffers from depression and chronic pain attempts suicide by overdosing on the collection of pain killers he has accumulated from multiple physicians. He is in the emergency depart- ment with stupor, pinpoint pupils, and hypotension. Which of the following tests should you order for this patient? Electrocardiogram, acetaminophen level, and aspirin level 4 BOARD REVIEW Key Concept/Objective: To understand that intentional overdose may involve multiple substances Prescription narcotic pain killers are often compounded with either aspirin or aceta- minophen. Early recognition and treatment of toxic levels of either of these are critical to preventing subsequent metabolic acidosis (aspirin) or hepatic injury (acetamino- phen). This patient, who has had multiple physicians and has been diagnosed with depression, may also have ingested tricyclic antidepressants. Electrocardiographic abnormalities, including widening of the QRS interval, prolongation of the QT interval, and right axis deviation of the terminal 40 msec of the QRS complex, may provide early clues to this potentially lethal ingestion. Although this patient is at risk for having a coexistent benzodiazepine ingestion, management is limited to supportive measures, so there is no clinical utility to checking a serum level. If he has or is suspected of having also ingested tricyclic antidepressants, use of flumazenil is contraindicated because of the risk of seizures. Having misunderstood your instructions on how she should adjust the dosages of her 12 different med- ications, a 68-year-old woman is now in the intensive care unit after taking an excess of propranolol. Her pulse is 35 beats/min, her blood pressure is 65/35 mm Hg, she is unresponsive, and her skin is mottled. Therapeutic options for this patient include which of the following? Intravenous glucagon and epinephrine drip Key Concept/Objective: To understand that dopamine and isoproterenol exert their effects pri- marily through beta-adrenergic pathways In the setting of profound beta blockade, dopamine and isoproterenol are likely to be ineffective. Glucagon does not require beta-adrenergic receptors to exert its positive inotropic effect. A 58-year-old farmer is brought in from the fields to the emergency department sweating, vomiting, and confused. On examination, his blood pressure is 100/60 mm Hg, his pulse is 80 beats/min, and his res- piratory rate is 24 breaths/min. He appears to be in moderate respiratory distress and has generalized muscle weakness. He is salivating profusely and has gurgling upper respiratory sounds. This patient most likely is suffering from which of the following conditions? Mushroom poisoning Key Concept: To know the constellation of cholinergic symptoms created by organophosphate poisoning Agricultural workers are at risk for exposure to organophosphates, which are widely used in pesticides. Organophosphates are absorbed from the skin, lungs, gut, and con- junctiva. They inhibit acetylcholinesterase; therefore, presenting signs and symptoms are those of cholinergic excess. Prompt diagnosis and treatment are essential because some organophosphates undergo aging, whereby they become permanently bound to 8 INTERDISCIPLINARY MEDICINE 5 acetylcholinesterase.

Young: You did not concentrate at the point in the back at that time? Then it went up the spine and so on all the way around cheap ibuprofen 400mg on line pain treatment quotes. Young: So basically you feel the point sensation rather than the current? Dan: I feel vibration generic 600 mg ibuprofen amex back pain treatment home, even though I have felt heat but’ moves like a vibration coming up. Dan: No, I feel warm and at the end of the meditation I fell my head getting big and warm. I also feel as though something were moving very fast all through my body. Young: You feel another body vibrating or your physical body? Dan: I felt as though another body came out of me and extended six to eight inches beyond my physical self. The thing I didn’t feel too happy about, though, is the pain in my right arm from an old injury. DAN: Yes, whenever I concentrate on my navel, now, whether it’s at home or in the subway, I feel the vibrations. Dan: Yes, but if I find a quiet place I can concentrate more effec- tively. I forgot to tell you that when I concentrated today I felt a sensation in my ears as though something had opened up, a sort of tickling. Master Chia described that as the channels opening up. Dan: What I like about this system is that it is so simple, a baby could do it. Young: You mean that you never concentrated in your prac- tice? Dan: Maybe once or twice but I used to concentrate in the higher centers, the thyroid or the solar plexus. Young: Did you know that he tells his students to concen- trate on different points along the line? Dan: He did tell me, too, to concentrate on the base of my spine, my back, crown, etc. Young: That is what is so important about your case. Dan: The main point that he is concerned about is to have the energy circulate and to get the channel open and strengthen the tissues. It is not imaginary, because I can feel something going up right now. Dan: Before that, I meditated very intently for hours on the point between my eyebrows. When I came here I probably did the right thing and completed the circle by sticking my tongue up against my palate. But right now it is still hard to tell what will happen. Young: Yes, at least you have developed something, but whether it is beneficial or not, we have to see in the future. Dan: I strained my left testicle and I have problems with hemor- rhoids. Young: Would you say your practice is spiritual or physical? Dan: It is spiritual, physical, scientific, technological and espe- cially related to my body.

Which of the following makes the diagnosis of spontaneous bacterial peritonitis (SBP) unlikely? Absence of abdominal pain or tenderness on examination D safe ibuprofen 600 mg pain treatment center american fork. Gram stain of ascitic fluid revealing no organisms E 400mg ibuprofen free shipping midsouth pain treatment center germantown tn. PMN count in the ascitic fluid < 250 cells/mm3 Key Concept/Objective: To understand the clinical presentation of SBP The clinical presentation of SBP is often subtle. The diagnosis of SBP should be con- sidered in any patient with known cirrhosis who has clinical deterioration, such as worsening of hepatic encephalopathy or hypotension. Paracentesis for evaluation of the ascitic fluid is necessary. Fever is a common symptom but is absent in 30% of patients with SBP. The peripheral WBC is not valuable in determining whether or not a patient has SBP. Abdominal pain is a common feature of SBP, but only half of patients will have tenderness on examination. The Gram stain of the ascitic fluid in SBP is typically negative, although visualization of a single bacterial type would be consistent with SBP (the presence of multiple bacterial forms would suggest second- ary peritonitis). The diagnosis of SBP is made from the PMN count of the ascitic fluid. Cultures of the ascitic fluid from the patient in Question 116 grow Escherichia coli. Bacterascites; do not treat with antibiotics, and repeat paracentesis in 48 hours D. Spontaneous bacterial peritonitis; treat with antibiotics E. Culture-negative neutrophilic ascites (CNNA) Key Concept/Objective: To understand the variants of SBP and their appropriate treatment Three variants of SBP are recognized on the basis of culture and neutrophil counts of the ascitic fluid. In a strict sense, SBP is defined by an ascitic fluid with a positive cul- ture and a PMN count > 250 cells/mm3. CNNA has a negative culture and a neutrocyt- ic ascites (PMN count > 500 cells/mm3). Bacterascites is characterized by a positive ascitic fluid culture in the absence of neutrocytic ascites (PMN count < 250 cells/mm3). SBP and CNNA are indistinguishable clinically and are managed identically with antibiotics. Bacterascites in the absence of symptoms is usually self-limited and can be managed by observation and repeat paracentesis in 48 hours. In this case, however, the patient is symptomatic with mental status changes, and treatment with antibiotics is indicated. A 48-year-old woman with cirrhosis secondary to hepatitis C and a history of SBP presents with com- plaints of diffuse abdominal pain and fever. On physical examination, she is febrile, with a temperature of 102. Her abdomen is distended and diffusely tender to palpation, without rebound or guarding; there is shifting dullness, and bowel sounds are present. Laboratory data show a peripheral WBC of 12,000; hematocrit, 30%; and platelets, 62,000. Which of the following treatments is NOT appropriate in the management of this patient? Norfloxacin, 400 mg/day, for an indefinite period after resolution of SBP Key Concept/Objective: To understand the treatment and prophylaxis of SBP The initial antibiotic therapy for SBP is empirical. Other third-generation cephalosporins—ampi- cillin-sulbactam, ticarcillin-clavulanic acid, meropenem, and imipenem—and combi- nation therapy with aztreonam and clindamycin are also useful. However, because of the potential for nephrotoxicity with amino- glycosides, this regimen should be avoided. The duration of treatment is typically 10 to 14 days, but short-duration therapy (5 days) is equally effective.

Paroxys- mal discount ibuprofen 600 mg with mastercard pain medication for shingles treatment, violent contractions of the involved muscles (reflex spasms) appear repet- 355 itively only in severe cases order ibuprofen 400mg pacific pain treatment victoria bc. Generalized spasms as well as laryngospasm contribute to ventilatory insufficiency and asphyxia. Autonomic features are hypertension, tachycardia, arrhythmia, sweating, and vasoconstriction, possibly leading to cardiac arrest. The alteration of consciousness and true convulsive seizures are the result of severe cerebral hypoxia. The severity continues to increase for 10 to 14 days after onset. Neonatal tetanus: Neonatal tetanus usually occurs as a generalized form and carries a high mortality. It usually develops during the first 2 weeks in children born to inadequately immunized mothers and frequently follows nonsterile umbilical stump treatment. Failure to suck, twitching, and spasms are the most frequent symptoms of neonatal tetanus. Maternal tetanus: Tetanus occurring during pregnancy or within 6 weeks after any type of pregnancy termination is regarded as maternal tetanus. Approximately 15,000 to 30,000 cases of maternal tetanus occur in developing countries each year. Cephalic tetanus: May occur in lesions of the head and neck (e. Symptoms are unilateral facial paralysis, trismus, facial stiffness, nuchal rigidity, and pharyngeal spasms. Caudal cranial nerves and oculomotor nerves may be affected. The incubation period is short, and it may progress to generalized tetanus. The absence of a wound does not Diagnosis exclude tetanus, and anaerobic cultures are only positive in a third of cases. EMG shows continuous discharges resembling forceful volun- tary contractions, with shortening or absence of the silent period. Cephalic tetanus may be mistaken for Bell’s palsy or trigeminal pain Differential diagnosis Neuroleptic malignant syndrome Rabies: muscle spasm in deglutition and respiratory muscles Stiff person syndrome (insidious onset) Strychnine intoxication (almost identical, except for trismus) Tetany: accompanied by Chvostek’s and Trousseau’s Trismus: peritonsilar abscess, purulent meningitis, encephalitis Therapy begins with elimination of the source of the toxin (if known), adminis- Therapy tration of human tetanus immunoglobulin (3–6000 units, im), and intensive care. The Ig antitoxin does not cross the blood brain barrier and has no effect on central symptoms. Sedatives and muscle relaxants are used to treat symptoms. Proper nutrition is important to counteract catabolism. Outcome is poor in neonatals and the elderly, and in those with a short incubation from onset of symptoms to spasm. Clinical course extends over 4–6 weeks, but recovery can be complete. In: Scheld WM, Whitley RJ, Durack DT (eds) Infections of the central nervous system, 2nd edn. Raven, Philadelphia, pp 629–653 Farrar JJ, et al (2000) Tetanus. J Neurol Neurosurg Psychiatry 69: 292–301 Fauveau V, Mamdani M, Steinglass R, et al (1993) Maternal tetanus: magnitude, epidemi- ology and potential control measures. Int J Gynaecol Obstet 40: 3–12 Mastaglia FL (2001) Cervicocranial tetanus presenting with dysphagia: diagnostic value of electrophysiological studies. J Neurol 248: 903–904 Orwitz JI, Galetta SL, Teener JW (1997) Bilateral trochlear nerve palsy and downbeat nystagmus in a patient with cephalic tetanus. Neurology 49: 894–895 357 Muscle and myotonic diseases 359 Fig. Human Skeletal Muscle showing the gross and microscopic structure. The sacroplasmic reticulum (SR) is an intracellular membrane system.

After inoculation of a wound with spores (which are ubiquitous in the environ- ment) buy ibuprofen 600mg amex pain treatment sciatica, replicative organisms are generated order ibuprofen 400 mg mastercard pain after zoom treatment. These organisms elaborate several toxins, including α-toxin. Typical features of severe infection include pain and swelling at the wound site, pallor, tachycardia, and diaphoresis. Progression to hypotension, acute renal failure, shock, and death occur in the absence of definitive treatment. Radiographs often reveal gas formation, for which the infection receives its common name. Gram stain may demonstrate the pathogenic Clostridia species and mixed anaerobic flora; a typical finding is the absence of a prominent inflammatory 7 INFECTIOUS DISEASE 19 response. If meticulously collected, anaerobic cultures will often grow C. Prompt surgical debridement of necrotic tissue is the mainstay of therapy. Adjuvant antibiotic therapy with high-dose penicillin G has been routinely recom- mended; studies have demonstrated that combination therapy with clindamycin appears superior to penicillin alone. Despite adequate medical and surgical manage- ment, there remains significant morbidity and mortality associated with clostridial myonecrosis. You are treating a 75-year-old woman for severe community-acquired pneumonia with ceftriaxone and azithromycin. By hospital day 6, she has improved markedly with respect to her pulmonary status but has developed frequent watery diarrhea with cramping abdominal pain. Oral bacitracin Key Concept/Objective: To know the most cost-effective therapy for C. Metronidazole is considerably less expensive, however, and the oral route is prefer- able over the I. Bacitracin is as effec- tive as vancomycin and metronidazole in treating the symptoms of C. A 46-year-old woman presents to the emergency department complaining of facial spasms and muscle stiffness. Five days ago, while working with barbed wire on her ranch, she sustained a deep puncture wound of the left thenar eminence. This morning during breakfast, she experienced difficulty opening her mouth and felt pain with swallowing; this has progressed to stiffness and pain in her back, neck, thighs, and abdomen. On examination, the patient’s face is held in a stiff grimace. Any sudden stimu- lus produces tonic muscle contractions. Which of the following therapies will best treat this patient’s muscle spasms? Tetanus toxoid Key Concept/Objective: To know the symptomatic management of patients who present with tetanospasm The use of muscle relaxants is essential to the control of muscle spasms and rigidity, and diazepam is the drug of choice because it acts rapidly as a muscle relaxant and produces a sedative effect without inducing depression. The value of antimicrobial agents in the treatment of tetanus is doubtful; the only beneficial effects of antibiotics would be to eradicate from the wound vegetative cells of C. Tetanus antitoxin binds circulating toxin, but its administration does not alter those manifestations of tetanus already evident. Propranolol can be useful in treating sympathetic overactivity (hypertension, tachycardia, sweating) but not muscle spasm. Tetanus toxoid must be administered after an episode of tetanus because clinical 20 BOARD REVIEW tetanus does not establish natural immunity, but tetanus toxoid will not control tetanospasm once it is established. Metronidazole is effective as monotherapy for which of the following infections? Lung abscess caused by Actinomyces Key Concept/Objective: To know the antimicrobial activity of metronidazole Metronidazole is the drug of choice for B. Some Actinomyces, Propionibacterium acnes, and microaerophilic streptococci are resistant, however, as are facultative anaerobes. Thus, the addition of a second antimicrobial agent is indicated for mixed facultative-anaerobic infections, such as intra-abdominal or pulmonary infections.