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Your Doctor Visit What your doctor will ask you about: urinary incontinence 20mg tadalis sx otc erectile dysfunction fact sheet, diffi- culty or pain with urinating discount tadalis sx 20mg line erectile dysfunction uk, blood in urine, pain or numbness in the buttocks or legs, abdominal pain, hip pain, fever or chills, nausea, vomiting, flank pain, vaginal discharge. Your doctor will also want to know whether you have ever had an X-ray, CT scan, or MRI of your spine, or any other tests of your backbone, and what they showed, and whether you have ever had surgery on your spine. Your doctor will want to know if your back pain began after a back injury or fall, and the precise location of the pain. Your doctor will want to know if you or anyone in your family has had any of these conditions: cancer, recent surgery, spinal fracture. Your doctor will do a physical examination including the fol- lowing: pushing on your abdomen, listening to your abdomen with 13 Copyright © 2004 by The McGraw-Hill Companies, Inc. CAUSE WHAT IS IT YPICAL SYMPTOMS Muscle strain Injury to muscles Muscle spasms near the spine, pain does not move to the legs, often begins after lifting Spinal fracture A break in one of the Severe, persistent pain, bones of the spine, tenderness, often the result called vertebrae of back injury or fall Osteomyelitis Bone infection Constant and progressive back pain lasting several weeks, may be history of recent infection Osteoarthritis The most common form Limited range of motion of of arthritis, or inflam- the spine, often accompa- mation of the joints nied by pain in other joints, more common in the elderly Ankylosing Arthritis affecting the Stiffness, lower back pain, spondylitis spine reduced flexibility in the spine, more common in young men Shingles Re-activation of the virus Painful skin sores that causes chicken pox; more common in the elderly who have had chicken pox Peptic ulcer Severe irritation of the Abdominal pain or tender- stomach lining ness, pain in the mid-back region, sometimes relieved by antacids BACK PAIN 15 WHAT CAN CAUSE BACK PAIN, AND WHAT IS TYPICAL FOR EACH CAUSE? Your Doctor Visit What your doctor will ask you about: how often the child wets the bed, if she has “accidents” during the day, if she is excessively hungry or thirsty, if she produces a large amount of urine or has trouble or pain with urination, seizures, numbness, or weakness, emotional or disciplinary problems, sleeping habits. Your doctor will want to know if the child or anyone in her fam- ily has had any of these conditions: diabetes, seizures, kidney dis- eases, bed wetting. CAUSE WHAT IS IT YPICAL SYMPTOMS Psychological Stress or other emotional No “accidents” during the problems, such as day difficulty reacting to the birth of a new sibling or other changes, often in children whose families have histories of bed wetting Diabetes or These conditions can Excessive thirst, producing kidney disease damage the kidneys a large amount of urine, dribbling urine, or having difficulty or pain with urination Seizures Convulsions Seizures that occur prior to bed wetting Neurologic Abnormalities in the Bed wetting is associated disease nervous system with neurological prob- lems such as mental retardation Blackouts What it feels like: temporarily losing consciousness or vision, some- times preceded by feeling faint or giddy. What can make it worse: coughing, urination, head-turning, exer- tion, pain, a fright, food, hitting your head. Your Doctor Visit What your doctor will ask you about: seizures, changes in vision, changes in sensation or movement, urination and bowel movements, chest pain, hunger, sweating, dizziness when standing, head injuries. Your doctor will want to know if you or anyone in your family has had any of these conditions: seizures, neurologic disease, dia- betes, cardiovascular disease, lung disease. Your doctor will want to know what happened when you blacked out, including what position you were in, and whether anyone watched you black out. Your doctor will do a physical examination including the fol- lowing: blood pressure, pulse, listening to your heart with a stethoscope, testing your stool for blood, thorough neurological examination. If you also feel abdominal pain, refer to the chapter on that subject for more information. Your Doctor Visit What your doctor will ask you about: abdominal pain, nausea, vomiting, change in bowel habits, black stools, change in abdominal girth, greasy bowel movements, weight change, gas, belching, regur- gitation, anxiety, depression, relation of bloating to bowel move- ments, results of previous X-rays or ultrasound examinations. Your doctor will want to know if you or anyone in your family has had any of these conditions: abdominal surgery, ulcer disease, coli- tis, diverticulosis, alcoholism, liver disease, hiatus hernia, obesity, emotional problems. CAUSE WHAT IS IT YPICAL SYMPTOMS Aerophagia Swallowing air Bloating, belching, gas, chronic, worsened with certain foods Flatulence Passing gas Bloating, belching, gas, chronic, worsened with certain foods Digestion Includes the inability to Diarrhea caused by certain problems digest certain foods and foods, greasy bowel move- difficulty absorbing ments, weight loss nutrients from foods Gastrointestinal A disorder of the stomach Weight loss, abdominal problems (See or intestines pain, change in bowel chapter on habits, nausea, vomiting Abdominal Pain. For instance, beets can turn stool red, while iron pills and bismuth (Pepto-Bismol) can turn stool black. Your Doctor Visit What your doctor will ask you about: abdominal pain, changes in bowel habits or stool, mucus or pus in stool, pain with bowel move- ments, nausea, vomiting, heartburn, vomiting blood, bruising, weight loss, dizziness when standing, whether you have had a bari- um enema, proctoscope, or abdominal X-ray done in the past, and what they showed. Your doctor will want to know if you or anyone in your family has had any of these conditions: hemorrhoids, diverticulosis, coli- tis, peptic ulcers, bleeding tendency, alcoholism, colon polyps. Your doctor will do a physical examination including the fol- lowing: blood pressure, pulse, pushing on your abdomen, checking your rectum for hemorrhoids, testing your stool for blood, thorough skin examination. IN ADULTS CAUSE WHAT IS IT YPICAL SYMPTOMS Hemorrhoids/ Swollen blood vessels in Rectal pain, light bleeding anal fissure the anus or rectum (See chapter on (hemorrhoids) or tears in Anus Problems. Your Doctor Visit What your doctor will ask you about: enlargement, pain, dis- charge, lumps, change in skin color, excessive milk production, fever, chills, mammography, swelling or lumps in the armpit. Your doctor will want to know if you or anyone in your family has had any of these conditions: pregnancy, tuberculosis, nervous system disease, breast cancer, benign cystic disease, alcoholism, liver disease. Your doctor will do a physical examination including the fol- lowing: thorough breast exam, checking lymph nodes under your arms, and, in males, checking testes for size and firmness. BREAST PROBLEMS 27 WHAT CAN CAUSE BREAST PROBLEMS, AND WHAT IS TYPICAL FOR EACH CAUSE? BREAST ENLARGEMENT CAUSE WHAT IS IT YPICAL SYMPTOMS Puberty Period of becoming Enlargement of one or both sexually mature, or breasts, common and capable of reproducing normal in male and female adolescents Long-term use Use of spironolactone Breast enlargement in adult of certain (Aldactone), digoxin men medications (Lanoxin), diphenyl- hydantoin (Dilantin), cimetidine (Tagamet) Liver disease Includes hepatitis and Breast enlargement in adult cirrhosis (scarring of the men, jaundice (skin taking liver) on a yellowish appear- ance), alcoholism, small and soft testicles Testicular An abnormal growth of Breast enlargement in adult cancer cells in the testicles men, firm mass in the testicles LUMPS OR MASSES CAUSE WHAT IS IT YPICAL SYMPTOMS Cystic mastitis Fluid-filled sacs in the Lumps in the breast, usual- breast ly becoming painful before each menstrual period Cancer An abnormal growth of Family history of breast cells in the breast cancer, lump with an ill- defined border, sometimes with dimpling of the over- lying skin 28 BREAST PROBLEMS WHAT CAN CAUSE BREAST PROBLEMS, AND WHAT IS TYPICAL FOR EACH CAUSE? What can make it worse: dust, chest injury, lying down, exertion, breathing in a particular substance, prolonged inactivity, recent sur- gery, certain times of year, allergies, emotional stress. Your Doctor Visit What your doctor will ask you about: anxiety, confusion, light- headedness, lethargy, fever, chills, night sweats, blueness or numb- ness in lips or fingers, cough, coughing up sputum or blood, wheez- ing, noisy breathing, swelling, weight change, the influence of being upright on your ability to breathe, chest pain, ankle swelling, previ- ous chest X-rays, electrocardiograms, tests of lung function, allergy skin tests. Your doctor will want to know if you or anyone in your family has had any of these conditions: heart disease, high blood pres- sure, obesity, pneumonia, chest surgery, anemia, tuberculosis, AIDS, allergies to drugs, eczema, hay fever, lung failure, chronic lung dis- eases such as bronchitis, emphysema, or fibrosis. Your doctor will want to know if you smoke cigarettes and, if so, how many and for how long.

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Procedure: With the patient supine and the leg raised discount tadalis sx 20 mg fast delivery cough syrup causes erectile dysfunction, the examiner smoothes the distended veins buy tadalis sx 20mg low price impotent rage random encounter. The examiner then compresses the greater saphenous vein with a tourniquet distal to its junction with the femoral vein at the inguinal ligament and asks the patient to stand up. Evaluation: If the varices only fill up slowly or not at all within 30 seconds of the patient standing up but then fill rapidly from proximal once the tourniquet is loosened, this indicates valvular insuf• ciency of the saphenous vein with normal function of perforating veins. Relatively rapid filling from distal can occur as a result of insuf• cient perforating veins or anastomoses with an insuf• cient lesser saphenous vein. Rapid filling of the varices from both distal and proximal once the tourniquet is released indicates insuf• ciency of both the greater saphenous vein and the communication with the deeper venous system. Procedure: With the patient standing, the examiner applies a tourni- quet to the thigh or lower leg proximal to the filled varices. Incomplete emptying is observed where there is moderate valvular insuf• ciency of the communicating veins. Unchanged filling in the varices occurs with significant insuf• ciency of the perforating veins and impaired blood flow in the deep veins. An increase in filling suggests a severe post-thrombotic syndrome with reversed blood flow in the perforating veins. Note: The Schwartz test or the percussion method of Schwartz and Hackenbruch is used to assess valvular insuf• ciency in the region of the greater saphenous vein. With the patient standing, the examiner places one finger on the distended vein being examined and taps on the junction of the greater saphenous and femoral veins with one finger of the other hand. If this tapping is transmitted back to the first finger, the blood flow is continuous, indicating that the valves in the portion of the vein being examined are not intact. The test is not necessarily definitive, but it is good method for determining whether a superficial venous branch communicates with the greater or lesser saphenous vein. Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. Assessment: Pain occurring upon dorsiflexion of the foot with the knee extended and flexed indicates thrombosis. Calf pain with the knee extended can also be caused by intervertebral disk disease (radicular symptoms) or muscle contractures. Notably, nearly 90% of all cases of obliterative arteriosclerosis involve exclusively the lower extremities. Prior to treating the actual orthopedic disorder, the physician must take care to exclude or identify any possi- ble arterial ischemic disorders. After obtaining a detailed history, a diagnosis can usually be made on the basis of inspection, palpation, and specific function tests, and usually will not require the use of any diagnostic technology. Weakened or absent arterial pulse, cool and pale skin (or cyanotic skin), patches of erythema, and trophic disturbances are signs of occlu- sive arterial disease. Where typical symptoms of intermittent claudication (calf pain after walking short distances) are present, determining the max- imum distance the patient can walk without experiencing these symp- toms can help in estimating the severity of the disorder (Fontaine clas- sification of the severity of occlusive arterial disease). The differential diagnosis of intermittent claudication must include spinal claudication from compression of the cauda equina, the cardinal symptom of lumbar spinal stenosis. The intermittent claudication in cauda equina pathology is not a sharply defined clinical syndrome. Radicular symptoms such as paresthesia,pain, sensory deficits, and weakness can occur in one or both legs when the patient stands or walks. These symptoms may improve or disappear when the patient stops moving, as in the vascular form, but more often will do so only on certain body movements. The patient is asked to walk up and down a long corridor for up to three minutes at about 120 paces per minute. The time of occurrence of symptoms and the site of pain are clinically assessed, as are gait and any pauses. If the patient pauses after only 60 seconds, this suggests disruption of vascular supply to the muscles.

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It is usually unwise to begin TPN in a patient who requires large amounts of fluid tadalis sx 20 mg without prescription erectile dysfunction drugs reviews, may need resuscitation for trauma discount tadalis sx 20mg without prescription erectile dysfunction drugs class, or is septic. Placement of a deep line must be done aseptically, as outlined in Chapter 13, page 253. Infection (bacteremia, fungemia) arising from the catheter or the catheter–skin interface is the most common complication of TPN. SMA-7 and SMA-12; in particular check phosphate, glucose, and routine elec- trolytes (Na, K, Cl) d. Medications are generally not added to TPN solutions except insulin and H2 receptor blockers. Check urine for sugar and acetone every 6-8 h, house officer should be called if sugar is >2+ or acetone is present. Triglyceride trough level (obtained at least 6 h after infusion has stopped, prefer- ably prior to hanging next bottle of fat) once or twice weekly. Advance to the maximum rate based on the calculated daily caloric need (page 209). Begin the IV fat emulsion the next day, provided that the serum triglyceride levels are less than 400 mg/dL. Remember that glucose intolerance is the major adverse effect seen during the initial infusion period. Urine sugar and acetone 12 levels should be less than 2+, and serum glucose values less than 180–200 mg/dL. If the sugar level rises above these levels, insulin must be given to achieve the desired level of caloric intake. If glucose intolerance develops when using a 25% dextrose so- lution, consider decreasing the amount of calories from dextrose and increasing the calories from fat. Glucose intolerance arising once the patient has been stabilized may signify sepsis. ASSESSING TPN THERAPY Nitrogen balance is a good measure of the success of the TPN regimen because the goal is protein-sparing (see page 229). Serum albumin will not change appreciably during TPN therapy lasting less than 3 wk. In stressed patients, albumin often falls due to reduced production because the body shifts to increased production of acute-phase reactant proteins. If there are concerns about hypoglycemia, then a 10% dextrose solution can be administered after cessation of the TPN. Other considerations include providing energy needs at the BEE + 30% for initiation of TPN calories, limiting protein initially to 0. Ideally, blood sugar should be well controlled or at least not >200 when initiating TPN. Remember that no more than 50% of total intake should be from fat and not more than 3 g/kg/d. Insulin should be added to the solution initially at 5–10 units/bag in patients requiring >20 units of insulin daily. Geriatrics: Patients older than 75 years have a documented need for fewer calories. Inflammatory Bowel Disease: TPN can be initiated in these patients at approxi- mately 1. Note: Patients with fistulas lose nitrogen via this route and need additional protein. Liver Disease: Specialized formulas of amino acids that contain primarily branched- chain amino acids (leucine, isoleucine, and valine) are available for use in cases of liver dis- ease. Theoretically, these products may improve arousal from hepatic encephalopathy by competing with the aromatic amino acids that are precursors for some centrally active amines. There is no definitive evidence that branched-chain formulas improve patient out- 12 come.

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