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Albuterol (Proventil generic sildalis 120 mg mastercard erectile dysfunction cream 16, Ventolin) COMMON USES: Bronchospasm in reversible obstructive airway disease; prevention of exercise- induced bronchospasm ACTIONS: β-Adrenergic sympathomimetic bronchodilator; relaxes bronchial smooth muscle DOSAGE: Adults purchase sildalis 120mg visa erectile dysfunction drug mechanism. Multiple cont inf and SCSC dosing schedules (including “high-dose” therapy with 24 × 106 IU/m2 IV q8h on d 1–5 and 12–16) SUPPLIED: Inj 1 buy discount sildalis 120mg line erectile dysfunction meds online. Capillary leak syndrome with hypotension, pulmonary edema, fluid retention, and weight gain. Renal toxicity and mild hematologic toxicity (anemia, thrombocy- topenia, leukopenia) and secondary eosinophilia. Adequate calcium and vitamin D supple- ment necessary Alfentanil (Alfenta) [C] COMMON USES: Adjunct in the maintenance of anesthesia; analgesia ACTIONS: Short-acting narcotic analgesic DOSAGE: Adults & Peds >12 y. Use only for treating hyperuricemia of malignancy in children (<10 y): 10 mg/kg/24h PO or 200 mg/m2/d IV ÷ q6–8h (max 600 mg/24h) SUPPLIED: Tabs 100, 300 mg; inj 500 mg/30 mL NOTES: Aggravates acute gouty attack; do not begin until acute attack resolves; administer pc. IV administration of 6 mg/mL final conc as single daily infusion or ÷ 6-, 8-, or 12-h intervals. Patients should be informed of other side effects, including priapism, penile fibrosis, and hematoma Alprostadil [Prostaglandin E1] (Prostin VR) COMMON USES: Any state in which blood flow must be maintained through the ductus arteriosus to sustain either pulmonary or systemic circulation until corrective or palliative surgery can be per- formed (eg, pulmonary atresia, pulmonary stenosis, tricuspid atresia, transposition, severe tetralogy of Fallot) ACTIONS: Vasodilator, platelet aggregation inhibitor. Have an intubation kit at bedside if patient is not intubated Alprostadil, Urethral Suppository (Muse) COMMON USES: Erectile dysfunction ACTIONS: Alprostadil (PGE1) absorbed through urethral mucosa. Portion of administered dose transported to the corpus cavernosa where it acts as vasodilator and smooth muscle relaxant DOSAGE: 125–1000 µg system 5–10 min prior to sexual activity SUPPLIED: 125, 250, 500, 1000 µg with a transurethral delivery system NOTES: Hypotension, dizziness, syncope, penile pain, and priapism. In AMI doses of >150 mg associ- ated with intracranial bleeding Altretamine (Hexalen) COMMON USES: Epithelial ovarian cancer ACTIONS: Unknown; cytotoxic agent, possibly alkylating agent; inhibits nucleotide incorporation into DNA and RNA DOSAGE: 260 mg/m2/d in 4 ÷ doses for 14–21 d of a 28-d treatment cycle; dose ↓ to 150 mg/m2/d for 14 d in multiagent regimens. Reduction of cumulative renal toxicity associated with repeated admin- istration of cisplatin ACTIONS: Prodrug, dephosphorylated by alkaline phosphatase to the pharmacologically active thiol metabolite DOSAGE: 910 mg/m2/d as a 15-min IV inf 30 min prior to chemotherapy SUPPLIED: Vials containing 500 mg of lyophilized drug with 500 mg of mannitol, reconstituted in sterile NS NOTES: Toxicity symptoms: Transient hypotension in >60%, nausea and vomiting, flushing with hot or cold chills, dizziness, hypocalcemia, somnolence, and sneezing. Does not reduce the effective- ness of cyclophosphamide plus cisplatin chemotherapy Amikacin (Amikin) COMMON USES: Serious infections caused by gram (−) bacteria and mycobacterial infections ACTIONS: Aminoglycoside antibiotic; inhibits protein synthesis DOSAGE: See also page 620. Toxicity symptoms: Nausea and vomiting, irritability, tachycardia, ventricular arrhythmias, and seizures; follow serum levels carefully (as theophylline, see Table 22–7, pages 631–634); aminophylline is about 85% theophylline; erratic absorption with rectal doses Amiodarone (Cordarone) (Pacerone) COMMON USES: Recurrent VF or hemodynamically unstable VT ACTIONS: Class III antiarrhythmic DOSAGE: Adults. Maintenance: 600–800 mg/d PO for 1 mo, then 200–400 mg/d IV: 15 mg/min for 10 min, followed by 1 mg/min for 6 h, then a maintenance dose of 0. En- cephalopathy possible; obtain aluminum levels, especially in renal insufficiency. Alum soln often precipitates and occludes catheters Amoxapine (Asendin) COMMON USES: Depression and anxiety ACTIONS: Tricyclic antidepressant; reduces reuptake of serotonin and norepinephrine DOSAGE: Initially, 150 mg PO hs or 50 mg PO tid; ↑ to 300 mg/d SUPPLIED: Tabs 25, 50, 100, 150 mg NOTES: ↓ in elderly; taper slowly when discontinuing therapy Amoxicillin (Amoxil, Polymox, others) COMMON USES: Infections resulting from susceptible gram (+) bacteria (streptococci) and gram (−) bacteria (H. Topical: Apply bid–qid for 1–4 wk depending on in- 22 fection 22 Commonly Used Medications 497 SUPPLIED: Powder for inj 50 mg/vial, oral susp 100 mg/mL, cream, lotion, oint 3% NOTES: Monitor renal function; hypokalemia and hypomagnesemia possible from renal wasting; pretreatment with acetaminophen and antihistamines (Benadryl) help minimize adverse effects as- sociated with IV infusion Amphotericin B Cholesteryl (Amphotec) COMMON USES: Refractory invasive fungal infection in persons intolerant to conventional ampho- tericin B ACTIONS: Binds to sterols in the cell membrane, resulting in changes in membrane permeability DOSAGE: Adults & Peds. Infuse at a rate of 1 mg/kg/h SUPPLIED: Powder for inj 50 mg, 100 mg/vial NOTES: Do NOT use in-line filter, final concentration 0. If inf >2 h, manually mix contents of the bag Amphotericin B Liposomal (Ambisome) COMMON USES: Refractory invasive fungal infection in persons intolerant to conventional ampho- tericin B ACTIONS: Binds to sterols in the cell membrane, resulting in changes in membrane permeability DOSAGE: Adults & Peds. Children >1 mo: 100–200 mg/kg/24h ÷ q4–6h IM or IV; 50–100 mg/kg/24h ÷ q6h PO up to 250 mg/dose. Meningi- tis: 200–400 mg/kg/24h ÷ q4–6h IV SUPPLIED: Caps 250, 500 mg; susp 100 mg/mL (reconstituted as drops), 125 mg/5 mL, 250 mg/ 5 mL, 500 mg/5 mL; powder for inj 125 mg, 250 mg, 500 mg, 1 g, 2 g, 10 g/vial NOTES: Cross-hypersensitivity with penicillin; can cause diarrhea and skin rash; many hospital strains of E. Low-dose: 1 million KIU load, 1 million KIU for the pump prime dose, followed by 250,000 KIU/h until surgery ends. Give all patients 1-mL IV test dose to assess for allergic reaction Ardeparin (Normiflo) COMMON USES: Prevention of DVT and PE following knee replacement ACTIONS: Low-molecular-weight heparin DOSAGE: 35–50 U/kg SC q12h. Joseph, others) COMMON USES: Mild pain, headache, fever, inflammation, prevention of emboli, and prevention of MI ACTIONS: Prostaglandin inhibitor DOSAGE: Adults. Tabs Fiorinal, Lanorinal, Marnal: Aspirin 325 mg/butalbital 50 mg/ caffeine 40 mg NOTES: Butalbital habit-forming Aspirin + Butalbital, Caffeine and Codeine (Fiorinal + Codeine) [C] COMMON USES: Mild pain; headache, especially when associated with stress ACTIONS: Sedative analgesic, narcotic analgesic DOSAGE: 1–2 tabs (caps) PO q4–6h PRN SUPPLIED: Each cap or tab contains 325 mg aspirin, 40 mg caffeine, 50 mg of butalbital, codeine: No. AMI: 5 mg IV ×2 over 10 min, then 50 mg PO bid if tolerated SUPPLIED: Tabs 25, 50, 100 mg; inj 5 mg/10 mL Atenolol and Chlorthalidone (Tenoretic) COMMON USES: HTN ACTION: β-Adrenergic blockade with diuretic DOSAGE: 50–100 mg/d PO SUPPLIED: Tenoretic 50: Atenolol 50 mg/chlorthalidone 25 mg; Tenoretic 100: Atenolol 100 mg/chlorthalidone 25 mg Atorvastatin (Lipitor) COMMON USES: Elevated cholesterol and triglycerides ACTIONS: HMG-CoA reductase inhibitor DOSAGE: Initial dose 10 mg/d, may be ↑ to 80 mg/d SUPPLIED: Tabs 10, 20, 40, 80 mg NOTES: May cause myopathy, monitor LFT regularly Atovaquone (Mepron) 22 COMMON USES: Rx and prevention mild to moderate PCP 22 Commonly Used Medications 501 ACTIONS: Inhibits nucleic acid and ATP synthesis DOSAGE: Rx: 750 mg PO bid for 21 d. Prevention: 1500 mg PO once/d SUPPLIED: Suspension 750 mg/5 mL NOTES: Take with meals Atracurium (Tracrium) COMMON USES: Adjunct to anesthesia to facilitate endotracheal intubation ACTIONS: Nondepolarizing neuromuscular blocker DOSAGE: Adults & Peds. Use adequate amounts of sedation and analgesia Atropine Used for emergency care (see Chapter 21) COMMON USES: Preanesthetic; symptomatic bradycardia and asystole ACTIONS: Antimuscarinic agent; blocks acetylcholine at parasympathetic sites DOSAGE: Adults. Interaction with allopurinol Azithromycin (Zithromax) COMMON USES: Acute bacterial exacerbations of COPD, mild community-acquired pneumonia, pharyngitis, otitis media, skin and skin structure infections, nongonococcal urethritis, and PID. Rx and prevention of MAC infections in HIV-infected persons ACTIONS: Macrolide antibiotic; inhibits protein synthesis DOSAGE: Adults. Oral: Respiratory tract infections: 500 mg on the first day, followed by 250 mg/d PO for 4 more d. Pharyngitis: 12 mg/kg/d PO for 5 d SUPPLIED: Tabs 250, 600 mg; susp 1-g single-dose packet; susp 100, 200 mg/5 mL; inj 500 mg NOTES: Take susp on an empty stomach; tabs may be taken with or without food Aztreonam (Azactam) COMMON USES: Infections caused by aerobic gram (−) bacteria, including Pseudomonas aerugi- nosa ACTIONS: Monobactam antibiotic; inhibits cell wall synthesis DOSAGE: Adults. Note: Neosporin ointment different from cream (page 576) Bacitracin, Ophthalmic (AK-Tracin Ophthalmic) Bacitracin and Polymyxin B, Ophthalmic (AK Poly Bac Ophthalmic, Polysporin Ophthalmic) Bacitracin, Neomycin and Polymyxin B, Ophthalmic (AK Spore Ophthalmic, Neosporin Ophthalmic) Bacitracin, Neomycin, Polymyxin B and Hydrocortisone, Ophthalmic (AK Spore HC Ophthalmic, Cortisporin Ophthalmic) COMMON USES: Blepharitis, conjunctivitis, and prophylactic treatment of corneal abrasions ACTIONS: Topical antibiotic with added effects based on components (antiinflammatory) DOSAGE: Apply q3–4h into conjunctival sac SUPPLIED: See Topical equivalents, above Baclofen (Lioresal, others) COMMON USES: Spasticity secondary to severe chronic disorders, eg, MS or spinal cord lesions, trigeminal neuralgia ACTIONS: Centrally acting skeletal muscle relaxant; inhibits transmission of both monosynaptic and polysynaptic reflexes at the spinal cord DOSAGE: Adults. IT: Through implantable pump SUPPLIED: Tabs 10, 20 mg; IT inj 10 mg/20 mL, 10 mg/5 mL NOTES: Use caution in epilepsy and neuropsychiatric disturbances, withdrawal may occur with abrupt discontinuation Basiliximab (Simulect) COMMON USES: Prevention of acute organ transplant rejections ACTIONS: IL-2 receptor antagonists DOSAGE: Adults. Repeat once weekly for 6 wk; repeat 3 weekly doses 3, 6, 12, 18, and 24 mo after the initial therapy SUPPLIED: Inj 27 mg (3. BCG vaccine occasionally used in high risk-children who are negative on the PPD skin test and cannot be given isoniazid prophylaxis. Becaplermin (Regranex Gel) COMMON USES: Adjunct to local wound care in diabetic foot ulcers ACTIONS: Recombinant human PDGF, enhanced formation of granulation tissue DOSAGE: Based on size of lesion; 1¹ ₃-in. May be repeated 3 more × q6h for a max of 4 doses/48h SUPPLIED: Suspension 25 mg of phospholipid/mL NOTES: Administer via 4-quadrant method Betaxolol (Kerlone) COMMON USES: HTN ACTIONS: Competitively blocks β-adrenergic receptors (β1) DOSAGE: 10–20 mg/d SUPPLIED: Tabs 10, 20 mg Betaxolol, Ophthalmic (Betoptic) COMMON USES: Glaucoma ACTIONS: Competitively blocks β-adrenergic receptors (β1) DOSAGE: 1 gtt bid SUPPLIED: Soln 0. Lung toxicity likely when the total dose >400 mg (U) Bretylium COMMON USES: Acute Rx of VF or tachycardia unresponsive to conventional therapy ACTIONS: Class III antiarrhythmic DOSAGE: Adults. Same as adults, except the maintenance dose is 5 mg/kg/dose q6–8h SUPPLIED: Inj 50 mg/mL; premixed inf 1, 2, 4 mg/mL (limited availability) NOTES: Nausea and vomiting associated with rapid IV bolus; gradually ↓ dose and discontinue in 3–5 d; effects seen within the first 10–15 min; transient rise in BP seen initially; hypotension most frequent adverse effect and occurs within the first hours of treatment Brimonidine (Alphagan) COMMON USES: Open-angle glaucoma ACTIONS: α2-Adrenergic agonist DOSAGE: 1 gtt in eye(s) tid SUPPLIED: 0. Dose dependent on procedure, vascularity of tissues, depth of anesthesia, and degree of muscle relaxation required (see Chapter 17) SUPPLIED: Inj 0. Smoking cessation: 150 mg/d for 3 d, then 150 mg bid for 8–12 wk SUPPLIED: Tabs 75, 100 mg; SR tabs 100, 150 mg NOTES: Associated with seizures; avoid use of alcohol and other CNS depressants Buspirone (Buspar) COMMON USES: Short-term relief of anxiety ACTIONS: Antianxiety agent; selectively antagonizes CNS serotonin receptors DOSAGE: 5–10 mg PO tid. No physical or psychological dependence Busulfan (Myleran) COMMON USES: CML, preparative regimens for allogeneic and ABMT in high doses ACTIONS: Alkylating agent DOSAGE: 4–12 mg/d for several weeks; 16 mg/kg once or 4 mg/kg/d for 4 d in conjunction with an- other agent in transplant regimens. Refer to specific protocol SUPPLIED: Tabs 2 mg NOTES: Toxicity symptoms: Myelosuppression, pulmonary fibrosis, nausea (high-dose therapy), gy- necomastia, adrenal insufficiency, and hyperpigmentation of the skin Butorphanol (Stadol) [C] COMMON USES: Moderate to severe pain and headaches ACTIONS: Opiate agonist–antagonist with central analgesic actions DOSAGE: 1–4 mg IM or IV q 3–4 h PRN. Osteo- porosis salmon calcitonin: 100 U/d IM/SC; Intranasal 200 U = 1 nasal spray/d SUPPLIED: Spray, nasal 200 U/activation; inj, human (Cibacalcin) 0. Ca gluconate inj 10% = 100 mg/mL = Ca 9 mg/mL; tabs 500 mg = 45 mg Ca, 650 mg = 58. RDA for Ca: Adults = 800 mg/d, Peds = <6 mo 360 mg/d, 6 mo–1 y 540 mg/d, 1–10 y 800 mg/d; 10–18 y 1200 mg/d Calfactant (Infasurf) COMMON USES: Prevention and Rx of RSD in infants ACTIONS: Exogenous pulmonary surfactant DOSAGE: 3 mL/kg instilled into lungs. May be retreated for a total of 3 doses administered 12 h apart SUPPLIED: Intratracheal susp 35 mg/mL NOTES: Monitor for cyanosis and airway obstruction during administration Candesartan (Atacand) COMMON USES: HTN ACTIONS: Angiotensin II receptor antagonists DOSAGE: 2–32 mg/d, usual dose is 16 mg/d SUPPLIED: Tabs 4, 8, 16, 32 mg Capsaicin (Capsin, Zostrix, etc) [OTC] COMMON USES: Pain due to postherpetic neuralgia, chronic neuralgia, arthritis, diabetic neuropa- thy, postoperative pain psoriasis, intractable pruritus ACTIONS: Topical analgesic DOSAGE: Apply tid–qid SUPPLIED: OTC creams; gel; lotions; roll-ons Captopril (Capoten, Various) COMMON USES: HTN, CHF, LVD, and diabetic nephropathy ACTIONS: ACE inhibitor DOSAGE: Adults. HTN: Initially, 25 mg PO bid–tid; ↑ to a maintenance dose q 1–2 wk by 25-mg increments/dose (max 450 mg/d) to desired effect. Give 1 h ac; can cause rash, proteinuria, and cough; con- tra in 2nd or 3rd trimester of PRG. Carbamazepine (Tegretol) COMMON USES: Epilepsy and trigeminal neuralgia ACTIONS: Anticonvulsant DOSAGE: Adults.

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Headache What it feels like: throbbing generic sildalis 120 mg erectile dysfunction jacksonville florida, sharp pain or pressure in the head or neck purchase 120 mg sildalis with amex erectile dysfunction pills walmart, sometimes accompanied by nausea 120 mg sildalis mastercard erectile dysfunction pills by bayer, neck aches, and muscle pain. What can make it worse: head injury, anxiety, alcohol, certain foods, pressure over points in the face, placing the head between the legs. The brain itself cannot feel pain—the pain comes from stimulation of blood vessels, muscles, or nerves in the head and neck. Your Doctor Visit What your doctor will ask you about: history of unconsciousness, change in memory, motor or sensory change, nausea, vomiting, stiff neck, fever, ear pain, eye pain, change in vision, nasal discharge or stuffy nose, muscle aches or pains, anxiety, depression, seeing flash- ing lights or having “funny” feelings before the headache, results of previous skull X-rays, CT, or MRI. Your doctor will want to know if you or anyone in your family has had any of these conditions: nervous system disease, previous skull fracture, migraine headaches, cluster headaches, emotional problems, sinus disease. Your doctor will want to know if your headache wakes you up from sleep, if it occurs more often at night, if it began suddenly, or if it recurs. Your doctor will do a physical examination including the fol- lowing: blood pressure, temperature, thorough eye exam, thorough ear exam, checking sinuses for tenderness, looking for discharge from the nose, checking the throat, examining the neck for stiffness, thorough examination of your reflexes and movement, a series of exercises to reproduce the pain. COMMON CAUSES OF HEADACHE CAUSE WHAT IS IT YPICAL SYMPTOMS Muscle tension Tightness in the muscles Constant band-like pres- of the shoulders, scalp, sure that lasts days to neck, and jaw weeks, pain often centers at the back of the head and worsens at the end of the day, triggered or worsened by anxiety Classic Severe form of headache Throbbing pain that can migraine last several days, often experience typical “funny” feelings before pain kicks in, headache often centers in the front of the head, often preceded by nausea and vomiting, family histo- ry of migraine, may be caused by alcohol or stress Common Severe form of headache Resembles classic migraine migraine (see above), often appears without typical “funny” feeling beforehand Cluster Recurring form of Brief pain centered in the headache headache front of the head, occurs often at night, tearing, nasal stuffiness, sometimes go for months with no symptoms HEADACHE 111 WHAT CAN CAUSE HEADACHES, AND WHAT IS TYPICAL FOR EACH CAUSE? Anxiety can produce symptoms of heart pounding in people with- out heart conditions. If you also lose consciousness, see the chapter on Loss of Consciousness for more information. If the heart pound- ing comes with chest pain, see the chapter on Chest Pain for more information. Your Doctor Visit What your doctor will ask you about: anxiety, depression, giddi- ness, weakness, tingling in hands or around mouth, fever, chills, chest pain, trouble breathing, loss of consciousness, pulse rate dur- ing palpitations, results of previous heart monitoring, the rhythm of heartbeats during palpitations. Your doctor will want to know if you or anyone in your family has had any of these conditions: heart disease, diabetes, high blood pres- sure, thyroid disease, blood disease, emotional problems, alcoholism. Your doctor will want to know how long each episode of heart palpitations lasts, if each episode begins and ends gradually or abruptly, and if you have experienced palpitations before. Your doctor will ask if you smoke cigarettes or drink alcohol, and how much caffeine you drink. CAUSE WHAT IS IT YPICAL SYMPTOMS Anxiety or Chronic feelings of a low Numbness in both hands, depression (See mood or anxiety faintness, pins and needles chapter on around lips, trouble breath- Depression, ing, occurs in people con- Suicidal cerned about their heart Thoughts, or health, can be a “panic Anxiety. If you are experiencing chest pain other than heartburn, refer to the chapter on Chest Pain for more information. If your pain is centered more in your abdomen, see the chapter on Abdominal Pain for more information. Your Doctor Visit What your doctor will ask you about: anxiety, depression, weight loss, weakness, abdominal pain, nausea, vomiting blood, tarry stools, results of any recent tests of the insides of your stomach, any suc- cesses with previous treatments or diets. Your doctor will want to know if you or anyone in your family has had any of these conditions: abdominal surgery, liver disease, arthritis, chronic lung disease, alcoholism, ulcer disease. Your doctor will want to know when and how you first noticed your heartburn, and how many times it has recurred. Some important factors to consider with ulcers caused by heartburn: • Ulcers are caused by the movement of stomach acid up into and through the esophagus, which connects the throat to the stom- ach. Over time, this movement of acid can lead to ulcer, or irri- tation of the stomach or intestinal lining. To keep this from happening, your doc- tor may ask you to: • Limit your intake of caffeine, cigarettes, alcohol, and cer- tain medications. Heatstroke What it feels like: collapse during extreme heat, sometimes leading to delirium or coma. Someone with a mild form of heatstroke, known as heat prostration, will appear faint, have cold and clammy skin, and have a slight fever. If a person with heatstroke falls into a coma, becomes delirious, or has hot and dry skin and a temperature of more than 103 degrees F, seek medical help immediately. Your Doctor Visit What your doctor will ask you about: headache, changes in think- ing, loss of consciousness, nausea, vomiting, diarrhea, decreased urine output, sweating, cold skin, muscle cramps, bleeding. Your doctor will want to know if you or anyone in your family has had any of these conditions: alcoholism, heart disease, high blood pressure, diabetes. Your doctor will want to know how long you were in a hot environ- ment, the temperature of the environment, your temperature at the time of collapse, and what you were doing when you collapsed. Your doctor will do a physical examination including the fol- lowing: temperature, breathing rate, blood pressure, pulse, thorough exam of your reflexes and movement, checking skin for sweating, color, and warmth. RISK FACTOR WHAT IS IT YPICAL SYMPTOMS Dehydration Not drinking enough Dry mouth, producing little water or no urine, sunken eyes, more common in people taking blood pressure med- ication or drinking alcohol Inadequate An inability to cool Lack of sweating when hot, sweating down by sweating more common in the eld- erly, diabetics, those with high cholesterol, people wearing too much clothing or engaging in excessive exercise, or people taking anticholinergic medica- tions such as Benadryl and Cogentin, or phenoth- iazines such as the antipsy- chotic Haldol Heavy Drinking (Alcohol) What it is: your drinking patterns become a problem when you expe- rience withdrawal if you stop drinking alcohol (see below), you devel- op an illness related to drinking, or it interferes with your social or work life; drinking to excess – a six-pack of beer in one sitting, or a fifth of a gallon of whiskey, for example, without becoming drunk – is also probably a sign of problem drinking. For example, if you answer “yes” to any of the following ques- tions, you may have a drinking problem: 1. Have you ever had a drink when you wake up, to “steady your nerves” or cure a hangover? Your doctor will also want to know if you or anyone in your fam- ily has had any of these conditions: seizures, delirium after cutting 119 Copyright © 2004 by The McGraw-Hill Companies, Inc. Your doctor will do a physical examination including the fol- lowing: temperature, pulse, blood pressure, thorough skin examina- tion, tests of memory, pushing on your abdomen, checking your limbs for tremors or shakiness, tests of brain function involving bal- ance, eye movements, and reflexes. PROBLEM WHAT IS IT YPICAL SYMPTOMS Tremulousness Trembling or shaking Irritability, flushed skin, stomach upset, sleepiness, occurs after several days of drinking Delirium Delirium that occurs Fever, confusion, tremor, tremens when you stop drinking hallucinations, sweating, dilated pupils Seizures Convulsions Occur within 2 days of when you stop drinking Cerebellar A type of brain disorder Unsteadiness, abnormal degeneration eyeball movements, unco- ordinated gait Wernicke- A brain disorder caused Confusion, memory loss, Korsakoff by a lack of thiamine disorientation, abnormal psychosis (vitamin B1) eyeball movements Neuropathy Nerve damage in the Unsteadiness, numbness or extremities burning in feet or hands Hiccough What it feels like: an involuntary and rapid intake of breath accom- panied by tightness in the abdomen, often persistent. Most cases of hiccoughs occur in people who are in otherwise perfect health, often the result of eating too quickly. Your Doctor Visit What your doctor will ask you about: abdominal pain, weakness, chest pain, new cough or change in cough pattern, trouble swallow- ing, anxiety. Your doctor will want to know if you or anyone in your family has had any of these conditions: alcoholism, kidney disease, liver disease, nervous system disease. CAUSE WHAT IS IT YPICAL SYMPTOMS Rapid eating Eating too quickly Otherwise healthy Gastroenteritis Infection of the stomach Nausea, vomiting, diar- rhea, cramping, muscle aches, slight fever Gastric An expansion of the “Gas,” discomfort distention (see stomach, either by food chapter on or gas Bloating) Lung tumor Unchecked, abnormal Change in cough patterns, growth of cells in the coughing up blood, chest lungs ache, more common in cigarette smokers Advanced renal Inability of the kidneys Pallor, gradual lapse into failure to function properly coma, history of kidney disease Encephalitis Inflammation or infection Fever, nausea, vomiting, of the brain stiff neck, headache, grad- ual lapse into coma Hoarseness What it feels like: a dry, scratchy voice. The most common cause of hoarseness that has lasted less than 2 weeks is inflammation in the voice box, often accompanied by a cold and sore throat. Your Doctor Visit What your doctor will ask you about: cough, fever, sore throat, trouble breathing, wheezing, weight loss, coughing up blood, neck or chest pain, trouble swallowing, thickening of hair, cold intolerance. Your doctor will want to know if you or anyone in your family has had any of these conditions: any chronic disease, alcoholism. Your doctor will want to know if you smoke cigarettes, drink alcohol, or sing professionally. Your doctor will do a physical examination including the fol- lowing: temperature, using an instrument to look into the back of the throat, checking the movement of the vocal cords, thorough neck exam, looking at the skin, checking your reflexes. CAUSE WHAT IS IT YPICAL SYMPTOMS Laryngitis Inflammation in the Runny nose, sore throat, voice box facial pain, general malaise; hoarseness lasts less than two weeks Puberty Period of becoming Voice changes, occurs only sexually mature, or in boys capable of reproducing Chronic Chronic inflammation of Husky voice lasting years, inflammation the vocal cords more common in people of the larynx who smoke cigarettes and drink alcohol Epiglottitis Inflammation of a Trouble breathing, drool- structure in the throat ing, sore throat, noisy that can block the air breathing; occurs in chil- passages dren, particularly between the ages of 3 and 7 years. Laryngeal Loss of function in the Progressive hoarseness, nerve paralysis nerve that supplies the weight loss, cough, cough- voice box ing up blood Hypothyroidism Decreased activity in the Progressive hoarseness, thyroid gland, which thickened skin, coarse hair, regulates metabolism intolerance to cold Tumor of the Unchecked, abnormal Progressive hoarseness, vocal cord growth of cells in the more common in people vocal cord who smoke cigarettes and drink alcohol Injury(Including Back Injury/Pain What it feels like: an accident results in some type of bodily harm, or you have a pain that may have been caused by an unknown injury. If the injury is primarily to your head, see below and the chapter on Head Injury for more information. Your Doctor Visit What your doctor will ask you about: the date of your last tetanus shot, the last time you ate before your injury occurred, details of the injury. Your doctor will want to know if you or anyone in your family has had any chronic diseases or allergies.

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Although genetic iosynostosis is discovered prenatally order 120 mg sildalis with visa erectile dysfunction treatment home, only the symptoms testing is available sildalis 120mg overnight delivery erectile dysfunction nclex questions, the diagnosis is usually made based can be treated order sildalis 120 mg overnight delivery erectile dysfunction facts and figures. Multiple surgeries are usually performed to progres- Often the doctor can determine which cranial suture sively correct the craniosynostosis and to normalize closed prematurely by physical examination. A team of surgeons is often involved, mation, an x ray or computerized tomography (CT) scan including a neurosurgeon and a specialized plastic sur- of the head may be performed. Patients is involved is crucial in making the correct craniosynos- with syndromic craniosynostosis often require surgery tosis diagnosis. The first surgery is usually performed early in the genetic abnormality, or it may be due to other, nongenetic first year of life, even in the first few months. In Pfeiffer syndrome, the tissue itself is abnormal Additional surgeries may be performed for other and causes the suture to fuse prematurely. Limb abnormalities often are not cor- consider nongenetic causes of craniosynostosis. If the limb malformations do not lead to a loss secondary causes include external forces such as abnor- of function, surgery is usually not required. Fixation of mal head positioning (in the uterus or in infancy) and a the elbow joints may be partially corrected, or at least small brain. Genetic testing may be useful for prenatal diagnosis, Hydrocephalus, airway obstruction, hearing loss, confirmation of the diagnosis, and to provide information incomplete eyelid closure, and spine abnormalities to other family members. Approximately one-third of affected individuals with Pfeiffer syndrome Prognosis do not have an identifiable mutation in the FGFR1 or FGFR2 gene. People with Pfeiffer syndrome due to a The prognosis for an individual is based on the mutation in the FGFR1 gene may have less severe abnor- symptoms he or she has. Individuals with Pfeiffer syn- malities than people who have Pfeiffer due to mutations drome type 1 have a better prognosis than individuals in the FGFR2 gene. Prenatal diagnosis is available by chorionic villus sampling (CVS) or amniocentesis if a mutation has Although people with Pfeiffer syndrome may not been identified in the affected parent. Amniocentesis is obtain a completely normal appearance, significant performed after the fifteenth week of pregnancy and CVS improvement is possible. Timing the surgeries correctly is usually performed in the tenth and twelfth weeks of is an important factor in whether they are successful and pregnancy. Although Pfeiffer syndrome is rare, craniosynostosis Conditions caused by mutations in the FGFR genes is relatively common. Multiple agencies and organiza- account for only a small portion of craniosynostosis. The OTHER identification of the FGFR genes that cause Pfeiffer (and Our child was just diagnosed with Craniosynostosis—What do other) craniosynostosis syndromes has promoted we do now? Craniosynostosis and Parents research into the underlying process that causes Pfeiffer Support, Inc. It will be another enormous challenge to go My child looks different: a guide for parents. In rare situations, the patient may experience Craniosynostosis and Parents Support, Inc. PO Box 11082, after the drug is given, so a person may have a pharma- Chattanooga, TN 37401. PO Box 515838, 7777 Forest otherwise in excellent health and has no family history of Lane, Ste C-621, Dallas, TX 75251-5838. WEBSITES Unexpectedly, there is a significant increase in body tem- Craniofacial Anomalies. Pediatric Surgery, perature, and the patient experiences sustained muscle Columbia University. Once diagnosed with malignant hyperthermia, it variations (poor, intermediate, extensive, and ultra) that is quite easy to avoid future episodes by simply using a result in different clinical phenotypes with respect to different type of anesthetic when surgery is necessary, drug metabolism. For example, a poor metabolizer has but it often takes one negative, and potentially life-threat- difficulty converting the therapeutic drug into a useable ening, experience to know the condition exists. To prevent this An incident that occurred in the 1950s further shows from happening, the prescribed dosage of the drug must the diversity of pharmacogenetic disorders. Korean War, service personnel were deployed in a region of the world where they were at increased risk for An ultra metabolizer, on the other hand, shows malaria. To reduce the likelihood of acquiring that dis- exceedingly rapid breakdown of the drug to the point that ease, the antimalarial drug primaquine was administered the substance may be destroyed so quickly that therapeu- prophylactically. Shortly thereafter, approximately 10% tic levels may not be reached, and the patient may there- of the African-American servicemen were diagnosed fore never show any benefit from treatment. In these with acute anemia and a smaller percentage of soldiers of cases, switching to another type of drug that is not asso- Mediterranean ancestry showed a more severe hemolytic ciated with CYP2D6 metabolism may prove more bene- anemia. Functional G6PD is important in ers, is less extreme than the ultra metabolism category, the maintenance of a balance between oxidized and but nevertheless presents a relatively rapid turnover of reduced molecules in the cells, and, under normal cir- drug that may require a higher than normal dosage to cumstances, a mutation that eliminates the normal maintain a proper level within the cells. And, finally, the enzyme function can be compensated for by other cellu- intermediate phenotype falls between the poor and exten- lar processes. However, mutation carriers are compro- sive categories and gives reasonable metabolism and mised when their cells are stressed, such as when the turnover of the drug. Clearly, both the medics who bolic classes has clearly shown that the usual “one size administered the primaquine and the men who took the fits all” recommended drug dose is not appropriate for all drug were unaware of the potential consequences. Research efforts Drugs are essential to modern medical practice, but, Future applications as in the cases of malignant hyperthermia and G6PD At the present time, pharmacogenetics is still in its deficiency, it has become clear that not all individuals infancy with its full potential yet to be realized. Reactions can vary from current studies, it is possible to envision many different positive improvement in the quality of life to life threat- applications in the future. New tests will be developed to research endeavors are now providing information that is monitor the effects of drugs, and new medications will be allowing a better understanding of the underlying causes found that will specifically target a particular genetic of pharmacogenetic anomalies with the hope that eventu- abnormality. Increased knowledge in this field should ally the number of negative episodes can be reduced. In time, these advances will improve the prac- The cytochrome P450 system is a group of related tice of medicine and become the standard of care. Stein, PhD 918 GALE ENCYCLOPEDIA OF GENETIC DISORDERS Phenotype see Genotypes and phenotypes Nerve cells have specialized extensions called dendrites and axons. Stimulating a nerve cell triggers nerve impulses, or signals, that speed down the axon. These nerve impulses then stimulate the end of an axon to release chemicals called neurotransmitters that spread IPhenylketonuria out and communicate with the dendrites of neighboring nerve cells. Definition Many nerve cells have long, wire-like axons that are Phenylketonuria (PKU) can be defined as a rare covered by an insulating layer called the myelin sheath. PKU is the most serious form of a class of nine levels in the blood and brain can produce nerve cells diseases referred to as “hyperphenylalaninemia,” all of with abnormal axons and dendrites, and cause imperfec- which involve above normal (elevated) levels of pheny- tions in the myelin sheath referred to as hypomyelination lalanine in the blood. This loss of myelin can “short circuit” PKU, mental retardation, is the result of consuming nerve impulses (messages) and interrupt cell communi- foods that contain the amino acid phenylalanine, which is cation.

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For this reason buy sildalis 120 mg free shipping erectile dysfunction herbal supplements, it is usually recommended that the fat emulsion be infused into the central line under strict aseptic technique via a ster- ile Y-connector buy sildalis 120 mg otc impotence hernia. As mentioned earlier buy discount sildalis 120mg on line erectile dysfunction pump youtube, some institutions combine the lipid with the TPN for- mula in one bag for 24-h administration. This limits the clinicians ability to validate fat clearance from the blood and makes baseline triglyceride data extremely important. STARTING TPN In general, TPN should not be started until a patient has a stable fluid and electrolyte profile. It is usually unwise to begin TPN in a patient who requires large amounts of fluid, may need resuscitation for trauma, 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. The specialized formulas should only be used in cases of severe hepatic disease ac- companied by encephalopathy. Lipid emulsions are not recommended in cases of severe hepatic failure when hypertriglyceridemia is present. Intravenous fat may be administered in these cases be- cause it is metabolized by peripheral tissue lipases. Pulmonary Disease: Carbohydrate metabolism produces higher amounts of CO2 than does fat metabolism. Consequently, the patient with CO2 retention problems often is stressed if overfed with carbohydrates. Increasing the percentage of daily nonprotein calo- ries provided by fat (not >60%) may decrease the CO2 load and assist with ventilator wean- ing. Higher fat percentages influence oxygen diffusion capacity and are not beneficial, especially in cases of mild pulmonary compromise. Phosphate depletion is a second clini- cally relevant concern in this population due to the depression of the hypoxic ventilatory drive. Once patients are started on TPN, PO −2 often decreases due to the incorporation into 4 ATP. Adequate supplementation and monitoring is very important in this group of patients. If a patient is not receiving dialysis or is not a dialysis candidate, protein must be restricted to 0. These products provide higher concentrations of essential amino acids than the standard amino acid products. Theoretically, the nitrogen waste products are recycled to make the nonessential amino acids, thereby reducing the BUN content. Risks exist, however, for ele- vations in ammonia when arginine is not also supplemented. Consequently, manufacturers have modified the original formulas to include several nonessential amino acids. Due to these changes, the renal products provide a very similar amino acid profile to those of the SAA solutions at very low concentrations (2. It is therefore recommended that patients with renal dysfunction receive SAA formulas at a re- duced concentration to provide the minimum daily allowance of protein.

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