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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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Saul P. Greenfield, MD
Eight studies reported on 10 or fewer participants (Benchimol medicine names buy cheap levaquin 500mg on-line, 2004; Berman treatment kidney stones generic levaquin 250 mg overnight delivery, 2006; Bruce 5 medications post mi generic 500mg levaquin with mastercard, 1988; Elmer symptoms uterine prolapse levaquin 750 mg overnight delivery, 1995; Garrido, 2005; Hensgens, 1976; Malkov, 2006; Reid, 2001; Weiss, 2010). Nineteen of the case series indicated that investigating the safety of the intervention was one of the main aims of the publication (Bibiloni, 2005; Bruni, 2009; Colecchia, 2006; Elmer, 1995; Fukuda, 2008; Gabrielli, 2009; Huynh, 2009; Karimi, 2005; Kitajima, 1997; Lamiki, 2010; Lombardo, 2009; Luoto, 2010; Mego, 2005; Nobuta, 2009; Rosenfeldt V, 2003; Uehara, 2006; Yim, 2006; Zahradnik, 2009). However, almost half of the case series did not report that they assessed adverse events as part of their treatment evaluation, as can be seen in Evidence Table C3, Assessment. Where specified, studies mentioned that they monitored gastrointestinal symptoms or blood chemistry results. To assess any adverse events that may occur during the treatment period, some studies used a patient diary (Barrett, 2008; Bekkali, 2007; Gionchetti, 2007; Huynh, 2009; Lamiki, 2010; Lombardo, 2009; Zahradnik, 2009) or a questionnaire (An, 2010; Barrett, 2008; Cobo Sanz, 2006; Colecchia, 2006; Dughera, 2007; Gruenwald, 2002; Nobuta, 2009), but in most cases, the assessment was done by a health care professional. It was often not clear whether the assessment of adverse events was prompted or whether the health care professionals recorded only adverse events that participants chose to mention. Colechia (2006) reported the use of a published questionnaire (Neri, 2000) for the harms assessment. The measure was designed to discriminate irritable bowel syndrome and gastrointestinal diseases from food allergies; however it also covered drug tolerance. Mego (2005 and 2006) graded toxicity according to the National Cancer Institute Common Toxicity Criteria (version 2. We also extracted which adverse events were reported on by the authors, regardless of whether the harm occurred or it was reported that no incidence of the harm was found. The most frequently recorded individual adverse event was diarrhea or watery stool (recorded in nine studies); gas, meteorism, or flatulence (nine studies); bloating or fullness (seven studies); abdominal pain or gastralgia (five studies); and nausea (six studies). As described under Key Question 1d, we did not identify conventional population surveillance studies that met our inclusion criteria. In this review, a case series was defined as a study reporting on a single group of participants using probiotics or synbiotics. The majority investigated Lactobacillus strain interventions, mainly alone or in some cases in combination with strains of other genera. Five studies investigated an intervention including Bifidobacterium, four used Saccharomyces, three Enterococcus, two Streptococcus, and two Bacillus organisms. All included genera are indicated in the Evidence Table C4, Results, details of the individual interventions are shown in Evidence Table C2, Intervention. For all case series, we extracted which adverse events were reported in the publication, using the exact wording from the articles. The most frequently reported incidence of an individual symptom across the case series was bloating or fullness (25 participants, recorded in 7 studies) followed by diarrhea or watery stools (22 participants across studies, 16 studies recorded the outcome). Flatulence or gas (20 participants, 9 studies recorded the outcome) and nausea (18 participants, recorded in 13 studies) were also recorded in more than 10 participants. In total, the case series reported 12 deaths across studies, and the outcome was recorded in 3 studies. During the study reported by Carlsson (2009), two dementia patients using Lactobacillus and Lactococcus among other medications died. Mego (2006) reported that no deaths occurred (Enterococcus faecium M-74 containing intervention). In the absence of a control group and multiple alternative explanations for the reported adverse events, it is not possible to attribute the events to the probiotics intervention. Long-Term Effects None of the included case series reported on long-term treatment effects (a followup of 1 or more years after the administration of probiotic organisms). Of the included studies that reported a specific adverse event, none could clearly be described as a mechanistic study. Studies primarily investigating possible mechanisms of action of probiotics are either not published in the peer-reviewed literature and databases we searched, which concentrated on health research, or they do not consider patient health outcomes, the focus of this review. We also identified only a very small number of studies that reported nonspecific safety statements and that could be described as mechanistic studies (see Appendix C, Evidence Table C6, Nonspecific Safety Statements). A study focusing in part on a mechanistic question (Garrido, 2005) investigated how the ingestion of different amounts of Lactobacillus johnsonii La1 influences the main bacterial populations of the fecal microbiota in eight symptomatic volunteers. The study stated that the participants showed good tolerance for the product and noted only mild increases of borborygmi. Satokari (2001) published an additional article on polymerase chain reaction and denaturing gradient gel electrophoresis monitoring of fecal Bifidobacterium populations in a prebiotic and probiotic trial, and reported one incident of abdominal discomfort in the control group and one control group participant who did not complete the study due to antibiotic treatment. Of the 387 included studies, 40 case studies (of all 43 case studies) described an antibiotic or antifungal therapy designed to treat unintended pathology potentially caused by the administered organism (Barton, 2001; Bassetti, 1998; Burkhardt, 2005; Cesaro, 2000; Cherifi, 2004; Conen, 2009; De Groote, 2005; Force, 1995; Fredenucci, 1998; Hennequin, 2000; Henry, 2004; Ku, 2006; Kunz, 2004; Land, 2005; Ledoux, 2006; Lestin, 2003; Lherm, 2002; Lolis, 2008; Lungarotti, 2003; Mackay, 1999; Munakata, 2010; Munoz, 2005; Niault, 1999; Oggioni, 1998; 38 Oh, 1979; Ohishi, 2010; Perapoch, 2000; Piarroux, 1999; Piechno, 2007; Pletinex, 1995; Presterl, 2001; Rautio, 1999; Richard, 1988; Rijnders, 2000; Riquelme, 2003; Tommasi, 2008; Trautmann, 2008; Viggiano, 1995; Zein, 2008; Zunic, 1991). However, causes for antibiotic or antifungal therapy were neither always clearly stated nor easy to establish, and authors might not have associated the treatment with the probiotic intervention. This summary does not include studies where all participants received antibiotics as a cotreatment or studies where the reduction or prevention of antibiotics use was an efficacy outcome. Only studies were considered that reported that a course of antibiotic or antifungal treatment was required to treat an adverse event of individual participants during or after the intervention period. Two case series reported that a participant required antibiotic treatment during a probiotic intervention. One study reported that participants receiving the probiotic had more otitis media, and it was then treated with an antibiotic (Abrahamsson, 2007). Allen (2010) reported more respiratory infections in the probiotic treatment group compared to placebo, and nine cases across arms were treated with antibiotics. Basu (2007) reported that two participants in each group were treated for septicemia (presumably with antibiotics, although not explicitly stated). Gerasimov (2010) reported that three preschool children (two treatment group and one control group) treated for atopic dermatitis were lost to followup due to respiratory tract infections requiring antibacterial therapy. Haschke-Becher (2008) reported that one child in a probiotic intervention and three children in control groups withdrew due to antibiotic intake. In another study, one case of perineal Candida was found in both arms and was treated with antibiotics (Millar, 1993). Niers (2009) reported that three mother-child pairs out of each treatment group discontinued a trial on prevention of allergic diseases due to use of antibiotics. Satokari (2001) reported that one control group participant did not complete the study because of an antibiotic treatment (details not reported). Sullivan (2003) reported that one participant in the probiotics group developed diarrhea, with no causative organism confirmed and was later treated with antibiotics. Tursi (2006 and 2008) reported that one case in a probiotics group was admitted to a hospital due to acute bronchial pneumonia and treated with antibiotics. Larsson (2008) reported that 10 participants received antibiotics for upper respiratory infections or other reasons, at least 4 of whom were in the probiotic group. De Preter (2006) 39 reported that 1 participant withdrew from a crossover trial comparing Saccharomyces boulardii [cerevisiae], lactulose, and placebo intake but the group to which the participant was assigned was not reported. To be included in the review, studies had to report an adverse patient health outcome; the recovery of the administered organism alone was not a sufficient outcome to be eligible for inclusion in the review. Nonetheless, a large number of included studies reported recovery of Lactobacillus, Bifidobacterium, Saccharomyces, Streptococcus, Enterococcus, and Bacillus in the gastrointestinal tract, serum, mouth, or vagina. In most cases, the attempt to recover the organism was used as an efficacy measure, an indicator of a successful intervention and quality check that the organism was indeed consumed. Some of the trials reported that infections and/or the recovery of the administered organisms in the blood were monitored but that no cases occurred. A description of the methods was not reported; however, any suspected positive identification may have changed that. Evidence From Controlled Trials In total, 36 trials reported that sepsis, bacteremia or fungemia, infections, or blood cultures were monitored to investigate associations with the administered organism as a safety precaution. A small number of trials reported explicitly on the absence of probiotics-associated sepsis, bacteremia or fungemia. BinNun (2005) reported no cases of sepsis due to administered probiotics (Bifidobacterium and Streptococcus strains). Jirapinyo (2002) reported no cases of sepsis due to Lactobacillus or Bifidobacterium. Kerac (2009) reported no cases of probiotics-related sepsis (Lactobacillus, Leuconostoc, and Pediococcus). Lin (2005) reported no cases of sepsis due to probiotics (Lactobacillus and Bifidobacterium). Lin (2008) reported no cases of sepsis due to probiotics (Lactobacillus and Bifidobacterium). Rouge (2009) reported no cases of sepsis due to Lactobacillus and Bifidobacterium. A small number of trials reported on the absence of probiotic-associated infections or signs of infections.
Diseases
The effect of respirator training on the ability of healthcare workers to pass a qualitative fit test medicine you cannot take with grapefruit 750mg levaquin for sale. Evaluation of single-use masks and respirators for protection of health care workers against mycobacterial aerosols symptoms zoloft dose too high purchase 500mg levaquin free shipping. Collection of three bacterial aerosols by respirator and surgical mask filters under varying conditions of flow and relative humidity treatment xerostomia order levaquin 250mg line. An outbreak of severe acute respiratory syndrome among hospital workers in a community hospital in Hong Kong treatment of strep throat generic 500mg levaquin visa. Comparison of ion plasma, vaporized hydrogen peroxide, and 100% ethylene oxide sterilizers to the 12/88 ethylene oxide gas sterilizer. Antimicrobial efficacy of endoscopic disinfection procedures: a controlled, multifactorial investigation. Evidence-based model for hand transmission during patient care and the role of improved practices. Biosafety level 3 laboratory for autopsies of patients with severe acute respiratory syndrome: principles, practices, and prospects. Geographic representativeness for sentinel influenza surveillance: implications for routine surveillance and pandemic preparedness. Australian and New Zealand Journal of Public Health, 2006, 30(4):337341. A practical tool for the preparation of a hospital crisis preparedness plan, with speical focus on pandemic influenza. Surge capacity associated with restrictions on nonurgent hospital utilization and expected admissions during an influenza pandemic: lessons from the Toronto severe acute respiratory syndrome outbreak. Research findings from nonpharmaceutical intervention studies for pandemic influenza and current gaps in the research. Physical interventions to interrupt or reduce the transmission of respiratory viruses resource use implications: a systematic review. Protecting healthcare staff from severe acute respiratory syndrome: filtration capacity of multiple surgical masks. Issues affecting respirator selection for workers exposed to infectious aerosol: emphasis on healthcare settings. Chemical disinfection to interrupt transfer of rhinovirus type 14 from environmental surfaces to hands. Chemical disinfection of non-porous inanimate surfaces experimentally contaminated with four human pathogenic viruses. Investigations of the effectiveness of detergent washing, drying and chemical disinfection on contamination of cleaning cloths. An outbreak of Acinetobacter respiratory tract infection resulting from incomplete disinfection of ventilatory equipment. Bronchopulmonary cross-colonization and infection related to mycobacterial contamination of suction valves of bronchoscopes. Effect of relative humidity, atmospheric temperature, and suspending medium on the airborne survival of human rotavirus. Killing of fabric-associated bacteria in hospital laundry by lowtemperature washing. Bacteriological quality of fabrics washed at lower-thanstandard temperatures in a hospital laundry facility. The potential spread of infection caused by aerosol contamination of surfaces after flushing a domestic toilet. Influenza virus receptor specificity and cell tropism in mouse and human airway epithelial cells. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care facilities. The impact of severe respiratory syncytial virus on the child, caregiver, and family during hospitalization and recovery. Evidence-based practice: examining the risk of toys in the microenvironment of infants in the neonatal intensive care unit. Multiresistant Pseudomonas aeruginosa outbreak in a pediatric oncology ward related to bath toys. Facemasks and hand hygiene to prevent influenza transmission in households: a cluster randomized trial. Effect of infection control measures on the frequency of upper respiratory infection in child care: a randomized, controlled trial. Rapid awareness and transmission of severe acute respiratory syndrome in Hanoi French Hospital, Vietnam. Factors associated with transmission of severe acute respiratory syndrome among health-care workers in Singapore. Effectiveness of personal protective measures in prevention of nosocomial transmission of severe acute respiratory syndrome. Effect of a comprehensive infection control program on the incidence of infections in long-term care facilities. Healthy hands: use of alcohol gel as an adjunct to handwashing in elementary school children. Reduction of illness absenteeism in elementary schools using an alcohol-free instant hand sanitizer. Alcohol-free instant hand sanitizer reduces elementary school illness absenteeism. The effect of hand hygiene on illness rate among students in university residence halls. Evaluation of a handwashing intervention to reduce respiratory illness rates in senior day-care centers. Effectiveness of a training program in reducing infections in toddlers attending day care centers. Reducing absenteeism from gastrointestinal and respiratory illness in elementary school students: a randomized, controlled trial of an infection-control intervention. A randomized, controlled trial of a multifaceted intervention including alcohol-based hand sanitizer and hand-hygiene education to reduce illness transmission in the home. Efficacy of organic acids in hand cleansers for prevention of rhinovirus infections. Two randomized controlled trials of virucidal nasal tissues in the prevention of natural upper respiratory infections. Efficacy of virucidal nasal tissues in interrupting familial transmission of respiratory agents. Interruption of transmission of rhinovirus colds among human volunteers using virucidal paper handkerchiefs. The use of gowns and masks to control respiratory illness in pediatric hospital personnel. Prevention of nosocomial transmission of respiratory syncytial virus in a newborn nursery. Prevention of nosocomial respiratory syncytial virus infections through compliance with glove and gown isolation precautions. Use of surgical face masks to reduce the incidence of the common cold among health care workers in Japan: a randomized controlled trial. Preliminary findings of a randomized trial of nonpharmaceutical interventions to prevent influenza transmission in households. Mask use, hand hygiene, and seasonal influenza-like illness among young adults: a randomized intervention trial. Routine isolation procedure vs routine procedure supplemented by use of masks and goggles. Dispersal of respiratory droplets with open vs closed oxygen delivery masks: implications for the transmission of severe acute respiratory syndrome. Adverse skin reactions to personal protective equipment against severe acute respiratory syndrome a descriptive study in Singapore. The use of eye-nose goggles to control nosocomial respiratory syncytial virus infection. Surgical mask vs N95 respirator for preventing influenza among health care workers: a randomized trial. Gowning does not affect colonization or infection rates in a neonatal intensive care unit. Archives of Pediatrics and Adolescent Medicine, 1994, 148(10):10161020.
Although bites from these spiders can be serious symptoms stomach ulcer 250mg levaquin visa, they are not as frequent as the bites that occur from mosquitoes symptoms wheat allergy trusted levaquin 750 mg, ants treatment tracker 500mg levaquin overnight delivery, fleas and flies symptoms underactive thyroid levaquin 250mg cheap. All bites have the potential to cause local skin irritation, pruritus, swelling, erythema and pain. Insect bites rarely cause systemic allergic reactions in children when compared to insect stings (1). Although uncommon, if a patient has enough of a repeated allergen load from proteins contained in the saliva of the biting arthropod, systemic allergic reactions could occur (1). Anaphylaxis has been reported from bites of the mosquito, horsefly, and the tick (2). Another health problem associated with insect bites is the potential to transmit disease. An outbreak of dengue fever in Hawaii (2001) by mosquitoes demonstrated the disease carrying ability of insects as vectors. Another noteworthy vector in Hawaii is the flea and its ability to transmit the plague. Fortunately Hawaii does not have ticks and fleas that carry Lyme disease and Rocky Mountain spotted fever. Envenomation occurs from such arthropods such as spiders and centipedes in Hawaii. A few of the spiders in Hawaii contain venom in their bite that can lead to serious complications. The Southern Black Widow Spider (Latrodectus mactans), as well as its cousins, the brown widow (Latrodectus geometricus), and the Western Black Widow (Latrodectus Hesperus), are found in Hawaii (3). The black widow lives in warm, dark, dry places outdoors or in sheds, basements and garages. Its venom causes severe muscle cramping which is mediated by a neurotoxin that acts on the presynaptic membrane causing the release and decreased uptake of acetylcholine (4). The victim usually experiences a pinprick sensation, followed by regional lymph node tenderness (30-120 minutes later), a target lesion (at the bite site), and muscle cramping near the bite site (4). Dysautonomia manifested with nausea, emesis, sweating, Page - 664 hypertension, tachycardia, and malaise can occur (3,8). Treatment is analgesia, while supportive care is given to hypertensive and tachycardic patients (4). Antivenom derived from horse serum is available but reserved for the severe cases due to the adverse effects from horse serum administration (4). The brown violin spider (Loxosceles rufescens) is a cousin of the brown recluse spider (Loxosceles reclusa), which is responsible for most of the clinically significant necrotic spider bites in the United States (5). The Brown recluse spider is not found in Hawaii but the brown Violin spider is found locally (3). All Loxosceles spiders are venomous and produce the clinical condition called loxoscelism, also known as necrotic arachnidism (5). The brown violin spiders are non-aggressive, nocturnal and found under boards and loosened bark (3). Bites usually are seen in children and can be asymptomatic or it can cause a mild to sharp stinging pain followed by potential development of a central blister to dermonecrosis (5). Loxosceles envenomation can usually be treated as an outpatient unless there are systemic symptoms, serious infection, or extensive necrosis (5). Fortunately, most arthropod bites are more of an annoyance rather than a potential life-threatening situation. Immediate management may include: local wound care, topical corticosteroids, antibiotics if infected, antihistamines if the lesion is pruritic for comfort and prevention of infection by excoriation, tetanus toxoid booster if not current, and analgesics. However, systemic allergic reactions occur more frequently from insect stings compared to insect bites in children (1). Stinging insects belonging to the order Hymenoptera (bees, wasp, and ants) are responsible for 40-50 deaths a year in the United States (2,7). Reactions to arthropod sting can be classified as usual, large local, anaphylactic and toxic reactions (2). The usual arthropod sting causes the local pain, swelling, and erythema, which resolves in a few hours (2). Large local reactions involve more extensive symptoms, which last 24-48 hours (2). Since wasps can sting repeatedly, one may find grouped lesions without any visible stinger. The bee stinger contains venom sacs which if pinched can increase the level of envenomation. The usual and local reactions of insect stings require control of pain, pruritus, and swelling, as well as local wound care to prevent infections. Localized hypersensitivity reactions can be treated with topical corticosteroids, urticaria can be treated with antihistamines and anaphylactic reactions are treated more intensively with epinephrine, antihistamines and corticosteroids. Repeat anaphylactic reactions to insect stings are more common in adults than in children (2). Children under 16 years old, who have isolated allergic reactions (urticaria and angioedema) after stings have a 10% incidence of subsequent systemic reactions and only a less than 0. An allergist should evaluate any child with an anaphylactic reaction to insect stings. Immunotherapy for insects can be used on children depending on the severity of the allergic reaction. However, any child with a history of anaphylaxis and positive skin test or in vitro assay for venom specific IgE should receive immunotherapy for 4-5 years (2). In children with large localized reactions and who are at risk for future frequent or multiple stings, immunotherapy is an option (2). These children should also be given a self-administered epinephrine kit with instructions and a demonstration of its use. Scorpions from other parts of the world do contain venoms, which can be substantially toxic. Avoidance of stinging arthropods becomes an important part of management and includes: identification and elimination of stinging insect nests, avoiding brightly colored clothing or strongly scented lotions, wearing shoes or protective footwear outdoors, exercising caution around sites frequented by stinging insects (eaves, attics, and areas where food is present outside), and wearing protective clothing when outside (long shirt, pants, hat, gloves, socks and shoes) (6). Marine envenomations common in Hawaii occur from box jellyfish, Portuguese man-of-war, and venomous fish. These animals produce protein-based venoms that are used in self-defense or to capture prey. Unfortunately the unwary beach goers may interact adversely with these animals and sustain intensely painful wounds. As a general rule, these venoms tend to be heat labile and can be denatured with heat. A twelve year old male moving boxes in the basement experienced a pinprick sensation on his right hand followed by muscle cramps and swelling in his right axilla. What two spiders are found in Hawaii that can inflict a serious and potentially deadly envenomation? True/False: Repeat anaphylactic reactions to insect stings are more common in adults than in children. True, anaphylaxis can occur from any repeated insect bite or sting in which re-exposure to an antigen occurs. Common Skin Conditions Annemarie Uliasz this is a 6 month old female who is brought to the office with her mother with a chief complaint of a diaper rash for one week. Mother has been using baby powder to keep the area dry, but the rash is worsening. Upon examination, the buttocks, perianal region, and tops of the thighs appear erythematous with no ulcerations or erosions. Areas of flexure are involved and there are some beefy red areas with a few satellite lesions. Baby powder does not keep the area dry once the child urinates, so its value is minimal. Petrolatum or zinc oxide applied to the diaper region is suggested as prophylaxis against irritation. Topical clotrimazole cream is also recommended to eliminate any yeast infection that may be present. The most superficial layer of the epidermis, the stratum corneum, serves as a protective barrier against the environment, and prevents desiccation.
He is not exposed to chemicals treatment without admission is known as generic 250 mg levaquin overnight delivery, uses a mild soap for personal cleaning and has no pets medications errors generic 750mg levaquin mastercard. Which of the following is the most appropriate initial treatment option for this patient? A 28-year-old man comes to the office because he would like to quit smoking cigarettes medicine 93 2264 cheap 750mg levaquin with mastercard. He says medications of the same type are known as cheap levaquin 250 mg visa, "I cannot go more than a day without cigarettes because I get so anxious and irritable. The patient is interested in using a nicotine patch and bupropion therapy because he says his friend found the treatments to be helpful. In combining these two therapies, this patient is at greatest risk for which of the following? A 55-year-old woman, gravida 1, para 1, comes to the office because she is concerned that she has continued to have regular menses while her friends of the same age have gone through menopause. She reports having her usual premenstrual breast tenderness and menstrual cramping. She has not had change in flow, intermenstrual spotting, hot flushes, or night sweats. Screening mammogram obtained 1 year ago and all previous Pap smears, including her most recent Pap smear 2 years ago, have shown no abnormalities. A 26-year-old male police officer comes to the office for an annual health maintenance examination. He is physically active and feels well, but he notes that his asthma has been more active during the past month. He says that he has had to use his albuterol inhaler one to two times daily for wheezing and chest tightness. Medical history is remarkable for atopic allergies, especially to pollen and cats. Physical examination shows no abnormalities except for scattered rhonchi and wheezes with forced expiration. A 40-year-old man with paranoid schizophrenia is transferred to the emergency department from the residential facility where he lives 2 hours after having swallowed a nail. Mental status examination discloses a flat affect, distractibility, and derailment of thoughts. X-ray of the abdomen is obtained and shows a 4-cm nail in the left upper quadrant. After admitting the patient to the hospital, which of the following is the most appropriate management? A 38-year-old male letter carrier returns to the office for follow-up of abnormal results of a liver chemistry profile ordered 3 weeks ago during a routine examination. Serum bilirubin and alkaline phosphatase concentrations were within the reference ranges. A 16-year-old high school student, whose prenatal course you have managed, delivers a 3256-g (7-lb 3-oz) baby girl during the night with the assistance of your associate. On morning rounds you note that the delivery records report that she had mildly elevated blood pressure during labor and sustained an estimated third-stage blood loss of 500 mL. Today blood pressure is 132/84 mm Hg, she is afebrile, and deep tendon reflexes are normal. The uterine fundus is firm and at the level of the umbilicus, and her perineum is slightly edematous. She was diagnosed with Turner syndrome in infancy during a work-up for coarctation of the aorta. It is most appropriate to counsel the patient that if she wishes to have a family she will need to do which of the following? A 51-year-old woman comes to the emergency department after falling on an icy sidewalk. Physical examination shows swelling of the left wrist and tenderness over the dorsum of the wrist. This is her first episode of urticaria and it has occurred and then resolved several times in the past week. A 25-year-old man, who was admitted to the hospital 5 hours ago because of nausea, light-headedness, and muscle aches that began after he completed a marathon, now reports worsening pain in his right leg. On admission, the patient reported only mild muscle aching, but he now rates the pain in his right lower extremity as a 9 on a 10-point scale. Laboratory studies on admission were notable for a serum creatine kinase concentration of 10,000 U/L and a serum creatinine concentration of 1. Passive flexion of the toes elicits pain over the anterior portion of the right lower extremity below the knee. A 16-year-old girl is brought to the office by her mother because she is concerned that she may have contracted meningitis from her soccer teammate, who was diagnosed with meningococcal meningitis and admitted to the hospital yesterday. Which of the following is the most appropriate intervention for this patient at this time? A 42-year-old man comes to the office for preoperative evaluation prior to undergoing adrenalectomy scheduled in 2 weeks. One month ago, he received care in the emergency department for pain over his right flank following a motor vehicle collision. Results of laboratory studies, including complete blood count, serum electrolyte concentrations, and liver function tests, were within the reference ranges. The patient otherwise had been healthy and had never been told that he had elevated blood pressure. A follow-up visit in the office 2 weeks ago disclosed elevated urinary normetanephrine and metanephrine and plasma aldosterone concentrations. Initial preoperative preparation should include treatment with which of the following? A 25-year-old woman is admitted to the hospital 6 hours after an episode of syncope. She reports feeling tired during the past few months but attributes the fatigue to a new, stressful job. Physical examination shows a prominent right cardiac impulse, a fixed and widely split S2, and a midsystolic flow murmur. The patient should be informed that if her condition is left untreated, the most likely outcome will be which of the following? Her last pregnancy resulted in cesarean delivery because of fetal distress during labor. Her history includes heavy use of alcohol and cigarettes, and multiple sexual partners. At a follow-up visit this patient should be counseled regarding which of the following? A 70-year-old man, who was admitted to the hospital 3 days ago for treatment of pneumonia, has now developed diarrhea and severe lower abdominal cramping. The patient has passed watery and yellow stools every 2 hours for the past 12 hours. Since admission, the patient has been treated with intravenous levofloxacin therapy and albuterol/ipratropium nebulizers every 4 hours, with only mild improvement of his respiratory symptoms. Medical history is also significant for hypertension, type 2 diabetes mellitus, and hyperlipidemia. Abdomen is diffusely tender to palpation with no distention, rebound, or guarding. Intravenous infusion of which of the following substances is the most appropriate next step? A 34-year-old woman comes to the office because of a 3- to 4-week history of swelling of her legs and a 9-kg (20-lb) weight gain. She has been taking 800 mg of ibuprofen three times daily for Achilles tendinitis diagnosed 1 month ago. She has smoked five cigarettes daily for the past 15 years, and she drinks one to five beers on weekends. She experimented with cocaine briefly 16 years ago, but she has never used intravenous drugs. Physical examination discloses periorbital edema but no jugular venous distention. Abdominal examination discloses bulging flanks and shifting dullness to percussion. Examination of the lower extremities shows pitting edema from the mid thigh to the ankles bilaterally.
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