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White cells suggest inflammatory processes such as urinary tract infection (most common) xenadrine erectile dysfunction buy generic viagra capsules 100 mg online, collagen vascular disease (eg erectile dysfunction books download free purchase viagra capsules line, lupus) does erectile dysfunction get worse with age cheap 100mg viagra capsules fast delivery, or inter stitial nephritis erectile dysfunction doctors in sri lanka 100mg viagra capsules fast delivery. Red cell casts are considered pathognomonic of glomerulonephritis; white cell casts erectile dysfunction drugs australia generic 100 mg viagra capsules amex, of pyelonephritis; and fatty (lipid) casts erectile dysfunction definition order 100mg viagra capsules with amex, of nephrotic syndrome. Comments See Table 8–28 for a guide to interpretation of urinalysis; and Figure 2–1 for a guide to microscopic findings in urine. Note: Fully automated urinalysis systems (either image or flow cytometry-based) are now available in many clinical laboratories, so manual microscopy examination may not be performed routinely in a central laboratory. Vaginal Fluid Wet-Mount Preparation Preparation of Smear and Staining Technique a. Examine under the microscope, using the high-dry (40×) lens and a low light source. Look for clue cells (vaginal epithelial cells with large numbers of organisms attached to them, obscuring cell borders), which are pathognomonic of Gardnerella vaginalis associated vaginosis. See Figure 2–2 for an example of a positive wet prep (trichomonads, clue cells) and Table 8–29 for the differential diagnosis of vaginal discharge. Obtain a skin specimen by using a scalpel blade to scrape scales from the skin lesion onto a glass slide or to transfer the top of a vesicle to the slide or, place a single drop of vaginal discharge on the slide. Point-of-Care Testing and Provider-Performed Microscopy 39 Microscopic Examination a. Examine the smear under low-power (10×) and high-dry (40×) lenses for mycelial forms. Branched, septate hyphae are typical of dermatophytosis (eg, trichophyton, epidermophyton, microsporum species); branched, septate pseudohyphae with or without budding yeast forms are seen with candidiasis (candida species); and short, curved hyphae plus clumps of spores ("spaghetti and meatballs") are seen with tinea versicolor (Malassezia furfur). Record and report any yeast, pseudohyphae, or hyphae, indicat ing budding and septation. Examine under a polarized light microscope with a red com pensator, using the high-dry lens and a moderately bright light source. Look for needle-shaped, negatively birefringent urate crystals (crystals parallel to the axis of the compensator appear yellow) in gout, or rhomboidal, positively birefringent calcium pyro phosphate crystals (crystals parallel to the axis of the compen sator appear blue) in pseudogout. Comments See Figure 2–4 for examples of positive synovial fluid examinations for these two types of crystals. Fern Test of Amniotic Fluid the Fern test, in conjunction with pH determination using pH paper (Nitrazine test), detects the leakage of amniotic fluid from the membrane surrounding the fetus during pregnancy. Examination of synovial fluid for crystals using a compensated, polarized microscope. In gout, crystals are needle shaped, negatively birefringent, and composed of monosodium urate. In pseudogout, crystals are rhomboidal, positively birefringent, and composed of calcium pyrophosphate dihydrate. In both diseases, crystals can be found free-floating or within polymorphonuclear cells. Point-of-Care Testing and Provider-Performed Microscopy 41 Preparation of Smear Technique a. If present, the amniotic fluid crystallizes to form a fern-like pattern (ferning) (Figure 2–5). If the Fern test is positive but the Nitrazine test is negative, there is probable rupture of membrane. If the Fern test is negative but the Nitrazine test is positive, a second specimen should be collected and examined using both tests. Premature rupture of the membranes may lead to fetal infection and subsequent morbidity. Pinworm Tape Test this test is a method used to diagnose a pinworm infection by microscopic examination of specimens taken from the perianal region to identify Enterobius vermicularis eggs or adult female worms, if present. Firmly press the sticky side of a 1-inch strip of transparent adhesive (Cellophane) tape over the right and left perianal folds for a few seconds. Using a microscope, examine the entire tape for eggs or worms under the low-power (10×) lens. The eggs are oval, elongated, and flattened on one side, with a thick colorless shell. The adult female worms are tiny, white, and threadlike, with a long, pointed tail. Comments Test should be done first thing in the morning before a bowel move ment or bath. Female pinworms deposit eggs sporadically, so test must be done on at least 4 consecutive days to rule out the infection. Positive Fern test showing crystallized amniotic fluid collected from the posterior vaginal fornix. Positive Pinworm tape test showing Enterobius vermicularis eggs (A) and adult female worms (B). Qualitative Semen Analysis Qualitative semen analysis is used to document the success of vasectomy. Semen samples should be examined for presence or absence of motile and/or non-motile sperm at 8–12 weeks post-vasectomy. Ask patient to collect the entire ejaculate by masturbation into a clean container labeled with patient name and unique identi fication number. For pres ence or absence of sperm, examine several fields before reporting the absence of sperm. If sperm are present, classify them accord ing to their motility (motile versus non-motile) in percentages. Comments Semen samples should be collected after an abstinence period of no less than 48 hours and no more than 7 days and maintained at body temperature. Specimen must be examined as soon as possible to ensure maximum accuracy of results. If sperm are present, the patient should be cautioned to continue temporary contraception and to resubmit a second specimen for re-examination after 4–6 additional weeks. For evaluation of infertility, full semen analysis should be performed at a central laboratory. Comparison of three automated systems for urine chemistry and sediment analysis in routine laboratory practice. Urine microscopy is associated with severity and worsening of acute kidney injury in hospitalized patients. Changing sexually transmitted infection screening protocol will result in improved case finding for Trichomonas vaginalis among high-risk female populations. Diagnostic accuracy of an initial azoospermic reading compared with results of post-centrifugation semen analysis after vasectomy. It includes most of the blood, urine, and cerebrospinal fluid tests found in this book, with the exception of drug levels and pharmacogenetic tests (see Chapter 4). Test/Reference Range/Collection this first outline listing begins with the common test name, the specimen analyzed, and any test name abbreviation (in parentheses). Below this, in the first outline listing, is the reference range (also called reference interval) for each test. The reference ranges provided are from several large medical centers; consult your own clinical laboratory for those used in your institution. This outline listing also shows which tube to use for collecting blood and other body fluids, how much the test costs (in relative symbolism; see below), and how to collect the specimen. Information on classification and biologic importance, as well as interactions with other biologic substances and processes, is included. Interpretation this outline lists clinical conditions that affect the substance being tested. When the sen sitivity of the test for a particular disease is known, that information follows the disease name in parentheses, for example, “rheumatoid arthritis (83%). Comments this outline listing sets forth general information pertinent to the use and interpretation of the test and important in vitro interferences with the test procedure. Test Name the test name is placed as a header to the rest of the outline list to allow for quick referencing. Type B with anti-A and anti-B for the presence or absence antigens A and B or their absence patients can receive type B or O of agglutination (forward or cell type), and patient’s $ (O) on a patient’s red blood cells. Test/Range/Collection Physiologic Basis Interpretation Comments Acetaminophen, serum In overdose, liver and renal toxicity Increased in:Acetaminophen Do not delay acetylcysteine (Mucomyst) treatment (140 (Tylenol; others) are produced by the hydroxylated overdose. Acetaminophen hepatotoxicity and acute liver fail 10–20 mg/L [66–132 with glutathione in the liver. When do the aminotransferases rise after acute interpreted, since the drug is still acetaminophen overdose? Acetoacetate, blood Acetoacetate, acetone, and Present in: Diabetic keto Nitroprusside test is semiquantitative; it detects aceto or urine β-hydroxybutyrate contribute acidosis, alcoholic ketoacidosis, acetate and is sensitive down to 5–10 mg/dL. Acetone is container are generally 20% acetoacetate, also not reliably detected by this method because the 78% β-hydroxybutyrate, and 2% sensitivity for acetone is poor. Failure of nitroprusside test to detect β hydroxybutyrate in ketoacidosis may produce a Urine sample should be seemingly paradoxical increase in ketones with clini fresh. Blood ketone bodies in patients with recent onset type 1 diabetes (a multicenter study). Prevention of diabetic ketoacidosis and self monitoring of ketone bodies: an overview. Sensitive 98–100%) neurologic disorders unrelated to the autonomic Negative radioimmunoassay or enzyme nervous system. Myasthenia gravis with anti-acetylcholine $$ α-bungarotoxin to the acetylcho receptor antibodies. Because different methodologies and a number specific) It is also used to determine the In general, the accepted goal dur of variables (eg, platelet count and function, dose of protamine sulfate to ing cardiopulmonary bypass sur hypothermia, hemodilution, and certain drugs like $$ reverse the heparin effect on gery is 400–500 sec. J Clin Endocrinol Metab Lavender, pink shows circadian variation, with Decreased in: Adrenal Cushing 2006;91:3746. The natural history of chronic hepatitis B $ liver”), extensive trauma; virus infection. Effect of a lifestyle intervention in patients Decreased in: Pyridoxine with abnormal liver enzymes and metabolic risk factors. Although disease, malnutrition, malab Independent risk factor for all-cause mortality in the [34–47 g/L] there are more than 50 different sorption, malignancy, congenital elderly (age >70) and for complications in hospital genetic variants (alloalbumins), analbuminemia [rare]). Preoperative hypoalbuminemia is an inde pendent risk factor for the development of surgical site infec tion following gastrointestinal surgery: a multi-institutional study. Albumin, urine the normal urinary albumin excre Increased in: Diabetes mellitus, Microalbuminuria is a useful indicator of early tion is less than 30 mg/24 hr. Urine dipstick analysis is often insensitive to <20 mcg/min mcg/mg) should be less than 30. Twenty-four-hour or timed urine that cannot be detected by con collections are more burdensome. Current issues in measurement and reporting 30–300 (mcg/mg) is considered of urinary albumin excretion. Na+/d for 3–4 days): volume and serum potassium adenomas) may account for In primary aldosteronism, plasma aldosterone is concentration. Aldosterone, urine* Secretion of aldosterone is con Increased in: Primary and Urinary aldosterone is the most sensitive test trolled by the renin-angiotensin secondary hyperaldosteronism, for primary hyperaldosteronism. Renin (synthesized and some patients with essential mcg/24 hours after 3 days of salt-loading have a for 3–4 days): 1. Analysis of screening and confi rmatory mcg/24 hr Renin then hydrolyzes angioten hypoaldosteronism). Primary aldosteronism: cardiovascular, renal then stimulates the adrenal gland and metabolic implications. Obtain 24-hour urine for aldosterone (and for sodium to check that sodium excretion is ≥ 250 meq/d). To evaluate hypoaldosteronism, patient is salt-depleted and upright; check patient for hypotension before 24-hour urine is collected. Use of rapid dipstick and latex agglutina tion tests and enzyme-linked immunosorbent assay for serodiagnosis of amebic liver abscess, amebic colitis, andEntamoeba histolyticacyst passage. Test 18–60 mcg/dL metabolism and is rapidly con cially if protein consumption is not useful in adults with known liver disease. Nat Rev Gastroenterol Hepatol edema; in chronic liver failure, it sion, and organic acidemias. Amylase, serum or Amylase hydrolyzes complex Increased in: Acute pancreatitis Macroamylasemia is indicated by high serum but low plasma carbohydrates. Serum amylase is derived primar cyst, pancreatic duct obstruction Serum or plasma lipase is an alternative test for acute 20–110 U/L ily from pancreas and salivary (cholecystitis, choledocholithia pancreatitis. It has clinical sensitivity equivalent to glands and is increased with sis, pancreatic carcinoma, stone, that of amylase but with better specificity. Acute pancreatitis: diagnosis, prognosis, and large intestine, and skeletal peritonitis, ruptured ectopic and treatment. Acute pancreatitis with normal serum lipase: a Decreased in: Pancreatic case series. Properly identified and ficity of any antibody detected Some antibody activity (eg, anti-Jka, anti-E) may labeled blood specimens (using panels of red cells of become so weak as to be undetectable but increase are critical. Primary response to first antigen exposure requires 20–120 days; antibody is largely IgM with a small quantity of IgG. Test/Range/Collection Physiologic Basis Interpretation Comments Antidiuretic hormone, Antidiuretic hormone, also Increased in: Nephrogenic Test very rarely indicated. Normal relative to plasma in a normovolemic patient with normal thyroid and If serum osmolality <290 Water deprivation provides both an osmolality in: Primary poly adrenal function are sufficient to make the diagnosis mosm/kg H2O: <2 pg/mL osmotic and a volume stimulus dipsia. The syndrome of inappropriate secretion of Lavender, pink plasma osmolality and decreas (neurogenic) diabetes insipidus. Specimen for serum receptor and the atrial volume osmolality must be receptor mechanisms. If positive, tests with of antibodies, either against the per red cell, depending on the reagent and technique monospecific reagents (anti-IgG drug itself or against intrinsic red used. A red top tube may be ceftriaxone), whereas others are Technical Manual of the American Association of Blood Banks, used, if necessary.

They reflect a global overview of all aspects of the health care process and not only the measurable ones erectile dysfunction in the morning purchase genuine viagra capsules on line. However erectile dysfunction vascular causes best buy viagra capsules, this is their major drawback as well erectile dysfunction treatments vacuum buy viagra capsules now, as risk adjustment is needed to filter the influence of confounding factors erectile dysfunction drugs trimix cheap viagra capsules uk, such as the natural history of the disease or patient’s characteristics erectile dysfunction kidney disease order 100 mg viagra capsules visa. Process indicators are the best measure of the clinical care provided by the clinician erectile dysfunction new treatments order cheap viagra capsules on-line. However, they do not always have a direct link with the patients’ outcomes, the major focus for all stakeholders involved. On the other hand, outcome indicators do not precisely reflect the quality of clinical care as they depend on many other influencing variables. Measurement-related technical aspects: Relevance: the topic area and aspect of health is of significant clinical importance. Reliability: an indicator should obtain the same result a high proportion of the time when repeatedly applied to the same population/organisation/practitioners. Aspects related to the development of indicators in connection with their use: Feasibility: an indicator should use currently available data or data that could be easily collected. Potential for improvement: the results of an indicator can be operationalized into actions or interventions that are under control of the user, leading to improvements that are known to be feasible. Interpretability: the results of an indicator should be comprehensible for the user. Adjustability: an indicator should be formulated in such way that it measures the quality of specific aspects of care of comparable units. An indicator that does not concern many patients is unable to measure the quality of 35 care and to identify potential problems. The 32 evidence supporting the measure is explicitly stated ; x predictive validity: the indicator should have the capacity for predicting 33 quality of care outcomes. Three common categories of reliability assessment exist: internal consistency (variation among items that should provide similar results), inter-rater reliability (variation among different evaluators) and test-retest reliability (variation when the same person repeats the measure at two 32 different time points). Each indicator should have explicit and detailed specifications for the numerator and denominator in order to be 15, 39, 32 specific. The data source used to measure the indicator 32 should be available, accessible and timely. Optimally, a quality indicator should use currently available data or data that could be easily 35 collected with a minimum of expense and personnel time. An indicator that is acceptable to both those being assessed and those undertaking the assessment is more likely of being used to facilitate quality 50 improvement. Quality indicators should also be enough sensitive to 51 detect these improvements in quality of care. Assessments of interpretability include statistical analysis (statistical significance), calibration of measures 45 (clinical significance) and effective presentation of information. If there is only limited comparability, all possible confounders should be identified and 47 statistically adjusted (see risk-adjustment below). The literature offers no definitive overview of the essential features of clinical quality indicators. It is clear however, that specific technical requirements first have to be fulfilled before looking at other characteristics as interpretability or adjustability, which infer the testing of the quality indicator on the field. Moreover, characteristics in connection with their use are also important to facilitate the utilization on the field, i. Finally, good (clinical) quality indicators should bear a potential for improvement. Indicators systems can be theoretically divided into four possible types, based on the source of control (internal/external) and on the nature of the resultant action (positive: supportive and 54 formative; or negative: punitive). A potential benefit of indicator systems is their potential to gain insight into practice, discussed and interpreted by clinicians and managers in the light of the local context and with the aim of continuously improving the quality of clinical care. Firstly, they carry the risk of displacing informal strategies of quality assurance, hereby generating suspicion and fear and undermining the conditions of trust required for quality improvement. Also, indicator systems are incapable of explaining why particular results are obtained. Moreover, many technical problems arise from significant problems with their validity, 48 reliability and comparability. The indicators should be developed in areas where the data suggest that there is poor quality of care in general, or variations 45, 15, 32 of quality among organizations/professionals indicating a need for improvement. A process indicator can be used with confidence if the measure aspects of improved processes leading to better outcomes. Definition of the audience and purpose of the indicator 29, 40, 56 Only a few authors address this first important step. The uses (quality improvement, regulation, purchasing, selection of providers) and the users (clinicians, administrators, purchasers, regulators, patients) of the indicator are important to define, 40, 60 since they will dictate the focus on particular clinical areas and elements of care. Different uses and users also determine the unit of analysis (patient, individual clinician, 40 clinical unit, hospital, nation). Blumenthal stressed the need for different approaches to the measurement of quality, depending on the different perspectives and definitions 61 of quality of care. For example, managers tend to be more interested in efficiency and outcomes, whereas patients are more focused on structure and communication skills of 13 the providers. Patients’ and consumers’ views play an increasing role in the assessment of the quality of health care services. Moreover health care plans, organizations and purchasers put emphasis on the organizational performance and on 61 the extent to which health care meet the needs of a group. In this particular case the users are the clinical units, the government and the patients. The purposes are quality improvement, quality documentation and 3 selection of providers respectively. Organisation of the measurement team All key stakeholders need to be involved in the development of the clinical quality indicator. The team should include representatives of the users, the unit of analysis and 40 the administrators whose resources will be used. Sometimes, quality of care researchers and patients 40, 56 representatives can be included. In the Danish National Indicator Project for example, the government (the Ministry of Health, the counties), the health care providers (physicians, nurses, physiotherapists, occupational therapists) and clinical 3 epidemiological experts were involved. Identification of the potential sources of indicators A large amount of indicator sets is available, usually developed by governments, health 2, 12, 3 agencies or professional organizations. The first appendix presents the main sets and databases of clinical quality indicators that are used worldwide. The objectives, the description of the sets and the methodology of development are summarized as well as the potential interest for the Belgian health care system. Most of these indicator sets were developed using a combination of literature searches and consensus techniques. However, a description of the literature search is only rarely provided in detail. These indicator sets are usually found by an internet search, although 62-64 some of them are published in peer-reviewed literature. Rigorously developed clinical practice guidelines are another useful source for clinical quality indicators. The New Zealand Guidelines Group 67 sometimes includes a separate chapter (‘appendix’ or ‘audit’) with indicators. An important advantage of these indicators is the potential explicit link with recommendations and levels of evidence. Unfortunately most other guidelines developers hardly ever mention the potential clinical quality indicators related to the content of their published guidelines. The authors extensively searched quality indicators in 104 guidelines and finally selected 29 potentially useful indicators based on the evidence. Caution is warranted when searching clinical quality indicators using the above mentioned sources. The transfer of clinical quality indicators between countries needs to take into account the variation in professional culture and clinical practice in order to 69 produce a set of valid and applicable quality indicators for the country. Evaluation of the strength of scientific evidence Providing an overview of the existing evidence allows the team to take into account the 40, 33 strength of evidence when selecting clinical indicators. The stronger the scientific evidence, the higher the (content) validity of the clinical indicator. In the case of the Danish National Indicator Project for example, a detailed description of the scientific evidence is 3 provided on the website in Danish. A possible 70-72 solution is to use the scales developed for grading clinical practice guidelines. An example is the scale provided by the Oxford Centre for Evidence-based Medicine distinguishing therapeutic, diagnostic, prognostic and economic studies. A good example of a scale grading diagnostic activities is the 73 one provided by Fryback and Thornbury. This grading scale provides a hierarchy of diagnostic efficacy, taking into account the technical efficacy, diagnostic accuracy, diagnostic thinking, therapeutic impact, patient outcome, and cost-effectiveness. Selection of clinical indicators Indicators should be selected based on the level of evidence. If no or little scientific evidence is available, expert opinion should be combined with the available evidence 33 using consensus techniques. First, the condition to be assessed is selected and a systematic review of the available evidence is conducted to generate the preliminary indicators to be rated. Then, the consensus panel is selected and in a first round postal survey the panelists are asked to critically read the accompanying evidence and to rate the indicators. Finally, the final ratings are analyzed and the recommended indicators are developed. First, the research problem is identified and the statements to rate are developed. Anonymous iterative postal rounds are conducted, with a feedback of the results between the rounds and a summary of the results at the end. Its result is a list of proposals and statements ranked by the panel according to their relevance. Write the indicator specifications 45 McGlynn proposed six elements for describing the indicator specifications : x Definition of the indicator: different specifications are needed to define the indicator (see table 4). At this step, the possibility of missing data should already be explored, since an indicator with a high chance of missing data is of low value. Specific problems that can arise in the interpretation of a clinical quality indicator (see below) should be kept in mind when defining the indicator. Another interpretation problem can arise when ‘intermediate outcome indicators’ (as glycosylated haemoglobin) are used, not necessarily 92 indicating poor care, but rather poor control. Process indicators require usually less risk-adjustment than do outcome indicators (see above). Risk-adjustment requires the definition and the measurement of many patient characteristics. An overview of possible factors influencing the outcome of 39 care is provided in table 7. Patient: Demographic factors (age, sex, height) Lifestyle factors (smoking, alcohol use, weight, diet, physical exercise) Psychosocial factors (social status, education) Compliance Illness: Severity Prognosis Comorbidity x Identification of the data sources and data collection procedures: four sources of data exist, each with its benefits and limitations (see also paragraph 2. Also, detailed instructions should be provided on how to collect the necessary information in a consistent manner in order to compare the results fairly (see also paragraph 45 2. However, caution is warranted when applying a threshold – based on strong evidence for a specific population. The scoring 45, 40 specifications should also include a plan for handling missing data. Pilot testing Pilot testing can identify possible areas requiring further adjustment, and can generally 40 be performed on a small sample. During this evaluation, the indicators’ reliability and 45, 40 validity should also be tested (see also above). Indicators with an acceptable 45 reliability and validity will also be tested for the interpretability of their results. Key points x Priority setting and defining the audience and purpose of the quality indicator are important first stages in the development and/or selection of clinical indicators. However, the practice often differs from the theory: the data sources and the data collection can raise potential problems. On the opposite, prospectively collected clinical data and survey data are more specific, but expensive to obtain and not readily available. Type of data Advantage Disadvantage Administrative data Readily available Lacks specificity and detail Inexpensive to collect Medical record data Available Expensive to obtain More detailed than administrative May have insufficient detail data; most complete source of information on diagnosis, treatment and outcomes Ifstan dardize d in an e le ctron ic Less available in automated form medical record, reduces data collection burden Prospectively collected Most specific; can define exactly Not readily available clinical data what data are required Quality control of data collection Expensive to obtain unless already incorporated into electronic medical record Survey data Can collect what is important to Not readily available patients C olle ctsdata n ot othe rw ise Expensive and timely to collect and available analyze Valid instrument required, because of the potential for bias 2. However, the consequences for the health care provider sometimes flaw the results. Data collected for quality measurement can be manipulated (‘gaming’), in order to influence the consequences of their use by external users (as the stakeholders or the patients). This is particular true for external and summative indicator systems (see below) or when data are publicly released. Under or over reporting of indicators can also be due to unintentional errors, such as 29 wrong coding or insufficient training of administrators. Another threat is a phenomenon called ‘ascertainment bias’: the staff working in better quality facilities are more likely to discover negative health outcomes than in lower 100 quality facilities, paradoxically leading to worse quality indicator rates. In our Belgian context, this potentially applies to the use of data from the Nursing 101 Minimum Data Set. The “regression to the mean” occurs whenever a sample is selected from a population 99 and two imperfectly correlated variables are measured. As an example, two consecutive blood pressure measurements are taken on the same person on different occasions: these measurements will have correlation <1 because of the inevitable random measurement error and biological random variation. The less correlated the two variables (or the larger the random error), the larger the effect of regression to the mean.

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Issues for Referral Detachments with macula involvement require repair within 1 day impotence ka ilaj buy 100 mg viagra capsules with amex. The only definitive treatment Lateral canthotomy and inferior cantholysis: Prep site with 5% Betadine Local anesthesia of cutaneous and deep tissues lateral to angle of the eye outcome erectile dysfunction without treatment 100mg viagra capsules overnight delivery. Take caution to avoid the globe and orbit Clamp across the lateral canthus with hemostats for ∼1 min With blunt scissors cut in lateral fashion along clamp marks from lateral angle of eyelid to the orbital rim Expose the inferior and superior crus of the lateral canthal tendon by pulling down the lateral aspect of the lower lid Ligate the inferior crus at its insertion into the lower lid with blunt scissors erectile dysfunction doctors in utah buy cheap viagra capsules 100 mg line. Emergency lateral canthotomy and cantholysis: A simple procedure to preserve vision from sight threatening orbital hemorrhage erectile dysfunction medication for diabetes 100mg viagra capsules fast delivery. Management of acute traumatic retrobulbar haematomas: A 10-year retrospective review erectile dysfunction causes medscape viagra capsules 100 mg sale. Severe soft tissue infections of the head and neck: A primer for critical care physicians erectile dysfunction low testosterone treatment best viagra capsules 100 mg. Normal recovery of neurologic function in survivors Skeletal and myocardial muscle Fatty infiltration and distorted mitochondria <10% of cases occur before the age of 1 yr: Average age is 7 yr Peak age is 4–11 yr Extremely rare in age >18 yr. Lab testing to assess for characteristic biochemical abnormalities Liver biopsy confirms the diagnosis. All efforts must be directed at identifying other possible causes of illness in the patient with suspected Reye syndrome. Adults: Trauma, toxicity, infection Children: Viral myositis, trauma Muscle injury—due to trauma/crush, burn, electrical shock—most common cause overall. If no trauma, consider in drug toxicity, heat illness, immobilization, or overexertion states. Ask about reddish brown urine and decreased urine output Most nontraumatic cases in children <9 yr old are due to viral illness with myositis Physical-Exam Hypothermia/hyperthermia Alert/obtunded Muscle pain (only 40–50%) Neurovascular status of involved muscle groups if compartment syndrome is suspected. May help compartment syndrome Furosemide and other loop diuretics if indicated in management of oliguric (<500 mL/d) renal failure; controversial Bicarbonate: Alkalinize urine (pH >6. Higher potassium correlates with more severe injury Treat hyperkalemia as usual but do not use calcium unless it is severe Hypocalcemia: Treat only if symptomatic (tetany or seizures) or arrhythmias present. Discontinue if urine pH fails to rise after 6 hr or if symptomatic hypocalcemia develops Albuterol, insulin/dextrose, polystyrene resin (kayexalate), for hyperkalemia treatment. Rhabdomyolysis: A review of clinical presentation, etiology, diagnosis, and management. Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: A scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: Endorsed by the American Academy of Pediatrics. Characteristics of children discharged from hospitals in the United States in 2000 with the diagnosis of acute rheumatic fever. Ribs usually break at the point of impact or the posterior angle, the structurally weakest region Stress fractures in upper and middle ribs can occur with recurrent, high force movements: Athletic activities: Golf, rowing, throwing Severe cough Pathologic fractures associated with minor trauma or significant underlying disease: Advanced age Osteoporosis Neoplasm Pediatric Considerations Relatively elastic chest wall makes rib fractures less common in children. Consider nonaccidental trauma for infants and toddlers without appropriate mechanism. Obtain a skeletal survey to assess for other fractures in infants suspected of being abused Geriatric Considerations Elderly are more prone to rib fractures as well as atelectasis, pneumonia, respiratory failure, and other associated complications. Segmental paradoxical movement of chest suggests flail chest indicating multiple, unattached fractured ribs. Ribs 9–12 are relatively mobile; their fracture suggests possible intra-abdominal injury. Multiple rib fractures may be associated with flail chest and pulmonary contusion. Morbidity correlates with degree of injury to underlying structures, number of ribs fractured, and age. Angiography can be used for the detection of vascular injury if signs and symptoms of neurovascular compromise are present: Injury to the 1st and 2nd ribs can be associated with vascular injury, particularly with posterior displacement. Multiple fractures, elderly patients, or significant underlying lung disease: Manage airway and resuscitate as indicated. Deep breathing or incentive spirometry should be encouraged with adequate pain control. Avoid binders or banding of the chest wall because these restrict ventilation and promote atelectasis. Multiple fractures, elderly patients, or significant underlying lung disease: Pain control and pulmonary toilet Search for associated injuries; treat exacerbation of underlying lung disease. Intercostal nerve blocks for multiple fractures are safe and effective providing 6–12 hr of pain relief. Do not exceed 4 g/24h acetaminophen in adults, 5 doses of 10–15 mg/kg/24 h acetaminophen in children. Secondary constricting band: Injury or disease process that causes swelling and edema as a result of tightness against the band. Tourniquet syndrome occurs when anything causes a constriction and there is distal tissue effect. Pediatric Considerations In the preverbal child, a constricting band may be a manifestation of child abuse or neglect. Geriatric Considerations the cognitively impaired nursing home resident or Alzheimer patient may be unable to give an indication of injury or pain. Pain on manipulation of the appendage or constricting band History Usually straightforward but in nonverbal populations it can be a cause of unidentified pain. If evaluating an inconsolable infant or agitated nonverbal adult, assess fingers, toes, and genitalia. Secondary constricting band: Diagnosis of underlying pathology may depend on results of imaging and lab test results. Lubrication with soap or mineral oil may allow slippage over an inflamed or edematous area. Digital block with 1–2% lidocaine without epinephrine decreases the discomfort of removal and manipulation of an underlying injury. The distal swollen finger, especially the proximal interphalangeal joint, is an important obstacle in constricting band removal. Distal to proximal edema reduction by sequential compression: Self-adherent tape is wrapped from distal to proximal to form a smooth and decompressed area over which the band is advanced. A Penrose surgical drain or a finger cut from a small glove is stretched to fit over the distal swelling before attempted removal. With lubrication, the proximal end of the drain is pulled under the ring to form a cuff around the ring; the cuff with distal traction applied advances the band over the decompressed area. Constricting band removal by division: Scissors may be used to 1st lift and then cut the offending fibrous band constricting a toddler’s toe or penis. A topical commercially available depilatory agent may be used to divide a tourniquet formed by a suspected hair obscured by local edema. A handheld wire cutter/stripper may divide small-girth metallic rings with minimal discomfort to the underlying injury; this type of removal may; however, impart a crush defect to the ring, making repair difficult. A long-handled bolt cutter, available in most operating rooms or hospital engineering departments, may be used to divide large-girth or broad-sized rings: Long handles provide the significant mechanical advantage needed to cut large rings. The reinforced cutting blades may not easily fit through a constricting band with adjacent swollen tissue and skin. A standard hand-powered, medically approved ring cutter (Steinmann pin cutter with a MacDonald elevator) may be used to divide small-girth metallic constricting bands made of soft metals (gold/silver) this method has the advantage of a cleaner cut for subsequent repair of the ring. The disadvantage is that the handheld ring cutter is labor-intensive and may aggravate the pain of an underlying injury. Cutting procedure: the initial cut is made on the band on the volar aspect of the extremity. For a 2nd cut, the band should be rotated 180° on the extremity, allowing the 2nd cut on the band over the volar aspect of the extremity. Place a thin aluminum splint (shaped to the curvature of the ring) between the patient’s skin and the ring as a shield to protect underlying tissue. Cool splint and cutting surface with ice water irrigations before and during the cutting procedure. Depilatory cream: Can be used if suspected constriction is caused by hair in place of “unwinding or excising” the hair. Swelling of tissues heaped up around the hair may obscure the hair tourniquet leaving only a visible crease with the underlying hair buried below. Depilatory cream applied to the crease may release the hair tourniquet within 10 min. Postdivision care: Underlying injuries should be irrigated thoroughly to remove metallic dust and avoid foreign-body reaction and granuloma formation. Issues for Referral Wounds at high risk for infection should have close follow-up in 1–2 days. Antibody may not be detected in the 1st few days of symptoms Methods: Immunofluorescent antibody (sensitivity of 95%) Complement fixation Indirect hemagglutination test Indirect immunofluorescence assay is reference standard. Initiate antibiotic therapy immediately based on clinical and epidemiologic findings. Should not be delayed until lab confirmation is obtained: Doxycycline—drug of choice Chloramphenicol in pregnant and allergic patients Sulfonamides make infection worse. Consider high-dose steroids for severe cases complicated by extensive vasculitis, encephalitis, or cerebral edema (controversial). Doxycycline is used in children due to potential for fatal cases, the relatively low risk of significant dental discoloration with a short course, and adverse effects of chloramphenicol Pregnancy Considerations Use chloramphenicol in pregnant patients. Clinical and laboratory features, hospital course, and outcome of Rocky Mountain spotted fever in children. Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain spotted fever, ehrlichiosis and anaplasmosis– United States: A practical guide for physicians and other health-care and public health professionals. Infants with congenital rubella shed large quantities of virus for several months. Begins after 2–3 days of illness Knees, wrists, fingers affected Hemorrhagic manifestations: Secondary to thrombocytopenia More common in children Neurologic sequelae: Encephalitis most common in adults; prognosis usually good No causal relationship to autism History Low-grade fever Malaise Headache Upper respiratory tract symptoms Physical-Exam Rash: Rash is fainter than measles rash and does not coalesce. False positives in parvovirus, infectious mononucleosis, rheumatoid factor May be useful to check for immunity of pregnant patients with potential exposure. Pharynx: Virus may be isolated from pharynx 1 wk before and until 2 wk after rash onset (valuable epidemiologic tool). Vaccine: Measles, mumps, and rubella vaccine Rubella vaccine is live attenuated virus. Indications: >12 mo and entry to school Susceptible postpubertal females High-risk groups (colleges, military, places of employment) Unimmunized contacts Healthcare workers and women of childbearing age born after 1957 Nonpregnant women may have arthralgia in up to 25% Contraindicated in pregnant women Avoid pregnancy for 3 mo after vaccination. Infected individual should be isolated from susceptible (pregnancy, immunocompromised) individual for 7 days. Rectal exam will elicit pain in the sacrum; blood in the rectum suggests an open fracture. Nondisplaced isolated transverse sacral fractures are treated symptomatically with touch-down weight bearing on affected side and early orthopedic referral. Discharge Criteria Isolated nondisplaced sacral fractures Consider intermediate or assisted-care setting for elderly patients. Detailed neurologic exam, including rectal sphincter tone and perianal sensation, is indicated to assess for associated sacral nerve root injury. Foley catheter in a trauma patient may mask voiding problems from sacral nerve root injury. Geriatric Considerations Greater morbidity Respiratory distress/altered mental status indicative of severe toxicity Diagnosis of salicylate intoxication delayed because underlying disease states mask signs and symptoms;. Watch for recurrence of signs of salicylate toxicity and increasing levels even after levels have declined due to intestinal absorption of enteric-coated products and salsalate Guidelines for Assessing Severity of Salicylate Poisoning Acute ingestion of: <150 mg/kg or <6. It is extremely difficult to achieve and maintain mechanical hyperventilation in these patients. Salicylate poisoning may result from topical exposure to salicylate-containing lotions or creams, rectal suppositories, oral antidiarrheal preparations. Salicylate levels may trend downward only to begin increasing again due to absorption of product from the intestine or from a salicylate bezoar in the gut. Mechanical ventilation was associated with acidemia in a case series of salicylate-poisoned patients. Delayed recrudescence to toxic salicylate concentrations after salsalate overdose. Factors related to missed diagnosis of incidental scabies infestations in patients admitted through the emergency department to inpatient services. Scabies and pediculosis pubis: An update of treatment regimens and general review. Classified as: Proximal 3rd (10–20%) Middle 3rd (the waist, 70–80%) Distal 3rd (the tuberosity) Tubercle fractures Fractures are missed on initial radiographs 10–15% of the time, and delayed diagnosis greatly increases risk of complications. The blood supply to the scaphoid enters distally the more proximal the fracture, the higher the likelihood for avascular necrosis As the wrist is forcibly hyperextended, the volar aspect of the scaphoid fails in tension and the dorsal aspect fails in compression resulting in a fracture. Dorsal wrist pain distal to the radial styloid and decreased range of motion of the wrist and thumb Rarely, incidental damage to the superficial branches of the radial nerve results in sensory changes. Palpate the scaphoid tubercle for tenderness by radially deviating the wrist and palpating over the palmar aspect of the scaphoid; 87% sensitivity, 57% specificity. Pediatric Considerations Carpal fractures are rare in children (and the elderly), as the distal radius usually fails 1st. Pay special attention to the middle 3rd, or waist, of the bone: 70% of injuries occur here. Diagnostic Procedures/Surgery If fracture is open or associated injuries are identified, urgent surgical intervention may be indicated. Clinically suspected scaphoid fractures without radiographic evidence: Should be treated as a nondisplaced scaphoid fracture Spica splint thumb in a position as if the patient was embracing a wine glass. Issues for Referral If fracture is angulated or displaced >1 mm, immediate orthopedic referral is indicated. If no radiographic abnormalities found on initial radiograph, after placing in thumb spica splint, refer to orthopedics or primary care in 7–10 days with repeat radiographs at that time. Avascular necrosis (especially with proximal 3rd fractures), occurs with inadequately reduced or immobilized fractures.

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Ipratropium (Atrovent) 2-4 puffs qid and prn can be used as an alternate bronchodilator erectile dysfunction 23 years old discount 100 mg viagra capsules. Long-acting bronchodilators erectile dysfunction caused by vicodin safe 100mg viagra capsules, such as salmeterol (Serevent) 2 puffs bid erectile dysfunction pills cheap 100mg viagra capsules mastercard, and corticosteroids erectile dysfunction at age 24 purchase viagra capsules 100mg on line, such as prednisone 1 erectile dysfunction kuala lumpur viagra capsules 100mg otc. Primitive: Caffeine has some bronchodilation effects and can be effective in some patients erectile dysfunction at 30 discount viagra capsules 100mg free shipping. Belladonna plant (deadly nightshade) was administered in the past by smoking the dried plant for the anticholenergic effects of the atropine found in the plant. Follow-up Actions Return Evaluation: Symptoms that do not improve should be referred for specialty care and additional special studies. It usually occurs when a thrombus (blood clot) in the deep venous system of the legs dislodges and travels to the lung, causing a loss of oxygenation of the blood owing to that area of the lung (hypoxemia). Embolism: Acute unexplained shortness of breath without other significant symptoms. Infarction: Chest pain associated with labored breathing, anxiety, occasional low-grade fever and cough (possibly with bloody sputum) for which no other cause (chest trauma, pneumonia, angina, etc. Difficulty breathing and severe shortness of breath, rapid progression (2-24 hours) of respiratory failure, increased agitation. If evacuation is not possible, skip steps below, make patient comfortable and treat expectantly. Pending evacuation and en route, administer oxygen– start with low flow 2 L/min and increase as needed. Administer fluid and blood products sparingly to minimize severity of pulmonary edema. Follow-up Actions Evacuation/Consultation Criteria: Urgently evacuate patients with severe injuries, particularly those who are elderly, very young, have underlying chronic diseases or are immunocompromised. Apnea is also known as “obstructive sleep apnea” or as “Pickwickian Syndrome” in the obese. The obstruction is usually due to enlarged pharyngeal tissues in the obese, inamed tonsils, low-hanging soft palate or uvula, or craniofacial abnormalities that narrow or close the airway. Apnea is associated with hypoxia and frequent nocturnal arousals (60-100 per hour), contributing to excessive daytime sleepiness. Apnea generally does not cause shortness of breath unlike other conditions associated with a narrow upper airway, such as epiglottis. Risk Factors: Obesity, nasal obstruction (due to polyps, deviated septum, old trauma), hypothyroidism, upper airway narrowing, sedative drugs and alcohol. Late: Morning headache, depression Focused History: Quantity: How much weight have you gained in the last year? Objective: Signs Using Basic Tools: Vital signs: Hypertension, tachycardia or bradycardia seen in chronic apnea. Inspection: Narrowed airway, large tonsils, low-hanging soft palate or uvula may predispose to airway block age at night. Neck: Inspect for “bull neck” indicating possible intrathoracic disease, tumor, pneumothorax. Auscultation: Turbulent airow during sleep may produce rhonchi that may be localized to neck or nasophar ynx. Assessment: Differential Diagnosis Excessive daytime somnolence narcolepsy (usually associated with sudden loss of muscle tone during emo tional moments, and/or hallucinations on awakening), inadequate sleep (review history), depression/anxiety disorder (see Symptom: Depression and/or Symptom: Anxiety). If occurs suddenly, see panic attacks in Symptom: Anxiety) Hypothyroidism causes sleep disturbances and sluggishness (see Endocrine: Thyroid Disorders). The extra oxygen can have the dramatic effect of “waking” someone up that has been partially asleep for years during the daytime. Protriptyline 10-30 mg or fluoxetine 20-60 mg po can occasionally be helpful for mild to moderate sleep apnea. Primitive: Apnea is related to sleep position (on the back), so have patient sleep on his side and elevate the head of the bed. Activity: Encourage exercise after ensuring cardiorespiratory system is healthy enough to tolerate the stress. Prevention: Avoid sedatives and alcohol, which act as central nervous system depressants and worsen sleep apnea. Proximate causes of such an event include gram-negative bacterial sepsis and blunt or penetrating abdominal trauma. Acute adrenal insufficiency is a medical emergency, heralded by severe orthostatic hypotension, shock, hyponatremia and often hyperkalemia. Sub-acute or chronic primary adrenal insufficiency is usually caused by autoimmune disease (Addison’s disease) or metastatic cancer in developed countries, but in the developing world, replacement of normal adrenal tissue by tuberculous infection is more prevalent. Secondary adrenal insufficiency, characterized by deficient production of cortisol but normal production of aldosterone, is due to some form of hypothalamic or pituitary gland disease. Acute causes include transection or infarction of the gland due to closed or penetrating head trauma. Subjective: Symptoms Acute: Severe orthostatic hypotension or shock; severe, poorly localized abdominal pain; nausea; vomiting; weakness; mood change; confusion or psychosis. Sub-acute and chronic: Fatigue, malaise, weight loss, poor appetite, nausea, postural faintness or lightheadedness, loss of libido, depression, anxiety, confusion or acute psychosis. Assessment: Definitive diagnosis will be beyond the capabilities of field laboratories (low sodium, high potassium, others). Differential Diagnosis Acute other hypotensive states, including blood loss hypovolemia, volume depletion from gastroenteritis related vomiting and diarrhea, pancreatitis, and diabetic ketoacidosis. Plan: Treatment Primary: Acute: Rapidly infuse normal saline solution (2 liters rapidly, then 250-500 cc hour, adjust rate of infusion based on pulse, blood pressure, and overall state of well-being); administer dexamethasone 4 mg intravenously as a single dose. Replacement therapy with hydrocortisone, 20 mg each morning and 10 mg each evening should be administered after resolution of acute symptoms until a definitive medical evaluation by a physician. Primitive: If no glucocorticoid medication is available, attempt hemodynamic stabilization by aggressive intravenous hydration using normal saline solution at 250-500 cc per hour or more. Empiric: In any case of shock or severe hypotension without obvious blood loss, render empiric treatment to cover the possibility of adrenal insufficiency. Patient Education General: Taking medication daily is essential to preserving health. In the event of any illness, double the daily dose of steroid medication for the duration. If steroid medication is unavailable, a high-salt diet can help minimize symptoms, preserve blood pressure and functional status. Medications: Chronic steroid use can result in weight gain and other side effects. No Improvement/Deterioration: Seek medical care promptly for any acute illness resulting in vomiting or if an illness persists for more than a day on double-dose steroid therapy. Follow-up Actions Return evaluation: Expect rapid improvement in symptoms after initiating steroid therapy. After starting maintenance therapy, reassess symptoms and vital signs, including weight and blood pressure within one week. Evacuation/Consultation Criteria: Referral to a medical center for appropriate confirmatory testing, and treatment. Diabetes mellitus results from either absolute deficiency of insulin (type 1 diabetes), or from subnormal target cell response to insulin (insulin resistance) combined with failure to compensate for this insulin resistance by producing higher concentrations of insulin (relative insulin deficiency) (type 2 diabetes). In the Americas and Western Europe, most cases of type 2 diabetes are associated with obesity, a sedentary lifestyle and/or a genetic predisposition. Type 1 diabetes is most often caused by autoimmune destruction of the insulin-producing beta cells within the pancreatic islets. Even though there are genetic factors which confer susceptibility, it is unusual to identify multiple first-degree relatives with type 1 disease. Patients with type 1 diabetes may exhibit other autoimmune diseases, such as hypothyroidism, rheumatoid arthritis or hyperthyroidism due to Graves’ disease. These women are often overweight, and have increased risk of type 2 diabetes in middle age or later. Subjective: Symptoms Classically: Excessive thirst (polydipsia), excessive urination, especially at night (polyuria/nocturia), weight loss despite increased appetite and food intake (polyphagia), blurred vision. Patients with new onset diabetes frequently have no symptoms or may present with complications of diabetes, such as foot ulcers or gangrene. Give an oral hypoglycemic agent for fasting blood sugar in the 200-250 mg/dl range: glyburide 5 mg/day or glipizide 5 mg/day are effective and widely available. Evacuate profoundly symptomatic patients; look for orthostatic hypotension, nausea and vomiting, “large” ketones on urine dipstick as major indications to evacuate. Give high volume fluid therapy and intravenous insulin (10 units initially, followed by 5 units per hour) while en route. Give newly diagnosed diabetics appropriate dietary and exercise regimens (see Patient Education below). Primitive: Severely symptomatic patients who are volume depleted can be treated with aggressive isotonic saline infusion intravenously (1-2 liters over one hour, followed by 150-250 cc per hour), pending transport to a definitive care facility. Empiric: Empiric drug or insulin therapy is potentially dangerous in the absence of blood glucose testing and should be avoided. Patients with positive urine ketones and a rapid respiratory rate probably have profound metabolic acidosis (ketoacidosis). Activity: Stable patients benefit from 40 to 60 minutes of moderate aerobic exercise daily. Obese patients should receive a total calorie prescription with a goal of long-term weight reduction; 1500-1800 calories a day are usually sufficient. Prevention and Hygiene: Patients should return for a urinary dipstick test bid until urinary glucose and ketones are negative or trace. No Improvement/Deterioration: Patients should be referred for definitive medical care. Follow-up Actions Return evaluation: Daily to twice weekly initially, as dictated by severity of hyperglycemia and ketonuria. Evacuation Consultation Criteria: Immediately evacuate all severely hyperglycemic, severely ketonuric or pregnant patients. All other patients with diabetes mellitus should be evacuated at the earliest availability. Metabolism of glucose is mediated by glucagon and epinephrine (which stimulate the liver to change stored glucagon into glucose for use as an energy source) and by cortisol and growth hormones. Insulin does the opposite, promoting removal of excess blood glucose for storage of in the liver as glycogen. Hypoglycemia is caused by an imbalance between insulin and glucagon, epinephrine, cortisol and growth hormone. Subjective: Symptoms Abrupt decline in mental status function, level of consciousness, amnesia, bizarre behavior, hemiparesis, poor coordination, double or blurred vision. Anxiety, generalized sweating, and tremor may occur prior to other neurologic symptoms. Vital Signs: Tachycardia, hypertension, tachypnea Inspection: Diaphoresis, dilated pupils, confusional or psychotic state, drowsy or comatose, ataxic gait, coma, generalized seizure Auscultation: Aortic or pulmonic flow murmurs Palpation: Left or right-sided facial/upper extremity/lower extremity weakness or paralysis; decreased visual acuity or visual fields Percussion: Brisk deep tendon reflexes Using Advanced Tools: Lab: Glucose and ketones on urine dipstick. Assessment: Always consider hypoglycemia as an easily treatable form of mental status impairment. At times hypoglycemia can provoke focal neurologic signs such as hemiparesis which reverse with treatment of hypoglycemia. Alternative: Mild symptoms and cooperative: 8 oz of sweetened fruit juice, non-diet colas or sports drink. Patient Education General: Wear a medical alert bracelet or necklace if prone to hypoglycemia. Diet: Normal diet unless frequent hypoglycemia, then add mid-morning, mid-afternoon, and bedtime snacks. Prevention and Hygiene: Do not miss meals or exercise strenuously after 4 or more hours of fasting. Recurrent hypoglycemia following treatment mandates additional 50% dextrose and evacuation. Follow-up Actions Return evaluation: Routine diabetes-oriented care should suffice for most patients. Evaluation/Consultation Criteria: Severe (coma, seizure, focal neurologic presentation) or frequent (> 1 severe episode per month) hypoglycemia should be evacuated. In part, goiter is an adaptive process, reecting increased size and number of thyroid follicles in an attempt to overcome decient production of thyroid hormones by individual cells. This condition is not expected in island or coastal regions where seafood or kelp (iodine-rich foods) is consumed regularly, but may occur inland in large continents. Areas of the world where iodine deciency is known to be a signicant problem include mountainous regions, parts of sub-Saharan Africa and central China. Finally, hyperthyroidism can result 4-31 4-32 from leakage of thyroid hormones from a gland damaged in trauma or from viral infection in a self-limited process called thyroiditis. Hypothyroidism (underactive thyroid) most commonly results from autoantibodies directed against thyroid enzymes, resulting in decreased production of thyroid hormones. Subjective: Symptoms Simple goiter: Mass in the anterior neck; dysphagia; dysphonia (hoarseness); stridor, cough or wheezing as a result of compression of the esophagus, recurrent laryngeal nerves or trachea by the goiter. Hyperthyroidism: Excessive sweating, intolerance of hot temperature, decreased stamina and endurance, nervousness, irritability, tremor, weight loss, increased size and frequency of bowel movements (hyperdefeca tion or diarrhea), palpitations, insomnia, and eye irritation/discomfort. Hypothyroidism: Fatigue, depressed mood, excessive sleepiness/reduced alertness, intolerance for cold temperature, weight gain, hair loss, constipation, and muscle cramps. Hyperthyroidism: Do you feel “hotter” than other members of your family and do you feel sick when it is hot? Inspection: Look for an obvious lump or mass in the anterior neck, below the thyroid cartilage (“Adam’s apple”). Palpation: Enlarged, smooth or nodular, eshy or rm to hard mass in the anterior neck, between the thyroid and cricoid cartilages.

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