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By O. Akrabor. University of Rio Grande.

Active immunization should then be given intramuscularly with a different syringe at a different site 50mg viagra for sale. Active immunization will lead to antibody formation in about 1 week and should last for several years cheap 100mg viagra amex. Snakebites Venomous snakes are found throughout the United States except in Maine purchase viagra 75mg visa, Alaska, and Hawaii. The Crotalinae, also called pit vipers because of the presence of a pitlike depression on their face, include rattlesnakes, copperheads, and water moc- casins. Not every snakebite results in the release of venom into the victim; “dry bites” occur up to 20% of the time. When venom is injected, it usually occurs in sub- cutaneous tissue and is absorbed via the lymphatic and venous system. Clinical manifestations of envenomation will vary depending on the toxin, depth of enven- omation, location of the bite, and size and underlying health of the victim. Pit viper envenomation ranges from minor local swelling and discomfort at the injection site to marked swelling, pain, blisters, bruising, and necrosis at the incision site; and systemic symptoms such as fasiculations, hypotension, and severe coagulopathy. In contrast, Elapid envenomation usually begins as minor pain at the incision with a delayed serious systemic reaction that may lead to respiratory distress secondary to neuromuscular weakness. The primary objectives in snakebite management are to determine if enven- omation occurred, to provide supportive therapy, to treat the local and systemic effects of envenomation, and to limit tissue loss and disability. If the species can be identified, the appropriate antivenin can be administered if required. Signs of envenomation can be broadly classified into either hematologic or neurologic. Hematologic effects of envenomation include disseminated intravascular coagu- lopathy, ecchymosis, and bleeding disorders. If there are signs of envenomation, then laboratory studies including, but not limited to, clotting studies, liver enzymes, and complete blood counts with platelets are necessary. Giving blood products to an envenomated patient with a coagulopathy will not correct the problem. The circulat- ing venom responsible for the coagulopathy is still present and will likely inactivate the blood products. Therefore, the mainstay in treatment in venom-induced coagu- lopathy is antivenin, preferably type specific, not blood products. Nonetheless, if the patient is bleeding, it is prudent to administer both antivenom and blood products. The most commonly available antivenom for treatment of North American Crotalid envenomations is Crotalidae polyvalent immune Fab CroFab. Surgical debride- ment or fasciotomy in the setting of envenomation should not be done as this may lead to further bleeding. Neurologic effects include weakness, paresthesia, paralysis, confusion, and respiratory depression. Asymptomatic patients who were bit by a pit viper should be observed for 8 to 12 hours after the bite. This should be extended to 24 hours for coral snakebites because of the absence of early symptoms. The local poison control center should be contacted early in all symptomatic snakebites and will be able to help with management and location of antivenin. His entire foot is purple, swollen to his mid-calf, and very painful to the touch. As always, clean the bite thoroughly and consider radiographs to be sure no broken teeth are in the wound or that the bone has been penetrated. Nonetheless, the wound should be cleaned and 3- to 5-day course of prophylactic antibiotics should be initiated. If this bite occurred on the hand or across a joint space, a radiograph should be performed. Although some percent of venomous snake- bites fail to inject venom, this bite is clearly envenomed. First responders should immobilize the site and place constriction bands that do not obstruct arterial flow. The swelling is not a compartment syndrome unless elevated pressures are measured. Remember that species-specific antivenin is important and that adminis- tration time is critical. An index of antivenin can be obtained from the American Zoo and Aquarium Association (301-562-0777) as well as your local poison control center (800-222-1222). Dusk is the usual time for bat activity, and although this man did not feel a bite, he discov- ered bite marks under his injury site. Because the animal cannot be examined, immediate passive and active immunization should be initiated and tetanus administered, if indicated. As always, watch for secondary bacterial infec- tion and update his tetanus status if it has been more than 5 years since his last immunization. Rabies prophylaxis is indicated for uncaught wild animals and animals that start behaving abnormally. Bites that are more than 6 hours old are, in general, left open, because of the risk of infection. Snakebites should be treated like other bites with special attention paid to species identification and rapid administration of antivenin if required. Part 13: First aid: 2010 American Heart Association and American Red Cross International consensus on first aid science with treatment recommendations. Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to prevent human rabies. The patient’s wife states he was in his normal state of health until one hour ago, when she heard a thud in the bathroom and walked in to find him collapsed on the floor. The patient has a noticeable left-gaze preference and is verbally unresponsive, although he will follow simple commands such as raising his left thumb. If the event is ischemic, the patient may be a candidate for thrombolytic administration. It remains the third leading cause of death in the United States and the number one cause for disability. Many of the surviving victims are left with neurologic deficits and may be unable to care for themselves. Stroke is a term that describes the loss of perfusion to a territory of the brain, resulting in ischemia and a corresponding loss of neurologic function. Symptoms vary widely depending on the type of infarct, the location, and the amount of brain involved (Tables 14–1 and 14–2). Eighty percent of strokes are ischemic—due to the blockage of a blood vessel secondary to thrombosis or embolism.

For example cheap viagra 100 mg with mastercard, if the pain is characteristic of angina (substernal pain discount viagra 100 mg with mastercard, exertional in nature order 25mg viagra fast delivery, and relieved by nitroglycerin) and the patient is a male over 50 the chance of the pain being ischemic cardiac pain is very high and should be expeditiously evaluated. In contrast, a 25 year old woman with exertional pain likely does not have ischemic coronary disease. A normal mediastinum rules out the diagnosis University of South Alabama, Department of Family Medicine June 30, 2008 37 Make a clinical assessment of the likelihood of the coronary artery disease. If the pretest probability is greater than 30% but less than 60% then further non-invasive testing is indicated. If the pre-test probability is greater than 60% then non-invasive testing should not be pursued and cardiac catheterization would be the next step. For those patients at risk for a deep venous thrombosis and pulmonary thromboembolism, a d-dimer or equivalent study should be obtained. If the D- University of South Alabama, Department of Family Medicine June 30, 2008 39 dimer is positive but the clinical suspicion is relatively low and the imaging study is negative then a venous doppler should be obtained and if negative repeated in a week. If the suspicion is high, then pulmonary artery catheterization would be indicated. A complete blood count with differential should be obtained on patients with fevers, in particular if the diagnosis is in doubt. Thus, in patients at significant risk, a cardiac etiology should be pursued prior to attributing the pain to panic disorder. Particularly in patients with risk factors for another disease, diagnostic testing should be pursued. Antiviral agents, oral University of South Alabama, Department of Family Medicine June 30, 2008 41 corticosteroids and adjunctive individualized pain-management modalities are used to achieve these objectives. Antivirals - Antiviral agents have been shown to decrease the duration of herpes zoster rash and the severity of pain associated with the rash. However, these benefits have only been demonstrated in patients who received antiviral agents within 72 hours after the onset of rash. Antiviral agents may be beneficial as long as new lesions are actively being formed, but they are unlikely to be helpful after lesions have crusted. The ―50-50-50‖ rule has been proposed to identify who would most benefit from antivirals, that is those who have had the symptoms for under 50 hours, and are over 50 or have more than 50 lesions. Other antiviral agents, specifically valacyclovir (Valtrex) and famciclovir (Famvir), appear to be at least as effective as acyclovir. Dosages are available from commonly available references Corticosteroids - Orally administered corticosteroids are commonly used in the treatment of herpes zoster, even though clinical trials have shown variable results. Prednisone used in conjunction with acyclovir has been shown to reduce the pain in patients more than 50 years of age and is useful for reducing symptoms for zoster involving the facial nerve. The dose in adults is generally 30 mg orally twice daily on days 1 through 7; then 15 mg twice daily on days 8 through 14; then 7. When analgesics are used, with or without a narcotic, a regular dosing schedule results in better pain control, and less anxiety, than "as-needed" dosing. Panic disorder – See Depression chapter Pneumonia - See Pneumonia chapter 8 Gastroesophageal reflux disease: Non-pharmacologic: Patients should be instructed to avoid large meals and should not lie down immediately after eating (up to 3 hours). They should also be counseled that acidic foods, alcohol, caffeinated beverages, chocolate, onions, and garlic may exacerbate symptoms and should be withdrawn initially; they can be added back as symptoms permit. These include calcium channel agonists, alpha-adrenergic agents, theophylline, nitrates and certain sedatives. Pharmacologic: After making diagnosis, it is reasonable to start with either an H2 blocker or a proton pump inhibitor. The choice is based on previous effective and University of South Alabama, Department of Family Medicine June 30, 2008 42 ineffective therapy and cost to patient. Once symptoms resolve, reduce dose to the lowest required to maintain patient symptom free. Antacids may be added for additional symptom relief, especially early on or when symptoms flair. Chest pain with cardiac risk factors - Those patients who following diagnostic testing are found to be of low immediate risk of having significant coronary artery disease should reduce their risk factors if possible. On the other hand patients can quit the use of tobacco products, reduce their blood pressure, monitor and control their lipids and blood pressure, increase their physical activity and reduce their weight. The ―stages of change‖ model identifies the likelihood of a patient making a significant lifestyle change. Physicians are most likely to make a difference when the patient is in the contemplation stage (by eliciting commitment) and in the preparation stage (by offering assistance) Precontemplation is the stage at which there is no intention to change behavior in the foreseeable future. Contemplation is the stage in which people are aware that a problem exists and are seriously thinking about overcoming it but have not yet made a commitment to take action. Individuals in this stage are intending to take action in the next month and have unsuccessfully taken action in the past year. Action is the stage in which individuals modify their behavior, experiences, or environment in order to overcome their problems. Action involves the most overt behavioral changes and requires considerable commitment of time and energy. Maintenance is the stage in which people work to prevent relapse and consolidate the gains attained during action. For addictive behaviors this stage extends from six months to an indeterminate period past the initial action. For patients with musculoskeletal pain, schedule follow-up for two to four weeks but if the pain resolves and the patient is not at risk for ischemic heart disease they may elect to cancel the appointment. For patients with pain from herpes zoster, they should follow-up for infection or non-resolution in 2 – 4 weeks Patients with gastroesophageal reflux disease should be re-evaluated for reduction of symptoms within 4 weeks and resolution within 8 weeks Patients felt to be symptomatic from stimulant use, a visit following a week of abstinence is usually sufficient. For patients with multiple cardiac risk factors, aggressive risk factor modification should begin when patient is amenable to change. The follow-up visit soon after a negative stress test will often present itself as an opportunity for the physician to facilitate change. Suggested for further reading: Chapter 23 Chest Pain in Current Diagnosis & Treatment in Family Medicine. University of South Alabama, Department of Family Medicine June 30, 2008 44 Resources for patients: Chest pain, acute accessed on Familydoctor. Management of herpes zoster (shingles) and postherpetic neuralgia Am Fam Physician 2000;61:2437-44,2447-8. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. University of South Alabama, Department of Family Medicine June 30, 2008 45 Appendix University of South Alabama, Department of Family Medicine June 30, 2008 46 University of South Alabama, Department of Family Medicine June 30, 2008 47 University of South Alabama, Department of Family Medicine June 30, 2008 48 Cough 786. Arrange for definitive care of identified specific causes of cough at time of presentation or with appropriate follow-up. Cough is a normal mechanism of the body that clears secretions from the bronchial tree and trachea. Voluntary control is manifested as cough inhibition (holding back a cough) or voluntary cough. Involuntary cough is triggered by vagus nerve stimulation in the back of the throat and bronchial tree.