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Opioids are generally avoided in osteoarthritis but may be useful in selected patients buy 200 mg viagra extra dosage mastercard. Opioids should be used with caution in elderly patients buy 200 mg viagra extra dosage fast delivery. Tramadol viagra extra dosage 130 mg amex, a centrally acting analgesic with dual mechanisms generic 120 mg viagra extra dosage amex, may give relief comparable to that achieved with acetaminophen and codeine generic 200mg viagra extra dosage fast delivery. Topical capsaicin may be useful in some patients, particularly those with involve- ment of the knees and hands. NSAIDs are useful in osteoarthritis mostly for their analgesic effects, although anti-inflammatory effects may have some clinical significance. NSAIDs are associated with an increased risk of gastric ulcers and bleeding, particularly in patients with a history of GI disease. The recently available COX-2–specific NSAIDs celecoxib and rofecoxib have been shown to reduce endoscopic gastritis and ulcers as well as serious GI 15 RHEUMATOLOGY 31 complications when compared to the previously available nonselective COX inhibitors. A 67-year-old African-American man comes to your office with low back pain. He has been experienc- ing progressive back pain for the past 2 weeks. He believes these symptoms started after he lifted a 20-lb box. Review of systems is significant for a weight loss of 10 lb over the past 6 months and urinary hesitancy. Physical examination reveals tenderness to percussion over L5 and a nodular, enlarged prostate. Of the following, which is the most appropriate step to take next in the treatment of this patient? Start nonsteroidal anti-inflammatory drugs (NSAIDs) and have the patient come back to your clinic only if the pain persists B. Start opiates and muscle relaxants Key Concept/Objective: To be able to identify patients with acute back pain who are at risk for serious underlying conditions For patients with acute back pain, the initial history should be used to identify those who are at risk for serious underlying conditions, such as fracture, infection, tumor, or major neurologic deficit. The initial physical examination should include evaluation for areas of localized bony tenderness and assessment of flexion and straight leg raising. This patient has symptoms and signs that suggest the presence of a malignancy. He has experienced weight loss, and there is bony tenderness and a nodular prostate. In this clinical scenario, imaging is indicated to evaluate for the possibility of metastatic disease to the spine. For the treatment of acute back pain, NSAIDs and mild analgesics may be useful for symptom control. Muscle relaxants and opiates should be used sparingly. Spinal manipulation or specific exercise programs may also be effective in acute back pain. Strict bed rest should be kept to a minimum, and continu- ation of normal activities should be enforced. A 42-year-old male postal worker presents to your clinic asking for a second opinion regarding the man- agement of his chronic low back pain. The pain is located in his lower back; it does not radiate. The patient denies having any weakness or sensory deficits. The pain is worse when he walks or when he lifts weights, and it is interfering with his work. The patient’s medical histo- ry and review of systems are unremarkable. He has tried over-the-counter acetaminophen and ibupro- fen, without relief. Recently, he saw another physician, who ordered a magnetic resonance imaging scan. The report describes a bulging disk on L4-5 with no signs of spinal cord compression.

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The most clin- From these nuclei 150 mg viagra extra dosage with mastercard, there is a diffuse distribution ically significant aspects are: of connections to all parts of the cerebral cortex cheap viagra extra dosage 120mg amex. This whole system is concerned with con- • Cardiac and respiratory centers in the medulla sciousness and is known as the ascending retic- • Descending systems in the pons and medulla ular activating system (ARAS) viagra extra dosage 150mg otc. These are not always tem © 2006 by Taylor & Francis Group 150mg viagra extra dosage with amex, LLC Functional Systems 115 Ascending reticular activating system (ARAS) Locus ceruleus Lateral group Medial group Raphe nuclei Reticulo-spinal tracts FIGURE 42A: Reticular Formation 1 — Organization © 2006 by Taylor & Francis Group trusted viagra extra dosage 130 mg, LLC 116 Atlas of Functional Neutoanatomy FIGURE 42B located within the core region. These include the periaq- ueductal gray and the locus ceruleus. RETICULAR FORMATION 2 The periaqueductal gray of the midbrain (for its location see Figure 65 and Figure 65A) includes neurons that are found around the aqueduct of the midbrain (see RETICULAR FORMATION: NUCLEI also Figure 20B). This area also receives input (illustrated In this diagram, the reticular formation is being viewed but not labeled in this diagram) from the ascending sen- from the dorsal (posterior) perspective (see Figure 10 and sory systems conveying pain and temperature, the antero- Figure 40). Various nuclei of the reticular formation, RF, lateral pathway; the same occurs with the trigeminal sys- which have a significant (known) functional role, are tem. This area is part of a descending pathway to the spinal depicted, as well as the descending tracts emanating from cord, which is concerned with pain modulation (as shown some of these nuclei. Functionally, there are afferent and efferent nuclei in The locus ceruleus is a small nucleus in the upper the reticular formation and groups of neurons that are pontine region (see Figure 66 and Figure 66A). In some distinct because of the catecholamine neurotransmitter species (including humans), the neurons of this nucleus used, either serotonin or noradrenaline. The afferent and accumulate a pigment that can be seen when the brain is efferent nuclei of the RF include: sectioned (prior to histological processing, see photograph of the pons, Figure 66). Output from this small nucleus is • Neurons that receive the various inputs to the distributed widely throughout the brain to virtually every RF are found in the lateral group (as discussed part of the CNS, including all cortical areas, subcortical with the previous illustration). In this diagram, structures, the brainstem and cerebellum, and the spinal these neurons are shown receiving collaterals cord. The neurotransmitter that is used by these neurons (or terminal branches) from the ascending ante- is noradrenaline and its electrophysiological effects at var- rolateral system, carrying pain and temperature ious synapses are still not clearly known. It has been implicated in reticular formation, at various levels. These a wide variety of CNS activities, such as mood, the reac- cells project their axons upward or downward. The nucleus gigantocellularis of the medulla, The cerebral cortex sends fibers to the RF nuclei, and the pontine reticular nuclei, caudal, and including the periaqueductal gray, forming part of the oral portions, give rise to the descending tracts cortico-bulbar system of fibers (see Figure 46). The nuclei that emanate from these nuclei — the medial that receive this input and then give off the pathways to and lateral reticulo-spinal pathways, part of the the spinal cord form part of an indirect voluntary motor indirect voluntary and nonvoluntary motor sys- system — the cortico-reticulo-spinal pathways (discussed tem (see Figure 49A and Figure 49B). In addition, this system is known to play an and project to all parts of the CNS. Recent extremely important role in the control of muscle tone studies indicate that serotonin plays a signifi- (discussed with Figure 49B). One special nucleus CLINICAL ASPECT of this group, the nucleus raphe magnus, Lesions of the cortical input to the reticular formation in located in the upper part of the medulla, plays particular have a very significant impact on muscle tone. This is the physiological basis nervous system at multiple levels. In this model, the same circuit knowing which parts of the limbs and body wall are is activated at a segmental level. We know that mental states and cognitive cussed with Figure 36). There is good evidence that some processes can affect, positively and negatively, the expe- “conscious” perception of pain occurs at the thalamic rience of pain and our reaction to pain. This system apparently func- CLINICAL ASPECT tions in the following way: The neurons of the periaque- In our daily experience with local pain, such as a bump ductal gray can be activated in a number of ways. It is or small cut, the common response is to vigorously rub known that many ascending fibers from the anterolateral and/or shake the limb or the affected region. What we may system and trigeminal system activate neurons in this area be doing is activating the local segmental circuits via the (only the anterolateral fibers are being shown in this illus- touch- and mechano-receptors to decrease the pain sensa- tration), either as collaterals or direct endings of these tion. This area is also known to be rich Some of the current treatments for pain are based upon in opiate receptors, and it seems that neurons of this region the structures and neurotransmitters being discussed here. Experimen- The gate theory underlies the use of transcutaneous stim- tally, one can activate these neurons by direct stimulation ulation, one of the current therapies offered for the relief or by a local injection of morphine. More controversial and certainly less certain is ing cortical fibers (cortico-bulbar) may activate these neu- the postulated mechanism(s) for the use of acupuncture rons (see Figure 46). The axons of some of the neurons of the periaqueduc- Most discussions concerning pain refer to ACUTE tal gray descend and terminate in one of the serotonin- pain, or short-term pain caused by an injury or dental containing raphe nuclei in the upper medulla, the nucleus procedure.

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Nasal packing viagra extra dosage 200 mg without prescription, and occasionally artery liga- tion cheap viagra extra dosage 120mg overnight delivery, may be necessary to control the bleeding discount viagra extra dosage 130 mg fast delivery. Any unexplained purchase viagra extra dosage 200 mg without a prescription, recurrent epistaxis war- rants investigation and possible referral to an ENT specialist 120 mg viagra extra dosage mastercard. History The past medical history should include medications the patient is taking that could be contributing, such as anticoagulants, aspirin, or NSAIDs, and the presence of other med- ical problems, such as hematologic disorders, or liver or vascular disease. Cocaine abuse is more common than might be expected and frequently causes epistaxis. There may be a need to explore this possibility with a patient. A complaint of recent trauma is a straight- forward cause of epistaxis, and an x-ray should be taken to rule out fracture. Ask about fre- quent sinus infections and the use of nasal sprays, obtained by prescription or over the counter (OTC). Steroid or antihistamine nasal sprays can cause dryness, irritation, and bleeding. Ask whether this is the first episode of bleeding, and, if not, ask about the frequency at which it has occurred. Chronic epistaxis warrants referral to an ENT special- ist to determine a structural or vascular cause. Physical Examination The physical examination should start with an inspection of the external nose for align- ment and the presence of any skin lesions. If possible, the practitioner should try to visu- alize the nasal mucosa for redness, purulent discharge, or lesions, although visualization is difficult to accomplish with active bleeding. Diagnostic Studies X-rays or CT scanning of the nose and/or sinuses would assist in the diagnosis of fracture, infection, tumor, and polyps. Culture and sensitivity of nasal discharge could be taken for resistant infections. Complete blood count with differential, platelet count, and coagula- tion studies might be needed to rule out hematologic or vascular causes. A liver profile might be needed to identify a hepatic cause of the epistaxis. Trauma Bleeding accompanied by edema and asymmetry of the nose indicates a possible fracture, and x-rays of the nose are warranted. Ice and pressure on the sides of the nose usually will control the bleeding, at least temporarily. HISTORY A history of a blow to the nose is given by the patient. If the cause of the trauma is not obviously reported by the patient, be alert for and inquire about any signs of abuse, par- ticularly in women and children. Ear, Nose, Mouth, and Throat 97 PHYSICAL EXAMINATION Edema occurs rapidly after a blow to the nose and is obvious on visual inspection. There may be abrasions or lacerations present, and asymmetry is seen with fracture. If the x-ray is positive for a fracture, the patient should be referred to the ENT and/or plastic surgeon. Medication Anticoagulant medications such as warfarin (Coumadin), heparin, or enoxaparin (Lovenox) are the most common medications to cause epistaxis. Other drugs that might cause bleeding include aspirin, NSAIDs, nasal sprays, and Ginkgo biloba. HISTORY A thorough medication history, including prescription and OTC/herbal preparations, will alert the practitioner to the cause of the epistaxis. PHYSICAL EXAMINATION Other than the nasal bleeding, the patient who is over-anticoagulated may have bruis- ing over the body from everyday minor contusions, particularly on the limbs. Bleeding from the gums also is commonly seen with over-anticoagulation. If the patient is taking anticoagulants, a prothrombin time with international normal- ization ratio should be done. Hematologic Disorders The hematologic disorders that are likely to cause increased bleeding include thrombocy- topenia, leukemia, aplastic anemia, and hereditary coagulopathies. Multiple hematologic disorders can be seen with liver disease, including anemia, thrombocytopenia, leukopenia, leukocytosis, and impaired synthesis of clotting factors causing increased prothrombin time. HISTORY A history of hematologic disorders will quickly point the practitioner toward the cause of the bleeding. Ask the patient about easy bruisability, fatigue, shortness of breath, fever, or frequent infections.

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On examination trusted 150mg viagra extra dosage, his blood pressure is 110/50 mm Hg cheap viagra extra dosage 120 mg fast delivery; his pulse is 96 beats/min and irregular order viagra extra dosage 150 mg on-line; his respiration rate is 20 buy 130mg viagra extra dosage overnight delivery; and his temperature is 99 best 130 mg viagra extra dosage. Fine rales are present in the lower two thirds of the lung fields. The jugular venous pressure is estimated to be 15 cm, and a large V wave is present. A distinct S3 gal- lop is audible; 2+ pitting edema is present in the ankles. Chemistry panel is normal, but the CBC reveals a WBC of 22,000, of which 60% are eosinophils. Chest x-ray shows interstitial and alveolar edema and Kerley B lines. Echocardiogram reveals mitral regurgitation and features suggesting a restrictive cardiomyopathy. Multiple stool samples are negative for ova and para- sites. Which of the following is the most likely diagnosis for this patient? Hypereosinophilic syndrome Key Concept/Objective: To understand the diagnosis of hypereosinophilic syndrome Hypereosinophilic syndrome consists of a chronic, unexplained eosinophilia without obvious cause (such causes would include parasitic infections, drug reactions, allergic reac- tions, hypersensitivity reactions, lymphoproliferative disorders, connective tissue disor- ders, and hematologic malignancies). The condition may be caused by excessive IL-5 pro- duction by a T cell clone. Eosinophils are found in the involved tissues and are thought to cause damage by the local deposition of toxic eosinophil products such as eosinophil major basic protein. Manifestations are multisystemic: fever, rash, cough and dyspnea, diarrhea, congestive heart failure, and peripheral neuropathy. The most severe complica- tions involve the heart and CNS. Careful evaluation is necessary to exclude other causes of eosinophilia. Endomyocardial fibrosis (Löffler endocarditis) is a cardiac manifestation of hypereosinophilic syndrome. Eosinophilic deposits may lead to direct injury of the endo- cardium, followed by platelet thrombi and fibrosis. The cardiac apices can become oblit- erated, creating a characteristic finding on echocardiography. The mitral and tricuspid valves are affected by the same fibrotic process, resulting in valvular regurgitation. A 57-year-old diabetic man presents to your office for presurgical evaluation for total hip replacement. After a thorough history and physical examination, you ask the patient if he has any questions. He says that the orthopedic surgeon told him that there was a possibility he will need blood products during or after the surgery, and the patient is concerned about the risks of contracting a contagious disease from blood products. Which of the following statements about the risk of infection associated with transfusion is true? Risk of transfusion-associated hepatitis A is higher in pooled products such as factor concentrates than in single-donor products B. Postdonation screening to identify donors likely to transmit blood- borne infections has produced the biggest decrease in the risk of trans- fusion-transmitted disease C. Directed donation offers a small but significant reduction in the risk of transfusion-associated infections D. Currently, there is no postdonation test available for West Nile virus Key Concept/Objective: To understand the screening process used to reduce transmission of infec- tious diseases through transfusion of blood products Available prevalence data show that the risk of infectious disease from directed donors is no different from that of first-time donors. Predonation donor screening to identify clini- cal and lifestyle characteristics associated with higher incidences of infection has produced the biggest decrease in the risk of transfusion-transmitted disease. Postdonation testing is essential in identifying donors likely to transmit blood-borne infections who are missed in the initial screening process. Because the viremic phase of hepatitis A lasts about 17 days in humans before signs and symptoms develop, hepatitis A transmission from single- donor products is extremely rare.

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