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The risk of infection is increased with puncture wounds discount 1mg finasteride otc hair loss in menopause symptoms, hand injuries order finasteride without a prescription hair loss patterns, full-thickness wounds, wounds requiring debridement, and those involving joints, tendons, ligaments or fractures. Comorbid medical conditions, such as diabetes, asplenia, chronic edema of the area, liver dysfunction, the presence of a prosthetic valve or joint, and an immunocompromised state may also increase the risk of infection. Other Complications of Bites Infection may spread beyond the initial site, leading to septic arthritis, osteomyelitis, endocarditis, peritonitis, septicemia, and meningitis. If enough force is used, bones may be fractured or the wounds may be permanently disfiguring. Initial Management Assessment regarding whether hospital treatment is necessary should be made as soon as possible. Always refer if the wound is bleeding heavily or fails to stop when pressure is applied. Penetrating bites involving arteries, nerves, muscles, tendons, the hands, or feet, resulting in a moderate to serious facial wound, or crush injuries, also require immediate referral. A full forensic documentation of the bite should be made as detailed in Chapter 4. Note if there are clinical signs of infection, such as erythema, edema, cellulitis, purulent discharge, or regional lymphadenopathy. Wound closure is not generally recom- mended because data suggest that it may increase the risk of infection. This is particularly relevant for nonfacial wounds, deep puncture wounds, bites to the hand, clinically infected wounds, and wounds occurring more than 6–12 hours before presentation. Head and neck wounds in cosmetically important areas may be closed if less than 12 hours old and not obviously infected. Viruses • Dog bites—outside of the United Kingdom, Australia, and New Zealand, rabies should be considered. In the United States, domestic dogs are mostly Infectious Diseases 265 vaccinated against rabies (57), and police dogs have to be vaccinated, so the most common source is from racoons, skunks, and bats. Antibiotic Prophylaxis Antibiotics are not generally needed if the wound is more than 2 days old and there is no sign of infection or in superficial noninfected wounds evalu- ated early that can be left open to heal by secondary intention in compliant people with no significant comorbidity (58). Antibiotics should be considered with high-risk wounds that involve the hands, feet, face, tendons, ligaments, joints, or suspected fractures or for any penetrating bite injury in a person with diabetes, asplenia, or cirrhosis or who is immunosuppressed. Coamoxiclav (amoxycillin and clavulanic acid) is the first-line treatment for mild–moderate dog or human bites resulting in infections managed in pri- mary care. For adults, the recommended dose is 500/125 mg three times daily and for children the recommended does is 40 mg/kg three times daily (based on amoxycillin component). It is also the first-line drug for prophylaxis when the same dose regimen should be prescribed for 5–7 days. If the individual is known or suspected to be aller- gic to penicillin, a tetracycline (e. In the United Kingdom, doxycycline use is restricted to those older than 12 years and in the United States to those older than 8 years old. Anyone with severe infection or who is clinically unwell should be referred to the hospital. Tetanus vaccine should be given if the primary course or last booster was more than 10 years ago. If the person has never been immunized or is unsure of his or her tetanus status, a full three-dose course, spaced at least 1 month apart, should be given. General Information Respiratory tract infections are common, usually mild, and self-limit- ing, although they may require symptomatic treatment with paracetamol or a nonsteroidal antiinflammatory. These include the common cold (80% rhi- noviruses and 20% coronaviruses), adenoviruses, influenza, parainfluenza, and, during the summer and early autumn, enteroviruses. Special attention should be given to detainees with asthma or the who are immunocompromised, because infection in these people may be more serious particularly if the lower respiratory tract is involved. The following section includes respiratory pathogens of special note because they may pose a risk to both the detainee and/or staff who come into close contact. General Information and Epidemiology There are five serogroups of Neisseria meningitidis: A, B, C, W135, and Y. In the United Kingdom, most cases of meningitis are sporadic, with less than 5% occurring as clusters (outbreaks) amongst school children. Between 1996 and 2000, 59% of cases were group B, 36% were group C, and W135 and A accounted for 5%. There is a seasonal variation, with a high level of cases in winter and a low level in the summer. The greatest risk group are the under 5 year olds, with a peak incidence under 1 year old. In Sub-Saharan Africa, the dis- ease is more prevalent in the dry season, but in many countries, there is back- ground endemicity year-round. Routine vaccination against group C was introduced in the United King- dom November 1999 for everybody up to the age of 18 years old and to all first- year university students. As a result of the introduction of the vaccination pro- gram, there has been a 90% reduction of group C cases in those younger than under 18 years and an 82% reduction in those under 1 year old (60,61). An outbreak of serogroup W135 meningitis occurred among pilgrims on the Hajj in 2000. Symptoms After an incubation period of 3–5 days (63,64), disease onset may be either insidious with mild prodromal symptoms or florid. The rash may be petechial or purpuric and characteristically does not blanche under pressure. Meningitis in infants is more likely to be insidious in onset and lack the classical signs. Even with prompt antibiotic treatment, the case fatality rate is 3–5% in meningitis and 15–20% in those with septicemia. Period of Infectivity A person should be considered infectious until the bacteria are no longer present in nasal discharge. Routes of Transmission The disease is spread through infected droplets or direct contact from carriers or those who are clinically ill. It requires prolonged and close contact, so it is a greater risk for people who share accommodation and utensils and kiss. It must also be remembered that unprotected mouth-to-mouth resuscita- tion can also transmit disease. Nevertheless, the risk of acquiring infection even from an infected and sick individual is low, unless the individual has carried out mouth-to-mouth resuscitation. Any staff mem- ber who believes he or she has been placed at risk should report to the occupa- tional health department (or equivalent) or the nearest emergency department at the earliest opportunity for vaccination. If the detainee has performed mouth-to-mouth resuscitation, prophylactic antibiotics should be given before receiving vaccination. Rifampicin, ciprofloxacin, and ceftriaxone can be used; however, ciprofloxacin has numer- ous advantages (66). Only a single dose of 500 mg (adults and children older than 12 years) is needed and has fewer side effects and contraindications than rifampicin.

Such combinations include benazepril with amlodipine (Lotrel) order 1 mg finasteride visa hair loss lotion, enalapril with diltiazem (Teczem) cheap 5mg finasteride mastercard hair loss 5 month old, enalapril with felodipine (Lexxel), and trandolapril with verapamil (Tarka). Diuretics lower blood pressure and decrease peripheral and pulmonary edema in congestive heart failure and renal or liver disorders by inhibiting sodium and water reabsorption from the kidney tubules resulting in increased urine flow (diuresis). It moves through blood vessels eventually causing a blockage—called a thromboem- bolism—resulting in decreased blood flow (ischemia) that causes death (necro- sis) of tissues in the effected area. Thromboembolisms disintegrate naturally in about two weeks through the fibrinolytic mechanism, which breaks down fibrin. An acute myocardial infarction (heart attack) can be caused by a thromboembolism block- ing a coronary artery. The ischemic (without oxygen) tissue becomes necrotic (dies) if left with- out an oxygen supply. Thrombolytics prevent or minimize necrosis that results from the blocked artery and therefore decreases hospitalization time. After thrombolytic treatment, the patient is evaluated for cardiac bypass or coronary angioplasty procedures. Thrombolytics are also used for pulmonary embolism, deep vein thrombosis, and noncoronary arterial occlusion from an acute thromboembolism. Anaphylaxis (vascu- lar collapse) occurs more frequently with streptokinase than with the other thrombolytics. The hemorrhage is stopped by using aminocaproic acid (Amicar) to inhibit plasminogen activation. The use of heparin with thrombolytic medica- tions is commonly done and can prevent formation of new clots but requires intensive care and close monitoring of the patient. A correct dose of medication for a pediatric patient is determined by (a) the patient’s weight. Barnabas Health Care System, Livingston, New Jersey The Encyclopedia of Complementary and Alternative Medicine Copyright © 2004 by Tova Navarra All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage or retrieval systems, without permission in writing from the publisher. Please call our Special Sales Department in New York at (212) 967-8800 or (800) 322-8755. For is not the essence of medicine to This path was one of self-exploration and develop- teach people to improve and maintain their ment. In fact, the Latin root for doctor, docere, and began to appreciate the benefits of improved means “to teach. After a num- start premed classes in summer school less than a ber of years of assisting, several fellow instructors week after graduation. I was in col- Over the next year and a half, I completed lege at the time and frequently finished classes and the premed requirements and was ultimately immediately raced down to the school to teach or accepted to Boston University School of Medicine. I found those days extremely challenging and During that time, I continued on my path of self- rewarding. I continued teaching martial arts and However, I soon discovered that my parents and began to question why conventional medicine did family did not fully appreciate my vision of my life not often utilize methods from other healing tra- as a martial arts instructor. I had seen multiple examples of problems, always supportive, they encouraged me to consider such as back pain, improved through the use of other avenues of employment. Given that my t’ai ch’i, or asthma through the use of various father was a lawyer and I was a history major, law breathing exercises. I had seen multiple students seemed a reasonable way to make a living while lose weight, improve their control of stress, and in continuing my career as a martial artist. To me a mar- through the application process, I was fortunate tial arts instructor, nothing felt more meaningful enough to be accepted for admission. To me, this was the essence of contemplate graduation from college and the good medicine. I simply did not feel passion- realized that teaching patients to improve or main- ate about becoming a lawyer. I began to reevaluate tain their health was a part of medicine that often what I did feel passionate about. What was it about got lost in trying to provide patients with the latest teaching martial arts that made me feel so fulfilled? I also realized that others were less than teaching and I enjoyed helping people improve understanding of my desire to expand the usual ix x The Encyclopedia of Complementary and Alternative Medicine treatment options to include “alternative” meth- is just now being researched and shown to be effec- ods. One day, during my second year of residency, tive for many ailments, such as nausea caused by the chairman of medicine asked me what I planned chemotherapy or pregnancy. I told him that I was such as ma huang (or ephedra) to assist with weight interested in alternative medicine, to which he loss may be efficacious but when used improperly responded, “Show me the evidence,” and quickly are potentially dangerous (there have been more changed the subject. Other treatments are Although I was somewhat disappointed by this newly invented or conceived. Although some of reaction, his statement ultimately turned out to be these treatments will ultimately be shown to be of one of those seemingly innocent comments that value, individuals who seek to take advantage of a unintentionally have a profound effect. I began vulnerable public are often marketing fraudulent pondering the challenge of integrating alternative products or interventions. The Internet has led to medicine into conventional medicine and the con- increased empowerment of the public through ventional medical establishment. I began to appre- access to an endless amount of medical informa- ciate more fully the need for additional research on tion. Only through that research seemingly endless amount of inaccurate or poten- can conventional medical providers know which tially misleading health information. Only Traditionally the public has turned to physicians through that research can the public truly know and other health care providers for reliable infor- which treatments are safe and effective. But multiple Ultimately I decided to pursue a two-year studies have shown that the majority of people research fellowship and a master’s degree in public who use alternative medicine do so without telling health with the goal of obtaining the skills neces- their physicians or other health care providers. Good research takes years and costs sig- the subject matter and a desire not to appear unin- nificant amounts of money. This omission often gives the impression cies are funding research on alternative medicine. At times physicians may be dis- the Study of Complementary and Alternative Med- missive of such therapies because of a perception icine under the National Institutes of Health, and that there is a lack of credible and authoritative evi- the amount and quality of research on alternative dence of their effectiveness. However, Patients, on the other hand, tend to believe that the various types of alternative treatments avail- it is unimportant for health care providers to know able are also increasing. They research is conducted, there will always be numer- often believe that the alternative therapy is irrele- ous treatment options available that have little or vant to the biomedical treatment course. They may no data beyond anecdotal evidence to support their think that a decision to pursue an alternative treat- use. There will always be treatments being utilized ment does not require input from the conventional that will ultimately be shown to be safe and effec- medical establishment, since they believe these tive as well as ones that will be harmful and futile. Still others hesitate Many treatments are from healing traditions to speak openly about their use of or desire to use that have developed over hundreds, if not thou- alternative medicine because of concern that their sands, of years through a process of trial and error questions may be dismissed or they may be viewed on thousands of patients. If undergo a conventional medical evaluation as well the public cannot turn to the conventional medical as see an acupuncturist, nutritionist, massage ther- establishment, turn to their own physicians or apist, clinical herbalist, or mind-body practitioner other health care providers for reliable information (licensed clinical social worker or Ph.

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A number of hepatic metab- and gives rise to problems because of its limited solubility purchase discount finasteride hair loss zoloft. Adverse effects Xanthine oxidase Adverse effects include the following: Figure 26 5 mg finasteride visa hormonal hair loss cure. The final enzymatic • peripheral neuropathy; reactions in the production of uric acid are shown in Figure 26. It is more soluble in Colchicine is well absorbed from the gastro-intestinal tract. Plasma uric acid concentration is is partly metabolized, and a major portion is excreted via the lowered either by increasing renal excretion or, more often, by bile and undergoes enterohepatic circulation, contributing to inhibiting synthesis. Hyperuricaemia often occurs in the setting of obesity and excessive ethanol consumption. Hyperuricaemia also Allopurinol is used as long-term prophylaxis for patients occurs when excretion is decreased, for example, in renal fail- with recurrent gout, especially tophaceous gout, urate renal ure or when tubular excretion is diminished by diuretics, pyraz- stones, gout with renal failure and acute urate nephropathy, inamide (Chapter 44) or low doses of salicylate (Chapter 25). It The acute attack is treated with anti-inflammatory analgesic must not be commenced till several weeks after an acute agents (e. Allopurinol is a xanthine oxidase inhibitor and decreases the production of uric acid (Figure 26. It is also used in patients with familial Adverse effects Mediterranean fever and Behçet’s disease. A low dose can be used pro- rashes and life-threatening hypersensitivity reactions (includ- phylactically. It is relatively contraindicated in the elderly and ing Stevens Johnson syndrome) can occur. There is a history of essential hypertension, and he has had a similar but less Drug interactions severe attack three months previously which settled sponta- • Allopurinol decreases the breakdown of 6-mercaptopurine neously. Following this, serum urate concentrations were determined and found to be within the normal range. His (the active metabolite of azathioprine) with a potential for toe is now inflamed and exquisitely tender. He therefore prescribes cocodamol for Use the pain and repeated the serum urate measurement. Review Their main effect on the handling of uric acid by the kidney is his medication (is he on a diuretic for his hypertension? Despite his occupation, the patient does not drink alcohol and he was receiving ben- precipitate an acute attack of gout. The patient should period of poor antihypertensive control in this setting is not drink enough water to have a urine output of 2L/day during of great importance. After the pain has settled and ibuprofen the first month of treatment and a sodium bicarbonate or stopped, the patient’s blood pressure decreases further to 140/84mmHg on amlodipine. He did not have any recurrence potassium citrate mixture should be given to keep the urinary of gout. The coxibs, selective inhibitors of cyclooxy- • Gout is caused by an inflammatory reaction to genase-2. Risk of acute myocardial infarction • Always consider possible contributing factors, including and sudden cardiac death in patients treated with cyclo-oxygenase drugs (especially diuretics) and ethanol. Medication use and the risk of Stevens- alternative when allopurinol causes severe adverse Johnson syndrome or toxic epidermal necrolysis. Since these are the major causes of morbidity and mortality among adults in industrialized societies, its prevention is of great importance. An important practical distinction is made between prevent- ive measures in healthy people (called ‘primary prevention’) and measures in people who have survived a stroke or a heart attack, or who are symptomatic, e. The absolute risk per unit time is greatest in those with clinical evidence of established disease, so secondary prevention is especially worthwhile (and cost-effective, since the number needed to treat to pre- Figure 27. Primary prevention inevitably involves larger populations who are at relatively low absolute risk per unit time, so inter- These plaques are rich in both extracellular and intracellular ventions must be inexpensive and have a low risk of adverse cholesterol. Epidemiological ulcerate, in which event the subintima acts as a focus for observations, including the rapid change in incidence of coron- thrombosis: platelet-fibrin thrombi propagate and can occlude ary disease in Japanese migrants from Japan (low risk) to the artery, causing myocardial infarction or stroke. Approximately two-thirds of cholesterol circu- intima and progress to proliferative fibro-fatty growths that lating in the blood is synthesized in the liver. Low-density lipoprotein that enters arterial walls ticles by lipoprotein lipase, an enzyme on the surface of at sites of endothelial damage can be remobilized in the form endothelial cells. Chylomicron and be taken up by macrophages as part of atherogenesis remnants are taken up by hepatocytes to complete the exoge- (see below). Intimal enrichment of the particles with cholesterol, with an increase injury initiates atherogenesis, which is a chronic inflammatory in their density through intermediate-density to low-density process. The injury may initially be undetectable morphologi- cally, but results in focal endothelial dysfunction. Blood Modifiable risk factors are potentially susceptible to therapeutic monocytes adhere to adhesion molecules expressed by injured intervention. These include smoking, obesity, sedentary habits, endothelium and migrate into the vessel wall, where they dyslipidaemia, glucose intolerance (Chapter 37) and hyperten- become macrophages. Lymphocytes and platelets adhere to matous disease were disproved by randomized controlled trials the injured intima and secrete growth factors and cytokines, (Figure 27. The plasma concentration of Lp(a) varies over attempts to give up are often unsuccessful. Most tine, bupropion and varenicline (partial agonist at the nico- drugs have little effect (nicotinic acid is an exception). Apo(a) tinic receptor) in conjunction with counselling in smoking contains multiple repeats of one of the kringles of plasminogen cessation programmes are covered in Chapter 53. Obesity is increasingly common and is a strong risk factor, partly via its associations with hypertension, diabetes and dyslipidaemia. Secondary forms of dyslipidaemia cells (including macrophages and endothelial cells). Dietary advice focuses on chemical messengers are released by lipid-laden reducing saturated fat and correcting obesity rather than macrophages (‘foam cells’), T-lymphocytes and reducing cholesterol intake per se. These interleukins and growth factors cause evidence of atheromatous disease, the decision as to whether the migration and proliferation of vascular smooth to initiate drug treatment at any given level of serum lipids muscle cells and fibroblasts, which form a fibro-fatty plaque. This is cal- • Cigarette smoking promotes several of these processes culated from cardiovascular risk prediction charts (e. Joint British Societies’ guidelines on prevention Use of cardiovascular disease in clinical practice. Randomized controlled trials have shown that simvastatin, atorvastatin and pravastatin reduce cardiac events and prolong life, and are safe. More serious Colestyramine or colestipol were used for hypercholesterol- adverse events are rare, but include rhabdomyolysis, hepatitis aemia, but have been almost completely superseded by statins.

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Table 7-2 shows the commonly used prefixes that you’ll see when calculating medication buy 1 mg finasteride with visa hair loss 9 year old boy. The prefix is placed before the unit of mea- sure such as 1 kilogram or 1 milliliter cheap 5mg finasteride free shipping hair loss in men magazine. The important point to remember is that the prefix of the measure implies the size of the measurement. Nurses encounter household measurements when providing home healthcare services and when determining a patient’s fluid intake and output in the hospital setting. Nurses also use pounds when calculating a dose that is based on a patient’s weight. Patients should use measuring spoons for medication administration at home and avoid using tableware. Patients are usually more comfortable self-administering medication if the dose is in household measurements. Therefore, a nurse must be able to convert household measure- ments to metric measurements. The nurse must convert that to milliliters (mL) or cubic centimeters (cc) in order to record the intake volume in the patient’s fluid input and output chart. Commonly used conversion factors for household measurement and metric measurement. For example, if the dose is in milligrams and the prescriber’s medication order specifies grams, you’ll need to convert grams to milligrams before calculating the dose. Converting from one metric unit to another metric unit isn’t difficult if you remember these three rules. Determine if the desired measurement is larger or smaller than the given measurement. Remember that gram, liter, and meter are larger units and milligram, milliliter, and millimeter are smaller units. If you are converting from a smaller unit to a larger unit, then you multi- ply by moving the decimal three places to the left. If you are converting from a larger unit to a smaller unit, then you divide by moving the decimal three places to the right. Therefore, you divide by moving the decimal three places to the left, as shown here. Therefore, you multiply by moving the decimal three places to the right, as shown here. This is also the easiest conversion because one milliliter (mL) is equal to 1 cubic centimeter (cc). Always place a zero to the left of the decimal when the quantity is not a whole number. There, you’ll use a teaspoon, tablespoon, or cups mea- sured in ounces to administer medication. When converting from milliliters or cubic centimeters to ounces, divide by 30, as shown here: [Remember 30 cc (30 mL) = 1 oz. For example, the medication prescription is for a 15-mg tablet of Inderal and the hospital has on hand a 15-mg tablet of Inderal. In the real world, the dose specified in the medical prescription may not be available. The hospital might have 10-mg tablets of Inderal and not the 15-mg tablets prescribed. Instead of asking the prescriber to change the medication order, the nurse calculates the proper medication to give the patient based on the medication order and the dose that is on hand. When applying either method, make sure that all the terms are in the same units before calculating the desired dose. For example, the medication order might be in grams and the dose on hand might be in milligrams. The nurse will need to convert the grams to milligrams before calculating the desired dose to give. D × V = A Quantity (Desired dose divided by dose you have H multiplied by vehicle of drug you have equals the amount calculated to be given to the patient) D = desired dose H = dose you have V = vehicle you have (tablets or liquids) A = amount calculated to be given to the patient Ratio and proportion method H V :: D x Means Extremes H is the drug on hand (available) V is the vehicle or drug form (tablet, capsule, liquid) D is the desired dose (as prescribed) x is the unknown amount to give, and :: stands for “as” or “equal to. Example: Give 500 mg of ampicillin sodium by mouth when the dose on hand is in capsules containing 250 mg. For example, use mg following a value in the formula if the value is in milligrams. Parenteral Medications Parenteral medication is a medication that is administered to a patient by an injection or by an intravenous flow. The dose for an injection is calculated using the formula method or the ratio-proportion method that is described previously in this chapter. The nurse must calculate the number of milliliters that should be administered to the patient. The intravenous order directs the nurse to administer a specific vol- ume of fluid to the patient over a specific time period. In order the calculate the drip rate you need to know: • The volume of fluid that is to be infused. This is found in the medication order in milliliters (mL) or cubic centimeters (cc). It is important to remember that although we use milliliters in the following examples, you can substitute cubic centi- meters (cc) for milliliters (mL) if cc is specified in the order. Total fluid multiplied by drip factor and divided by the infusion time in minutes. Total fluid = 250 mL(cc) Drip factor = 60 gtts/min Infusion time in minutes = 600 min 250 mL × 60gtts / min 15,000 mL = 25gtts / minute 600 minutes 600 min Heparin infusion Heparin is a medication that inhibits the formation of platelets and can be admin- istered either as a subcutaneous injection or as a continuous intravenous infu- sion. The proper dose of heparin is always calculated using either the formula method or the ratio-proportion method. Therefore, you must calculate a new dose that is proportional to the prescribed dose. You must be able to convert within the metric system and convert between household measurements and metric because patients are likely to self medicate using household measure- ment—such as a teaspoon—rather than using metric measurements. Converting between metric units is performed by moving the decimal to the left or right depending on whether you are moving from a smaller metric unit to a larger metric unit or vice versa. Converting between household measurements and metric is achieved by multiplying or dividing using a conversion factor. This depends on whether you are converting from household measurements to metric or vice versa. Both use the on hand dose of a med- ication to determine the desired dose based on the medication prescription. The formula method and the ratio-proportion method are also used to calcu- late parenteral medications. Alternatively, parenteral medication can be adminis- tered through a vein either as a bolus or an infusion.

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An 82-year-old woman becomes acutely short of breath while at rest on the rehabilitation unit purchase finasteride online now hair loss in men journal. Upon chest auscultation finasteride 5 mg online hair loss in men robes, there are equal bilateral breath sounds with some scattered rhonchi. Her nurse tells you that 2 days ago she underwent internal fixation of a right-femur fracture and has been on anticoagulant therapy. Given the history and pre- sentation of this patient, what is the most likely etiology of her symptoms? Despite distant breath sounds, you hear end-expiratory rhonchi and a prolonged expiratory phase. Given this patient’s history and physical examination, which of the following conditions does this patient most likely have? Her physical examination is significant for decreased breath sounds bilaterally and tenderness to palpation along the right side of her chest. After initial stabilization, which of the following is the diagnostic test of choice for this patient’s condition? She is able to speak in full sentences and tells you that she cannot breathe and that her hands and feet are cramping up. Which of the following conditions is most likely the etiology of this patient’s symptoms? He is currently on an oxygen face mask and was admin- istered one nebulized treatment of a β2-agonist by the paramedics. Upon chest auscultation, there are minimal wheezes localized over bilateral lower lung fields. Which of the following medications, in addition to a rescue β2-agonist inhaler, should be pre- scribed for outpatient use? Upon physical examination, the patient has clear breath sounds bilaterally and no signs of trauma. Given this clinical presentation, what initial antibiotic coverage is most appropriate for this patient? The patient is endotracheally intubated, given a 2-L bolus of normal saline, and started on antibiotics. You see a friend that accompanied the patient to the hospital and ask him some questions. What is the most likely organism that is responsible for the patient’s presentation? Upon physical examination, there are decreased breath sounds on the right as compared to the left. A chest radiograph indicates blunting of the right costophrenic angle with a fluid line. Given this patient’s history, which of the following most likely describes his effusion? Upon physical examination, the patient appears to be in mild distress with audible wheezing. She is able to speak in partial sen- tences and states that she occasionally uses an inhaler. Given this patient’s history and physical examination, which of the following measures should be taken next? If pharyngeal or laryngeal structures become involved, or there is significant tongue swelling, the patient may begin to compromise their airway and emergent intubation or surgical cricothyroidotomy needs to be performed. All patients need to be on a monitor and should receive supplemental oxygen despite normal oxygen saturation. Heparin is the first-line therapy in this patient and should be administered promptly. Warfarin initially causes a temporary hypercoagulable state because the anticoagulants, protein C and S (inhibited by warfarin), have shorter half-lives compared with the procoagulant vitamin K–dependent proteins that warfarin also inhibits. Classically, it presents with a productive cough with currant jelly sputum, fever, general malaise, and an overall toxic appearance. A dense lobar infiltrate with a bulging fissure appearance on a chest radiograph is often described. Streptococcus pneumoniae (a) is the most common etiology in community- acquired pneumonia among adults. Mycoplasma pneumoniae (c) is a common cause of community-acquired pneumonia in patients under the age of 40. Legionella pneumophila (d) is an intracellular organism that lives in aquatic environments and is not transmitted from person to person. It is a pleomorphic gram-negative rod that can be encapsulated and identified as various serotypes, with type b as the most commonly causing bacteremia. Mild tachycardia, decreased breath sounds to auscultation, or hyperresonance to percussion are the most common findings. It typically occurs in healthy young men of taller than average stature without a pre- cipitating factor. Mitral valve prolapse and Marfan syndrome are also asso- ciated with pneumothoraces. Although suggested by this patient’s symptoms, the diagnosis of pneumothorax is generally made with a chest radiograph. The classic sign is the appearance of a thin, vis- ceral, pleural line lying parallel to the chest wall, separated by a radiolucent band that is devoid of lung markings. If clinical suspicion is high with a negative initial chest x-ray, inspiratory and expiratory films, or a lateral decubitus film may be taken to evaluate for lung collapse. A D-dimer (b) is a blood test used as a screening tool in patients who have a low pretest probability for a thromboembolism. If the chest radiograph is unremarkable in this patient, sending a D-dimer may help in the workup of his dyspnea. An upright abdominal x-ray (d) can assess for abdominal perforation, char- acteristically revealing air under the diaphragm. Streptococcus pneumoniae is the most common cause of community-acquired pneumonia. Auscultation of the lungs reveals decreased breath sounds over the infiltrate and the radiograph shows a lobar pattern. Radiograph findings include a necrotizing right-upper lobe infiltrate or abscess with an air-fluid level. Although the patient in the scenario is an alcoholic, S pneumoniae is still the most common cause of community-acquired pneumonia. She is tachycardic, tachypneic, and hypoxic, cardinal signs of cardiovascular distress. The clas- sic triad of dyspnea, pleuritic chest pain, and hemoptysis is uncommon and present in less than 25% of patients. Most patients have constitutional symptoms, in addition to conjunctivitis, pharyngitis, or bullous myringitis. The hallmark of the disease is the disparity between the patient’s clinically benign appearance and the 66 Emergency Medicine extensive radiographic findings. This is a reversible bronchospasm initiated by a variety of environmental factors that produce a narrowing and inflammation of the bronchial airways.

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