By D. Nasib. Hofstra University. 2019.
Patient denies slurred speech order genuine tadapox on-line, weakness purchase 80 mg tadapox visa, numbness buy tadapox discount, nausea, vomiting, bowel or bladder changes, neck stiffness, photophobia, or fever. Eyes: mild right ptosis, right pupil 3 mm, left pupil 5 mm, extraocular move- ments intact, visual acuity normal, normal sweating on both sides of face. Neck: right paraspinal neck tenderness, right carotid bruit (must ask), no mid- line C-spine tenderness g. This is a case of carotid artery dissection secondary to injury from a recent motor vehicle accident. In our patient, the recent neck injury caused a tear- ing in the wall of the carotid artery that led to a stroke presenting with visual changes. Important actions in this case include imaging of the brain and of the carotid artery. If carotid artery dissection is not considered in the differential and the patient is not started on anticoagulation, the patient should develop signs of an acute stroke in the distribution of the right middle cerebral artery, with left-sided hemiparesis and slurred speech. Carotid artery dissection is rare, but it is a common cause of stroke in patients younger than 50 years old. They can occur spontaneously or secondary to minor trauma, such as chiro- practic manipulation, talking on the phone for long periods of time, coughing, and motor vehicle accidents. Patients can present with headache, neck pain, facial pain, hypoageusia (dec- reased taste), or focal neurologic complaints. Some patients have a partial Horner syndrome on examination (ptosis, miosis, without anhidrosis). If the dissection is extracranial, then treatment involves anticoagulation with heparin to prevent thromboembolic events. Do not give heparin if there is an intracranial dissection as this can lead to a subarachnoid hemorrhage. Patient is an elderly male, awake and alert, uncomfortable appearing secondary to pain. Last bowel movement was several days ago; no fevers or chills; no diarrhea, urinary symptoms; worse with eating. Heart: rate and rhythm regular, no murmurs, rubs, or gallops 480 Case 109: Abdominal Pain Figure 109. Abdomen: hypoactive bowel sounds, soft, moderate diffuse tenderness, no rebound or guarding, distended l. Gastroenterology performs sigmoidoscopy and decompresses volvulus with rectal tube. Patient is admitted for monitoring and surgical intervention to prevent recurrence. This is a case of sigmoid volvulus in a nursing home patient with chronic con- stipation. Volvulus is a twisting of the intestine, commonly occurring in the sigmoid colon, which leads to severe pain and distension of the stomach and ultimately perforation of the intestine if not treated. Important early actions include an obstructive series, nasogastric tube placement, gastroenterology consult, and surgery consult. Sigmoid volvulus often occurs in elderly patients who are debilitated or in patients with psychiatric or neurologic disorders. Abrupt onset, severe intensity, ripping or tearing, radiation to back: aortic dis- section or esophageal rupture 2. Gradual onset, pressurelike: myocardial infarction Essential examination features and what they suggest are as follows: 1. Signifcant tachypnea or respiratory distress: pulmonary embolism or spon- taneous pneumothorax 2. Immediate decompression with 14-gauge angiocatheter, second intercostal space, followed by tube thoracostomy 5. Severe = myxedema coma ◼=Hyperthyroid – agitated and tremulous, tachycardia, fever. Abnormalities in the patient’s vital signs (heart rate, blood pressure, temperature, respiratory rate, pulse oxymetry, and fnger stick glucose) are also corrected at this time. History As with other patients, a key element in the approach to the poisoned patient is in obtaining a history of present illness. The presentation of the overdosed/poisoned patient will depend on both the patient and the toxin. Therefore it is important to ask about the patient’s general medical condition, medications and allergies, and the circumstances surrounding the overdose/poisoning. It is also important to inquire about what toxin(s) the patient may have access to, and the dose, route, and time of overdose/poisoning. When inquiring about the circumstances surrounding the event, it is important to ask what signs and symptoms were experienced, their onset, and if anything has been done about them. However, it is simplifed by classifying the toxidromes into categories that correspond to a large pharmacological class (ie, opioids, sympa- thomimetics, cholinergics, etc). This is important since a specifc agent may give you most but not all the signs and symptoms of that particular class of toxin. The physical examination is one of the most important tools that a physician has during the medical assessment since it provides supporting information in making the correct diagnosis. The name given to the constellation of signs and symptoms that a patient may have after an exposure to a specifc toxin is called toxidrome. The fnding of a specifc toxidrome during a focused physical examination gives a clue to the type of toxin ingested. As such, the physical examination will manifest mixed signs and symptoms of the agents involved. The toxicological physical examination begins with careful evaluation of the vital signs. These include pulse, blood pressure, respiratory rate, temperature, and pulse oximetry. Since normal vital signs are infuenced by age and general state of health, attention should be paid to these parameters during the clinical assessment. Vital signs should be monitored for further clues to temporal changes of end-organ mani- festations since this may be relevant to a specifc toxin. Abnormalities of vital signs detected during a physical examination may also point to specifc toxins involved (Table C. To quickly identify common toxidromes, the physical examination in toxicology is simplifed. Conducting an assessment of the mental status frst is important, especially in toxins that cause mental disturbances. For ease of its determination, this assess- ment may be described as normal, depressed (lethargy or comatose), or agitated (hyper- dynamic). In the following part of the physical assessment, the size and reactivity of the pupils should be noted. The abdominal examination should note presence or absence of bowel sounds, including hyperactivity.
Therapeutic Considerations The primary areas of intervention from a natural medicine perspective are prevention (addressing suspected causative factors) and treatment with natural measures (to improve mental function in the early stages of the disease) discount 80 mg tadapox with mastercard. A diet high in saturated fat and trans-fatty acids and low in dietary antioxidants may lead to increased serum and brain concentrations of aluminum and transition metal ions discount tadapox 80mg without prescription, which are implicated in oxidative stress buy 80 mg tadapox amex. It is likely that it is the combination of all of these factors that provides the highest degree of protection, rather than any single dietary factor. Celery and celery seed extracts contain a unique compound, 3-n-butylphthalide (3nB), that is responsible for both the characteristic odor of celery and its health beneﬁts. It was also shown that 3nB markedly directed amyloid precursor protein processing toward a pathway that precludes beta-amyloid formation. The researchers concluded that “3nB shows promising preclinical potential as a multitarget drug for the prevention and/or treatment of Alzheimer’s disease. However, the evidence to support the potential beneﬁts of estrogen is contradictory. Aluminum Considerable attention has been focused on aluminum concentrations in neuroﬁbrillary tangles. Whether the aluminum accumulates in the tangles in response to the formation of lesions or whether it actually initiates the lesions has not yet been determined, but signiﬁcant evidence shows that it contributes, possibly signiﬁcantly, to the disease. The most signiﬁcant source is probably drinking water, as the aluminum in water is in a more bioavailable and thus potentially toxic form. Researchers measuring the absorption of aluminum from tap water added a small amount of soluble aluminum in a radioactive form to the stomachs of animals. They discovered that the trace amounts of aluminum from this single exposure immediately entered the animals’ brain tissue. The frightening news is that aluminum in water not only occurs naturally but also is added (in the form of alum) to treat some water supplies. In addition, citric acid and calcium citrate supplements appear to increase the efﬁciency of absorption of aluminum (but not lead) from water and food. Nutritional Considerations Nutritional status is directly related to mental function in the elderly. These results appear to be signiﬁcantly better than those achieved with vitamin C, vitamin E, and beta-carotene either alone or in combination without the minerals. It is entirely possible (and very likely) that vitamin E, vitamin C, and beta-carotene may simply be markers of increased phytochemical antioxidant intake and do not play a signiﬁcant role on their own. Often researchers make the mistake of thinking that the antioxidant activity of a particular fruit or vegetable is due solely to its vitamin C, vitamin E, or beta-carotene content. However, these nutrient antioxidants often account for a very small fraction of a food’s antioxidant effect—for example, only about 0. The overwhelming antioxidant activity of fruit and vegetables comes from phytochemicals such as ﬂavonoids, phenols, polyphenols, and other carotenoids. In an attempt to gauge the prevalence of thiamine deﬁciency in the geriatric population, 30 people visiting a university outpatient clinic in Tampa, Florida, were tested for thiamine levels. Depending on the thiamine measurement (plasma or red blood cell thiamine), low levels were found in 57% and 33%, respectively, of the people studied. Speciﬁcally, it both potentiates and mimics acetylcholine, an important neurotransmitter involved in memory. These results highlight the growing body of evidence that a signiﬁcant percentage of the geriatric population is deﬁcient in one or more of the B vitamins. Given the essential role of thiamine and other B vitamins in normal human physiology, especially cardiovascular and brain function, routine B vitamin supplementation appears to be worthwhile in this age group. Several investigators have found that the level of vitamin B12 declines with age (probably due to gastric atrophy) and that vitamin B12 deﬁciency is found in 3% to 42% of people 65 and older. One way to determine whether there is a deﬁciency is by measuring the level of cobalamin in the blood. In one study of 100 geriatric outpatients who were seen in ofﬁce-based settings for various acute and chronic medical illnesses, 11 had serum cobalamin levels of 148 pmol/l or below, 30 had levels between 148 and 295 pmol/l, and 59 patients had levels above 296 pmol/l. The patients with cobalamin levels below 148 pmol/l were treated and not included in the analysis of declining cobalamin levels. The average annual decline in serum cobalamin level was 18 pmol/l for patients who had higher initial serum cobalamin levels (224 to 292 pmol/l). For patients with lower initial cobalamin levels, the average annual decline was much higher, 28 pmol/l. These results indicate that screening for vitamin B12 deﬁciency appears to be indicated in the elderly given the positive cost- beneﬁt ratio. When individuals with low cobalamin levels were supplemented with vitamin B12, signiﬁcant clinical improvements were noted. In other studies, supplementation has shown tremendous beneﬁt in reversing impaired mental function when there are low levels of vitamin B. Several studies have shown that the best clinical responders are those who have been showing signs of impaired mental function for less than six months. Only those patients who had had symptoms for less than one year showed improvement. The most common form is cyanocobalamin; however, vitamin B12 is active in the human body in only two forms, methylcobalamin and adenosylcobalamin. Although methylcobalamin and adenosylcobalamin are active immediately upon absorption, cyanocobalamin must be converted to either methylcobalamin or adenosylcobalamin. The body’s ability to make this conversion may decline with aging and may be another factor responsible for the vitamin B12 disturbances noted in the elderly population. Finally, the damaging effects of low vitamin B12 levels are aggravated by high levels of folic acid that mask a vitamin B12 deﬁciency. While the addition of folic acid to the food supply in 1998 helped decrease neural tube defects in infants, it may also have worsened the problems caused by low vitamin B12. With insufﬁcient zinc, the end result could be the destruction of nerve cells and the formation of neuroﬁbrillary tangles and plaques. Only two patients failed to show improvement in memory, understanding, communication, and social contact. In one 79-year-old patient, the response was labeled “unbelievable” by both the medical staff and the family. There is ambivalence in recent medical literature about zinc because in vitro, zinc accelerates the formation of insoluble beta-amyloid peptide. A possible explanation is that the higher localized levels of zinc result in increased amyloid formation when the free-radical-scavenging mechanisms have been inadequate. This enzyme combines choline (as provided by phosphatidylcholine) with an acetyl molecule to form acetylcholine, the neurotransmitter. Studies have shown inconsistent improvements in memory from choline supplementation in both normal and Alzheimer patients. If there is no noticeable improvement within the 90-day time frame, supplementation should be discontinued. Low levels of phosphatidylserine in the brain are associated with impaired mental function and depression in the elderly. Statistically signiﬁcant improvements were noted in mental function, mood, and behavior for the phosphatidylserine group.