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Etiology: the cause of migraine is often unknown arthritis in neck and shoulders order celecoxib in india, but several common precipitants have been observed rheumatoid arthritis gene purchase celecoxib with a mastercard. Pathogenesis: different hypothesis are proposed including: 1) Vascular theory: in this theory it is said that migraine and neurological symptoms are results of extracranial vasodilatation and intracranial vasoconstriction rheumatoid arthritis wrist mri discount celecoxib 200mg. Clinical feature Migraine may be precipitated by some of the factors mentioned above. The syndrome of Classical migraine has five phases: � Prodromal phase: characterized by lassitude, irritability difficulty in concentrating � Aura phase: patients with aura often report visual complaints, vertigo, aphasia or other neurological deficit before the onset of the headache � Headache phase � characteristic migraine headache � Headache termination � usually occurs within 24 hours � Post headache phase � feeling of fatigue. Sleepiness and irritability Characteristic Migraine head ache is: Moderate to severe head pain, pulsating quality often unilateral (affecting half part of the head) It is exacerbation by physical activity and relived by sleeping It is often associated with Nausea and/or vomiting, photophobia, phonophobia/ sonophobia (dislike ad avoidance of laud sounds or noises). There are different variants of Migraine Common migraine � this is the commonest variation of migraine headache � No focal neurological disturbance precedes the recurrent headache 494 Internal Medicine Classic migraine � It is associated with characteristic premonitory sensory, motor or visual symptoms. Most common symptoms reported are visual which include scotomas and/or hallucinations. Complicated migraine � Migraine associated with dramatic transient neurological deficit, or a migraine attack that leaves a persisting residual neurological deficit. These drugs are effective for mild to moderate attacks and are most effective when taken early. Nonselective (Ergot preparations: Ergotamine and dihydro-ergotamine) o Widely used for relief of acute attacks o Has oral, sublingual, rectal, nasal and parentral preparation. Excess use may lead to rebound headache and dependency o Contraindication: patients with vascular diseases like coronary heart disease ii. Selective Triptans including (Naratriptan, Ritatriptan, Sumatriptan, and Zolmitriptan): are new drugs in management of migraine. Prophylactic Treatment: includes drug regimens and changes in patients behavior Medical therapy: � these are drugs that have capacity to stabilize migraine. Prophylactic treatment is indicated if the patient has three or more attacks per month. It lessens migraine attacks by helping patients deal more effectively with stress B) Cluster Headache � Cluster head ache is a vascular headache syndrome, characterized by severe, acute headache that occurs in clusters lasting several weeks followed by pain free intervals that averages a year. Male: Female ratio is 8:1 rd th � Usually begins 3 to 6 decades � Cluster headache is periorbital less commonly temporal. It is also severe and explosive in quality lasting 30 min to 2hrs, subsiding abruptly. Preventions/prophylactic therapy: clusters attacks can be prevented effectively by: 496 Internal Medicine � Prednisolone, Lithium, Methysergide, Ergotamine, Sodium valproate and verapamil C) Tension headache (Tension type headache) � Most common cause of headache in adults � Common in women than men � Can occur at any age, but onset during adolescence or young adulthood is common. Etiology: various precipitating factors may cause tension headache in susceptible individual including. Clinical feature � Tension headache is characterized by mild or moderate, bilateral pain. Headache is a constant, tight, pressing or band like sensation in the frontal, temporal, occipital or parietal area. If treatment is unsatisfactory addition of caffeine or other analgesic is beneficial. Physical Therapy: different techniques can be used including Hot or cold application Positioning Stretching exercises Traction Massage 3. Psychological Therapy � Includes reassurance, Counseling, relaxation, stress management programs and biofeedback techniques reduce both the frequency and severity of chronic headache. D) Headache Associated with Brain Tumor � About 30% of patients with brain tumor present with headache. Headache of brain tumor is usually intermittent dull aching, moderate intensity which worsens with time. It disturbs sleep in about 10% of patients, exacerbated by exertion and postural changes. Clinical feature � Typical presenting symptom includes headache, polymyalgia rheumatica, jaw claudication, fever and weight loss. Diseases of the Spinal cord Learning objectives: at the end of this lesson the student will be able to: 1. The white matter contains ascending sensory and descending motor fibers and gray matter contains nerve cell bodies. Generally diseases of spinal cord are characterized by: � the presence of a level below which motor/sensory and/or autonomic function is disturbed. Motor disturbance causes weakness (paraplegia, quadriplegia), spasticity, hypereflexia and extensor plantar response, which is due to disruption of descending corticospinal fibers.

One week later he develops a shaking chill in conjunction with a temperature spike of 39 arthritis in feet remedies order genuine celecoxib on line. His blood pressure is 70/40 mm Hg rheumatoid arthritis herbs best order celecoxib, pulse is 140 beats per minute arthritis in fingers lumps cheap celecoxib 200 mg on-line, and respiratory rate is 45 breaths per minute. Which of the following is consistent with the expected initial Swan-Ganz catheter readings A 27-year-old man was assaulted and stabbed on the left side of the chest between the areola and the sternum. He is hemodynamically unstable with jugular venous distention, distant heart sounds, and hypotension. Which of the following findings would be consistent with a diagnosis of hemodynamically significant cardiac tamponade More than a 10 mm Hg decrease in systolic blood pressure at the end of the expiratory phase of respiration b. Which of the following clinical markers is most likely to predict a cardiac event during her noncardiac surgery and should prompt further cardiac workup prior to her operation A 70-kg woman is to undergo nail removal from her right ring finger in the ambulatory surgery clinic. Local injection around the nail bed with 1% lidocaine with epinephrine up to 7 mg/kg/mL 69. A 58-year-old woman with multiple comorbidities and previous cardiac surgery is in a high-speed motor vehicle collision. Because of hemodynamic instability, a central venous catheter is placed in the right subclavian vein. While the surgeon is securing the catheter, the cap becomes displaced and air enters the catheter. A 30-year-old man is scheduled for a laparoscopic cholecystectomy for biliary colic. Her blood pressure is 120/60 mm Hg, heart rate is 155 beats per minute, and respiratory rate is 30 breaths per minute. A patient develops a fever and tachycardia during a blood transfusion after a redo coronary artery bypass procedure. The nurse subsequently discovers that there was a mix-up in the cross-match because of a labeling error. Which of the following is diagnostic in a patient with an immediate hemolytic reaction secondary to a blood transfusion A 72-year-old man with diabetes, renal insufficiency, and coronary artery disease presents in septic shock from emphysematous cholecystitis. Which of the following treatment options will improve his oxygen delivery the most A 65-year-old man who had a 25-lb weight loss over the previous 6 months is diagnosed with adenocarcinoma of the distal esophagus. Which of the following is the most accurate measure of adequacy of his nutritional support A 63-year-old man with multiple rib fractures and a pulmonary contusion requires prolonged intubation. He has a tracheostomy and a percutaneous gastrotomy in place through which he is being fed. Based on this information, which of the following is the next step in his management A 22-year-old woman is involved in a major motor vehicle accident and receives a tracheostomy during her hospitalization. Five days after placement of the tracheostomy she has some minor bleeding around the tracheostomy site. A 39-year-old woman with a known history of von Willebrand disease has a ventral hernia after a previous cesarean section and desires to undergo elective repair. Which of the following patients is the most appropriate recipient of this service

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A 67-year-old woman is brought into the emergency room She is on no medications except for acetaminophen recently after being found unresponsive at her nUrsing home arthritis in cats back legs buy celecoxib 100mg with mastercard. Her scleroderma is characterized by difuse was intubated in the feld by the paramedics rheumatoid arthritis eczema order discount celecoxib online. On arrival in involvement of the hands how bad can arthritis in the neck get order celecoxib paypal, face, and trunk, and she is anti-ScI the emergency room, stat laboratory samples are drawn and 70 positive. Laboratory results revealed Na+ 134 mEq/L, K+ Examination in the emergency room shows blood pressure 7. Cardiac examination demonstrates normal heart sounds and a 1/6 systolic murmur at the left lower sternal border. Skin thick� ening and induration consistent with scleroderma are present on the hands, face, and trunk; there are several telangiectasias. Pertinent laboratory values include: Complete blood count Normal Blood urea nitrogen 58 mg/dL (normal 8-25) Creatinine 2. A 19-year-old college student who presents with jaun� the frst sample was probably hemolyzed. A 67-year-old man with cirrhosis, end-stage liver disease, sents to your ofce for follow-up. He had a successful resec� and a history of multiple transfusions in 1975 following tion of a unilateral pheochromocytoma 4 years ago and has an auto accident done well since. A 21-year-old homosexual man who presents with father and grandfather had pheochromocytomas. A patient who presents with bilateral nipple discharge is more likely to have an underlying breast malig� nancy than one who presents with unilateral nipple discharge. The use of annual screening mammography has been shown to decrease mortality from breast cancer in women over the age of 50 years. When properly performPd, mammography-guided fne-needle aspiration has as high a sensitivity as exci� sional biopsy and is less disfguring. Following defnitive surgical treatment, estrogen receptor-negative tumors respond more favorably than estrogen r ceptor-positive tumors to adjuvant therapy with tamoxifen. The genetic mode of transmission of this disease is ing a tumor in the contralateral breast fo llowing X-linked. His unaffected paternal uncle has a 50 chance of passing the disease to his children. Hypercalcemia in this family should be assumed to be tive pulmonary diseases for which of the following from a parathyroid adenoma. This syndrome is most often caused by a mutation in leading to dynamiC airway collapse. She has no specifc complaints A 70-year-old woman presents to your offce with a chief but has noticed some increasing fatigue at the end of the day. Myxomatous degeneration of the valve An 18-year-old college student is brought in by her room�. Before coming to start: college, she reported that she would need to use her inhaler a. Which of the following is appropriate in the initial man� in by the emergency medical technicians. She reports no bright red blood administration of an albuterol nebulizer or coffee-ground material. High-dose administration of the nonsteroidal anti� has no history of liver disease. Measurement of arterial blood gases On examination, he is a lethargic-appearing man who. Obtain a sputum specimen for acid-fast bacilli stain responds to loud voice and who smells of alcohol. Vital signs and culture include blood pressure 76/palp, pulse 170, and respiratory rate 20. Jugular venous pressure is not seen, and carotid Which of the following would be appropriate changes in pulses are 1+ bilaterally. The patient exercises for medical problems include hypertension, hyperlipidemia, and 10minutes and his heart rate increases to 150 beats/minute osteoarthritis. He stops because of the cussion, she describes occasional palpitations without chest occurrence of his pain, which is associated with 1-mm S pain on exertion. She also notes increasing ankle swelling and depression in the lateral leads that resolves with rest.

Bacterial or amoebic abscesses can be either microabscesses (less than 2 cm) or macroabscesses (greater than or equal to epidural for arthritis in back purchase line celecoxib 2 cm) that can appear as hypoechoic (most common) or hyperechoic lesions arthritis left knee icd 9 buy 100 mg celecoxib with visa. Echinococcus lesions typically show well-de ned arthritis in old dogs home remedies generic celecoxib 200mg with mastercard, round to oval, multiloculated cysts with inter nal septations and varying degrees of calci cations. Tuberculosis-related liver abscesses usually manifest as multiple small hypoechoic lesions. Amoebic lesions are typically well de ned with uid attenuation (10�200 Houns eld units) and a 3 to 15 mm thick rim enhancement with or without septations. Echinococcus can show a well-de ned lesion with hypoattenuation of uid and rim enhancement (E. Schistosomiasis hepatic cysts have the charac teristic presence of calci ed septations and appear as a �tortoise shell� (S. Candidiasis usually appears as multiple round, discrete areas of low attenuation (2�20 mm). Traditionally, treatment has consisted of: (a) drainage of abscess contents (pericystectomy or formal hepatic resection for Echinococcus), (b) admin istration of parenteral antimicrobial agents, and (c) treatment of the underly ing condition. Antibiotics without drainage should only be reserved for small lesions, lesions not amenable to drainage, or patients with unacceptable risks. Duration is typically 2 to 3 weeks of parenteral therapy followed by 4 to 6 weeks of oral therapy. The antimicrobial of choice for fungi other than Candida spp is amphotericin B liposomal 3 to 5 mg/kg. However, the majority of cases are related to hepatosplenic candidiasis, and the treatment options include: 1. Surgical removal is best performed after injection of the cyst with hypertonic saline, alcohol, or iodophor to kill daughter cysts. More likely to occur with American Indians, Alaskan Indians, and Hispanics (lowest occurrence in Caucasians, Asians, and African Americans). More likely to occur in Central and South America, Africa, India, the Middle East, and parts of Asia (lowest in the United States and Japan). Most commonly transmitted by oral�fecal route; however, no identi ed source occurs in approximately 50% of cases. Contaminated food or water (particularly associated with green onions and strawberries). Consumption of shell sh from contaminated water (a signi cant cause out side the United States). Nonenveloped virus (a lack of a lipid envelope confers resistance to bile lysis in the small intestine and liver). The coding region of the genome codes for four structural proteins and seven nonstructural proteins. Transportation across gastrointestinal epithelium to mesenteric veins of liver (viremia). The illness is typically self-limited (approximately 8 weeks) and consists of two phases: 1. Characterized by fever, malaise, and fatigue (in uenza like) and nausea, emesis, and diarrhea approximately 1 week prior to the appearance of dark urine. While the majority of adults are symptomatic, historical ndings may be nonspeci c. Medications: acetaminophen, isoniazid, rifampin, sulfonamides, and oral contraceptives. A complete physical examination should be performed, but areas to focus attention include: 1. Neurologic examination (to evaluate mental status for signs of encepha lopathy and asterixis). Usually nonspeci c but chronic renal insuf ciency may suggest chronic liver disease (usually associated with thrombocytopenia). Cultures may be helpful in cases with a fever and a concern for cholecystitis or choledocholithiasis.