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They fire project from the dorsal horn to the mesencephalic continuously without decay if the noxious stimu- reticular formation and periaqueductal gray lus is maintained generic 30mg pioglitazone otc diabetes insipidus blood glucose levels. Some demyelination or local pressure damage discount 15mg pioglitazone amex diabetes type 1 low carb diet, while dis- of these impulses eventually reach the thalamus tal damage may be secondary to infection cheap pioglitazone 30 mg on-line diabetes mellitus exercise, etc. Both pain pathways only Aδ fibers fire ectopically, the result is painless interact with interneurons, where again pain mod- paresthesias, like hitting the ulnar nerve at the ulation occurs. If C fibers or both fiber types ectopically rich in endorphin-containing interneurons that fire, the individual may experience dysesthesias, can inhibit pain signals. This brain area is also a which are spontaneous uncomfortable sensations, target for pain medications. Morphine activates or allodynia, which is discomfort from gently rub- opioid receptors and affects descending pathways bing the skin. Both central nociceptor input is amplified peripherally or cen- pathways are thought to be responsible for slower, trally, yielding more pain than would otherwise be more diffuse, burning types of pain sensation. Headache Pain The most recent evolutionarily pain pathway conducts nocioceptive pain signals generated by Overview mechanical, thermal, or chemical noxious stimuli For most types of head pain, the first and second all the way to the cerebral cortex and thus into divisions of the trigeminal nerve bring noxious consciousness. Stimulation gener- These include all blood vessels (arteries, veins, and ates signals that are felt as sharp, pricking, localiz- sinuses), meninges, bone, and several cranial able pain. In addition, the thinly myelinated Aδ fibers that conduct at 5–30 scalp, skull muscles, sinus mucosa, and teeth con- m/s. However, the brain parenchyma is that decline with time even if the stimulus is main- insensitive to pain. Again, complex interneurons eral, a simple classification divides headaches into modulate further transmission of the pain signal. Primary headaches (like Second-order axons in the spinothalamic pain tension type, migraine, and cluster) are those pathway cross the spinal cord mid-line and travel headaches in which pain is the primary symptom up the contralateral spinothalamic tract to termi- and no structural damage occurs to the brain. Sec- nate at the thalamus (ventral posterior lateral and ondary headaches (from tumor, infection, sub- central lateral nuclei). Secondary headaches may be due to signals reach conscious perception is poorly serious conditions and often produce other neuro- understood. The exam should be occur from degeneration of a distal sensory nerve, thorough, with attention for the presence of also called dying back neuropathy. This ectopic fir- papilledema, neck stiffness, cranial nerve signs ing can also occur from nerves adjacent to tissue (especially the trigeminal nerve), signs of sinus or damage occurring at the nerve ending or proximal tooth or mouth infection, etc. If the neurologic exam is abnormal, the headache is not aggravated by physical activity, headache may be secondary and the result of struc- light, or sound. Nausea and vomiting are uncom- tural damage of the face, skull, meninges, or brain. The headache begins as a dull pain, often in If structural damage is suspected, neuroimaging the neck, that slowly progresses in intensity and should be considered, especially if the neurologic cranial area over several hours. Specific headache triggers are seldom identified except for stress, lack or excess of sleep, Introduction and missed meals. Some migraines are bilateral and nonthrobbing and some tension-type headaches will develop migraine-like symptoms if the headache becomes intense or prolonged. Avoiding caffeine may decrease relaxants (such as benzodiazepines) and migraine- headache frequency, although caffeine-withdrawal specific drugs are seldom effective. They should expect Nonpharmacologic treatments are often effec- recurring headaches that continue for years and tive and include hot and cold packs to the head or the need to develop their own patterns of coping neck and hot baths or showers. If the headache becomes severe, treatment is Migraine Headache often difficult as simple analgesics are seldom effective. Stronger analgesics and medications Introduction aimed at inducing sleep are often needed. If headaches become frequent (>15 d/mo), pro- Migraine headache is a common and often-debili- phylactic treatment is indicated. The syndrome is regular aerobic physical exercise (walking, jogging, characterized by recurrent attacks of headache that or swimming for 20 to 30 min 5 times per week), vary widely in intensity, duration, and frequency. It neck-stretching exercises, and pharmacologic pro- is associated with varying amounts of nausea, phylaxis. About 28 million and nortriptyline) in low doses taken daily are Americans suffer from migraine, with a prevalence widely used and often successful in reducing fre- rate of 18% for adult women and 6% for adult quency and intensity of the headache. Migraine usually begins during adolescence headache frequency reduces (usually over weeks to or young adulthood. After the age of 50 years, several months), the drugs are then slowly discon- migraines begin to subside spontaneously. A few patients take analgesics in high doses sionally children from ages 5 to 10 years also may many times daily to control the pain. There is a dominant genetic viduals are prone to developing a rebound predisposition to migraines, but specific genes headache when they do not take the analgesic. The etiology of migraine is unknown and the Occasionally patients have a prodrome and are pathophysiology is incompletely understood. Early aware a migraine attack is coming hours before the theories focused on intracranial blood vessels that headache begins.

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Sam e influenz a Pharyng itis Strep 10% 5–15% D iag nosis Antig en test Antig en test N o culture N o culture Antibiotic Centor 2–3* + pos Strep Sam e antig en Centor 3–4 alone Antibiotic Penicillin Penicillin Alternative E rythrom ycin E rythrom ycin * Centor criteria (M ed D ecis M aking 1981;1:239):1)Tonsillar ex udates cheap 45mg pioglitazone otc diabetes diet recipes indian,2)cervical adenopathy;3)fever;4)absence of coug h cheap 30mg pioglitazone otc diabetes type 2 straight talk. If 0–1:N o test order pioglitazone 45 mg online treatment diabetes mellitus pdf,no antibiotics;2–3:Antig en assay-antibiotic (penicillin)for positives;3–4:em piric penicillin. These g uidelines call for evidence of G roup A streptococci byculture or rapid antig en detection test. Considerlocalresistance rates before m aking em piric antibiotic selections* Chronic sinusitis Anaerobes Penicillinoram oxicillin Am oxicillin+ clavulanate Usuallyreserve antibiotic (sym ptom s >3m o) S. Title: 2004 PocketBook of I nfectiousDisease Therapy,12th E dition Copyrig ht©2004L ippincottW illiam s & W ilkins > Table of Contents > Specific I nfections > Pulm onaryInfections Pulm onary I nfections A. Etiolog ic diag nosis:Diag nosis of pneum onia based on clinicalcriteria of fever,x-rayevidence of an infiltrate,and purulentrespiratorysecretions is often erroneous based on quantitative brush catheters of bronchoscopic aspirates (Ann Intern M ed 2000;132:621. The debate w ith ventilator associated pneum onia is em piric treatm entvs quantitative bronchoscopic specim ens (L ancet2000;356:874. Chestx-ray:U sefulin hospitalized patients (up to 23% show new finding s)and itm aybe usefulin E W visits;there are notdata for or ag ainstits use in office practice b. Treatm ent—hospitalized patients Inhaled anticholinerg ic bronchodilators or short-acting beta2-ag onists;anticholinerg ics are used first and to m axim um dose because of few er side effects System ic steroids for up to 2 w eeks N oninvasive positive-pressure ventilation supervised bytrained physician Cautious adm inistration of O 2 to hypoxem ic patients c. Antibiotic decision-m aking Reserve antibiotics for severe exacerbations If used,the preference is narrow -spectrum ag ents. Antibiotics other than penicillin, clindam ycin,and m etronidazole have notbeen studied S. Footnotes *M acrolide:Azithrom ycin,clarithrom ycin,or erythrom ycin **F luoroquinolone:L evofloxacin,sparfloxacin,g atifloxacin,or m oxifloxacin or other fluoroquinolone w ith enhanced activityversus S. Title: 2004 PocketBook of I nfectious Disease Therapy,12th Edition Copyrig ht©2004 L ippincottW illiam s & W ilkins > Table of Contents > Specific Infections > E ndocarditis Endocarditis I. Patholog ic criteria M icroorg anism s:D em onstrated byculture or histolog yin a veg etation,or in a veg etation thathas em bolized,or in an intracardiac abscess,or Patholog ic lesions:Veg etation or intracardiac abscess present,confirm ed by histolog yshowing active endocarditis 2. Clinicalcriteria (using specific definitions listed below under “D efinitions of Term inolog y”) Two m ajor criteria,or one m ajor and three m inor criteria,or five m inor criteria B. R esolution of m anifestations of endocarditis with antibiotic therapyfor 4 days or less,or 3. N o patholog ic evidence of infective endocarditis atsurg eryor autopsy,after antibiotic therapyfor 4 days or less Definitions of Term inolog y 1. Typicalm icroorg anism for infective endocarditis from two separate blood cultures a. Persistentlypositive blood culture,defined as recoveryof a m icroorg anism consistentwith infective endocarditis from a. Allof three or a m ajorityof four or m ore separate blood cultures,with firstand lastdrawn atleast1 hr apart 3. Sing le positive blood culture for Coxiellaburnetii or antiphase I I g G antibodytiter >1:800 b. O scillating intracardiac m ass,onvalve or supporting structures,or in the path of reg urg itantjets,or on im planted m aterialin the absence of an alternative anatom ic explanation,or b. N ew valvular reg urg itation (increase or chang e in preexisting m urm ur not sufficient) 2. Vascular phenom ena:M ajor arterialem boli,septic pulm onaryinfarcts,m ycotic aneurysm ,intracranialhem orrhag e,conjunctivalhem orrhag es,Janewaylesions d. M icrobiolog ic evidence:Positive blood culture butnotm eeting m ajor criterion as noted previouslyor serolog ic evidence of active infectionwith org anism consistentwith infective endocarditis f. Culture neg ative endocarditis M icrobe M ethods to establish pathogen Atiotrophia 1)G row in thiog lycolate,and 2)as colonies around S. Echocardiog raphy Transthoracic echo is inadequate in up to 20% of adults due to obesity,chronic lung disease, and chestwalldeform ities. Transesophag ealecho increases sensitivityfor detecting veg etations to 75–95% and shows specificityof 85–98% (Am J M ed 1999;107:198. F or patients with a probabilityof 4–60% ,initialuse of transesophag ealecho is m ore cost-effective. Penicillin only:Aqueous penicillinG ,12–18 m ilunits/dayeither continuously or in 6 equallydivided doses × 4 wk. Peak g entam icin level(1 hr after startof 20-to 30-m in infusion)should be 3 Pg /m L ;troug h should be <1 Pg /m L. Penicillin allerg y:Vancom ycin,30 m g /kg /d I V × 4 wk in2–4 doses notto exceed 2 g /d unless serum levels are m onitored. Vancom ycinlevels 1 hr post dosing should be 30–45 Pg /m L with twice dailydosing.

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