Program Director, Dell Medical School at The University of Texas at Austin
It empties into the superfcial temporal vein prevent the dissemination of infectious material in an within the substance of the parotid gland women's health zinc discount alendronate 35mg without a prescription. Intracranial venous connections Lymphatic drainage As it crosses the face menstrual goddess order 35mg alendronate amex, the facial vein has numerous connec Lymphatic drainage from theface primarily moves toward tions with venous channels passing into deeper regions of three groups of lymph nodes (Fig womens health editorial calendar order alendronate 70mg with mastercard. There a part of the external nose, and the lateral part of are no valves in the facial vein or any other venous the cheek. Ophthalmic veins Cavernous sinus Submandibular nodes Deep facial vein Pre-auricular and parotid nodes Fig. Preservation and loss of the diferent pathological processes and sites at which the special functions are determined by the extent these processes occur. It enters the internal acoustic meatus, passes are accompanied bylossofmotor function on the whole to the geniculate ganglion (which gives rise to further ofthe ipsilateral (same) side of the face. Taste tothe branches), and emerges from the skull base afer a anterior two-thirds ofthe tongue, lacrimation, and some complex course within the temporal bone, leaving salivation also are likely to be afected because the lesion through the stylomastoid foramen. It enters the parotid is proximal to the greater petrosal and chorda tympani gland and gives rise to fve terminal groups of branches branchesofthe nerve. Typically the patient has an ipsilateral loss of Centra/ lesions motor function of the whole side of the face. However, because the upper not be afected if the lesion remains distal to the greater part of the nucleus receives motor input from the lef and petrosal and chorda tympani branches that originate deep rightcerebral hemispheres a lesion occurring above the in the temporal bone. In thisexample, motor innervation tothe upper face is In the clinic Trigeminal neuralgia sensory route of the maxillary [V2] and mandibular [V3] Trigeminal neuralgia (tic douloureux) is a complex sensory nerves may be involved. If symptoms persist and are unresponsive to medical Typically the pain is in the region of the mandibular [V3] care, surgical exploration of the trigeminal nerve (which is and maxillary [V; nerves, and is usually of sudden onset, is not without risk) may be necessary to remove any excruciating in nature, and may be triggered by touching aberrant vessels. The scalp is the part of the head that extends from the Skin superciliary arches anteriorly to the external occipital pro tuberance and superior nuchal lines posteriorly. Itis similar structurally to skin throughout the body with The scalp is a multilayered structure with layers that the exception that hair is present on a large amount of it. This layer • C-connective tissue (dense), anchors the skin to the third layer and contains the arter • A-aponeurotic layer, ies, veins, and nerves supplying the scalp. When the scalp • L-loose connective tissue, and is cut, the dense connective tissue surrounding the vessels • P-pericranium (Fig. Layers Aponeurotic layer Examining the layers of the scalp revealsthat the frst three The deepest layer of the frst three layers is the aponeurotic layers are tightly held together, forming a single unit. Firmly attached to the skin by the dense connective Skin Connective tissue (dense) Skin Dense connective tissue Aponeurotic layer Aponeurotic layer Bone Pericranium Loose connective tissue Fig. A layer of loose connective tissue separates the aponeu The frontal belly of the occipitofrontalis begins anteri rotic layer from the pericranium and facilitates movement orly where it is attached to the skin of the eyebrows. It also passes superiorly to attach to the aponeurotic The pericranium is the deepest layer of the scalp and is the tendon. It is The occipitofrontalis muscles move the scalp, wrinkle attached to the bones of the calvaria but is removable, the forehead, and raise the eyebrows. These reaching the vertex of the head, and supplies the scalp branches are the supratrochlear, supra-orbital, zygomati over the temporal region and anterior to the ear to near cotemporal, and auriculotemporal nerves: the vertex. These branches are the to the obliquus capitis inferior muscle, ascends superf great auricular, the lesser occipital, the greater occipital, cial to the suboccipital triangle, pierces the semispinalis and the third occipital nerves: capitis and trapezius muscles, and then spreads out to supply a large part of the posterior scalp as far superi • The great auricular nerve is a branch of the cervical orly as the vertex. They branch from the ophthalmic artery while it is in the orbit, continue In the clinic through the orbit, and exit onto the forehead in association with the supratrochlear and supra-orbital nerves. Like the Scalp laceration nerves, the arteries ascend across the forehead to supply The scalp has an extremely rich blood supply from the the scalp as far posteriorly as the vertex of the head.
During the 2 years since her diagnosis menopause crying purchase online alendronate, her disease has been stable with regular clinic and laboratory follow-up every 4 months breast cancer 10 year survival rate cheap alendronate line. How would you evaluate patient readiness for antiretroviral Problem Identification treatment initiation? Recommend an antiretroviral regimen that would be appropri- ate if this patient has a history of chronic kidney disease women's health center camp hill pa alendronate 70mg line, not Therapeutic Alternatives requiring hemodialysis. What clinical and laboratory parameters are necessary to evaluate the clinical efficacy and toxicity of the antiretroviral regimen 1. Identify potential barriers to medication adherence, and dis- Panel on Antiretroviral Guidelines for Adults and Adolescents. The patient returns to the clinic for follow-up 6 weeks and 12 management of persons infected with human immunodeficiency virus: weeks after treatment initiation. Review the current literature regarding recommended therapy for the antiretroviral-naive and treatment-experienced individuals. Fletcher, PharmD resistance to antiretroviral agents and strategies for the preven- tion and management of resistance. The ideal time to start • Identify important considerations for choosing alternative anti- treatment for asymptomatic patients is constantly revised based on retroviral therapies. Clinicians should always individu- • Utilize the primary and secondary literature to provide pharma- alize therapeutic choices based on available data and unique patient cotherapy recommendations for conditions without definitive factors. Nine weeks ago, she began treatment with peginterferon alfa-2a and ribavi- Neck/Lymph Nodes rin for hepatitis C. What information (signs, symptoms, laboratory values) indicates Patient Education the presence or severity of the patient’s drug therapy problems? What additional information is needed to satisfactorily assess adherence, ensure successful therapy, and minimize adverse effects? At her last visit, the zidovudine, lamivudine, and efavirenz were discontinued, and she initiated an Therapeutic Alternatives antiretroviral regimen of tenofovir disoproxil fumarate 300 mg po once daily (as Truvada), emtricitabine 200 mg po once daily (as 3. What nondrug and pharmacologic treatments are available for Truvada), and atazanavir/ritonavir 300/100 mg po once daily. On physical exam, she exhibits slow motor function, poor fine-motor control, diffuse muscle tenderness, Outcome Evaluation and decreased muscle strength in all four extremities. Abnormal laboratory findings include: each of the patient’s drug regimens for achievement of the desired serum potassium 1. No supra- Rosalita Garza is a 61-year-old woman presenting for evaluation of clavicular or infraclavicular adenopathy. She first noticed a palpable breast mass on self-examination approximately 14 months ago but was unable Breasts to have this further investigated due to loss of health insurance. A mammogram mately 3 cm from the nipple margin, not fixated to skin; no was performed prior to her current visit, which was suspicious for nipple retraction or discharge is visualized; the mass is exquisitely malignancy. Core needle biopsy of left breast mass: í Labs Left breast, 6 o’clock: infiltrating ductal carcinoma, modified Na 142 mEq/L Hgb 12. In addition to the stage of disease, what other factors are important for determining the prognosis for breast cancer? List the treatment modalities available for this patient’s breast cancer, and discuss their advantages and disadvantages. Design an appropriate plan for treating this patient’s breast cancer, focusing on pharmacologic and nonpharmacologic mea- sures. If the plan includes chemotherapy, identify a specific regimen, and provide your rationale for selecting it. What parameters should be monitored to evaluate the efficacy abnormality highly suspicious for malignancy.
The inflamed peritoneum becomes sticky with fibrin that may be replaced by fibrous connective tissue during healing women's health center kalamazoo mi buy alendronate overnight, forming adhe- sions menopause 50 years old purchase 35mg alendronate visa, which may have to be surgically removed if they com- promise proper function of the viscera women's healthy eating tips order 35mg alendronate with amex. Surgical puncture of the peritoneum is sometimes necessary to remove excess fluid (ascites) that accumulates during inflammation, to introduce anesthetic agents (intraperitoneal injection), or to conduct peritoneal dialysis. The normally mobile greater omentum forms adhesions in response to inflammation to wall off the affected area. When a person is standing, purulent material may travel along the gutters into the pelvis, where absorption of toxins is slow. Although it is uncommon, a loop of small intestine may pass through the omental foramen into the omental bursa and be strangulated by the edges of the foramen. Perforation of the posterior wall of the stomach results in the passage of its contents into the omental bursa. An inflamed or injured pancreas may pass pancreatic fluid into the bursa, forming a pancreatic pseudocyst. Flow through the cystic artery can be controlled by compressing the hepatic artery in the hepatoduodenal ligament. Sliding hiatal hernia In a congenital diaphragmatic hernia, part of the stomach and intestine protrude through a posterior defect in the diaphragm. The ulcer may perforate the duodenal wall, leading to peritonitis or erosion of the posteriorly related gastroduodenal artery, resulting in severe hemorrhage. The shared blood supply to the duodenum and head of the pancreas makes it impossible to remove the entire pancreas in a pancreatectomy. A rim of the pancreas is retained along the medial border of the duodenum to preserve the blood supply. An appendectomy may be neces- sary to remove the inflamed appendix to ameliorate pain and prevent rupture. When the inferior part of the ascending colon (normally secondarily retroperitoneal) has a mesentery, volvulus of the colon, or an obstruction of intestine resulting from twisting, may occur. In some cases, a colectomy is performed, during which the terminal ileum, colon, rectum, and anal canal are removed. Total or partial removal of the spleen is performed to prevent excessive blood loss subsequent to injury. The spleen enlarges (splenomegaly) in response to a variety of conditions; the enlarged spleen can be detected by palpation below the costal margin. Pancreatic cancer is difficult to identify and treat because of its location and quick metastasis to the liver, which results in a low survival rate. A needle inserted into the right 10th intercostal space near the midaxillary line is used to obtain hepatic tissue for biopsy. The patient is asked to hold his or her breath in full expiration to lessen the risk of damaging the lung. It is most commonly seen in alcoholics (alcoholic cirrhosis), the most common cause of portal hypertension. Hepatomegaly, or enlargement of the liver, may be caused by hepatic engorgement (such as from congestive heart failure), bacterial or viral disease, or tumor. An enlarged liver may cause pain and may be palpable below the costal margin in the right upper quadrant. Aberrant hepatic arteries are also possible: the right hepatic branch often comes off the superior mesenteric, while the left branch often comes off of the left gastric artery. The distal end of the hepatopancreatic ampulla and the infundibulum of the gallbladder are common sites for impaction of gallstones. The blood then flows into the systemic system at places of portal-systemic anastomosis, producing varicose veins.
Syndromes
Halos around objects (yellow, green, white)
Hematoma (blood accumulating under the skin)
MRI of the brain
Reactions to medicines
Lethargy
Medicine to increase blood flow to the lungs called phosphodiesterase inhibitor (such as sildenafil)
Speech or language difficulties such as aphasia (a problem understanding or producing words) or dysarthria (a problem making the sounds of words), poor enunciation, poor understanding of speech, difficulty writing, lack of ability to read or understand writing, inability to name objects (anomia)
Urination - frequent
Gonadotropin Estrogen replacement therapy is associated with an in- profiles should be normal 3 months after combination creased risk of thromboembolic disease women's health questions- discharge buy alendronate 35mg otc, and alternative oral contraceptive use is stopped menopause and hair loss buy discount alendronate 35 mg on line. The incidence of pro- therapies for osteoporosis and cardiovascular protec- longed amenorrhea extending beyond 6 months is 2 to tion are recommended for individuals with prior throm- 3% pregnancy 0-0-1-0 purchase 70mg alendronate overnight delivery. Breast Feeding These preparations alter liver function more signifi- cantly than do the natural estrogens, such as the sulfate The use of oral contraceptives may interfere with lacta- conjugates or esterified estrogens. In addition, the hormones may be present in the synthesis of specific liver proteins, such as coagulation mother’s milk, hence be taken in by the nursing child. If factors and fibrinogen, are implicated in the formation breast feeding is planned, the use of oral contraceptives of thromboembolisms. Gallbladder Disease Current estimates are that oral contraceptive use doubles to triples the overall risk of thromboembolic There is a 2. At very high doses, generally Estrogen usage is associated with a mild decrease in no longer used in cancer treatment, ocular toxicity has glucose tolerance. There is a slight risk of hepatocellular their concurrent use in the diabetic patient may neces- carcinoma in humans receiving long-term (5 years) ta- sitate adjustment in insulin dosage. This reaction is generally regarded to neomycin, penicillin V, chloramphenicol, sulfonamides, be a premalignant state, because individuals reported nitrofurantoin, phenytoin, barbiturates, primidone, to have endometrial hyperplasia later have a higher analgesics, and phenothiazines. The oral contraceptives also may decrease the effec- Administration of estrogens only is associated with a 1. Women receiving progestins 10 days per in hepatic microsomal drug-metabolizing enzymes, month during estrogen therapy generally do not de- competition for binding sites on plasma proteins, and velop endometrial carcinoma. The occurrence of multiple births fol- lowing ovulation induction with clomiphene is 4 to 9%; Formulation 90% of these multiple births are twins. Since clo- Estrogens Breast or endometrial cancer or vaginal miphene is teratogenic, therapy should be discontinued bleeding of unknown origin if there is a chance that conception has occurred. Pregnancy Rarely, irreversible ocular toxicities have been reported Hepatic dysfunction or liver cancer Preexisting cardiovascular disease with clomiphene use. Progestins Pregnancy Nausea, vomiting, and hot flashes may accompany Depression tamoxifen administration. Tamoxifen may cause a tran- Oral contraceptives Pregnancy sient flare of tumor growth and increased pain due to Smokers over age 35 bone metastases. These reactions are thought to be due Antiestrogens Pregnancy Endometrial cancer to an initial estrogenic action of this drug. Although progestin-only oral contraceptive for- (A) Estrogen only mulations are available, the combination of estro- (B) Progestin only gen and progestin is considered the safest and most (C) Combination of estrogen and progestin desirable type. Estrogen therapy is contraindicated in the pres- tion of estrogen and progestin should be consid- ence of breast cancer. The use of estrogen replacement for ing menopause but that she does not want to take short periods (up to 2 years) is not associated with any hormones because her mother had breast can- an increased incidence of breast cancer. You should cer and she was afraid that this would increase her also point out that osteoporosis is the most serious risk. She should be that there is an increased risk of breast cancer after scheduled for baseline determination of her bone estrogen or estrogen–progestin combination ther- density so that any evidence of loss of bone mass apy but that the risk is relatively small. During the first two the dissociation of the connective tissue between the trimesters of pregnancy, the uterus remains in a rela- pelvic bones, a process that also aids in the facilitation tively quiescent state, demonstrating little or no con- of birth. This inactivity is largely the mic contractions of the uterus begin, and as labor pro- result of the inhibitory action of high circulating levels gresses, the myometrial contractions increase in inten- of progesterone on the uterine musculature (see sity and strength.
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