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By: C. Ugolf, M.B. B.CH. B.A.O., Ph.D.

Assistant Professor, Louisiana State University School of Medicine in Shreveport

Patient 5­23 A 28-year-old man complained of mild diurnal temperature elevation for several days with intermittent sore throat menopause 041 generic gyne-lotrimin 100 mg free shipping, chills women's oral health issues buy gyne-lotrimin overnight, and malaise breast cancer0rg safe 100 mg gyne-lotrimin. He saw his physician, who found him to be warm and appear acutely ill, but he lacked significant abnormalities on examination, except that his pharynx and ear canals were reddened. A diagnosis of influenza was made, but the next afternoon he had difficulty thinking clearly and was admitted to the hospital. His blood pressure was 90/70 mm Hg, pulse 120 per minute, respirations 20 per minute, and body temperature 38. He was acutely ill, restless, and unable to sustain his attention to cooperate fully in the examination. There was slight nuchal rigidity and some mild spasm of the back and hamstring muscles. Two hours later he had a chill followed by severe headache and he became slightly irrational. In one series, 50% of patients with meningitis were admitted to the hospital with an incorrect diagnosis. The pupils were equal and reactive; the optic fundi were normal; the deep tendon reflexes were equal and active throughout. Because of the high white cell count, fever, and coma, administration of large doses of antibiotics was started, but the diagnosis was uncertain. The next morning the spinal fluid and throat cultures that had been obtained the evening before were found to contain Neisseria meningitides and a lumbar puncture now revealed purulent spinal fluid containing 6,000 white cells/mm3 under a high pressure, with high protein and low glucose contents. Patients with overwhelming meningococcal septicemia, and few or no polymorphonuclear leukocytes in their spinal fluid, represent the worst prognostic group of patients with acute bacterial meningitis. Although a high concentration of polymorphonuclear leukocytes and a decreased spinal fluid glucose strongly suggest the diagnosis of bacterial meningitis, viral infections including mumps and herpes simplex can also occasionally cause hypoglycorrhachia. Fewer than 50% of adults with meningoencephalitis have a history of pulmonary tuberculosis. The protein concentration is elevated (above 100 mg/dL) and the glucose concentration is usually decreased, but rarely below 20 mg/dL. The severity of the illness should lead one to suspect the possibility of tuberculosis. There may be systemic symptoms including weight loss, abdominal pain, diarrhea, arthralgias, and uveitis. The characteristic neurologic abnormality in these patients is oculomasticatory myorhythmia, a slow convergence nystagmus accompanied by synchronous contraction of the jaw. The myorhythmias are present in only about 20% of patients and are always associated with a supranuclear vertical gaze palsy. However, only viruses, bacteria, and the rickettsial infection Rocky Mountain spotted fever405 invade the brain acutely and diffusely enough to cause altered states of consciousness and to demand immediate attention in the diagnosis of stupor or coma. During intrauterine development these disorders include cytomegalovirus, rubella, and herpes infections, although nonviral causes such as toxoplasma or syphilis can have a similar result. During childhood, progressive brain damage may occur with subacute sclerosing panencephalitis, subacute measles encephalitis, or progressive rubella panencephalitis, but all of these are now rarely seen in vaccinated populations. These latter disorders are subacute or gradual in onset, producing stupor or coma in their terminal stages. Hence, they do not cause problems in the differential diagnosis of stupor or coma, and are not dealt with here in detail. Progressive multifocal leukoencephalopathy is considered along with the primary neuronal and glial disorders of brain (Table 5­1, heading G). Prion infections,408,409 including Creutzfeldt-Jakob disease, GerstmannStraussler disease, and fatal familial insomЁ nia,410 were at one time also thought to be ``slow viral' illnesses, but they are now known to be due to a misfolded protein. With the occasional exception of Creutzfeldt-Jakob disease, these disorders likewise are gradual in onset; they do not represent problems in differential diagnosis and are not discussed here. In each of the pathologically defined viral encephalitides, the viruses produce neurologic signs in one of three ways: (1) they invade, reproduce in, and destroy neurons and glial cells (acute viral encephalitis). Cell dysfunction or death may occur even in the absence of any inflammatory or immune response. Furthermore, within each of these categories, specific viral illnesses may have individual clinical features that strongly suggest the diagnosis. To compound the complexity, certain viruses can cause different pathologic changes in the brain depending on the setting.

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Some insight into the explanatory mechanisms linking literacy to breast cancer north face generic gyne-lotrimin 100mg fast delivery health outcomes is provided by LeVine and colleagues in several studies conducted in developing countries (LeVine et al menstrual cycle day 7 buy gyne-lotrimin master card. These investigators have found a relationship between literacy skills level and comprehension of oral communication women's health center methuen ma buy 100 mg gyne-lotrimin amex. The authors suggest that literacy builds a cognitive process that facilitates comprehension of formal spoken language, such as that commonly included in health messages. This research suggests that low literacy not only presents obvious barriers to effective patient education, but may also complicate the process of history taking and establishment of the primary complaint. An analysis of focus groups and individual interviews with low-literate patients revealed serious and widespread communication difficulties with their health providers (Baker et al. Patients complained that they felt they were neither listened to nor adequately informed about their medical problems and treatments in ways they could understand. Despite this frustration, few patients asked questions or otherwise revealed their difficulties to their providers. Though some patients concealed this information out of embarrassment, others simply did not think this was something the physician would be interested in knowing. While better-designed, learner-centered materials are undoubtedly helpful to patients, there is little offered in the literature to help physicians better communicate with their low-literate patients. Consequently, it is not surprising that when patients with poor literacy skills are recognized, few physicians feel competent to adequately respond to their needs (Miles and Davis, 1995; Weiss and Coyne, 1997). The patient sample was 43% white, 45% African American, and 12% other race/ethnic groups (5% Asian, 5% Hispanic, and 2% Native American). To study the potential influence of race concordance or discordance be- Copyright National Academy of Sciences. African-American patients had significantly less participatory visits with white physicians than white patients ([beta] = ­4. Asian and Hispanic patients had less participatory visits with African-American physicians than African-American patients; however, these results were based on very small sample sizes. However, there were only two Hispanic physicians in the study sample; therefore, reliable conclusions regarding the participatory decision-making style of Hispanic physicians could not be drawn. Patients in race-concordant relationships with their physicians rated their physicians as significantly more participatory than patients in race discordant relationships ([beta] = 2. In another study of the impact of racial concordance on patient ratings of care by physicians, researchers used data from a nationwide telephone survey of 2,201 white, black, and Hispanic adults who reported having a regular physician (Saha et al. In this study, black respondents with black physicians were more likely than those with non-black physicians to rate their physicians as excellent overall, at treating them with respect, explaining problems, listening, and being accessible to them. Hispanic patients with Hispanic physicians were more likely than those with non-Hispanic physicians to be very satisfied with their healthcare overall, but not significantly more likely to rate their physicians as excellent. The Hispanic respondents were primarily of Mexican and Puerto Rican descent, and the majority of them were born in the United States. Studies have shown that ethnic minority physicians, particularly blacks and Hispanics, are more likely to provide healthcare to ethnic minority, underserved, medically indigent, and sicker populations than are their white counterparts (Moy and Bartman, 1995; Komaromy et al. Furthermore, ethnic minority patients are more likely than white patients to report having an ethnic minority physician as their regular doctor (Gray and Stoddard, 1997). Nevertheless, minority patients are far more likely to receive their care from white and Asian physicians than from physicians who are African American or Hispanic since the number of physicians from these ethnic groups is so small. About 42% of the Hispanic respondents who chose a Hispanic physician did so because of language. Other reasons for ethnic minority patient preference for and higher ratings of care in raceconcordant relationships with physicians are unclear, but potential explanations include more cultural sensitivity to the needs of these patients by race-concordant physicians and more shared cultural values, beliefs, and experiences in society between ethnic minority patients and physicians (Cooper-Patrick et al. Evidence of Race-Concordance Consequences for the Communication Process In an ongoing cross-sectional study using post-visit surveys and audiotape analysis, we have examined the relationship between race concordance and actual patient and physician communication behaviors (252 adult patients-142 white, 110 African-American; 31 primary care physicians-13 white, 18 African-American). Our preliminary analysis shows significant differences in communication dynamics along several dimensions. Both African-American and white patients appear to have shorter visits (by about 2. In addition to length of the visit, the strongest communication element that discriminated between race-concordant and discordant dyads was positive patient affect.

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Eosinophilia women's health center warner robins ga buy 100mg gyne-lotrimin with amex, greater than 10% eosinophils menstrual gas and bloating cheap 100 mg gyne-lotrimin, usually results from pleural injury and signifies recent hemothorax or pneumothorax menopause 51 buy cheap gyne-lotrimin 100mg online. Pulmonary infarction, parasitic or fungal infection, and drug hypersensitivity reactions are other causes of eosinophilic pleural effusions. Cytology of the pleural fluid is essential for an undiagnosed lymphocytic effusion, a basophilic effusion, or an exudate in the presence of malignancy at another site. Biochemical analysis of a pleural effusion provides further information regarding its nature and etiology. Samples sent for pleural fluid pH should be handled, transported, and analyzed in the same way as arterial blood samples. Pleural fluid glucose is <50% of blood values in cases of decreased transport to the pleural space or increased uptake. Empyema, tuberculosis, rheumatoid arthritis, lupus pleuritis, pancreatitis, malignancy, and esophageal rupture reduce pleural fluid glucose levels. All pleural fluid samples should be cultured appropriately, including tuberculosis and fungal cultures, in the proper clinical setting. A chylous effusion is characterized by a normal pleural fluid/serum glucose concentration ratio (>0. Nevertheless, the pleural glucose level is less than that of the infusate due to active transport. The fluid may have a neutrophilic predominance or may be hemorrhagic, as shown by cell counts. Pleuritis caused by collagen vascular disease can be further evaluated by assays of the pleural fluid. Pleural fluid rheumatoid factor levels exceeding blood levels and pleural fluid titers >1:320 are positive for rheumatoid arthritis. Similarly, pleural fluid antinuclear antibody titers >1:160, or greater than serum levels, are positive for lupus pleuritis. This typically occurs in the context of malignancy-either as a primary cause or as a precursor for infection during periods of immunosuppression. Although a variety of special cutting needles have been developed for bedside use, the majority of these procedures are now done in the operating room with thoracoscopy. The specific needles used for percutaneous sampling, namely, the Cope, Abrams Ballestero, Vim-Silverman, and Harefield needles, vary slightly, but in general they obtain a sample of pleural tissue via a side-biting mechanism. The tissue specimen includes portions of intercostal muscle and the adjoining parietal pleura. It is approximately 4 mm in diameter and is sent for histologic and culture studies. Thus, biopsy is most easily accomplished at the time of initial thoracentesis, when there is the least chance of lacerating the underlying lung. The greatest value of percutaneous parietal biopsy is in clinical disorders that cause lymphocytic pleural effusions and widespread involvement of the pleural surface. Management of Noninflammatory Pleural Effusions and Transudates Treatment of transudates and hemorrhagic and chylous pleural effusions is directed at supportive therapy of the functional disturbances and at specific management of the underlying disorder. Evacuation of a transudate after the initial diagnostic thoracentesis is indicated only for relief of dyspnea and other cardiorespiratory disturbances caused by mediastinal displacement. Diuretics administered to some patients may slow re-accumulation of the transudate and may decrease or eliminate the need for frequent thoracentesis. Specific treatment of the underlying disorder emphasizes the need for thorough history taking and meticulous physical examination to arrive promptly at an accurate clinical diagnosis. In general, a requirement for blood transfusion of more than 20 mL/kg or ongoing blood loss of >3 mL/kg/hr is an indication for immediate thoracotomy. Smaller bleeds should be evacuated because healing may be associated with pleural adhesions. Cautious use of fibrinolytic enzymes instilled into the pleural cavity may help if clots have formed.

On rare occasions women's health issues in haiti generic gyne-lotrimin 100mg with visa, epidural hematomas may result from bleeding into skull lesions such as eosinophilic granuloma womens health partners st louis buy gyne-lotrimin 100mg low price,1 metastatic skull or dural tumors pregnancy x ray purchase generic gyne-lotrimin on line,2 or craniofacial infections such as sinusitis. Thus, in- stead of causing symptoms that develop slowly or wax and wane over days or weeks, a patient with an epidural hematoma may pass from having only a headache to impairment of consciousness and signs of herniation within a few hours after the initial trauma. Although epidural hematomas can occur frontally, occipitally, at the vertex,4 or even on the side opposite the side of trauma (contrecoup),5 the most common site is in the lateral temporal area as a result of laceration of the middle meningeal artery. The epidural hemorrhage pushes the brain medially, and in so doing stretches and tears pain-sensitive meninges and blood vessels at the base of the middle fossa, causing headache. The image in (A) shows the lensshaped (biconvex), bright mass along the inner surface of the skull. In (B), the skull is imaged with bone windows, showing a fracture at the white arrow, crossing the middle meningeal groove. Subsequently, the hematoma compresses the adjacent temporal lobe and causes uncal herniation with gradual impairment of consciousness. Early dilation of the ipsilateral pupil is often seen followed by complete ophthalmoparesis and then impairment of the opposite third nerve as the herniation progresses. In many patients the degree of head trauma is less than one might expect to cause a fracture. The hematoma appears as a hyperdense, lens-shaped mass between the skull and the brain. Certainly, all patients with head trauma should be cautioned that it is important to remain under the supervision of a family member or friend for at least 24 hours; the patient must be returned to the hospital immediately if a lapse of consciousness occurs. The surgery is an emergency, as the duration from time of injury to treatment is an important determinant of the prognosis. The potential space between the inner leaf of the dura mater and the arachnoid membrane (subdural space) is traversed by numerous small draining veins that bring venous blood from the brain to the dural sinus system that runs between the two leaves of the dura. These veins can be damaged with minimal head trauma, particularly in elderly individuals with cerebral atrophy in whom the veins are subject to considerable movement of the hemisphere that may occur with acceleration-deceleration injury. A useful rule when faced with a comatose patient is that ``it could always be a subdural,' and hence imaging is needed even in cases where focal signs are absent. Subdural bleeding is usually under low pressure, and it typically tamponades early unless there is a defect in coagulation. Acute subdural bleeding is particularly dangerous in patients who take anticoagulants for vascular thrombotic disease. Continued venous leakage over several hours can cause a mass large enough to produce herniation. The conventional treatment includes administering fresh frozen plasma and vitamin K. However, these measures take hours to days to become effective and are too slow to stop subdural bleeding. Acute subdural hematomas, which are usually the result of a severe head injury, are often associated with underlying cerebral contusions. Rarely, acute subdural hematomas may occur without substantial trauma, particularly in patients on anticoagulants. Rupture of an aneurysm into the subdural space, sparing the subarachnoid space, can also cause an acute subdural hematoma. Ischemic brain edema results when herniation compresses the anterior or posterior cerebral arteries and causes ischemic brain damage. Early evacuation of the mass probably improves outcome, but because of underlying brain damage, mortality remains significant. Prognostic factors include age, time from injury to treatment, presence of pupillary abnormalities, immediate and persisting coma as opposed to the presence of a lucid interval, and volume of the mass. Chronic alcoholism, hemodialysis, and intracranial hypotension are also risk factors. A history of trauma can be elicited in only about onehalf of patients, and then the trauma is usually minor. One hypothesis is that minor trauma to an atrophic brain causes a small amount of bleeding. Vessels of the membrane are quite friable and this, plus an increase of fibrinolytic products in the fluid, leads to repetitive bleeding, causing an enlarging hematoma. This subdural hygroma also causes membrane formation that leads to repetitive bleeding and an eventual mass lesion. However, if the hematoma is larger or it is enlarged gradually by recurrent bleeds, it may swell as the breakdown of the blood into small molecules causes the hematoma to take on additional water, thus further compressing the adjacent brain.

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