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What can make it worse: touching the area 80mg super cialis visa impotence in women, chewing super cialis 80 mg on-line impotence sentence examples, lowering the head between the legs. Your Doctor Visit What your doctor will ask you about: headaches, recent facial injury, anxiety, depression, fever, earache, eye pain, visual change, nasal discharge, toothache. Your doctor will want to know if you or anyone in your family has had any of these conditions: diabetes, headaches, migraine headaches, nervous system disease, recurrent ear infection, rheuma- toid arthritis, glaucoma, sinus disease, dental infections. Your doctor will do a physical examination including the fol- lowing: temperature, checking teeth for hygiene and pain, thorough head, eye, and ear exam. CAUSE WHAT IS IT YPICAL SYMPTOMS Acute sinusitis Sudden inflammation of Sudden facial pain, the sinuses headache, nasal conges- tion, runny nose, pain worsens when lowering the head between the legs Acute angle Sudden buildup of Sudden facial pain, eye is closure pressure in the eyeball painful and red, headache, glaucoma nausea, vomiting, blurred vision, halo around lights, may be precipitated by darkness or stress Dental abscess Collection of pus in the Sudden tooth pain gums, caused by an infection Herpes zoster Inflammation of the Sudden facial pain, begins nerves in the spine and before, during, or after skull, causing redness on outbreak the skin; also known as shingles Tic douloureux Nerve problem causing Jabs of pain, pain often facial pain and spasms occurs near the eye, may in facial muscles be brought on by cold, heat, or pressure over the “trigger” area Temporoman- Pain in the lower jaw Pain on chewing, some- dibular joint times history of rheumatoid pain — “TMJ” arthritis Chronic or Infection of the middle Earache, decreased hearing acute otitis ear media Migraine Severe headache Throbbing pain that can headache last several days, often experience typical “funny” feelings before pain kicks in, headache often centers in the front of the head, often preceded by nausea and vomiting, family histo- ry of migraine, may be caused by alcohol or stress (see chapter on Headache) Fever In adults, fever often accompanies illness, and may be the first sign you are ill. In children, a spike in fever can occur in response to vaccination, or after a seemingly mild infection, such as an earache, cold, or flu. Your Doctor Visit What your doctor will ask you about: shaking chills, changes in weight, night sweats, headache, stiff neck, ear pain or ear pulling, sore throat, chest pain, cough, sputum production, trouble breath- ing, abdominal pain, urinary frequency, pain or difficulty urinating, crying on urination (child), dark urine, bone or joint pain, skin rash or pustules. Your doctor will want to know if you or anyone in your family has had any of these conditions: valvular heart disease, diabetes, tuberculosis, mononucleosis, AIDS, positive tuberculin test. Your doctor will want to know if you recently traveled to anoth- er country, received a tick bite within the past two weeks, or had contact with someone with tuberculosis, pneumonia, strep, a cold, or the flu. If the patient is a child, your doctor will want to know if he was wearing excessively warm clothing when his temperature was taken, and if he has been vaccinated within the past three days. FEVER 89 Your doctor will do a physical examination including the fol- lowing: temperature, pulse, weight, blood pressure, complete physi- cal examination, check head for sinus tenderness, thorough ear exam, looking in the throat, checking the neck for stiffness, listening to the chest and heart with a stethoscope, pushing on the abdomen, checking extremities for swelling or tenderness or redness, thorough skin exam, checking lymph nodes to see if they are enlarged. IN ADULTS CAUSE WHAT IS IT YPICAL SYMPTOMS Upper Cold Sore throat, runny nose, respiratory cough, mild fever illness Mononucleosis Flu-like illness caused by Sore throat, fatigue the Epstein-Barr virus “Flu” syndrome Conditions that produce Muscle aches and pains, flu symptoms but that are nausea, vomiting, diarrhea, not necessarily the flu loss of appetite, malaise, mild fever Urinary tract Infection of the bladder Frequent urination, pain or infection or urethra difficulty urinating, pain in the sides, sometimes blood in urine Drug fever Fever resulting from a Sometimes skin rash reaction to a drug SERIOUS, LESS COMMON ILLNESSES THAT CAN PRODUCE FEVER IN ADULTS CAUSE WHAT IS IT YPICAL SYMPTOMS Pneumonia Inflammation of the lungs Cough, coughing up green or yellow material, chest pain Meningitis Infection or inflammation Headache, stiff neck of the covering of the brain 90 FEVER WHAT CAN CAUSE FEVER, AND WHAT IS TYPICAL FOR EACH CAUSE? What can make it worse: certain activities, such as walking, stand- ing, or wearing shoes. Your Doctor Visit What your doctor will ask you about: joint pain, foot numbness, any previous X-rays or evaluations of the foot and ankle. Your doctor will want to know if you or anyone in your family has had any of these conditions: gout, alcoholism, pernicious ane- mia, diabetes, rheumatoid arthritis. Your doctor will want to know exactly where you feel pain, and if you experienced a recent injury to your foot or ankle. Your doctor will do a physical examination including the fol- lowing: a test of your nerves and movement, thorough foot and ankle exam, including checking for bone deformities, pain, swelling, range of motion, and pain on movement or weight bearing. FOOT OR ANKLE PAIN 93 WHAT CAN CAUSE FOOT AND ANKLE PAIN, AND WHAT IS TYPICAL FOR EACH CAUSE? CAUSE WHAT IS IT YPICAL SYMPTOMS Foot strain Sore feet following Foot pain, sometimes cal- certain activities luses, may occur after a change in occupation, shoes, or activity Rheumatoid Autoimmune disease that Foot pain, pain in other arthritis causes joint problems joints Ankle sprain Injury to ankle Ankle pain, tenderness, swelling in the ankle, his- tory of twisting the ankle Ankle fracture A break in one of the Ankle pain, deformity, ankle bones instability in the joints Fasciitis Inflammation in heel Heel pain, aching or pain tissue after stress, tenderness in the ball of the heel Achilles Inflammation of the Heel pain, tenderness and tendonitis or Achilles tendon or swelling in the Achilles bursitis lubricating sac near a tendon joint (bursitis) Osteochondritis Inflammation of the bone Pain in the heel and mid- and cartilage foot, more common in children between the ages of 4 and 14, may occur after injury Neuroma Abnormal, unchecked Burning pain, pain worsens growth of cells from a when squeezing the front nerve foot Degenerative Joint inflammation Chronic pain in the big arthritis toe, hurts with each step Stiff toe Stiffness in the big toe Chronic pain in the big toe, hurts with each step Bunion Swelling in the big toe Chronic pain in the big joint toe, hurts with each step 94 FOOT OR ANKLE PAIN WHAT CAN CAUSE FOOT AND ANKLE PAIN, AND WHAT IS TYPICAL FOR EACH CAUSE? If your skin has been exposed to the extreme cold for a long period of time, and appears hard, pale, and insensitive to touch, you may have frostbite. Your Doctor Visit What your doctor will ask you about: how many previous tetanus shots you have received, and if the exposed area is numb, blue, white, or painful. Your doctor will do a physical examination including the fol- lowing: thorough skin exam, to check the extent of frostbite and how well you can feel in the exposed area. If you believe you have experienced severe frostbite, seek medical help immediately. If help is not readily available, place affected areas in warm—not hot—water, or cover them in warm cloths for 20 to 30 minutes. Wrap the affected areas in sterile dress- ing, try to keep them immobile, and drink lots of fluids. Allowing the areas to refreeze could be very dangerous, so only begin the thawing process if you are sure the area can be constantly kept warm. Gait-Coordination Problems What it feels like: varies from limping, tremor, or weakness to lack of coordination. People can feel unsteady on their feet if they experience dizziness when standing up. Your Doctor Visit What your doctor will ask you about: headache, tinnitus, weakness or changes in sensation, tremor, joint, back, neck, or leg pain.

Partial seizures evolving May generalize to tonic generic 80mg super cialis mastercard erectile dysfunction treatment maryland, clonic order super cialis 80 mg without a prescription erectile dysfunction shake recipe, or tonic-clonic to secondary generalized seizures II. Generalized seizures 3-Hz polyspike and wave Brief loss of consciousness with or without motor involve- A. Absence seizures ment; occurs in childhood with a tendency to disappear (petit mal epilepsy) following adolescence B. Tonic-clonic seizures Fast activity (10 Hz or more) Loss of consciousness; sudden sharp tonic contractions of (grand mal epilepsy) increasing in amplitude dur- muscles, falling to ground, followed by clonic convulsive ing tonic phase; interrupted movements; often postictal depression and incontinence by slow waves during clonic phase F. Atonic seizures (astatic) Polyspikes and wave Sudden diminution in muscle tone affecting isolated muscle groups or loss of all muscle tone; may have extremely brief loss of consciousness Modified from the International Classification of Epileptic Seizures. The tinue anticonvulsant medication regardless of the need prognosis depends in part upon the type of seizure disor- for other drugs. Since it may be dangerous to withdraw der, but overall, only about 40 to 60% of patients become anticonvulsant medication from a pregnant woman with totally seizure free with available drugs. These agents are epilepsy, the teratogenic potential of anticonvulsant chemically and pharmacologically diverse, having in drugs also is a consideration in the treatment of women common only their ability to inhibit seizure activity with- of childbearing age. The choice of drug or drugs used depends on seizure classification, since a particular The Development of Effective Drug drug may be more or less specific for a particular type of Treatment for Convulsive Disorders seizure; patients having a mixture of seizure types pres- ent particular therapeutic difficulties. It is not always The first effective treatment of seizure disorders was the clear when to treat with one drug (monotherapy) or serendipitous finding in 1857 that potassium bromide more than one drug (polytherapy) in a particular patient. Even though Approximately 25% of patients given a single anticon- side effects were troublesome, the bromides were vulsive agent do not achieve successful seizure control widely used for many years. While other barbiturates were synthesized and used, Convulsive disorders often begin in childhood, and none were shown to be superior to phenobarbital, and drug therapy must be continued for decades; therefore, the latter compound is still used. A chemically related 376 IV DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM nonbarbiturate, phenytoin, was discovered about 20 of calcium channels. Several anticonvulsant drugs act to become hyperexcitable and begin firing bursts of action facilitate the actions of GABA. These may typically seen during epileptic discharges may be due in be the result of abnormalities in neuronal membrane part to the action of glutamate acting on N-methyl-D- stability or in the connections among neurons. It is aspartate (NMDA) receptor channels to produce depo- known that the epileptic bursts consist of sodium- larization. It is likely that a major part of the anticon- dependent action potentials and a calcium-dependent vulsant activity of felbamate involves blockade of the depolarizing potential. Modulation of neuronal CLINICALLY USEFUL DRUGS sodium channels decreases cellular excitability and the propagation of nerve impulses. Inhibition of sodium Anticonvulsant drugs may be divided into four classes, channels appears to be a major component of the based on their most likely mechanism of action. Although it may be premature to assign a mechanism of Much interest is also centered on the role of calcium action to some of these compounds, the proposed channels in neuronal activity, since the depolarization classes are a convenient way to group the drugs. For a proposed mechanism of action to be considered relevant for a given drug, the effect must occur at concentrations sim- Extracellular ilar to those that are likely to be achieved therapeuti- cally. Cell membrane Sodium Channel Blocking Agents Drugs sharing this mechanism include phenytoin (Di- lantin), carbamazepine (Tegretol), oxcarbazepine (Tri- A Intracellular leptal), topiramate (Topamax), valproic acid (Depakene), Na zonisamide (Zonegran), and lamotrigine (Lamictal). All of these agents have the capacity to block sustained high-frequency repetitive firing (SRF) of action poten- tials. This is accomplished by reducing the amplitude of sodium-dependent action potentials through an en- hancement of steady-state inactivation. The sodium channel exists in three main conformations: a resting (R) or activatable state, an open (0) or conducting state, and an inactive (I) or nonactivatable state. Because it takes time for the bound drug to dis- sociate from the inactive channel, there is time depen- Na dence to the block. Since the fraction of inactive chan- nels is increased by membrane depolarization as well as by repetitive firing, the binding to the I state by antiepileptic drugs can produce voltage-, use-, and time- dependent block of sodium-dependent action potentials. These agents are discussed together because their pharmacological properties, clinical indications for the C treatment of epilepsy, and presumed mechanisms of ac- tion are similar. An macokinetic properties, their adverse reactions, and activation gate is closed and sodium ions cannot pass their interactions with other drugs. The channel activation gate opens ing sodium channels, some possess other therapeutically rapidly following depolarization and sodium enters freely. Soon after opening, an inactivation gate (C) closes, preventing further entry of sodium ions into the cell. Phenytoin Phenytoin and drugs with a similar mechanism of action stabilize and prolong the existence of the inactivated state, Phenytoin is a valuable agent for the treatment of gen- and therefore, sodium entry is impeded longer than occurs eralized tonic–clonic seizures and for the treatment of in the absence of the drug.

Disorders of associated structures—bursitis super cialis 80mg erectile dysfunction vitamin d, bunions cheap 80 mg super cialis otc zopiclone impotence, ten- movement dinitis, shinsplints, carpal tunnel syndrome 174 ✦ CHAPTER EIGHT Questions for Study and Review Building Understanding Fill in the blanks 1. Normally, acetyl- aches, tenderness, and stiffness and with no choline is broken down shortly after its release into the known cause is synaptic cleft by the enzyme acetylcholinesterase. McPhillips Early in human history a natural bond formed be- CONTRIBUTIONS OF MANY CULTURES tween religion and the use of drugs. Those who became The ancient Chinese wrote extensively on medical most proficient in the use of drugs to treat disease were subjects. The Pen Tsao, for instance, was written about the “mediators” between this world and the spirit 2700 B. The Chinese doctrine the community was derived from the cures that they of signatures (like used to treat like) enables us to un- could effect with drugs. It was believed that the sick derstand why medicines of animal origin were of such were possessed by demons and that health could be re- great importance in the Chinese pharmacopoeia. The largest and perhaps the most impor- Originally, religion dominated its partnership with tant of these, the Ebers papyrus (1550 B. However, the use of drugs to effect today in that they have one or more active substances as cures led to a profound change in both religious thought well as vehicles (animal fat for ointments; and water, and structure. As more became known about the effects milk, wine, beer, or honey for liquids) for suspending or of drugs, the importance of divine intervention began to dissolving the active drug. These prescriptions also com- recede, and the treatment of patients effectively became monly offer a brief statement of how the preparation is a province of the priest rather than the gods whom the to be prepared (mixed, pounded, boiled, strained, left priest served. This process lead to a growing under- overnight in the dew) and how it is to be used (swal- standing of the curative powers of natural products and lowed, inhaled, gargled, applied externally, given as an a decreasing reliance on supernatural intervention and enema). Cathartics and purgatives were particularly in forever altered the relationship between humanity and vogue, since both patient and physician could tell al- its gods. The level of drug usage achieved by the Egyptians This was the cornerstone for the formation of a science- undoubtedly had a great influence on Greek medicine based practice of medicine. Observations on the medical effects of 3 4 I GENERAL PRINCIPLES OF PHARMACOLOGY various natural substances are found in both the Iliad By the first century A. Battle wounds frequently were cov- cian and protopharmacologist alike that there was ered with powdered plant leaves or bark; their astrin- much variation to be found from one biological extract gent and pain-reducing actions were derived from the to another, even when these were prepared by the same tannins they contained. It was reasoned that to fashion a rational and root (containing atropinelike substances that induce a reproducible system of therapeutics and to study phar- twilight sleep) that protected Ulysses from Circe. The macological activity one had to obtain standardized and oriental hellebore, which contains the cardiotoxic uniform medicinal agents. Veratrum alkaloids, was smeared on arrow tips to in- At the turn of the nineteenth century, methods be- crease their killing power. The fascination of the Greeks came available for the isolation of active principles from with the toxic effects of various plant extracts led to an crude drugs. The development of chemistry made it pos- increasing body of knowledge concerned primarily with sible to isolate and synthesize chemically pure com- the poisonous aspects of drugs (the science of toxicol- pounds that would give reproducible biological results. Many other chemically pure active com- paralysis of sensory and motor nerves, followed eventu- pounds were soon obtained from crude drug prepara- ally by central nervous system depression and respira- tions, including emetine by Pelletier (1788–1844) from tory paralysis, precisely matches the known actions of ipecacuanha root; quinine by Carentou (1795–1877) the potent hemlock alkaloid, coniine. The use of drugs played an inti- an analysis of what was to become one of the basic con- mate part in the rites, religions, history, and knowledge of cerns of pharmacology, that is, the quantitative study of the South American Indians. It was soon realized that drug action is pro- was closely tied to religious thought, and Indian cultures duced along a continuum of effects, with low doses pro- treated their patients with a blend of religious rituals and ducing a less but essentially similar effect on organs and herbal remedies. It also was noted that the appear- various deities were as important as the appropriate ap- ance of toxic effects of drugs was frequently a function plication of poultices, decoctions, and infusions. Early drug practitioners, both in Europe and South Until the nineteenth century, the rapid development America, gathered herbs, plants, animals, and minerals of pharmacology as a distinct discipline was hindered by and often blended them into a variety of foul-smelling the lack of sophisticated chemical methodology and by and ill-flavored concoctions. The preparations were so distasteful led to an attempt to significant advances made through laboratory studies of improve on the “cosmetic” properties of these mixtures animal physiology accomplished by early investigators to ensure that patients would actually use them. Estonia, in the late 1840s by Rudolph Bucheim (1820– There has long been a tendency of some physicians 1879) (Fig. We can trace the history of this such as cathartics, alcohol, chloroform, anthelmintics, polypharmaceutical approach to Galen (A. Bucheim believed that “the investi- who was considered the greatest European physician gation of drugs. Galen believed that drugs had cer- for a chemist or pharmacist, who until now have been tain essential properties, such as warmth, coldness, dry- expected to do this. Unfortunately, he often formulated more was required to raise this discipline to the same general rules and laws before sufficient factual informa- prominent position occupied by other basic sciences; this tion was available to justify their formulations.

In these Alteration—Change or mutation in a gene buy super cialis 80 mg free shipping impotence 60 years old, specif- instances buy super cialis 80mg visa erectile dysfunction premature ejaculation, an individual may have other health problems ically in the DNA that codes for the gene. As an example, Hereditary examination of living tissue for diagnostic pur- Non-Polyposis Colorectal Cancer (HNPCC) is a syn- poses. HNPCC is due to changes in sev- procedure that produces a three-dimensional pic- eral genes including hMLH1, hMSH2, hMSH6, and ture of organs or structures inside the body, such as hPMS2. Laparoscopy—A diagnostic procedure in which a Demographics small incision is made in the abdomen and a slen- der, hollow, lighted instrument is passed through On average, a North American woman faces a life- it. The doctor can view the ovaries more closely time risk of approximately 2% to develop ovarian cancer. The American Cancer Society states Laparotomy—An operation in which the abdomi- that in the year 2000 about 23,100 new cases of ovarian nal cavity is opened up. Specific BRCA alter- Magnetic resonance imaging (MRI)—A technique ations are common in certain ethnic groups, which may that employs magnetic fields and radio waves to make hereditary ovarian cancer more common in these create detailed images of internal body structures populations. Ovarian cancer has no specific signs or symptoms in Transvaginal ultrasound—A way to view the the early stages of the disease. A probe is inserted rience some of the following: into the vagina and the ovaries can be seen. Color doppler imaging measures the amount of blood • Pain or swelling in the abdominal area flow, as tumors sometimes have high levels of • Bloating and general feeling of abdominal discomfort blood flow. This • Close genetic relationships between people with cancer, is why it is important for a physician to be informed right such as parent-child, sibling-sibling away if any of the above symptoms are present. In addition, if a woman has had, or has a family history of breast can- • An individual with bilateral or multi-focal breast cancer cer she may be at an increased risk for ovarian cancer. This is because specific BRCA1 and BRCA2 For women with ovarian cancer who are found to alterations are known to be more common in this group have a BRCA alteration, this now places them at an of individuals. For some women, this may be a new risk they were not aware of before the testing, particularly if they have no family history of Diagnosis breast cancer. If a woman has symptoms of ovarian cancer, a pelvic For all women with a BRCA2 alteration, there may examination is usually conducted to feel the ovaries to be a slightly increased risk for colon and pancreatic can- see if they have enlarged, indicative of a tumor. Additionally, because the testing process and test tests to determine the level of a protein, known as carbo- results are quite complex (and may have strong emo- hydrate antigen 125 (CA-125), may be done. CA-125 tional consequences) everyone should receive proper blood levels can be high when a woman has ovarian can- genetic counseling before pursuing any BRCA1 and cer. Prenatal BRCA testing is available, but (with color Doppler imaging) may be used to get several is rarely performed unless accompanied by extensive views of the ovaries, carefully checking their shape and genetic and psychological counseling. A CT scan may be helpful if the ultrasound is technically unsatisfactory for accurate interpretation. Treatment and management A biopsy and surgery is necessary in order to deter- As with many other cancers, treatment is determined mine the type of tumor, as not all tumors are cancerous. This may require abdomen and a slender, hollow, lighted instrument is a laparotomy procedure in order to remove as much can- inserted through it. If the ovary and fallopian tubes, may also be removed (especially if has suspicious findings on laparoscopy and biopsy, a the cancer has spread there). Chemotherapy, the use of laparotomy (open surgery performed under general anes- strong chemicals to kill cancer cells, is usually done fol- thesia) and removal of that ovary is usually performed. The purpose is to destroy any remaining Large masses are investigated by open surgery. Radiation therapy (using radioactive waves Standard imaging techniques such as Computed to kill cancer cells) is not typically used for ovarian can- Tomography (CT) and Magnetic Resonance Imaging cer because it is not as effective as other treatments. A blood sample is used, • Transvaginal ultrasound with color Doppler imaging and both BRCA genes are studied for alterations. There every six months or yearly, beginning at age 25-35 is also targeted testing for people in high-risk ethnic • Yearly blood CA-125 testing, starting at age 25-35 groups (such as Ashkenazi Jewish) in which only the For women with a BRCA1 or BRCA2 alteration, common BRCA alterations can be tested. Resources In addition to cancer screening, women with BRCA1 or BOOKS BRCA2 alterations should know about their preventive Dollinger, Malin.