Inflammation on Pap smear

Mild inflammation on an otherwise normal smear does not need further evaluation. b. Moderate or severe inflammation should be evaluated with a saline preparation, KOH preparation, and gonorrhea and Chlamydia tests. If the source of infection is found, treatment should be provided, and a repeat Pap smear should be done every 6 to 12 months. If no etiology is found, the Pap smear should be repeated in 6 months. c. Persistent inflammation may be infrequently the only manifestation

Alopecia Areata

Alopecia areata is characterized by asymptomatic, noninflammatory, non-scarring areas of complete hair loss, most commonly involving the scalp, but the disorder may involve any area of hair-bearing skin. B. Auto-antibodies to hair follicles is the most likely cause. Emotional stress is sometimes a precipitating factor. The younger the patient and the more widespread the disease, and the poorer the prognosis. C. Regrowth of hair after the first attack takes place in 6 months in 30 of cases,...

Nonpharmacologic therapy for acne

Patients should be advised to eat a well-balanced diet and to avoid foods which consistently result in acne flare-ups. B. Cleanliness. Development of acne is not related to dirt. Excessive scrubbing may worsen the condition. Patients should be encouraged to wash affected areas with any standard soap once or twice a day and after strenuous physical activities. C. Medications that worsen acne include oral contraceptives, corticosteroids, anabolic steroids, phenytoin, lithium, and...

Asthma

Asthma is the most common chronic disease among children. At least 75 percent of asthmatic patients demonstrate immediate hypersensitivity to common aeroallergens. Asthma triggers include viral infections environmental pollutants, such as tobacco smoke certain medications, (aspirin, nonsteroidal anti-inflammatory drugs), and sustained exercise, particularly in cold environments. I. Diagnosis A. History 1. Symptoms of episodic complaints of breathing difficulties, seasonal or nighttime cough,...

Hypertension

Hypertension is a major risk factor for coronary artery disease (CAD), heart failure, stroke, and renal failure. Approximately 50 million Americans have hypertension. I. Clinical evaluation of the hypertensive patient A. Evaluation of hypertension should include an assessment of missed doses of maintenance antihypertensive therapy, use of nonsteroidal antiinflammatory drugs, decongestants, diet medications, cocaine, or amphetamines. B. History should exclude the presence of coronary heart...

Differential diagnosis

Acute bronchitis or pneumonia can present with fever, constitutional symptoms and a productive cough. Patients with pneumonia often have rales. When pneumonia is suspected on the basis of the presence of a high fever, constitutional symptoms or severe dyspnea, a chest radiograph should be obtained. Differential Diagnosis of Acute Bronchitis Evidence of reversible airway obstruction even when not infected Eosinophilia in sputum and peripheral blood smear Symptoms worse during the work week...

Clinical diagnosis of panic disorder

Panic disorder is characterized by unexpected panic attacks. A panic attack is defined as a discrete episode of intense symptoms that peak within 10 minutes and primarily involve sympathetic nervous system manifestations. B. A diagnosis of panic disorder is made if the patient has experienced recurrent, unexpected panic attacks and shows at least one of the following characteristics (1) persistent concern about having another attack (anticipatory anxiety) (2) worry about the implications of...

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD), is characterized by unrealistic or excessive anxiety and worry about two or more life circumstances for at least six months. A. Chronic worry is a prominent feature of GAD as opposed to the intermittent terror that characterizes panic disorder. Patients may report that they can't stop worrying, which may revolve around life concerns relating to money, job, marriage, health, and safety of children. B. Other features of GAD include insomnia, irritability,...

Bile acidbinding resins

The anion exchange resins cholestyramine (Questran) and colestipol (Colestid) bind cholesterol-containing bile acids in the intestines. These agents decrease LDL cholesterol levels by up to 20 percent. They may be a good choice in patients with hepatic disease because they do not affect hepatic metabolism. They are also a good choice in very young patients and women of childbearing age. 2. Bile acid-binding resins may cause an increase in triglyceride levels. Side effects include constipation,...

Exercise electrocardiography

Sensitivity of exercise electrocardiography (Master 2-step exercise test, graded exercise treadmill test) may be reduced for patients unable to reach the level of exercise required for near maximal effort, such as 1. Patients taking beta blockers 2. Patients in whom fatigue, dyspnea, or claudication symptoms develop 3. Patients with vascular, orthopedic, or neurologic conditions who cannot perform leg exercises B. Reduced specificity may be seen in patients with abnormalities on baseline...

Treatment of erectile dysfunction

Testosterone cypionate (200 mg IM q 2 weeks) or testosterone patches may be beneficial if the serum-free testosterone is low (< 9 ng dL). Older males (> 50 years) are at risk for development of prostate cancer. A careful rectal examination and PSA testing is recommended prior to institution of, and during, testosterone therapy. Patients with elevated prolactin and a pituitary secreting tumor should be referred to an endocrinologist or neurosurgeon for bromocriptine treatment or surgical...

Pathophysiology of bulimia nervosa

Bulimia nervosa may have a genetic predisposition. Other predisposing factors include psychologic and personality factors, such as perfectionism, impaired self-concept, affective instability, poor impulse control and an absence of adaptive functioning to maturational tasks and developmental stressors (eg, puberty, peer and parental relationships, sexuality, marriage and pregnancy). B. Bulimia nervosa appears to have a chronic, sometimes episodic course in which periods of remission alternate...

Pityriasis Versicolor

Pityriasis versicolor (tinea versicolor) most commonly presents as small perifollicular, scaly, hypopigmented or hyperpigmented patches on the upper trunk in young adults. The perifollicular patches expand over time and become confluent. B. In tinea versicolor, fungus does not grow in standard fungal culture media (eg, Sabouraud's dextrose), but KOH examination shows the abundant spaghetti and meatballs pattern of short hyphae and round spores. Pityrosporon ovale is part of the normal flora...

Tretinoin Retin A

Prescription retinoids remain the premier agents for both inflammatory and noninflammatory acne. Tretinoin loosens and removes comedones. The agent is available in six different strengths and formulations a cream (0.025 , 0.05 , 0.1 ), a gel (0.01 , 0.025 ), and liquid (0.05 ). b. Fair-skinned patients may begin by applying the 0.025 cream shortly after washing nightly. The quantity of tretinoin applied may be gradually increased as tolerated, and twice-daily applications may be appropriate....

Treatment of candida vulvovaginitis

For severe symptoms and chronic infections, a 7-day course of treatment is used, instead of a 1 day or 3 day course. If there is vulvar involvement, a cream should be used instead of a suppository. 2. Most C. albicans isolates are susceptible to either clotrimazole or miconazole. An increasing number of nonalbicans Candida species are resistant to the OTC antifungal agents and require the use of prescription antifungal agents. Greater activity has been achieved using terconazole, butoconazole,...

Corticosteroid therapy

Topical corticosteroids are the most widely used treatment for psoriasis. Corticosteroids have anti-inflammatory, immunosuppressive and antiproliferative properties. 2. Mid-potency corticosteroids are used for lesions on the torso and extremities, while low-potency corticosteroids are used for areas with delicate skin, such as that on the face, genitals or flexures. These delicate areas are at increased risk for cutaneous atrophy. High-potency corticosteroids are usually reserved for use on...

Scabies

Scabies is an extremely pruritic eruption usually accentuated in the groin, axillae, navel, breasts and finger webs, with sparing the head. B. Scabies is spread by skin to skin contact. The diagnosis is established by finding the mite, ova, or feces in scrapings of the skin, usually of the finger webs or genitalia. C. Treatment of choice for nonpregnant adults and children is lindane (Kwell), applied for 8-12 hours, then washed off. D. Elimite, a 5 permethrin cream, is more effective but...

Potassium hydroxide KOH preparation

Place a second sample on a slide, apply one drop of 10 potassium hydroxide (KOH) and a coverslip. A pungent, fishy odor upon addition of KOH--a positive whiff test--strongly indicates bacterial vaginosis. 2. The KOH prep may reveal Candida in the form of thread-like hyphae and budding yeast. G. Screening for STDs. Testing for gonorrhea and chlamydial infection should be completed for women with a new sexual partner, purulent cervical discharge, or cervical motion tenderness. A. The most common...

Resistant or recurrent cases

Recurrent infections always should be reevaluated. Repeating topical therapy for a 14-21-day course may be effective. Oral regimens have the potential for eradicating rectal reservoirs. 2. Cultures are helpful in determining whether a non-candidal and difficult-to-treat species is present. Patients with recalcitrant disease should be evaluated for diabetes and HIV. A. Trichomonas, a flagellated anaerobic protozoan, is a sexually transmitted disease with a high transmission rate. Non-sexual...

Diagnostic criteria for constipation 2 or more of the following

Fewer than 3 bowel movements week. 2. Excessive straining during bowel movements. 3. A feeling of incomplete evacuation after bowel movements. 4. Passage of hard or pellet-like stools. 1. The time of onset of constipation, stool frequency and consistency, the degree of straining, a sensation of complete or incomplete evacuation should be determined. 2. Chronic suppression of the urge to defecate contributes to constipation. Determine the amount of fiber and fluid consumed. Obstetric, surgical...

Candida Vulvovaginitis

Candida is the second most common diagnosis associated with vaginal symptoms. It is found in 25 of asymptomatic women. Fungal infections account for 33 of all vaginal infections. B. Patients with diabetes mellitus or immunosuppressive conditions such as infection with the human immunodeficiency virus (HIV) are at increased risk for candidal vaginitis. Candidal vaginitis occurs in 25-70 of women after antibiotic therapy. C. Symptoms. The most common symptom is pruritus. Vulvar burning and an...

Treatment of refractory constipation

Saline cathartics, such as magnesium-containing compounds and the phosphate enemas, work by an osmotic effect. Magnesium or phosphate overload may occur in renal insufficiency. Long-term use is not recommended. Magnesium hydroxide (1 -2 tbsp qd-bid) is most commonly used. In refractory cases, a half to 1 glassful of magnesium citrate is effective. B. Lactulose is a hyperosmotic non-absorbable sugar that is often used for long-term management. Its advantages are nonsystemic absorption,...

Causes of insomnia

Situational stress concerning job loss or problems, or an illness in the family often disrupt sleep. Patients under stress may experience interference with sleep onset and early morning awakening. Attempting to sleep in a new place, changes in time zones, or changing bedtimes due to shift work may interfere with sleep. Exercise or overstimulation late in the day may cause insomnia. B. Drugs associated with insomnia include antihypertensives, caffeine, diuretics, oral contraceptives,...

Diuretics

Diuretics lower BP by inhibiting renal sodium and water reabsorption. Diuretics are considered first-line therapy in patients with uncomplicated hypertension or with systolic heart failure. They are drugs of choice for isolated systolic hypertension. Diuretics are effective agents in African-American and elderly patients, since they tend to be more renin-dependent than Caucasian hypertensive patients. b. Hydrochlorothiazide HCTZ effectively lowers BP at doses as low as 12.5-25.0 mg qd. Its...

Medical therapy

One aspirin tablet daily is strongly recommended unless there are medical contraindications. In patients with mild, stable CAD, drug therapy may be limited to short-acting sublingual nitrates on an as-needed basis or prophylactically in situations known to cause angina. Use of a lower dose 0.3 mg may reduce the incidence of side effects, such as B. A beta-blocker is indicated in asymptomatic patients with recent myocardial infarction. The use of angiotensin-converting enzyme inhibitors has...