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Patient appears stated age buy discount flomax 0.2mg online, alert order 0.2 mg flomax overnight delivery, oriented × 3, sitting up on stretcher, in no acute distress. The pain is localized to the mid chest, and is sharp, nonradiating, worse with inspiration. If asked, he reports it is made worse with lying down, and made better by sitting forward. If asked about recent illnesses, he states that he had “a cold” about a week ago that resolved on its own; no recent travel; no swelling or pain in leg. General: alert, oriented × 3, sitting forward on stretcher, in no acute distress Figure 60. Heart: friction rub is heard over the left apex (must ask), normal rate and rhythm k. Often caused by viral illnesses or idiopathic, it is not an acute coronary syn- drome, and rarely requires admission. Once the candidate diagnosis pericardial effu- sion, the patient should be admitted for observation and management to watch for cardiac tamponade. The candidate should still consider other differentials such as pulmonary embolism or myocardial infarction by reviewing risk factors such as family history of cardiac disease and recent travel history. Pericarditis may be caused by viral or bacterial illnesses, malignancy, radia- tion, or a variety of other causes. Patients often present with chest pain, made worse with lying down and improved with sitting forward. Additional symptoms can include dysphagia, dyspnea, and intermittent low-grade fevers. A friction rub heard over the left side of the chest is the most frequently encountered physical fnding. Test such as laboratory tests, chest radiographs, and echocardiogram can aid in ruling out other causes of chest pain. Patient appears stated age, confused, garbled response to questions, with obvi- ous facial droop on right side. She has a history of hyperten- sion, high cholesterol, diabetes, and hypothyroid disease. She suffers from mild dementia and forget- fulness, but is otherwise active, walks frequently, and is usually alert and con- versational. Upon questioning she states she took her regular medications but did not eat breakfast because she had a doctor’s appointment at 1 p m. If D50 is not given, patient will continue to be confused with focal neurological fndings c. No dextrose – patient remains confused Case 61: Altered Mental status 263 Figure 61. Eyes: pale conjunctivae, extraocular movement intact, pupils equal, reactive to light d. No dextrose – facial droop with garbled speech, does not cooperate with examination, refexes normal, Babinski refex normal, withdraws to pain q. Option 3: octreotide 50 to 125 mcg subcutaneously Case 61: Altered Mental status 265 b. This is a case of altered mental status with neurological defcits as a result of hypoglycemia. Hypoglycemia (low blood glucose) can mimic stroke syndromes presenting with weakness and confusion, and can typically be reversed with the administration of dextrose. The hypoglycemia in this scenario is due to not eating breakfast after taking a diabetes medicine (glipizide, a sulfonylurea). Obtaining an immediate blood glucose level is crucial to the diagnosis in this case. With the ingestion in this case, further action is required beyond a rapid correction of blood glucose with dextrose in the case. Blood sugar levels must be maintained because sulfonylurea drugs can cause delayed or rebound hypoglycemia for many hours. Feeding fuids with dextrose, or octreotide are all adequate options for this, with two or all three sometimes required. Symptoms of hypoglycemia are due to both the effects on the brain and a refex sympathetic surge. Neurological effects include confusion, altered mental sta- tus, agitation, unresponsiveness, and symptoms that may mimic acute stroke such as focal neurological defcits. Peripheral effects due to a sympathetic out- put of catacholamines cause anxiety, irritability, vomiting, palpitations, tremor, and sweating.

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Neurological effects include confusion flomax 0.2mg mastercard, altered mental sta- tus purchase 0.2 mg flomax otc, agitation, unresponsiveness, and symptoms that may mimic acute stroke such as focal neurological defcits. Peripheral effects due to a sympathetic out- put of catacholamines cause anxiety, irritability, vomiting, palpitations, tremor, and sweating. One amp of D50 is about 100 calories, which is insuffcient to maintain adequate blood glucose beyond a few minutes. Rapid blood glucose determination is essential in all patients with altered men- tal status. The elderly and severely malnourished (ie, alcoholics) can present with hypo- glycemia in the absence of sympathetic signs or even awareness of hypoglyce- mia, often mimicking intoxication, unresponsiveness, or stroke. They had arrived 2 days before to go skiing for the week and the symptoms started yesterday morning after waking up. This morning, they were planning to go skiing but the patient complained of worsening headache and unsteadiness; no chest pain, shortness of breath, palpita- tions, vomiting, diarrhea, fever, or blurry vision. Nobody else with similar symp- toms; arrived yesterday to the mountains by helicopter, ascended 10 000 feet. Social: lives with wife at home, smokes one pack of cigarettes a day for 20 years, denies alcohol, drugs, not sexually active; works as an investment banker g. Travel history: arrived yesterday to the mountains by helicopter, ascended 10 000 feet G. Eyes: extraocular movement intact, pupils equal, reactive to light, no papille- dema on fundoscopic examination d. Neuro: intact refexes throughout, ataxic on tandem gait, poor fnger to nose, positive Romberg’s test, no focal weakness, no sensory defcit p. Our patient pres- ents with fu-like symptoms a day after rapid ascent to a mountain by heli- copter, commonly seen with acute mountain sickness. The history of being there to ski can be given early but the candidate must ask specifc questions on how he got there to illicit the history of rapid ascent. Important early actions include early recognition, treatment with oxygen, steroids, and acet- azolamide, and rapid decent. If there is early recognition and management, the patient will do well and will be stable for transferred. High altitude illness typically occurs within the frst 48 hours after rapid ascent above altitudes of 2500 m. Patient appears stated age, speaking in full sentences, nauseous, and inattentive. Patient’s wife states that her husband is increasingly confused at home over the past few days and had been complaining of weakness, dizziness, and nausea. He has also been stating that things look funny (if asked, states “things have yellowish hue”). Patient denies chest pain, shortness of breath, fever, cough, urinary symptoms, headache, or pain; baseline mental status is good and he is able to go to the store on his own. He was placed on erythromy- cin several days ago for bronchitis that has now resolved. Social: lives with wife at home, leaving apartment less these days, denies alco- hol, smoking, drugs, not sexually active 272 Case 63: Altered Mental status Figure 63. Extremities: full range of motion, no deformity, normal pulses, 1+ pitting edema Case 63: Altered Mental status 273 n. Digibind 6 vials over 30 minutes (if digiband not given, patient will continue to be bradycardia and more confused) b. This is a case of chronic digoxin (digitalis) toxicity from new renal insuffciency and new antibiotic. Digoxin is heart medicine used to control irregular cardiac rhythms which, in excess, can lead to life threatening abnormalities in heart con- duction. The patient presents with nonspecifc complaints of nausea, confusion, and dizziness but also has disturbances in color vision that can occur with digoxin toxicity. The candidate should initially cast a broad differential to exclude causes of altered mental status such as low blood sugar, myocardial infarctions, and infection. A thorough history should illicit digoxin as a medication and a level should be ordered. As the case continues, the patient will become more brady- cardic and hypotensive complaining of dizziness and sweating. At this time, the patient should be empirically treated with the antidote, digibind. Symptoms may be nonspecifc including weakness, dizziness, shortness of breath, confusion, disturbances in color vision (yellow-green tendency), nau- sea, vomiting, and headache. Digoxin level does not necessarily correlate with toxicity, especially in chronic toxicity. There are three methods for calculating the appropriate dose of digibind in the settings of digoxin toxicity.

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Accidental injuries of the external genitalia of female children are well documented in the literature cheap 0.4 mg flomax with mastercard. The site and nature of the injury will depend on the type of trauma and the conformation of any object involved (136 discount flomax 0.2mg,137). Hymen The hymen must be examined in detail after an allegation of a nonconsensual penetrative act. When the hymen is fimbriated, this assess- ment may be facilitated by the gentle use of a moistened swab to visualize the hymenal edges. When the hymenal opening cannot be seen at all, application of a few drops of warm sterile water or saline onto the hymen will often reveal the hymenal edges. Foley catheters are also a useful tool to aid hymenal visu- alization in postpubertal females (138). A small catheter is inserted through the hymenal opening, the balloon is then inflated with 10–20 mL of air, and the catheter is gently withdrawn so that the inflated balloon abuts the hymen. Obviously, in the acute setting, none of these maneuvers should be attempted until the relevant forensic samples have been retrieved. There is little specific information available regarding the type and fre- quency of acute hymenal injuries after consensual sexual acts, particularly regarding the first act of sexual intercourse. They found lac- erations (tears) with associated bruising at the 3-o’clock and 9-o’clock posi- tions on the hymen of a 14-year-old and bruises at the 6-o’clock and 7-o’clock Sexual Assualt Examination 95 positions on the hymens of two other females (aged 13 and 33 years). Unfortunately, no details regarding pre- vious sexual experience are recorded on their pro forma. In the same article, the hymen was noted to be one of the four most commonly injured genital sites among 311 postpubertal complainants of nonconsensual sexual acts. The hymenal injuries detected colposcopically were bruises (n = 28), lacerations (n = 22), abrasions (n = 13), swelling (n = 10), and redness (n = 4). The hymenal lacerations were either single (n = 12), nine of which were at the 6-o’clock position, or paired around the 6-o’clock position (n = 10). The authors found that hymenal lacerations were four times more common in the younger age groups. Bowyer and Dalton (133) described three women with hymenal lacerations (detected with the naked eye) among 83 complainants of rape who were examined within 11 days of the incident; two of the three women had not previously experienced sexual intercourse. One retrospective survey of the acute injuries noted among adolescent com- plainants of sexual assault (aged 14–19 years) found that hymenal tears were uncommon, even among the subgroup that denied previous sexual activity (132). Bruises, abrasions, reddening, and swelling completely disappear within a few days or weeks of the trauma (90,139). Conversely, complete hymenal lacerations do not reunite and thus will always remain apparent as partial or complete transections (123), although they may be partially concealed by the effects of estrogenization (140). However, lacerations that do not extend through both mucosal surfaces may heal completely (2). There is one case report of a 5-year-old who was subjected to penile penetration and acquired an imperforate hymen resulting from obliterative scarring (141). On the basis of the current literature, complete transections in the lower margin of the hymen are considered to provide confirmatory evidence of pre- vious penetration of the hymen. However, it is not possible to determine whether it was a penis, finger, or other object that caused the injury, and there is an urgent need for comprehensive research to determine whether sporting activi- ties or tampon use can affect hymenal configuration. Although partial or com- plete transections of the upper hymen may represent healed partial or complete lacerations beyond the acute stage, there is no method of distinguishing them from naturally occurring anatomical variations. Goodyear and Laidlaw (142) conclude that, “it is unlikely that a normal- looking hymen that is less than 10 mm in diameter, even in the case of an elastic hymen, has previously accommodated full penetration of an adult fin- ger, let alone a penis. On the other hand, it is now generally accepted that postpubertal females can experience penile vaginal penetration without sustaining any hymenal deficits; this is attributed to hymenal elasticity (142,143). Furthermore, the similarity between the dimensions of the hymenal opening among sexually active and nonsexually active postpubertal females (96) makes it impossible for the physician to state categorically that a person has ever had prior sexual intercourse unless there is other supportive evidence (pregnancy, spermato- zoa on a high vaginal swab; see Subheading 8. Vagina Lacerations and ruptures (full-thickness lacerations) of the vagina have been described in the medical literature after consensual sexual acts (145– 147). They are most commonly located in the right fornix or extending across the posterior fornix; this configuration is attributed to the normal vaginal asymmetry whereby the cervix lies toward the left fornix, causing the penis to enter the right fornix during vaginal penetration (147). Factors that pre- dispose to such injuries include previous vaginal surgery, pregnancy, and the puerperium, postmenopause, intoxication of the female, first act of sexual intercourse, and congenital genital abnormalities (e. Although most vaginal lacerations are associated with penile penetration, they have also been documented after brachiovaginal intercourse (“fisting”) (147), vaginal instrumentation during the process of a medical assessment (147), and the use of plastic tampon inserters (148). Vaginal lacerations have been documented without any direct intravagi- nal trauma after a fall or a sudden increase of intra-abdominal pressure (e. Injuries of the vagina have been noted during the examinations of com- plainants of sexual assault. These were described as “tears” (n = 10), bruises (n = 12), and abrasions (n = 4).

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