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Become familiar with patterns of infectious diseases that may affect your patient. In contrast, recent ingestion of aspirin, acet aminophen, corticosteroids, and nonsteroidal anti-inammatory drugs may mask it. Approximately 70 million Americans report persisting or intermittent pain, often underassessed. More than 85% of people with type 2 diabetes and roughly 20% of those with hyper tension or elevated cholesterol levels are overweight or obese. Increasing obesity in children contributes to rising rates of child hood diabetes. Thirty minutes of moderate activity (dened as walking 2 miles in 30 minutes, or its equivalent, on most days of the week) is recommended. Patients can increase exercise by such simple measures as parking further away from their place of work or using stairs instead of elevators. If not, promptly assess level of Is the patient awake, alert, and consciousness (see p. Signs of Distress Cardiac or respiratory distress Clutching the chest, pallor, diapho resis; labored breathing, wheezing, cough Pain Wincing, sweating, protecting painful area Anxiety or depression Anxious face, fdgety movements, cold and moist palms; inexpressive or fat afect, poor eye contact, psychomotor slowing Skin Color and Obvious Pallor, cyanosis, jaundice, rashes, Lesions. These excesses are central or dispersed distribution proven risk factors for diabetes, heart of fat To measure blood pressure accurately, choose a cuff of appropriate size and ensure careful technique. There should be no arterio venous stulas for dialysis, scarring from prior brachial artery cutdowns, or signs of lymphedema (seen after axillary node dissection or radiation therapy). M easuring Blood Pressure Center the inatable bladder over the brachial artery. As you feel the radial artery with the ngers of one hand, rapidly inate the cu until the radial pulse disappears. Use of this sum as the tar get for subsequent inations prevents discomfort from unnecessarily high cu pressures. Because the sounds to be heard(Korotko sounds)are relatively low in pitch, they are heard better with thebell. The disappearance point, usually only a few mm Hg below the muing point, is the best estimate ofdiastolic pressure. A fall in systolic pressure of 20 mm Hg or more, especially when accompanied by symptoms, indicates orthostatic (postural) hypotension. For example, 170/92 mm Hg is Stage 2 hyper tension; 135/100 mm Hg is Stage 1 hypertension. In isolated systolic hypertension, systolic blood pressure is 140 mm Hg, and diastolic blood pressure is <90 mm Hg. With the pads of your index and middle ngers, compress the radial artery until you detect a maximal pulsa tion. When the rhythm is irregular, evaluate the rate by auscultation at the car diac apex (the apical pulse). Palpation of an irregularly irregular Check the rhythm again by lis rhythm reliably indicatesatrial fbrilla tening with your stethoscope at tion. If irregular, try to identify a pattern: (1) Do early beats appear in a basically regular rhythm

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These signs were when this maneuver produces distal paresthesias in mul originally described in conjunction with the lumbar spine. In the patient with a narrowed cervi the first of Waddell`s signs is superficial nonanatomic ten derness. This sign is considered present when the patient reports disproportionate pain in response to extremely light touch or tenderness whose distribution does not correspond to the configuration of known anatomic struc tures (. The examiner must make this somewhat subjective judgment based on previous experience with the response of other patients to similar levels of pressure. It should be kept in mind that reflex sympathetic dystrophy and its variants may cause hypersensitivity in an extremity. A report of pain in response to the rotation simulation maneuver is, therefore, considered a positive simulation sign and suggests nonorganic pathology. When a positive distraction sign is present, the response of the patient to the straight-leg raising test varies depending on whether it is performed with the patient in the supine or the seated position. In the presence of true nerve root tension, the patient should experience radiat ing pain in whichever position the straight-leg raising test is performed. Patients with nonorganic pain often know by experience that straight-leg raising in the supine posi tion should be painful but may not realize that passive extension of their knee while seated produces the same position of tension on the sciatic nerve roots (. Such an inconsistent response is said to represent a positive dis the axial compression test or a painful response to the traction sign because the patient is distracted from the rotation simulation maneuver. A regional sensory dis sion test are judged as having a positive simulation sign. A shoulders are rotated in a manner coplanar with the pelvis regional motor disturbance is suspected if the examiner while the patient is standing (. This is essentially discovers diffuse motor weakness of multiple muscle groups, such as weakness of every muscle group tested in the upper extremity, or if the examiner senses, during Figure 8-52. Palpation of the cervical spine should be Cervical Radiculopathy performed to identify any areas of tenderness or Restricted range of motion "step-off. Nerve tension tests are helpful at identifying nerve root (variable) pressure on a nerve root such as that caused by a Cervical Spondylitic Myelopathy (Cervical Spinal herniated disk. Profound or progressive neurologic deficit Restricted range of motion mandates immediate patient work-up. Cervical Strain (Whiplash Injury, Mechanical Cervical Pain) Breig A: Adverse Mechanical Tension in the Central Nervous System: An Diffuse tenderness of the posterior neck muscles Analysis of Cause and Effect: Relief by Functional Neurosurgery. Daniels L, Williams M, Worthingham C: Muscle Testing: Techniques of Manual Examination, 2nd ed. The fifth nonorganic sign of Waddell is called overreac Grieve C, ]> Common Vertebral Joint Problems. In Mayo Clinic: Clinical Waddell also found that the most sensitive sign was over Examinations in Neurology, 5th ed. The physical findings in common conditions of the Pullos J: the upper limb tension test. Waddell G, Somerville D, Henderson I, Newton M: Objective clinical Steindler A: Kinesiology of the Human Body, Springfield, 111, Charles C evaluation of physical impairment in chronic low back pain. Edinburgh, Churchill Wohlfart G: Clinical considerations on innervation of skeletal muscle. Phillips Lumbar Spine Bruce Reider Vishal Mehta he examination of the lumbar spine may be seen as a collectively known as the erector spinae, or Tcontinuation of the procedure already described for sacrospinaiis. The erector spinae is split longitudinally the cervical and the thoracic spine; the lumbar spine can into three components. Abnormalities of the lum side, they are the multifidus, the longissimus, and the ilia bar spine may lead to compensatory or secondary costalis muscles. The individual contours of these muscles abnormalities in other portions of the spine or pelvis. The region may actually be due to abnormalities of adjacent prominence due to the paraspinous muscles should be structures.

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If it were not broken down very quickly after its release, blood flow to the region could exceed metabolic needs. They can impede the growth of tumors by limiting their blood supply and therefore their access to gas and nutrient exchange. Chapter 21 1 the three main components are the lymph vessels, the lymph nodes, and the lymph. The larger lymphatics merge to form trunks that enter into the blood via lymphatic ducts. Macrophages release cytokines that attract neutrophils, followed by more macrophages. Other mediators released by mast cells increase blood flow to the area and also vascular permeability, allowing the recruited cells to get from the blood to the site of infection, where they can phagocytose the dead cells and debris, preparing the site for wound repair. C-reactive protein is induced to be made by the liver and will opsonize certain species of bacteria. These memory B cells are what respond during a secondary or memory antibody response. IgM is replaced with other classes of antibodies later on in the primary response due to class switching. The immune response to these bacteria actually causes most of the lung damage that is characteristic of this life-threatening disease. The histamine released increases vascular permeability, causing edema and (swelling), making breathing difficult. Complement is then activated and the heart is damaged, leading to abnormal function. Tolerance is broken because heart myosin antigens are similar to antigens on the Streptococcus bacteria. Short-term stress has little effect on the health of an already healthy individual, whereas chronic stress does lead to increases in disease in such people. Chapter 22 1 Inflammation and the production of a thick mucus; constriction of the airway muscles, or bronchospasm; and an increased sensitivity to allergens. A spirometry test can determine how much air the patient can move into and out of the lungs. If the air volumes are low, this can indicate that the patient has a respiratory disease or that the treatment regimen may need to be adjusted. If the numbers are normal, the patient does not have a significant respiratory disease or the treatment regimen is working as expected. Oxygenated blood traveling through the systemic arteries has large amounts of oxyhemoglobin. As blood passes through the tissues, much of the oxygen is released into systemic capillaries. The deoxygenated blood returning through the systemic veins, therefore, contains much smaller amounts of oxyhemoglobin. The more oxyhemoglobin that is present in the blood, the redder the fluid will be. As a result, oxygenated blood will be much redder in color than deoxygenated blood. The first region is the nasopharynx, which is connected to the posterior nasal cavity and functions as an airway. The second region is the oropharynx, which is continuous with the nasopharynx and is connected to the oral cavity at the fauces. Both the oropharynx and laryngopharynx are passageways for air and food and 109 drink. As a person swallows, the pharynx moves upward and the epiglottis closes over the trachea, preventing food or drink from entering the trachea. As a result, the person may have problems with food or drink entering the trachea, and possibly, the lungs.

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E Explain: Use simple language and short sentences when working with an interpreter. This will ensure that comparable words can be found in the second language and that all the information can be conveyed clearly. On the chart, note that the patient needs an interpreter and who served as an interpreter this time. Simply handing the patient written material upside-down to see if the patient turns it around may settle the question. Assess health literacy, or the skills to function effectively in the health care system: interpreting documents, reading labels and medication instructions, and speaking and listening effectively. Patients may use American Sign Lan guage, a unique language with its own syntax, or various other com munication forms combining signs and speech. When patients have partial hearing impairment or can read lips, face them directly, in good light. For patients with severe mental retardation, obtain the history from the family or caregivers. Patients may ask you for advice about personal problems outside the range of health. Letting the patient talk through the problem is usually more valuable and thera peutic than any answer you could give. If you become aware of such feelings, accept them as a normal human response, and bring them to the conscious level so they will not affect your behavior. Denying these feelings makes it more likely that you Chapter 3 | Interviewing and the Health History 45 will act inappropriately. Any sexual contact or romantic relationship with patients is unethical; keep your relationship with the patient within professional bounds and seek help if you need it. Cultural constructs of mental illness vary widely, causing marked differences in acceptance and attitudes. Clinicians should routinely ask about current and past use of alcohol or drugs, patterns of use, and family history. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compul sive use, continued use despite harm, and craving. Also ask about blackouts (loss of memory for events during drinking), seizures, accidents or injuries while drinking, job loss, marital conict, or legal problems. With adolescents, it may be helpful to ask about substance use by friends or family members rst. Many authorities recommend routine screening of all female and older adult patients for domestic violence. Kubler-Ross has described ve stages in our response to loss or the anticipatory grief of impending death: denial and isolation, anger, bargaining, depression or sadness, and acceptance. Dying patients rarely want to talk about their illnesses all the time, nor do they wish to conde in everyone they meet. Give them opportunities to talk and then listen receptively, but be supportive if they prefer to stay at a social level.

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The prevalence of chronic pelvic pain in women in the United Kingdom: a systematic review. Chronic pelvic pain in women in New Zealand: comparative well-being, comorbidity, and impact on work and other activities. Prevalence and correlates of three types of pelvic pain in a nationally representative sample of Australian women. The prevalence of sexual dysfunction and associated risk factors in women with chronic pelvic pain: a cross-sectional study. Pelvic floor muscle dysfunctions are prevalent in female chronic pelvic pain: A cross-sectional population-based study. Biofeedback is superior to electrogalvanic stimulation and massage for treatment of levator ani syndrome. Muscle tenderness in men with chronic prostatitis/chronic pelvic pain syndrome: the chronic prostatitis cohort study. Management of men diagnosed with chronic prostatitis/chronic pelvic pain syndrome who have failed traditional management. Clinical features and spectrum of light microscopic changes in interstitial cystitis. Caveolin-1 may participate in the pathogenesis of bladder pain syndrome/ interstitial cystitis. Intravesical nitric oxide production discriminates between classic and nonulcer interstitial cystitis. Acid-sensing channels in human bladder: expression, function and alterations during bladder pain syndrome. Can the adrenergic system be implicated in the pathophysiology of bladder pain syndrome/interstitial cystitis Interstitial cystitis: unexplained associations with other chronic disease and pain syndromes. Antecedent nonbladder syndromes in case-control study of interstitial cystitis/ painful bladder syndrome. Numbers and types of nonbladder syndromes as risk factors for interstitial cystitis/painful bladder syndrome. Are ulcerative and nonulcerative interstitial cystitis/painful bladder syndrome 2 distinct diseases Anatomic variability of the ilioinguinal and genitofemoral nerve: implications for the treatment of groin pain. A review of the efficacy of surgical treatment for and pathological changes in patients with chronic scrotal pain. Early and late morbidity after vasectomy: a comparison of chronic scrotal pain at 1 and 10 years. Laparoscopic extraperitoneal inguinal hernia repair versus open mesh repair: long term follow-up of a randomized controlled trial. Intravesical potassium sensitivity in patients with interstitial cystitis and urethral syndrome. Urethral syndrome and associated risk factors related to obstetrics and gynecology. Anatomical basis of chronic pelvic pain syndrome: the ischial spine and pudendal nerve entrapment. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Pudendal canal syndrome as a cause of vulvodynia and its treatment by pudendal nerve decompression. Prevalence, symptom impact and predictors of chronic prostatitis-like symptoms in Canadian males aged 16-19 years. Sexual Functioning and Cognitions During Sexual Activity in Men With Genital Pain: A Comparative Study.

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The concept of disc disease unfortunately does not enjoy universal acceptance by the various medical specialties that are entrusted with the care of the patient with low back pain. Terms such as disc degeneration, rupture, slipping, bulging, and herniation are used indiscriminately to explain all symptoms of pain in the low back with or without radiation of pain into the lower extremity. Sufcient knowledge is had today to interpret its normal function and to evaluate its deviation from normal. Chronic pain in the low back sufferer may someday be decreased as the acute, recurrent, and persistent episodes are better evaluated and treated. This nucleus has definite intrinsic pressure that maintains the separation of the verebral bodies so that the functional unit retains its stability and its mobility. The interertebral disc is the predominant porion of the functional unit and any defect, injury, or degenerative change will, and does, change the dynamics of the unit. Its place in the low back syndrome must be clearly and carefully evaluated and ascertained. The formulapreviously mentioned may be applied here and the solution sought for in (1) abnormal stress on normal mechanism, (2) normal stress on an abnormal mechanism, or (3) normal stress on a normal mechanism when the mechanism is not prepared to accept the stress. Compressive forces applied directly to the fnctional unit will cause vertebral body compression before any disc disruption of the intact disc. Rotational forces, however, place torque upon the annular fibers which become disrupted, and the intradiscal nuclear pressure is no longer contained. It is suficient to say that the term used is of less importance than the realization of what is happening. It is much more significant to know the where and what of the disc heriation that is causing the symptoms, the why of the consequent treatment, and the when if there is a need for surgical intervention. Symptoms Clinically the patient who sustains a disc heriation presents a history of acute low back pain with or without sciatic radiation. A history of an immediate preceding trauma, a fall, a blow, or an incident of heavy lifting need not be elicited. The strain or repeated stresses have frequently occurred prior to the acute onset and have set the stage for the ultimate heriation. By setting the stage is meant the weakening of the annulus fibrosus which diminishes the elastic recoil against a stress. In a large percentage of patients, pain is felt in the lower area of the back and simultaneously along the leg. Pain may be felt as a sensation of aching or "spasm" in the anterior upper thigh area. The spine splints into an antalgic posture (fattening of the lordosis), movement becomes restricted, and usually an acute functional scoliosis develops. Sciatic pain, usually considered a pressure neuritis, is a pain due to nere irritation that is referred down the leg.

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Of some importance in trawl fisheries along the Atlantic coast of Spain and Morocco. Caught by traps in the Azores and the Canary Islands where its fishery potential is being studied. Of importance to fisheries in the western Mediterranean; trawled commercially along the Spanish, Italian, Algerian and Tunisian coasts. The species is recorded from exploratory fisheries off the Guianas, in the western Atlantic where it is also taken in industrial trawl fisheries. Distribution: Eastern Atlantic: from northwest Spain south to Sierra Leone (some records as far south as Angola); Mediterranean, except the Adriatic and the Black Seas. Also recorded from the Red Sea and Indian Ocean and Indo-West Pacific, as far as Indonesia and the Philippines. Eye with maximum diameter nearly one-third of carapace length, ocellus subcircular, somewhat constricted at juncture with cornea; stylocerite broadly acute, reaching level of dorsal arc of distal margin of basal antennular segment; scaphocerite 5 to 7 times as long as wide, distolateral tooth distinctly extending beyond distal margin of lamina; third maxilliped with epipod, penultimate segment slightly longer than terminal segment; legs with well-developed epipods on 4 anterior pairs, second pair subequal, with 14 to 20 carpal segments, third pair reaches beyond distal margin of antennal scale by lengths of dactylus and distal half of propodus, dactylus short, laterally compressed, 0. Colour: reddish carapace and appendages; abdomen with dark red transverse bands; eggs dark blue. Habitat, biology, and fisheries: Occurring at depths between 100 and 1 250 m, most commonly between 230 and 730 m on muddy bottoms. In the western Atlantic it is taken in industrial trawl fisheries, but no data on its commercial value there are available. Distribution: Eastern Atlantic: from southwest Spain along the west African coast south to Angola, also recorded from Madeira, the Canary Islands and the Cape Verde Islands; western Mediterranean. Third margin of abdominal segment with blunt posterior carina, rostrum teeth on ventral without posteromesial tooth, fourth and fifth segments with posteroventral tooth on pleuron, sixth segment about 1. Eye with maximum diameter about one-fifth of carapace length, ocellus longitudinally oval, constricted at juncture with cornea. Stylocerite acute, reaching dorsal arc of distal margin of first antennular segment. Second pair distinctly unequal; left leg much longer than right, overreaching scaphocerite with chela, carpus and distal half of merus, with 107 to 215 carpal segments, 88 to 111 meral segments and about. Third pair overreaching antennal scale by lengths of dactylus and distal half of propodus; dactylus subspatulate, long, about 0. Adults have luminescent bluish green chromatophores along the anterior margins of the pleura of the second to fourth abdominal segments. Habitat, biology, and fisheries: Occurring at depths between 35 and 850 m (most commonly between 150 and 400 m) on muddy bottoms. Found regularly in the markets of Spain and northern Italy, but only occasionally in those of Morocco, Tunisia, Greece and Sicily. In Algeria this species is more abundantly caught (20 to 80 kg/h), but apparently not consumed in that country. Distribution: Eastern Atlantic: from Portugal to Angola; Mediterranean, except the northern part of the Adriatic Sea and the Black Sea. Abdomen without rostrum posteromesial tooth or median dorsal scaphocerite carina on third segment, fourth segment with pleuron rounded, without marginal denticle, fifth segment with pleuron tapering to strong posteroventral tooth, sixth somite nearly as long as to fully 1. Stylocerite broadly acute, hardly reaching level of dorsal arc of distal margin of first antennular segment. Scaphocerite with distolateral tooth typically extending beyond distal margin of blade. Epipod absent or rudimentary at third maxilliped; terminal segment of third maxilliped never shorter than penultimate segment. Second pair of legs with 20 to 25 carpal articles; legs very slender, none of them with epipods. Third pair extending beyond distal margin of scaphocerite by lengths of dactylus, propodus and slightly more or less than length of carpus, dactyl about one-tenth as long as Pleocyemata: Caridea: Pandaloidea: Pandalidae 183 propodus, accessory distal spine somewhat divergent from main terminal spine, not extending beyond basal one-fourth. Colour: carapace with red longitudinal lines dorsally, reddish laterally; abdomen with moderately broad bright red longitudinal lines alternated by rows of white chromatophores; anterior appendages and rostrum reddish; pereiopods with red and white bands; pleopods red; eggs orange. Habitat, biology, and fisheries: Occurring on soft bottoms at depths between 55 and 500 m.

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Early in the course of the disease, the patient may be asymptomatic but as the disease 25 progresses, the patient may complain of pain in the groin area. In the late stages of 25 the disease, the patient may have severe pain, limp, and loss of hip motion. Other areas of the skeleton that can become affected by avascular necrosis are the humeral 25 head and the distal femur, especially the medial femoral condyle. The disorder may be bilateral in up to 20% of patients; boys are affected three to five times more often than girls. Those affected usually present with a limp accompanied by pain in the hip or referred to the thigh or knee often following traumatic injury. Those affected may recover without residual problems if the signs and symptoms of the disease develop before the age of five years. However, patients older than nine years at presentation almost universally have a poor prognosis. Bone Tumors Many skeletal disorders result from either a benign or malignant bone tumor. Tumors can originate in the bone (primary tumors) or arise from metastases from tumors originating elsewhere in the body. For example high-grade malignant tumors generally spread rapidly through the medullary cavity. Low-grade malignant lesions tend to spread slowly, but they can also destroy the cortical bone and produce a soft tissue mass. Both malignant and benign bone tumors may grow and compress healthy bone tissue, Benign tumors however do not spread, do not destroy bone tissue, and rarely a threat to life. Osteosarcoma arises from osteoid tissue in bone and occurs most often in the knee and upper arm. Chondrosarcoma begins in cartilaginous tissue and primarily occurs in the pelvis, upper leg, and shoulder. Metastatic lesions from breast cancer are usually osteolytic, while 26 most prostate cancer metastases are osteoblastic. A few primary tumors account for most metastatic bone lesions; however, cancers that are most likely to metastasize to bone include prostate, breast, kidney, thyroid, and lung. The anatomic location of a lesion within bone is also a key to its identification. For example adamantinoma, a malignant tumor, usually occurs in the tibia in young 26, 27 patients. A giant cell tumor typically begins in the metaphysis and extends through the epiphysis to lie just below the cartilage. Osteogenic sarcoma usually occurs in the metaphysis of the distal femur and proximal 26, 27 tibia but occurs within the diaphysis in about 7% of patients with long-bone tumors. The axial skeleton often is the site of increased metastases because of the presence of red bone marrow. Radiography images often demonstrate lytic bone metastases but at least 30% to 26 50% of the bone must be destroyed before it is evident. Formulation of the differential diagnosis is based on several clinical and radiographic parameters. For example, in the middle and older age group of patients (ages 40-80 years), the most likely diagnosis is metastatic bone disease, multiple myeloma, or lymphoma. In young patients (ages 15 to 40 years), multiple lytic and oval lesions are most likely a vascular 26, 27 tumor. Although bone cancer does have a clearly defined cause, researchers have identified several factors that increase the likelihood of developing these tumors. Osteosarcoma occurs more frequently in people who have had high-dose external radiation therapy or treatment with certain anticancer drugs; children seem to be particularly susceptible. For example, children who have had hereditary retinoblastoma are at higher risk of 174 developing osteosarcoma, particularly if they have been treated with radiation. Additionally, people who have hereditary bone defects and people with metal appliances like those used in fracture repair are more likely to develop osteosarcoma.