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By: D. Navaras, MD

Associate Professor, Emory University School of Medicine

Older individuals tend to have diminished thirst perception and diminished awareness of volume contraction symptoms 9 weeks pregnancy buy abhigra cheap online. The response to aldosterone is impaired medications kidney stones order abhigra cheap online, and the ability to conserve sodium is limited medicine 319 order genuine abhigra on-line. The age-related decline in other renal functions such as urine concentration and dilution medications similar buspar discount 100mg abhigra fast delivery, tubular secretion and reabsorption, and hydrogen ion secretion render the elderly more susceptible to disorders of fluid, electrolyte, and acidbase imbalance. Suggested explanations include altered central or peripheral chemoreceptor function as well as reduction in neuromuscular inspiratory output. Right atrial, pulmonary artery, and pulmonary capillary wedge pressures are unchanged in the healthy elderly at rest. There is a reduction in the effectiveness of cough and mucociliary clearance with aging and a decline in the cellular and humoral components of pulmonary immunity. Similarly, a diminished gag reflex, dyscoordination of swallowing, prolonged periods in the supine position, and sedation contribute to an increased risk of aspiration. The Aging Kidney Many cross-sectional and longitudinal studies of large human populations have shown a steady decline in creatinine clearance with age. As in any other area, the decline in renal function with age is highly variable among individuals. In general, changes owing to disease and to aging are in the same direction and are additive. This loss occurs primarily in the renal cortex, with relative sparing of the medulla. A 50% reduction has been shown between young adulthood and the eighth decade, averaging 10% per decade. Various studies have found an average of three to four medical conditions in ambulatory older patients and five to nine medical diagnoses among elderly patients in chronic care facilities. On the other hand, normal aging does not significantly impair the conjugation capacity of the liver. Compared with renal function, hepatic function is extremely difficult to quantitate. Only sparse data are available on hepatic drug metabolism in aging human subjects, and evidence for altered hepatic metabolism in humans is largely indirect and frequently inconsistent. For example, in studies with antipyrine (a useful model compound for the study of drug metabolism), large individual variation frequently exceeds the effect of age such that only 3% of the variance in metabolic clearance is explained by age alone. Pharmacodynamics is the study of the physiologic response to a drug or combination of drugs and is based on drug-receptor interactions. For reasons that are not well understood, the aging process appears to be associated with an altered sensitivity of receptors for many commonly used medications. In general, elderly subjects are more sensitive to some medications, including warfarin, narcotics, sedatives, and anticholinergic medications, and less sensitive to others, such as -adrenergic agonists and antagonists. However, given the marked heterogeneity of the elderly as a group, careful individualization should be the general rule when drawing conclusions about such matters. Because of multiple diseases and polypharmacy in the elderly, the clinician always should check for possible drug-drug and drug-disease interactions before prescribing any new medication. The probability of a significant drug-drug interaction is nearly 7% for patients using more than 5 drugs and 24% for those using more than 10 medications. Adverse drug effects can mimic almost any clinical syndrome in geriatrics and should be considered in the differential diagnosis of vague symptoms or deterioration of function. For example, timolol eye drops-a -blocker used for glaucoma treatment-may be absorbed systemically and can cause cardiac decompensation in a patient with poor cardiac function. Owing in part to the progressive decrease in physiologic reserve with age and comorbidity, the elderly may have unusual presentations of diseases. The onset of a disease in the elderly generally affects the most vulnerable organ system first. This explains the frequent apparent lack of relation between the presenting symptom and the underlying disease. This emphasizes the need for a thorough evaluation when searching for the cause of nonspecific symptoms. The incidence of iatrogenic problems among acutely hospitalized geriatric patients is close to one in three.

Syndromes

  • Rare tumors, including pheochromocytoma,acromegaly,Cushing syndrome, or glucagonoma
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The plaque itself may or may not result in stenosis of the artery severe enough to cause symptoms treatment dry macular degeneration cheap abhigra 100 mg mastercard, although more severe atherosclerotic stenoses may be associated with exertional angina medicine for bronchitis buy abhigra 100mg visa. The pathophysiologic sequence of events then probably includes plaque rupture with exposure of the subintimal components of the plaque to coronary blood flow medicine buddha purchase generic abhigra from india. Platelet activation occurs as the contents of the atherosclerotic plaque (including cholesterol and calcium) interact with circulating blood components symptoms 10 days post ovulation generic abhigra 100 mg with mastercard. Platelet activation releases thromboxane A2, a vasoconstrictive substance that may lead to localized vasospasm, which further impedes coronary artery blood flow. The net result of these events is interruption of coronary blood flow by thrombus formation followed by myocardial necrosis if therapy is not effective. Symptoms-Acute myocardial infarction is classically associated with precordial chest pain with or without radiation to the left arm, shoulder, or jaw. The pain is identical to that described in the section on angina pectoris but often more severe. The pain is poorly responsive to nitroglycerin and may require morphine for relief. Dyspnea and orthopnea may be associated with acute congestive heart failure and pulmonary edema. Signs-During myocardial infarction, an S3 gallop, pulmonary rales, or the murmur of mitral regurgitation may appear. Patients should be examined carefully for murmurs of mitral regurgitation and for the presence of pericardial friction rubs. Rales and wheezes may indicate acute pulmonary edema from congestive heart failure. Since the latter value is a rough estimate of the left ventricular end-diastolic pressure, pulmonary capillary wedge pressure can provide valuable information regarding the necessity for volume expansion or diuresis. The right-sided heart catheters are equipped with a temperature-measuring thermistor that allows determination of cardiac output by thermodilution. Right-sided heart catheterization should be considered at any point during the course of an acute myocardial infarction when a question exists regarding fluid volume status. For example, a patient with acute myocardial infarction and possible pneumonia may have a lung examination that could represent pulmonary edema, pneumonia, or both. On the other hand, treatment of hypotension in the presence of suspected right ventricular infarction usually can commence without right-sided heart catheter guidance. However, should further volume supplementation seem necessary or should incipient left-sided heart failure be present or suspected, right-sided heart catheterization would be invaluable in determining the true volume status of the patient. For patients in whom hypotension persists for more than an hour despite use of vasopressors, right-sided heart catheterization is strongly advised. Rather, patients who have an uncomplicated myocardial infarction (no recurrent chest pain) can safely undergo stress testing (usually with a low-level exercise protocol) prior to hospital discharge to identify those at high risk for reinfarction or death who should undergo further study. Cardiac catheterization before hospital discharge is indicated in two classes of patients: (1) patients who develop chest pain after acute myocardial infarction, which is thought to be ischemic in nature, and (2) patients who have chest pain or evidence of ischemia on electrocardiography or myocardial perfusion scintigraphy during low-level exercise stress testing. These patients have "failed" medical therapy by virtue of having chest pain in the hospital (presumably while on adequate medication) and are likely to be best served by undergoing coronary angioplasty or coronary bypass grafting if their anatomy is found to be suitable by angiography. Initial Outpatient Treatment-Sublingual nitroglycerin tablets or nitroglycerin spray should be self-administered if the patient has either drug. Otherwise, sublingual nitroglycerin should be administered by paramedics or by personnel in the emergency department. Repeat doses of nitroglycerin can be administered once blood pressure monitoring is available and the patient has no significant side effects such as dizziness or severe headaches. Immediate Hospital Therapy-Initial therapy of a patient in the hospital suspected of having myocardial infarction consists of nitroglycerin as indicated earlier. Oxygen therapy, usually 2 L/min by nasal cannula, is frequently begun empirically and adjusted based on pulse oximetry. One aspirin tablet (325 mg) should be chewed and swallowed by the patient to reduce subsequent morbidity and improve chances for survival.

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These drugs may be taken orally or treatment efficacy buy discount abhigra line, after being crushed and dissolved treatment for vertigo cheap 100mg abhigra with mastercard, intravenously medicine prescription drugs order abhigra 100 mg on line. Clinical features Mild intoxication (Hollister and Gillespie 1970) is characterized by increased energy withdrawal symptoms purchase abhigra with paypal, varying degrees of elation, increased self-confidence, and talkativeness; the pupils are dilated, the blood pressure, both systolic and diastolic, is increased, the heart rate may be increased or reflexively decreased, and the deep tendon reflexes are diffusely brisk. With more severe intoxication there may be agitation and some bizarre behavior: often patients take a particular interest in things mechanical, and hours may be spent first taking apart, and then trying to put back together, various items, such as clocks, radios, televisions, etc. In severe intoxication a delirium may ensue, with confusion, incoherence, and disorientation. Abnormal movements, such as bruxism, chorea (Lundh and Tunving 1981), and, in some cases, generalized dystonia, may occur; intracerebral hemorrhage has also been reported (Harrington et al. The temperature rises, there may be extreme diaphoresis, and patients may experience nausea, vomiting, abdominal cramping, and diarrhea. Arrhythmias may appear, and with severe elevations of blood pressure there may be a hypertensive encephalopathy. Regardless of the degree of intoxication, most patients recover within hours to a day or so. In some cases, delusions and hallucinations, rather than being fleeting, may dominate the clinical picture of the intoxication, and in some of these cases, such symptoms may persist beyond the resolution of the intoxication, thus yielding a stimulant-induced psychosis. Although this is typically seen only with intravenous stimulant use, it has been reported after high-dosage oral use. In some cases there may be bizarre delusions, including Schneiderian first rank symptoms (Janowsky and Risch 1979). This amphetamine-induced psychosis generally clears within a matter of days or weeks, but it may occasionally last many months. With the development of tolerance, patients require ever larger doses to achieve euphoria, in some cases up to several grams daily. Some patients may develop an abusive pattern of use, however, and continue to seek intoxication despite suffering social or legal consequences. Withdrawal symptomatology, if severe and accompanied by suicidal ideation, may require hospitalization. Hospitalization is often required to break the pattern of use, and long-term involvement with groups such as Cocaine Anonymous or Narcotics Anonymous may be helpful. Both the free base and crack preparations evaporate with heating and thus may be smoked. Etiology It appears that the euphoria seen with stimulants occurs secondary to dopamine release within the ventral striatum (Drevets et al. Clinical features Differential diagnosis Intoxication with cocaine may be clinically indistinguishable from stimulant intoxication, and the differential may rest on history or drug screening. Lacking a history (as is often the case, given the deceit and denial seen in many cases), the elation and talkativeness of the intoxication may suggest mania, and the irritability, fatigue, and sleep disturbance of withdrawal may suggest depression. Drug screening is helpful here; however, observation in a controlled environment will also tell the tale, as the symptoms resolve over the expected time period. The stimulant-induced psychosis represents one of the toxic psychoses, discussed in Section 7. During intoxication (Kleber and Gawin 1984), patients become euphoric, hyperalert, talkative, and grandiose. Hyperactivity is common, and with higher doses agitation may occur (Fischman et al. With mild intoxication libido increases, and in males there may be delayed ejaculation; with more severe intoxication, however, there may be erectile dysfunction. In severe intoxication, especially after intravenous use or smoking, a delirium may occur, with confusion, incoherence, lability, and delusions and hallucinations. Other symptoms and signs include mydriasis, hypertension, headache, nausea and vomiting, tachycardia, and arrhythmias or cardiac arrest (Hsue et al. In severe cases one may utilize an antipsychotic such as haloperidol, in a dose of approximately 5 mg, either as the concentrate or parenterally, with repeat doses every hour or so until the patient is calm, limiting side-effects occur or a maximum dose of approximate 20 mg is reached.

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Labetalol is also an efficacious agent because of its blockade of both -adrenergic and -adrenergic receptors symptoms women heart attack purchase abhigra 100mg without a prescription. With this said medicine everyday therapy buy generic abhigra 100mg online, for acute blood pressure control medications kidney failure best order abhigra, -blocker therapy combined with sodium nitroprusside symptoms 38 weeks pregnant abhigra 100mg lowest price, as needed, is regarded as the therapy of choice. Calcium blockers produce both decreased blood pressure and decreased contractility. Central sympatholytics include trimethaphan, clonidine, methyldopa, and reserpine. They are used less commonly but do have a role in acute and chronic care as adjuncts to standard drug regimens. Intrinsic Factors-Age is associated with supraventricular arrhythmias and heart block in both cardiac and other thoracic surgical patients. The etiology of this association is unclear, but the incidence in patients over 65 years of age is high enough to warrant prophylactic therapy in many cases. Although routine preoperative prophylaxis against postoperative arrhythmias (particularly atrial fibrillation) remains controversial, it is increasingly supported by emerging data. Intrinsic cardiac disease, including cardiomyopathy, acute coronary insufficiency, valvular heart disease, congenital lesions, pulmonary hypertension, ventricular outflow obstruction, and ventricular failure, also increases the incidence and severity of arrhythmias in both the preoperative and postoperative periods. Cardiomyopathy, both ischemic and nonischemic, as well as dilated and nondilated, frequently causes both atrial and ventricular rhythm irregularity and is one of the more common presenting complaints. Surgical therapy (excluding aneurysm resection and endocardial ablation) frequently does not eliminate the cause. Atrial arrhythmias can result from primary involvement of atrial muscle or secondary dilation of atrial chambers by ventricular failure. Ectopic foci and reentrant circuits are the primary underlying causes, but the metabolic complications of diuresis and inotropes frequently contribute. Ventricular rhythm disturbances develop by these same mechanisms and are often life-threatening. Acute coronary arterial insufficiency frequently presents with severe arrhythmias (particularly ventricular) or heart block. They can recur or present postoperatively from residual or recurrent ischemia and reperfusion injury. Valvular heart disease frequently has residua that predispose to arrhythmias despite correction of the valvular lesion. The conduction system is anatomically close to valvular structures and is easily interrupted. Endocarditis is particularly likely to be associated with heart block pre- and postoperatively. Aortic disease leads to left ventricular hypertrophy or ventricular dilatation, both of which predispose to reentrant circuits or arrhythmic foci. Mitral and tricuspid valve disease most commonly causes atrial arrhythmias, primarily fibrillation. These should be expected to recur with almost 100% certainty in the postoperative period. Congenital lesions frequently are associated with abnormalities of the location and function of the conduction system and with chamber enlargement or hypertrophy. Gross anatomic disease is also occasionally associated with specific rhythm changes. General Considerations Significant cardiac dysrhythmias occur in up to one-third of postoperative cardiac surgical patients. Age is the most consistently identified predictor of postoperative arrhythmias, although many other risk factors exist, including valvular disease, cardiomyopathy, ischemia, reperfusion, adequacy of myocardial protection, metabolic derangements, adrenergic states, medications, temperature, and mechanical irritants. Bradycardias include sinus bradycardia, heart block, sinus arrest, and slow junctional rhythms. Tachycardias include (1) supraventricular arrhythmias (eg, atrial fibrillation, atrial flutter, premature atrial contractions, paroxysmal atrial tachycardia, and fast junctional rhythms) and (2) ventricular tachycardia, flutter, fibrillation, and premature ventricular contractions. Sometimes, the origin of a rapid arrhythmia is indeterminate and should be referred to as a nonspecific wide complex tachycardia. Both originate either from abnormal cardiac tissue affected by ischemia, hypertrophy, dilation, cardiomyopathy, and scar or from normal cardiac tissue induced by inotropes, endogenous catecholamines, autonomic stimulation, and metabolic derangements. Extrinsic Factors-Mechanical irritants (eg, chest tubes, central catheters, blood, and tamponade), metabolic derangements (eg, hypo- or hypermagnesemia, -kalemia, -phosphatemia, and -calcemia), adrenergic or vagotonic states, and cardiovascular drugs are frequent in the postoperative period and can induce and aggravate arrhythmias. Differential Diagnosis Problems peculiar to postoperative cardiac surgical patients that may lead to arrhythmias include hypovolemia, bleeding, pericardial tamponade, tension pneumothorax, thrombosis or dehiscence of a prosthetic valve, coronary ischemia, and hypoxia.

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