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Orthostatic Sodium Retention

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121. Gynecologic Pain (Follow-up)

improvement in patients with IC who were treated with amitriptyline. [ ] Corticosteroids are not widely used because of adverse effects such as fluid retention and osteoporosis. However, a study reported improved pain control and overall satisfaction with oral prednisone in a cohort of women with severe refractory IC. [ ] Pentosan polysulfate sodium (PPS) (Elmiron) is claimed to restore the depletion in the glycosaminoglycan (GAG) layer. A double-blind placebo-controlled trial revealed subjective (...) a reproductive age woman presents with pelivic pain and a positive pregnancy test. An unruptured ectopic pregnancy produces localized pain due to dilatation of the fallopian tube. Once the ectopic pregnancy is ruptured, the pain tends to be generalized due to peritoneal irritation. Symptoms of rectal urgency due to a mass in the pouch of Douglas may also be present. Syncope, dizziness, and orthostatic changes in blood pressure are sensitive signs of hypovolemia in these patients. Abdominal examination

2014 eMedicine.com

122. Hypertension (Follow-up)

using newer techniques. [ ] Consultations Consultations with a nutritionist and exercise specialist are often helpful in changing lifestyle and initiating weight loss. Consultation with a hypertension specialist is indicated for management of secondary hypertension attributable to a specific cause. Next: Nonpharmacologic Therapy Dietary changes A number of studies have documented an association between sodium chloride intake and BP. The effect of sodium chloride is particularly important (...) in individuals who are middle-aged to elderly with a family history of hypertension. A moderate reduction in sodium chloride intake can lead to a small reduction in blood pressure. The American Heart Association recommends that the average daily consumption of sodium chloride not exceed 6 g; this may lower BP by 2-8 mm Hg. [ , ] One randomized controlled trial published found that moderate dietary sodium reduction (about 2500 mg Na + or 6 g NaCl per day) added to angiotensin-converting enzyme (ACE

2014 eMedicine.com

123. Geriatric Rehabilitation (Follow-up)

physiologic factors that can lead to falls include the following: decreased muscle mass (which decreases overall strength), postural changes of the hips with increasing valgus deformity, change in the center of gravity to behind the hips, increased postural sway, decreased righting reflexes, increased reaction time, visuoperceptual decline, decreased vibratory sensation and altered proprioception (poor lower-extremity sensory input), impaired mobility, orthostatic hypotension (systolic blood pressure [SBP (...) ] < 20 mm Hg), balance disorders, and vasovagal syncope. Depression, confusion, dementia, and other cognitive deficits also contribute to falls. Cognitive impairment, depressive symptoms, and orthostatic hypotension most contribute to gait dysfunction. Slower performance on the Timed Up-and-Go Test (TUG), a mobility task, is independently associated with poorer performance on measures of global cognition, executive function, memory, and processing speed, suggesting that a thorough cognitive

2014 eMedicine.com

124. Esophageal Varices (Follow-up)

can reduce arterial blood pressure and promote the activation of endogenous vasoactive systems that may lead to sodium and water retention. Although ISMN has been demonstrated to reduce HVPG markedly in acute administration, it provides significantly less reduction after long-term administration (due to probable development of patient tolerance). Combination therapy Although many authorities recommended a combination therapy of pharmacologic treatment and EVL as the first-line treatment (...) procedures, and liver transplantation. Decompressive shunts and devascularization procedures are mainly rescue therapies. Management of patients with liver cirrhosis and ascites but without variceal hemorrhage includes a low-sodium diet and diuretics. Nasogastric tube In patients with hemodynamically significant upper gastrointestinal (GI) tract bleeding, a nasogastric tube should remain in place for 24 hours to assist in identifying any rebleeding. Gastric lavage may be performed frequently through

2014 eMedicine.com

125. Nephrotic Syndrome (Diagnosis)

of plasma water into the interstitial space. The resulting contraction in plasma volume (PV) leads to stimulation of the renin-angiotensin-aldosterone axis and antidiuretic hormone. The resultant retention of sodium and water by the renal tubules contributes to the extension and maintenance of edema. While the classical model of edema (also known as the "underfill hypothesis") seems logical, certain clinical and experimental observations do not completely support this traditional concept. First, the PV (...) has not always been found to be decreased and, in fact, in most adults, measurements of PV have shown it to be increased. Only in young children with MCNS have most (but not all) studies demonstrated a reduced PV. Additionally, most studies have failed to document elevated levels of renin, angiotensin, or aldosterone, even during times of avid sodium retention. Active sodium reabsorption also continues despite actions that should suppress renin effects (eg, as albumin infusion or angiotensin

2014 eMedicine Pediatrics

126. Perioperative Management of the Geriatric Patient

; aortic aneurysm surgery; noncardiac thoracic surgery; and abnormal preoperative sodium, potassium, or glucose levels were found as independent, specific factors that preoperatively predicted postoperative delirium in elderly patients. Other independent precipitating factors are the use of physical restraints, malnutrition, respiratory insufficiency, dehydration, addition of more than 3 medications, and any iatrogenic event, such as nosocomial infection. Vulnerability factors are visual impairment (...) of symptoms. Patients may experience hypoxia from stiffening of chest wall muscles, transfer dysphagia, and worsened tremor (which can cause increased pain at the operative site). If possible, a weighted feeding tube can be used to administer the medication at appropriate times. Patients who take levodopa may develop orthostatic hypotension, nightmares, hallucinations, and, occasionally, delirium, all of which may worsen with the addition of surgery and anesthesia. Anticholinergic drugs

2014 eMedicine.com

127. Perioperative Management of the Female Patient

, date and method Sexual history – Preference (ie, heterosexual, bisexual, homosexual); orgasmic; if sexually active, dyspareunia; problems, concerns, questions – Difficulty becoming pregnant, evaluation or treatment for infertility Papanicolaou (Pap) smear – Last Pap test, abnormalities Infection – Vaginal discharge, previous vaginal infections, sexually transmitted diseases (STDs), Pelvic relaxation – Prolapse, vaginal splinting to defecate, urinary retention, Breast disease – Masses, discharge (...) count is close to 10,000/mm 3 . Platelet transfusion may be given to these patients before and during surgery to raise the count above 50,000/mm 3 . Electrolyte disturbances Vomiting, diarrhea, and the use of diuretics are the most common factors that result in electrolyte disturbances and intravascular volume depletion in gynecologic patients. Hemorrhage, starvation, and fluid restriction contribute to intravascular volume reduction. Patients with severe vomiting deplete their sodium and potassium

2014 eMedicine.com

128. Nephrotic Syndrome (Overview)

of plasma water into the interstitial space. The resulting contraction in plasma volume (PV) leads to stimulation of the renin-angiotensin-aldosterone axis and antidiuretic hormone. The resultant retention of sodium and water by the renal tubules contributes to the extension and maintenance of edema. While the classical model of edema (also known as the "underfill hypothesis") seems logical, certain clinical and experimental observations do not completely support this traditional concept. First, the PV (...) has not always been found to be decreased and, in fact, in most adults, measurements of PV have shown it to be increased. Only in young children with MCNS have most (but not all) studies demonstrated a reduced PV. Additionally, most studies have failed to document elevated levels of renin, angiotensin, or aldosterone, even during times of avid sodium retention. Active sodium reabsorption also continues despite actions that should suppress renin effects (eg, as albumin infusion or angiotensin

2014 eMedicine Pediatrics

129. Diabetes Mellitus, Type 2 (Follow-up)

or insulin secretagogues. [ ] These effects may induce or worsen heart failure in patients with left ventricular compromise and occasionally in patients with normal left ventricular function. TZDs have not been tested in patients with New York Heart Association class III or IV heart failure. Fluid retention from TZDs has been considered resistant to treatment with loop diuretics, because of upregulation of renal epithelial sodium channels. However, a randomized, double-blind, placebo-controlled (...) in type 2 diabetes. Drug classes used for the treatment of type 2 diabetes include the following: Biguanides Sulfonylureas Meglitinide derivatives Alpha-glucosidase inhibitors Thiazolidinediones (TZDs) Glucagonlike peptide–1 (GLP-1) agonists Dipeptidyl peptidase IV (DPP-4) inhibitors Selective sodium-glucose transporter–2 (SGLT-2) inhibitors Insulins Amylinomimetics Bile acid sequestrants Dopamine agonists A literature review by Alfayez et al indicated that GLP-1 agonists, DPP-4 inhibitors, and SGLT-2

2014 eMedicine Emergency Medicine

130. Cauda Equina Syndrome (Follow-up)

therapy. Methylprednisolone should be administered. It treatment must be started within 8 hours of injury. No evidence exists of any benefit if it is started more than 8 hours after injury; on the contrary, late treatment may have detrimental effects. Administration of ganglioside GM1 sodium salt beginning within 72 hours of injury may be beneficial; the dose is 100 mg IV qd for 18-32 days. Tirilazad mesylate (a nonglucocorticoid 21-aminosteroid) has been proven to be of benefit in animals (...) are to maximize the medical, physical, psychological, educational, vocational, and social function of the patient. To maximize medical function, ensure adequate prevention and treatment of possible medical complications already discussed, especially deep venous thrombosis, bladder and bowel problems, and decubitus ulcers Physical therapy Perform range of motion and strengthening exercises, sitting balance, transfer training, and tilt table as tolerated (because of tendency to orthostatic hypotension). Tilt

2014 eMedicine Emergency Medicine

131. Toxicity, Neuroleptic Agents (Diagnosis)

. With loxapine, seizures may be recurrent. Cardiac effects: Prolongation of the QT interval and QRS complex can result in arrhythmias. QT prolongation in antipsychotic use is caused by potassium channel blockade. Sodium blockade causes prolongation of the QRS complex. This effect is mainly seen with thioridazine and mesoridazine. Hypotension: Phenothiazines are potent alpha-adrenergic blockers that result in significant orthostatic hypotension, even in therapeutic doses for some patients. In overdose (...) is no-to-minimal risk; 1+ is low risk; 2+ is moderate risk; 3+ is high risk. Although all antipsychotic preparations share some toxic characteristics, the relative intensity of these effects varies greatly, depending on the individual drug and specific receptor affinity. Generally, all neuroleptic medications are capable of causing the following symptoms: Anticholinergic effects: Neuroleptic agent toxicity can result in tachycardia; hyperthermia; urinary retention; ileus; mydriasis; toxic psychosis; dry mucous

2014 eMedicine Emergency Medicine

133. Proteinuria (Diagnosis)

function. Glomerular proteinuria can also be categorized according to whether pathological damage of the glomerulus is present. Types that do not result from pathological damage to the glomerulus include transient and orthostatic proteinuria. Transient proteinuria occurs in persons with normal renal function, bland urine sediment, and normal blood pressure. The quantitative protein excretion is less than 1 g/day. The proteinuria is not indicative of significant underlying renal disease; it may (...) be precipitated by high fever or heavy exercise, and it disappears upon repeat testing. Exercise-induced proteinuria usually resolved wihtin 24 hours. Orthostatic proteinuria is diagnosed if the patient has no proteinuria in early morning samples but has low-grade proteinuria at the end of the day. It usually occurs in tall, thin adolescents or adults younger than 30 years (and may be associated with severe lordosis). Patients have normal renal function and proteinuria is usually < 1 g/day, with no hematuria

2014 eMedicine.com

134. Toxic Neuropathy (Diagnosis)

and symptoms Patients with neuropathy typically present with symptoms of pain, tingling, or numbness in their feet, consistent with dysfunction affecting the longest and largest fibers of the peripheral nervous system (PNS). Other manifestations of neurologic dysfunction that may be present include the following: Hypohidrosis or hyperhidrosis Diarrhea or constipation Urinary incontinence or retention Gastroparesis Sicca syndrome Blurry vision Facial flushes Orthostatic intolerance Sexual dysfunction (...) of neuropathy, such as sodium channel, neuromuscular transmission, or cranial neuropathies, also have toxic etiologies. In North America, sodium channel dysfunction may be the result of ciguatera toxin from reef fish or saxitoxin from shellfish. This often presents as an acute or subacute illness. Puffer fish may be intoxicated with tetrodotoxin in Japan. Neuromuscular transmission dysfunction is associated most commonly with organophosphate intoxication; however, envenomation from snake bites or botulism

2014 eMedicine.com

135. Diabetes Mellitus, Type 2 (Treatment)

or insulin secretagogues. [ ] These effects may induce or worsen heart failure in patients with left ventricular compromise and occasionally in patients with normal left ventricular function. TZDs have not been tested in patients with New York Heart Association class III or IV heart failure. Fluid retention from TZDs has been considered resistant to treatment with loop diuretics, because of upregulation of renal epithelial sodium channels. However, a randomized, double-blind, placebo-controlled (...) in type 2 diabetes. Drug classes used for the treatment of type 2 diabetes include the following: Biguanides Sulfonylureas Meglitinide derivatives Alpha-glucosidase inhibitors Thiazolidinediones (TZDs) Glucagonlike peptide–1 (GLP-1) agonists Dipeptidyl peptidase IV (DPP-4) inhibitors Selective sodium-glucose transporter–2 (SGLT-2) inhibitors Insulins Amylinomimetics Bile acid sequestrants Dopamine agonists A literature review by Alfayez et al indicated that GLP-1 agonists, DPP-4 inhibitors, and SGLT-2

2014 eMedicine Emergency Medicine

136. Cauda Equina Syndrome (Treatment)

therapy. Methylprednisolone should be administered. It treatment must be started within 8 hours of injury. No evidence exists of any benefit if it is started more than 8 hours after injury; on the contrary, late treatment may have detrimental effects. Administration of ganglioside GM1 sodium salt beginning within 72 hours of injury may be beneficial; the dose is 100 mg IV qd for 18-32 days. Tirilazad mesylate (a nonglucocorticoid 21-aminosteroid) has been proven to be of benefit in animals (...) are to maximize the medical, physical, psychological, educational, vocational, and social function of the patient. To maximize medical function, ensure adequate prevention and treatment of possible medical complications already discussed, especially deep venous thrombosis, bladder and bowel problems, and decubitus ulcers Physical therapy Perform range of motion and strengthening exercises, sitting balance, transfer training, and tilt table as tolerated (because of tendency to orthostatic hypotension). Tilt

2014 eMedicine Emergency Medicine

137. Lower Gastrointestinal Bleeding: Surgical Perspective (Treatment)

, and urine output. Orthostatic hypotension (ie, a blood pressure fall of >10 mm Hg) is usually indicative of blood loss of more than 1000 mL. Next: Resuscitation and Initial Assessment The 2016 American Academy of Family Physicians (AAFP) guidelines recommend the following for the initial evaluation, risk stratifcation, and hemodynamic resuscitation [ ] : Obtain a focused history, physical examination, and laboratory studies at time of patient presentation (to determine bleeding severity and potential (...) postural changes with dyspnea, tachypnea, and tachycardia. An orthostatic drop in systolic blood pressure of more than 10 mm Hg or an increase in heart rate of more than 10 beats per minute is indicative of at least 15% of blood volume loss. Severe postural dizziness with a postural pulse increase of at least 30 beats per minute is a sensitive and specific indicator of acute blood loss of more than 630 mL. [ ] A hematocrit level of less than 18% or a decrease of about 6% is indicative of significant

2014 eMedicine Surgery

138. Rehabilitation of Persons With Spinal Cord Injuries (Treatment)

. Clinical problems result from inappropriately low or high sympathetic responses, the former during the acute phase and the latter in the subacute and chronic phases. Problems are most common in those with injuries to level T6 and above, as such levels isolate the sympathetic outflow to the splanchnic vascular bed. Resting blood pressure is low with higher cord injury, which is asymptomatic. Orthostatic blood pressure changes can cause weakness, light-headedness, and fainting. Management includes (...) gradual mobilization, liberal sodium intake, use of compression hose, and an abdominal binder. [ , ] Fludrocortisone acetate (0.1 mg PO qd) can expand intravascular volume and therefore is helpful. Midodrine (titrated upward daily from a dosage of 5 mg PO bid/tid) may be helpful. Midodrine can cause supine hypertension and presumably may exacerbate any tendency toward autonomic hyperreflexia (AH). Bradycardia is common soon after injury and usually resolves after several weeks. Tracheal suctioning can

2014 eMedicine Surgery

139. Cauda Equina Syndrome (Treatment)

therapy. Methylprednisolone should be administered. It treatment must be started within 8 hours of injury. No evidence exists of any benefit if it is started more than 8 hours after injury; on the contrary, late treatment may have detrimental effects. Administration of ganglioside GM1 sodium salt beginning within 72 hours of injury may be beneficial; the dose is 100 mg IV qd for 18-32 days. Tirilazad mesylate (a nonglucocorticoid 21-aminosteroid) has been proven to be of benefit in animals (...) are to maximize the medical, physical, psychological, educational, vocational, and social function of the patient. To maximize medical function, ensure adequate prevention and treatment of possible medical complications already discussed, especially deep venous thrombosis, bladder and bowel problems, and decubitus ulcers Physical therapy Perform range of motion and strengthening exercises, sitting balance, transfer training, and tilt table as tolerated (because of tendency to orthostatic hypotension). Tilt

2014 eMedicine Surgery

140. Toxicity, Neuroleptic Agents (Overview)

. With loxapine, seizures may be recurrent. Cardiac effects: Prolongation of the QT interval and QRS complex can result in arrhythmias. QT prolongation in antipsychotic use is caused by potassium channel blockade. Sodium blockade causes prolongation of the QRS complex. This effect is mainly seen with thioridazine and mesoridazine. Hypotension: Phenothiazines are potent alpha-adrenergic blockers that result in significant orthostatic hypotension, even in therapeutic doses for some patients. In overdose (...) is no-to-minimal risk; 1+ is low risk; 2+ is moderate risk; 3+ is high risk. Although all antipsychotic preparations share some toxic characteristics, the relative intensity of these effects varies greatly, depending on the individual drug and specific receptor affinity. Generally, all neuroleptic medications are capable of causing the following symptoms: Anticholinergic effects: Neuroleptic agent toxicity can result in tachycardia; hyperthermia; urinary retention; ileus; mydriasis; toxic psychosis; dry mucous

2014 eMedicine Emergency Medicine

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