Medical

Question 1

10 drugs that changed the world

Answer 1

Pharmacists will be aware of the heritage of many drugs used today and most will be familiar with the serendipitous discovery of penicillin. But some may be less acquainted with the role of happy chance in the unearthing of several other frequently used medicines.

In Ten Drugs: how plants, powders, and pills have shaped the history of medicine, science writer Thomas Hager provides a biography of ten common drugs that have had an important impact on modern medicine. The book simultaneously charts the rise of the pharmaceutical industry and considers how its careful advertising promoted benefits of the latest wonder drug, while muffling adverse effects.

The book begins with a chapter detailing humans’ long relationship with the poppy, which was once used for its euphoric constituent opium. Desire for the substance was insatiable and culminated in two opium wars between China and Britain in the mid-19th century. The chapter also describes how morphine was ultimately isolated from opium and became an effective painkiller in the 1800s, but also led to a plague of addiction.

The second chapter depicts the development of vaccination; as early as 1717, aristocrat Lady Mary Wortley Montagu, who lived in Constantinople (now Istanbul), recorded the practice of ‘engrafting’ — the prototype of inoculation — in which someone would scratch the skin of a child until it bled, and then place into the wound a small amount of smallpox scabs. This induced a mild form of the disease from which the child would recover.

A later chapter explains the origin of the term ‘a Mickey Finn’ — a drink that has been spiked with a drug — which emerged in 1915. It turns out that a saloon manager of the same name used chloral hydrate to sedate, and later rob, his semi-conscious customers. Chloral hydrate had been used to sedate mentally ill patients in the 1800s.

It was interesting to see that heroin was once used in over-the-counter cough mixtures and approved for general use by the American Medical Association in 1906. While in the 1930s, work with azo-dyes by chemists at Bayer led to the discovery of sulpha-like drugs, which were effective antibiotics.

Other breakthroughs include RP-4560 (chlorpromazine), an antihistamine that was shown to be valuable in sedating patients with mental health problems, and the fascinating development of the contraceptive pill in the 1950s. The book also covers more recent discoveries, including UK-94280, a drug originally developed to treat coronary heart disease, which had an unusual side effect in men; it was later named sildenafil and approved for medical use in 1998. Other opioid-like drugs, such as pethidine, methadone and fentanyl, are also described in some detail. Finally, separate chapters are devoted to statins and monoclonal antibodies — it is a travesty of justice that the two scientists who identified monoclonal antibodies in 1975 did not patent their discovery and, as a result, did not make any money from their work.

The book’s epilogue focuses on looking forward to potential innovations such as the polypill, which contains a combination of many medicines commonly used to treat heart disease; digital drugs, which send out signals once they have been consumed; and personalised medicine, based on an individual’s unique genome.

Hager finishes with a discussion of the problems facing the pharmaceutical industry. The rate of new innovations is ebbing, and sales are flattening; and in addition to persuading doctors to prescribe their drugs, the industry is lobbying an ever-widening group, including media personalities, lawyers and patient advocacy groups to improve sales.

Question 2

Poison ivy treatment

Answer 2

•• Next up is Rachel; she’s 45 years old and spent yesterday golfing
with friends. Now she has two problems: sunburn on her shoulders
and face, and a very itchy rash on her legs. She says she’s a terrible
golfer, and spent a lot of time in the rough looking for her ball. She
figures she got poison ivy then.

•• Rachel is entirely correct. The sunburn is red, and the skin feels
warm, and there are blisters in places. Sunburn treatment is similar
to other burns: Try to prevent it, if you can, but once it’s there, get
out of the sun. Drink extra fluids, like you would after any burn;
take pain medications, and use soothing cool wet washcloths. Aloe
vera can help as well.

•• The poison ivy rash is shaped in streaks, from where the plant
touched her skin. Anyone with a poison ivy rash should clean up
the area well with soapy water, and wash their hands and clothes
and anything else that could have gotten poison ivy sap on it.

•• After cleaning, the rash can be treated with topical steroids—
usually, the potent prescription-strength kind. Often, oral or injected
steroids are given, too, in addition to oral antihistamines. The
allergic reaction that causes the rash of poison ivy is really quite
intense, and you sometimes need high doses of several medicines at
the same time to calm it down.

Question 3

Diagnosing headaches

Answer 3

􀁸􀀃 We are going to need more history and a physical exam. Headaches
are almost always diagnosable based only on the history, with
a physical exam to con rm suspicions. This is not a high-tech
diagnosis. It involves going through some crucial questions with
the patient to get an in-depth history.

􀁸􀀃 The most crucial headache question is as follows: Is this your rst
headache or your worst headache? That’s very important—things
like an intracranial bleed will cause a severe, worst-in-your-life
headache, and that’s a huge red ag for immediate action.

􀁸􀀃 More questions include the following: What happens when the
headache starts? What symptoms develop with the headache? With
migraines, there is often an aura—a visual or auditory phenomenon,
such as ashing lights, that precedes the headache.

􀁸􀀃 Does the pain spread around? What does the pain feel like? Do you
have any other medical problems? Are you stuffy all the time or
just with the headaches? Is there anything that makes the headache
get worse or better? Are you taking any medicines? What happens
when you get a headache?

Question 4

Migraines

Answer 4

􀁸􀀃 The most common primary headache disorder is migraine. These
headaches last 4 to 72 hours and are unilateral (or at least begin
unilaterally). The pain is of moderate to severe intensity and has a
pulsating or throbbing quality. They get worse with activity, such as
walking around or working.

􀁸􀀃 Migraines will always be accompanied by either nausea or vomiting
or a combination of photophobia and phonophobia—which means
that the headache gets worse with light and sound.

􀁸􀀃 Though not part of the de nition of migraines, they characteristically
improve after sleep. Gordon mentioned sleeping off his headaches.
We’ve ruled out secondary headaches with our history and
physical, and his headache pattern ts perfectly into the de nition
of migraine. That’s our diagnosis.

􀁸􀀃 Often, migraines are accompanied by changes in what’s called the
autonomic nervous system, the part of our nervous system that’s
automatic—the things we don’t have to think about. It includes
the nerves that make us sweat and the nerves that constrict blood
vessels and make the skin look pale.

􀁸􀀃 Some migraine sufferers become pale and sweaty, and many feel
nausea or abdominal pain from these autonomic nerve changes.
Autonomic nerves also innervate the lining of the nose and
can cause nasal congestion or stuf ness from increased tissue
swelling—explaining why our patient thought he was having
sinus headaches.

Question 5

Kims game.

Answer 5

Practice kims game and see what info you can remember.

Race, sex, age, height, weight colors, Dielect, Tattoos, Hair

Question 6

Heat Exhaustion V Heat Stroke V Hyperthermia

Answer 6

Heat exhaustion and heat stroke are both serious conditions that can occur when the body is exposed to high temperatures and prolonged physical exertion. Here are the symptoms and treatments for each:

Heat Exhaustion:
Symptoms:
- Heavy sweating
- Fatigue and weakness
- Dizziness or lightheadedness
- Nausea or vomiting
- Headache
- Pale, cool, and moist skin
- Rapid heartbeat
- Muscle cramps
- Fainting or loss of consciousness (in severe cases)

Treatment:
- Move to a cool environment: Get out of the heat and into a shaded or air-conditioned area.
- Hydrate: Drink cool water or sports drinks to replace fluids and electrolytes lost through sweating.
- Rest: Lie down and elevate the legs to help improve blood flow to the heart and brain.
- Cool the body: Apply cool, wet cloths to the skin or take a cool shower.
- Loosen clothing: Remove or loosen tight or unnecessary clothing to allow heat to escape.
- Monitor symptoms: If symptoms worsen or do not improve within 30 minutes, seek medical attention.

Heat Stroke:
Symptoms:
- High body temperature (above 103°F or 39.4°C)
- Altered mental state or confusion
- Rapid and shallow breathing
- Rapid heartbeat
- Flushed, hot, and dry skin (lack of sweating)
- Headache
- Nausea or vomiting
- Fainting or loss of consciousness
- Seizures (in severe cases)

Treatment:
- Call emergency services: Heat stroke is a medical emergency that requires immediate medical attention.
- Move to a cool place: Get the person out of the heat and into a shaded or air-conditioned area.
- Cool the body rapidly: Immerse the person in a cool bath or shower, or use cool water spray and fan the person to promote cooling.
- Monitor vital signs: Check the person’s temperature and monitor their breathing and heart rate until medical help arrives.

It’s important to note that heat stroke is a life-threatening condition, and delaying medical treatment can have severe consequences. If you suspect someone is experiencing heat stroke, it is crucial to seek emergency medical help immediately.

Hyperthermia is a condition characterized by an elevated body temperature that is above the normal range due to external factors, such as exposure to hot environments or strenuous physical activity. It can encompass both heat exhaustion and heat stroke. Here’s some additional information on hyperthermia:

Hyperthermia:
Hyperthermia refers to an elevated body temperature that is not necessarily caused by an infection but rather by external factors. It can be broadly categorized into two types:

Heat Exhaustion: Heat exhaustion is a form of hyperthermia and is considered a milder condition than heat stroke. The symptoms and treatment for heat exhaustion are described in the previous response.

Heat Stroke: Heat stroke is the most severe form of hyperthermia and is a medical emergency. It occurs when the body’s internal temperature regulation system fails, leading to a dangerously high body temperature. Symptoms and treatment for heat stroke are also described in the previous response.

Treatment for hyperthermia, regardless of the specific type, involves immediate actions to lower the body temperature and prevent further complications. These measures include:

Moving to a cool environment: Get out of the heat and into a shaded or air-conditioned area.
Cooling the body: Apply cool water to the skin, use fans or air conditioning, or apply ice packs to areas with a rich blood supply, such as the armpits and groin.
Hydrating: Drink cool water or sports drinks to replace fluids and electrolytes lost through sweating.
Resting: Lie down and elevate the legs to improve blood flow to the heart and brain.
Seeking medical attention: If symptoms worsen, do not improve within 30 minutes, or if there are signs of heat stroke, seek immediate medical help.

Question 7

Ear Infections

Answer 7

To treat an ear infection:

1. Use over-the-counter pain relievers for pain relief.
2. Apply a warm compress to the affected ear.
3. Keep the ear dry during bathing or swimming.
4. Use prescribed antibiotic ear drops if recommended.
5. Take prescribed oral antibiotics and complete the full course.
6. Follow up with your healthcare provider if symptoms persist or worsen.
7. Seek immediate medical attention for severe symptoms or complications.

Note: Consult a healthcare professional for personalized advice and treatment based on your specific condition.

Question 8

How to lose a tail.

Answer 8

Use them - Put receipt in trash can. Hand a news paper to a stranger.

Abuse them - Waste their day. Stay in book stores way too long.

Lose them - Use elevators. Go to places in other entrances.

Question 9

Hay Fever

Answer 9

Hay fever, also known as allergic rhinitis, is an allergic reaction to airborne substances such as pollen, dust mites, pet dander, or mold spores. It commonly occurs during specific seasons when certain allergens are prevalent. Here are the symptoms and treatment options for hay fever:

Symptoms of Hay Fever:
- Sneezing
- Runny or stuffy nose
- Itchy or watery eyes
- Itchy throat or ears
- Coughing
- Fatigue
- Mild headache
- Postnasal drip (mucus draining down the throat)

Treatment for Hay Fever:

1. Avoid allergens: Minimize exposure to allergens that trigger your symptoms. Stay indoors when pollen counts are high, use air purifiers with HEPA filters, keep windows closed, and avoid outdoor activities during peak pollen times.
2. Use nasal saline rinses: Regularly rinsing your nasal passages with a saline solution can help flush out allergens and reduce congestion. This can be done using a neti pot, squeeze bottle, or nasal irrigation device.
3. Over-the-counter medications:
   
   • Antihistamines: These medications block the effects of histamine, a chemical released during an allergic reaction. They can help relieve sneezing, itching, and runny nose. Examples include cetirizine, loratadine, and fexofenadine.
   • Decongestants: These medications help reduce nasal congestion by narrowing blood vessels. They are available in oral or nasal spray forms. Note that nasal decongestant sprays should not be used for more than a few days, as they can cause rebound congestion.
   • Nasal corticosteroids: These nasal sprays help reduce inflammation and relieve nasal symptoms. They can take a few days to reach full effectiveness. Examples include fluticasone, budesonide, and mometasone.
4. Eye drops: Over-the-counter antihistamine eye drops can help relieve itchy, red, and watery eyes. Avoid rubbing your eyes, as it can worsen symptoms.
5. Allergy shots (Immunotherapy): If hay fever symptoms are severe or not well-controlled with medications, your healthcare provider may recommend allergy shots. These shots expose you to gradually increasing amounts of allergens over time, which can help desensitize your immune system and reduce symptoms.
6. Allergy-proof your home: Take steps to minimize exposure to allergens indoors. Use dust mite-proof covers on bedding, vacuum regularly with a HEPA-filtered vacuum cleaner, and keep indoor humidity levels low to prevent mold growth.
7. Consult a healthcare professional: If your symptoms are persistent, severe, or significantly affecting your quality of life, it’s advisable to consult a healthcare professional. They can assess your condition, provide a proper diagnosis, and recommend appropriate treatment options.

Remember, the effectiveness of treatment may vary for each individual, and it may take some trial and error to find the right combination of therapies that work best for you. It’s also important to start treatment before the onset of symptoms or allergy season for better symptom control.

Question 10

Treating Scorpion Stings

Answer 10

If you or someone else has been stung by a scorpion, it’s important to take the following steps for treatment:

Localized pain: The site of the sting may be painful, ranging from mild to severe, and can persist for several hours or even days.

Swelling and redness: The sting area may become swollen, red, and inflamed.

Numbness or tingling: Some individuals may experience numbness or tingling around the sting site or in the surrounding area.

Paresthesia: Unusual sensations like pins and needles or a “tingling” feeling may be felt in other parts of the body.

Muscle spasms: In some cases, muscle spasms or cramping can occur, especially in the area near the sting.

Sweating and increased heart rate: The person stung may experience increased sweating and a faster heart rate.

Restlessness or agitation: Restlessness, anxiety, or a feeling of restlessness can sometimes occur.

Systemic symptoms: Severe reactions to scorpion stings are rare, but in some cases, more serious symptoms can develop, such as difficulty breathing, chest pain, high blood pressure, or rapid heartbeat. These symptoms may indicate a severe allergic reaction and require immediate medical attention.

1. Stay calm: Although a scorpion sting can be painful, try to remain calm to help slow the spread of venom.
2. Remove the stinger (if present): Some scorpions may have a stinger that remains in the skin after a sting. If visible, carefully remove the stinger using tweezers or the edge of a credit card. Be cautious not to squeeze the venom sac attached to the stinger, as it can release more venom.
3. Clean the area: Wash the sting site gently with mild soap and water to reduce the risk of infection. Pat it dry with a clean cloth.
4. Apply a cold compress: Place a cold compress or ice pack wrapped in a thin cloth on the sting area for about 10-15 minutes. This can help reduce swelling and provide temporary relief from pain.
5. Manage pain and discomfort: Over-the-counter pain relievers, such as acetaminophen or ibuprofen, can help alleviate pain and reduce swelling. Follow the recommended dosage instructions.
6. Monitor for severe symptoms: While most scorpion stings cause only localized pain and swelling, some individuals may experience more severe symptoms. Watch for signs of an allergic reaction, such as difficulty breathing, chest tightness, or swelling of the face, lips, or throat. If these symptoms occur, seek immediate medical attention.
7. Seek medical attention: It is recommended to seek medical attention for scorpion stings, especially if the following apply:
   • The sting was from a potentially dangerous scorpion species.
   • Severe pain, swelling, or other systemic symptoms are present.
   • The person stung is a child, elderly, or has pre-existing health conditions.

It’s important to note that specific treatment for scorpion stings may vary based on the species of scorpion and the severity of symptoms. Medical professionals can provide appropriate evaluation, manage complications, and administer antivenom if necessary.

Prevention is key to avoid scorpion stings. Take precautions such as wearing protective clothing, shaking out shoes and clothing before wearing them, and keeping living areas clean and free of scorpions.

Question 11

Major Depression

Answer 11

It’s important to make the distinction between depression—that is, the common word meaning “sadness”—and depression, the pervasive emotional disorder with speci c symptoms that span far outside the realm of sadness. Of course, we all experience sadness
related to life’s disappointments, bereavement, and ordinary turmoil.
􀁸􀀃 When we speak of depression as a diagnosis, we’re referring to
something not only more intense in quality, but also broader in its
effect on lives and families. Sometimes, the medical diagnosis is
referred to as “major depression” to underscore this difference.

􀁸􀀃 The rst primary symptom of depression is depressed mood. This can be something reported by the patient—for example, “I feel sad a lot”—or something noticed by the family. In teenagers, a depressed mood can come across as more of an irritable mood, with
frequent ghting and outbursts. To qualify as major depression,
the depressed mood occurs most of the day, nearly every day. Our
patient was at times sad and at times quite irritable.

􀁸􀀃 The second main symptom is a lack of interest in pleasurable
activities. In teenagers, this often presents as social withdrawal,
dropping out of activities, or spending very little time with friends or hobbies that used to be enjoyable. One or the other, or both, of
these two main symptoms of withdrawal and depressed mood are
always present in major depression. Our patient had both.

􀁸􀀃 There are also a number of other symptoms, and for a formal
diagnosis, at least four of these must be present to con rm the
diagnosis of depression.
􀁸􀀃 So-called vegetative symptoms affect our basic life functions. There
can be signi cant changes in appetite leading to either weight loss
or weight gain. Depression can also affect sleep cycles, leading to
either reduced or increased sleep. Even when there is a lot of sleep,
fatigue or loss of energy is reported.

􀁸􀀃 There are also qualitative and quantitative changes in thinking
patterns. Many patients with depression experience cognitive
slowing, or a lack of ability to think or focus. Thoughts that do
occur are often preoccupied with feelings of guilt or worthlessness
that may even border on delusional—sometimes patients blame
themselves for many things that are clearly not their fault. There can
be pervasive hopelessness and recurrent thoughts of death, which
may include thinking about suicide or planning or performing a
suicidal act.

􀁸􀀃 Although the symptoms of depression in children and adults
are similar in many ways, there are some signi cant differences.
Teenagers are as likely to present with irritability, anger, or
abusive language as with sadness. They more often have somatic
complaints, such as bellyaches, headaches, nausea, or dizziness. In
fact, chronic unexplained pain should always raise the suspicion of
depression as a possible diagnosis.

􀁸􀀃 Depressed teens often complain of being bored and have low energy.
They may become extremely sensitive to perceived rejection or lack
of success. School absences and/or decreasing school performance
are nearly universal ndings in childhood depression.

􀁸􀀃 Depression is a serious problem. About four to eight percent of adolescents experience a major depressive episode each year,
leading to substantial problems at school and at home. Depressed teens may fail in school, lose their jobs, or turn to drugs of abuse. In addition, depression contributes to most cases of suicide, which
is now the number one killer of young adults in the United States.

􀁸􀀃 There are clearly both environmental and genetic factors that
contribute to the development of depression. Risk factors for
children can include a history of neglect, abuse, loss of a parent
(especially the same-sex parent), psychosocial deprivation, or
chronic illness. However, although these factors increase the risk of
depression, most children with, for example, chronic illness do not
become depressed.

􀁸􀀃 In addition, whether stresses are accompanied by a supportive
family may in uence the possible development of depression.Familial or genetic factors also play a role in how resilient people
can be to life’s stress.

􀁸􀀃 There are several ways to treat adolescent depression. Certainly,
helping to create a supportive home and school environment is
essential, as is trying to gradually get the patient involved again
with pleasurable activities and exercise. Sleep habits and daily
routines may need to be normalized.

􀁸􀀃 Any coexisting anxiety or other mental problems, substance abuse,
learning problems, or medical issues need to be evaluated and
addressed, even while pursuing active therapy for depression.

􀁸􀀃 Psychotherapy can be effective, especially for mild-to-moderate
depression. The most well-studied form of therapy is called
cognitive behavioral therapy, which at its core is an application of
the idea that our thoughts cause our feelings and behaviors.

􀁸􀀃 Although talking is of course involved, cognitive behavioral
therapy isn’t just talking about feelings—it’s a focused approach to
help patients learn to recognize their own thoughts, learn how they
lead to distressing symptoms, and most importantly, how to change
the way they think about things. Psychotherapy isn’t as effective
for more severely affected patients and may take weeks or months
to help.

􀁸􀀃 The other effective therapeutic option is antidepressant medications.
These aren’t in any way “happy pills.” They do not work quickly,
but over the span of weeks, these medications can help with the
mood and physical symptoms of depression.

􀁸􀀃 The most widely used group of these medications are called SSRIs.
Overall, SSRIs are quite safe and well tolerated. However, some
studies have showed an increase in suicidal thoughts (though not
actions) in the rst weeks of therapy, leading to an FDA warning
on the label concerning the suicide risk. Ironically, the drop in SSRI
usage caused by concerns raised by this warning has led to a net increase in teen suicide, probably because fewer teens could get
effective therapy.

Question 12

How to treat blisters

Answer 12

To treat a blister, you can follow these steps:

1. Leave it intact: If the blister is small, unbroken, and not causing significant discomfort, it’s generally best to leave it intact. The blister acts as a natural protective barrier against infection.
2. Clean the area: If the blister has popped or is at risk of popping due to friction or pressure, clean the area with mild soap and water to reduce the risk of infection. Gently pat the area dry with a clean towel.
3. Apply a protective covering: Use a sterile adhesive bandage or a moleskin pad to protect the blistered area from further friction or irritation. Ensure that the covering is larger than the blister to provide adequate protection.
4. Relieve discomfort: If the blister is causing pain or discomfort, you can take over-the-counter pain relievers like acetaminophen or ibuprofen, following the recommended dosage instructions.
5. Avoid draining unless necessary: Avoid intentionally draining the blister unless it is large, painful, or likely to burst on its own. If drainage becomes necessary, clean a needle or pin with rubbing alcohol, then gently puncture the edge of the blister, allowing the fluid to drain. Leave the overlying skin intact to serve as a natural bandage.
6. Keep it clean and dry: Keep the blister clean and dry to promote healing. Change the protective covering daily or whenever it becomes dirty or wet.
7. Monitor for infection: Keep an eye out for signs of infection, such as increased pain, redness, warmth, swelling, or pus. If signs of infection develop, seek medical attention promptly.

It’s important to note that if you have diabetes, poor circulation, a compromised immune system, or the blister is extensive or located in a sensitive area, it’s best to seek medical advice for proper evaluation and treatment.

Question 13

Folk cures for allergies

Answer 13

While natural remedies may not be as extensively studied as conventional medical treatments, some people find them helpful in managing allergy symptoms. Here are a few natural remedies that some individuals have reported to be beneficial:

1. Nasal rinses with saline solution: Using a saline rinse, such as a neti pot or nasal irrigation device, can help flush out allergens from the nasal passages and reduce congestion. It can be effective in relieving nasal symptoms.
2. Quercetin: Quercetin is a plant pigment with antioxidant and anti-inflammatory properties. It is found naturally in foods like onions, apples, berries, and leafy greens. Some studies suggest that quercetin may help reduce allergy symptoms by stabilizing mast cells, which release histamine during an allergic reaction. However, more research is needed to establish its effectiveness.
3. Butterbur: Butterbur is a herb that has been used traditionally for various conditions, including allergies. It may have antihistamine and anti-inflammatory effects. However, it’s important to note that raw butterbur contains compounds that can be toxic to the liver, so it should only be used in a processed form that removes these compounds.
4. Probiotics: Probiotics are beneficial bacteria that can support gut health and immune function. Some studies suggest that certain strains of probiotics may help modulate the immune response and reduce allergy symptoms. However, more research is needed to determine the specific strains and dosages that are effective.
5. Local honey: Some people believe that consuming local honey, which contains trace amounts of local pollen, can help build tolerance to allergens and reduce symptoms. However, scientific evidence supporting this claim is limited.

It’s important to note that natural remedies may not work for everyone, and their effectiveness may vary. Additionally, it’s crucial to consult with a healthcare professional before trying any natural remedies, especially if you have underlying medical conditions or are taking medications, to ensure they are safe and appropriate for you.

Remember, if your allergy symptoms are severe or significantly impacting your quality of life, it’s advisable to seek medical advice from a healthcare professional for proper diagnosis and treatment options.

Question 14

Ringworm / Athletes food

Answer 14

Ringworm, also known as dermatophytosis, is a fungal infection of the skin that can affect various parts of the body, including the scalp, body, feet (athlete’s foot), and groin (jock itch). The symptoms and treatments of ringworm can vary depending on the location of the infection:

1. Scalp Ringworm (Tinea Capitis):
   - Symptoms: Itchy, red, scaly patches on the scalp, hair loss, small black dots (broken hair shafts), swollen lymph nodes.
   - Treatment: Antifungal medications taken orally (such as griseofulvin, terbinafine, or itraconazole) are typically prescribed for several weeks. Antifungal shampoos or topical creams may also be recommended.
2. Body Ringworm (Tinea Corporis):
   - Symptoms: Red, circular or ring-shaped patches with a raised, scaly border. The patches may be itchy or cause a burning sensation.
   - Treatment: Topical antifungal creams or lotions (such as clotrimazole, miconazole, or terbinafine) are commonly used for 2 to 4 weeks. Keeping the affected area clean and dry is important.
3. Feet Ringworm (Athlete’s Foot or Tinea Pedis):
   - Symptoms: Itchy, peeling skin between the toes, redness, blistering, cracking skin, and a stinging or burning sensation.
   - Treatment: Over-the-counter antifungal creams or sprays containing ingredients like clotrimazole, miconazole, or terbinafine are usually effective. Good foot hygiene, including keeping the feet clean and dry, wearing clean socks and shoes, and avoiding walking barefoot in public areas, is essential.
4. Groin Ringworm (Jock Itch or Tinea Cruris):
   - Symptoms: Itchy, red, scaly rash in the groin area, inner thighs, buttocks, or genitals. The rash may have raised edges and central clearing.
   - Treatment: Topical antifungal creams or powders (such as clotrimazole, miconazole, or terbinafine) are typically applied twice daily for several weeks. Keeping the area clean and dry is important.

In addition to the specific treatments mentioned above, general measures for managing ringworm include:

• Good hygiene: Keep the affected area clean and dry. Wash and dry towels, clothing, and bedding regularly.
• Avoid sharing personal items: Do not share towels, clothing, combs, or other personal items with someone who has ringworm.
• Prevention: Practice good hygiene, keep the skin dry, wear clean clothes, and avoid walking barefoot in public areas.

It’s important to note that while over-the-counter treatments may be sufficient for mild cases of ringworm, more severe or persistent infections may require prescription-strength antifungal medications. If you suspect you have ringworm or if the symptoms worsen or do not improve with treatment, it is advisable to consult a healthcare professional for a proper diagnosis and appropriate treatment plan.

Question 15

Night movement

Answer 15

Move extremely slow at night,

Camo up

Stay in the shadows

Move from concealment to concealment.

Beware the third dimension of the city. They can see you from the top of buildings.

Question 16

Mother and son vomiting

Answer 16

•• Today we start with two patients together, a mother and her
20-month-old son. Typically, we don’t see two patients at the
same time in the ED, to protect privacy and to make sure we do a
complete job, but in this case it doesn’t make any sense to separate
them. The mom is Kayla; she’s 20 years old. We’ll call her son
Junior. They’re here with a chief complaint of “vomiting.”

•• Kayla says that this started in December, three weeks ago. She
noticed she was having headaches, but thought it was because she
was working hard around the holidays. Some days she’d wake up
feeling sick and she’d throw up. But she had to go to work so she
would take Junior to his grandmother’s or day care. Usually, once at
work, she would feel OK.

•• Kayla says they had moved into their own place, but that was in
November. She has a new job, and Junior had started going to day
care three days a week—the other days he stays with his grandmother.
Perhaps he’s catching something from the other kids in day care?

•• At about the same time Kayla got sick, Junior started having
occasional vomiting, too. Not frequently, but a few times a week,
usually in the mornings. Once he was at his grandmother’s, he would usually feel better. You do your physical exams, and find that
both patients seem well.

•• You’ve got an explanation: Ever since Junior started day care he’s
been catching viral infections and bringing them home to Kayla.
Does it all fit? Healthy paranoia says to keep digging.

•• You ask Kayla whether they seem to catch the vomiting from each
other. She says yes, but the grandmother never seems to catch it.
Neither Kayla nor Junior has had fevers or diarrhea—two symptoms
of viral infections. That absence points away from a virus.

•• Still, what else could it be? Maybe it’s just a coincidence. You’re
not sure, yet. Let’s see another patient while Kayla and her son are
observed for a further interval in the ED.

•• They look fine. Junior (who had been kind of sleepy earlier) is now
running around the room, and Kayla, again, says she feels better.
You say, “I just want to make sure I’m not missing anything. When,
exactly, did this start?”

•• Kayla says the symptoms started two weeks after they moved into
their new apartment. Kayla looks embarrassed—it sounds like her
apartment is a basement of a building, but again, she says it’s all she
can afford.

•• What’s in the apartment that’s making them both sick? You only
need one test, and you ask the nurse to draw it on both the mom
and the child. It’s a carboxyhemoglobin level, which detects carbon
monoxide. And you find that both mom and Junior have elevated
carboxyhemoglobins. Both of them, since the weather got colder
and the furnaces in their basement apartment have been running,
have been exposed to carbon monoxide.

•• The most important step is to make sure they don’t go back to
their apartment, and to call the health department to investigate the
building. Kayla and Junior, you tell them, should go back to live
with Junior’s grandmother, at least for a little while.

•• Though they weren’t badly ill now, it was a matter of time—if
one night was even colder, the furnaces could have made enough
carbon monoxide to kill Kayla and her son. Getting the diagnosis

Question 17

Broken wrist or something worse?

Answer 17

•• The X-ray of Tonya’s wrist is complete, and her mom is here with
her now. On Tonya’s X-ray you see a broken bone at the end of
the wrist. You head into Tonya’s room to talk with her family, and
something isn’t right. Tonya is lying down, and she looks pale and
sweaty. Her mother says, “Is it broken? She looks really bad.”

•• You try to shake her awake, and she doesn’t respond. You call for a
nurse to help out, and start your ABCs. Airway: Tonya’s airway is
open. Breathing: You can see her chest rising and falling. Circulation:
You feel a pulse, and it’s fast and does not feel especially strong.

•• The clinical scenario that’s most likely here is shock, which means
that there’s not enough blood and oxygen getting to where it needs
to go, leading to cellular injury and organ dysfunction. Her heart rate
has sped up in an effort to get more blood around, but it’s not enough.

•• The nurse has already started work on getting an IV in place, and
another splints her wrist to prevent further injury. You also put
Tonya on oxygen, and tell the nurse what fluids to run into the IV
once it’s started. Tonya’s mom is escorted to the hall.

•• With Tonya, our top concern is that she’s in shock related to trauma,
from the fall off of the bike. Internal bleeding in her abdomen or in
her skull could cause her symptoms. A quick bedside test is done.
There’s no free fluid, meaning it’s unlikely that there’s bleeding in
the abdomen. Her exam is fairly normal.

•• Tonya’s vitals look a little better since the fluid started running in,
and she’s coming around and talking more. You’ve decided she
doesn’t need mechanical ventilation, though you’ll certainly keep
an eye on her ABCs.

•• The next step is to arrange for a head CT scan to look for bleeding
in the brain. But before she’s rolled over to radiology, you repeat the
exam. On her upper chest is a new cluster of reddish-purple marks,
kind of like bruises. You press the skin, and the discoloration does
not fade away with pressure.

•• These marks are called petechiae—they’re small broken blood
vessels under the skin, or small areas where blood has leaked out of
the vessels. When a bunch of petechiae cluster together, it’s called
purpura. Whatever it’s called, it’s not good.

•• You order IV antibiotics—overwhelming infection is one cause of
purpura, and that would explain shock, too. You notify the blood
bank that your patient may need transfusions of blood or platelets,
and you arrange admission to the intensive care unit upstairs.

•• Within a few hours, Tonya becomes completely unresponsive. She
requires intense medical support, and develops other signs of organ
dysfunction. Testing confirms that Tonya was septic, with bacteria
growing in her blood. Hopefully, she’ll pull through this, but it’s
going to be a battle for her.

•• Tonya came in with a hurt wrist; when she became very ill, the
logical thought was that the fall that broke her wrist also caused
internal injuries. But, in fact, the cause of her significant illness
was sepsis. Treat the cause, not the symptoms—though sometimes
that’s easier said than done.
Suggested

Question 18

Healing Fractures

Answer 18

Setting and healing a fracture should be done under the supervision of a healthcare professional. However, here are some general steps involved in the process:

1. Medical evaluation: Seek immediate medical attention for a suspected fracture. A healthcare professional will examine the injury, potentially using X-rays or other imaging tests to confirm the fracture and determine its severity.
2. Immobilization: The injured area needs to be immobilized to prevent further damage and promote healing. This may involve the use of splints, casts, braces, or traction, depending on the type and location of the fracture. The healthcare professional will determine the appropriate immobilization method.
3. Reduction: If the fracture is displaced or unstable, a reduction may be necessary to realign the bones. There are two types of reduction:a. Closed reduction: The bones are manipulated and realigned without surgical intervention. This is typically done under anesthesia or with the use of pain medication.b. Open reduction: In more complex fractures, surgery may be required. The surgeon will make an incision to access the fracture site and realign the bones using screws, plates, or other fixation devices.
4. Pain management: Pain medication may be prescribed or recommended to manage pain during the healing process.
5. Follow-up care: Regular follow-up appointments with the healthcare professional are essential to monitor the healing progress, ensure proper alignment, and make any necessary adjustments to the treatment plan.
6. Rehabilitation: Once the initial healing phase has passed, rehabilitation exercises and physical therapy may be recommended to restore strength, range of motion, and function to the affected area.

It’s crucial to emphasize that setting and healing a fracture should be done by a qualified healthcare professional. They have the expertise and tools to ensure proper alignment, minimize complications, and promote optimal healing.

Question 19

Obesity

Answer 19

􀁸􀀃 The treatment of obesity hypoventilation syndrome starts with weight loss. This is not easy to do, and often patients are not
successful in losing weight. However, if weight can be lost,
sometimes even a small percentage, there can be a big improvement
in sleep quality and ventilation.

􀁸􀀃 For a patient like Joe, who is already in heart failure, weight loss
is still a goal, but more aggressive therapy would be started right
away. This would include ventilatory assistance during sleep, using
a mask device that can provide positive pressure—a sort of push on the air to keep the airway open and make sure that there is airflow both in and out. The device also makes sure that enough breaths are
taken each minute to ensure adequate ventilation.

􀁸􀀃 Joe also needs treatment for his heart failure. This may include
diuretic medications to increase urine output and decrease retained fluid; it may also include medicines to get the heart to pump harder
or more ef ciently, plus medication to control Joe’s blood pressure.
􀁸􀀃 If treatment of his obesity hypoventilation syndrome itself is
successful, his heart can recover, and he may not continue to need
these heart medicines, but for now, there isn’t time to wait and see.

􀁸􀀃 The most aggressive therapy to help patients like Joe lose weight
is bariatric surgery, which includes methods like stomach stapling or intestinal bypass to decrease the amount of food he can eat or
decrease the number of calories that he can absorb.
􀁸􀀃 In Joe’s condition, with heart failure, this kind of surgery is too
risky, but perhaps with some improvement he may be able to
tolerate a bariatric procedure. Improvements in bariatric techniques
are making the surgery less risky, but they’re still not suitable for
patients like Joe.
􀁸􀀃 Obesity can lead to heart failure. Obesity also contributes to
orthopedic problems like bad knees and hips, high blood pressure,
coronary artery disease, some cancers, cholesterol disorders, stroke,
liver and gallbladder disease, etc.

Question 20

Insect Bite

Answer 20

Rachel’s Boil
•• Let’s meet Rachel. She’s 28, and her chief complaint is “spider
bite.” She has a warm, raised, pink area on her forearm, with a
small central area that looks white or yellowish. She says it hurts
a little, but that otherwise she feels OK. She thinks she got bitten a
few days ago.

•• Only two spider species cause problematic bites in the U.S. The black
widow spider’s initial bite is usually painless, but if a significant
amount of venom was transferred with the bite, a few hours later
there can be painful muscle cramps or twitching, then rarely trouble
breathing and other systemic symptoms. In contrast, the brown
recluse spider can cause a severe local reaction at the site of its bite,
including an open ulcer with dying tissue 5–7 days after a bite. Very
rarely, there can be systemic reactions to the venom, but for the most
part the concern after a brown recluse bite is local wound care.

•• Does it sound like Rachel has a spider bite? It’s certainly not a
black widow bite, and it’s almost certainly not a brown recluse
spider bite, either. In fact, what Rachel has is called a furuncle,or more commonly a
boil. This is an acute,
tender superficial skin
infection that’s almost
always caused by the
bacteria Staphylococcus
aureus.

•• Using a warm wet
compress can help, and
if there’s a pocket of
pus there we’d typically
open up the boil to let
it drain. Sometimes a
topical or oral antibiotic
effective against staph
can help, though the
most important step is
draining the abscess.
•• Rachel is reassured
to learn that it’s not a
spider bite, but she’s
still worried—what if
it’s a tick bite? Certain
ticks can carry Lyme
disease (rash, ongoing
complications if untreated) or Rocky Mountain spotted fever
(headache, fever, rash, vomiting, abdominal pain, other problems).
Both are potentially severe if untreated, but both can be treated with
antibiotics.

•• But you tell Rachel that this doesn’t look like a tick bite. If more
symptoms begin, she ought to come back here or go see her own
doctor, but for now all she needs is local wound care. You tell her
to use warm soaks and a topical antibiotic cream, and you send
her home.

Question 21

Treating Diarrhea

Answer 21

Mild Diarrhea:

Symptoms: Mild diarrhea is typically characterized by loose or watery stools, occurring a few times a day.
Duration: It usually lasts for a short duration, commonly a few days.

General well-being: Despite experiencing diarrhea, individuals with mild cases generally maintain normal hydration and are able to go about their daily activities.
Treatment:

Hydration: Focus on maintaining fluid intake to prevent dehydration. Drinking water, clear broths, oral rehydration solutions (ORS), or electrolyte-rich drinks can be helpful.
Diet: Gradually reintroduce bland, easy-to-digest foods such as rice, bananas, toast, and boiled potatoes. Avoid spicy, fatty, or greasy foods, caffeine, and alcohol.

Symptom relief: Over-the-counter anti-diarrheal medications, such as loperamide (Imodium), may help alleviate symptoms. However, these medications should be used with caution and only as directed.

Serious Diarrhea:

Symptoms: Serious diarrhea often involves frequent, persistent, or severe watery stools that may contain blood or mucus. Other symptoms can include abdominal pain, cramps, fever, and dehydration.

Question 22

Phases of societal Crash

Answer 22

Phase 1: Cooperation: 24 hours.

People will work together and are willing to share

Phase 2: Self Preservation: 48 hours.

People will think more of preserving food and water.

Phase 3: Anarchy: 2 weeks.

Cops home and take of their families. 600 people died in this stage of katrina.

Phase 4-5: Tribalism/Warlords.

Indeterminate

Question 23

How to treat burns

Answer 23

The treatment for different types of burns can vary. Here are some general guidelines for treating different degrees of burns:

1. First-degree burns (Superficial burns):
   - These burns affect the outermost layer of the skin (epidermis).
   - Remove the source of heat and run cool (not cold) water over the burn for about 10-20 minutes to help alleviate pain and reduce heat.
   - Do not use ice or icy water as it may further damage the skin.
   - Gently pat the burn dry with a clean, sterile cloth.
   - Apply a soothing burn ointment or aloe vera gel to the burn to promote healing and relieve discomfort.
   - Cover the burn with a sterile non-stick dressing or a clean cloth to protect it.
2. Second-degree burns (Partial-thickness burns):
   - These burns affect the epidermis and extend into the second layer of skin (dermis).
   - For superficial second-degree burns, follow the same steps as first-degree burns.
   - For deeper second-degree burns, seek medical attention as they may require professional care, such as cleaning, dressing changes, and potential use of antibiotics or specialized burn treatments.
3. Third-degree burns (Full-thickness burns):
   - These burns extend through all layers of the skin and may involve underlying tissues.
   - Third-degree burns require immediate medical attention. Call emergency services or go to the nearest emergency room.
   - While waiting for medical help, do not remove any clothing stuck to the burn.
   - Cover the burn with a clean, dry cloth or sterile dressing to protect it.
   - Keep the affected person lying down and elevate the burned area, if possible.
   - Do not apply any creams, ointments, or home remedies to third-degree burns, as they can interfere with medical treatment.

Remember, these are general guidelines, and it’s important to seek medical attention for severe burns, burns on sensitive areas (face, hands, feet, genitals), burns caused by chemicals or electricity, or burns in individuals with pre-existing health conditions. Proper medical evaluation and treatment are crucial to promote healing, prevent infection, and minimize scarring.

Question 24

Kidney Stones

Answer 24

Kidney stones are hard deposits that form in the kidneys. They can cause significant pain and discomfort when they obstruct the urinary tract. Here are the symptoms and treatments for kidney stones:

Symptoms:
1. Severe pain in the side or back, below the ribs.
2. Pain that radiates to the lower abdomen and groin.
3. Hematuria (blood in urine).
4. Cloudy or foul-smelling urine.
5. Frequent urination.
6. Urgency to urinate.
7. Painful urination.
8. Nausea and vomiting.
9. Fever and chills (if there is an accompanying infection).

Treatment:
1. Pain management: Over-the-counter pain relievers, such as nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, can help alleviate the pain associated with kidney stones. In some cases, stronger prescription pain medications may be needed.
2. Hydration: Drinking plenty of fluids, especially water, can help flush out the kidney stones and prevent new ones from forming. Adequate hydration is crucial in the treatment and prevention of kidney stones.
3. Medications:
- Alpha-blockers: These medications help relax the muscles in the urinary tract, facilitating the passage of kidney stones.
- Medications to control underlying conditions: Depending on the composition and underlying causes of kidney stones, specific medications may be prescribed to manage conditions such as hyperparathyroidism or gout.
4. Medical procedures:
- Extracorporeal Shock Wave Lithotripsy (ESWL): This procedure uses shock waves to break the kidney stones into smaller pieces, making it easier for them to pass through the urinary tract.
- Ureteroscopy: A thin tube is inserted into the urinary tract to remove or break up larger stones.
- Percutaneous Nephrolithotomy (PCNL): In cases of larger or more complex stones, a surgical procedure may be performed to remove or break up the stones using a small incision and specialized instruments.
5. Surgery: In rare cases where other treatments are not effective, open surgery may be necessary to remove the kidney stones.

Prevention:
1. Hydration: Drinking plenty of water and maintaining adequate fluid intake can help prevent the formation of kidney stones.
2. Dietary modifications: Depending on the type of kidney stones, specific dietary changes may be recommended to reduce the risk of stone formation. This may include reducing sodium and animal protein intake and avoiding high-oxalate foods.
3. Medications: In some cases, medications may be prescribed to prevent the formation of specific types of kidney stones.

It is important to consult with a healthcare provider for proper diagnosis, treatment, and prevention strategies tailored to individual circumstances.

Question 25

when are amputations performed

Answer 25

Amputations are performed as a last resort when other treatment options have been exhausted or when the limb or body part is severely damaged or diseased beyond repair. The most common reasons for amputations include: 1. Traumatic injury: Severe accidents or injuries that result in extensive damage to the limb, such as crush injuries, severe burns, or avulsion injuries, may require amputation. 2. Peripheral vascular disease: In cases where there is a significant blockage of blood vessels in the limbs (peripheral artery disease) or severe infections, amputation may be necessary to prevent further complications or to save the person's life. 3. Cancerous tumors: Malignant tumors that affect the bones, muscles, or soft tissues of the limb may require amputation to remove the cancer and prevent its spread to other parts of the body. 4. Severe infections: Infections that do not respond to antibiotics or other treatments and pose a risk to the person's overall health may necessitate amputation to control the infection. Its done Where the extremity looses pulse, temperature, its no longer sensitive to the touch, Its very red or black and when a bone had been crushed beyond repair The process of amputation typically involves the following steps: 1. Evaluation and planning: A team of healthcare professionals, including surgeons and rehabilitation specialists, will assess the individual's condition, evaluate the extent of the injury or disease, and develop a personalized treatment plan. 2. Anesthesia: Before the surgery, the person will receive anesthesia to ensure they are comfortable and pain-free during the procedure. The type of anesthesia used may vary based on the specific circumstances and the individual's overall health. 3. Surgical procedure: The surgeon will remove the damaged or diseased part of the limb, taking care to preserve as much healthy tissue as possible. Surgical techniques and the level of amputation will depend on the specific circumstances. 4. Wound closure and healing: After the amputation, the surgical site is closed using sutures or other closure methods. The wound is then carefully monitored and managed to promote healing and prevent infection. 5. Rehabilitation and prosthetics: Following the amputation, the individual will undergo rehabilitation to help regain strength, mobility, and independence. This may involve physical therapy, occupational therapy, and the fitting and use of prosthetic devices or assistive devices to aid in daily activities. It's important to note that amputations are complex procedures with long-term physical and psychological implications. The decision to perform an amputation is made after careful consideration of all available treatment options, weighing the risks and benefits, and with the active involvement of the individual and their healthcare team.

Question 26

Treating Burns

Answer 26

For burns, first aid begins with stopping the burning process by removing clothes and jewelry. Then, burns should be cooled by irrigating them with room-temperature water. This reduces cellular damage by limiting the depth and width of burns. Ice is not a good idea—it freezes tissue, and can actually increase tissue damage.

Question 27

Surviving a fire

Answer 27

Surviving a fire requires quick thinking, preparedness, and decisive action. Here are some essential steps to increase your chances of survival in a fire emergency: 1. Stay calm and alert: Panic can impair your ability to make clear decisions. Stay as calm as possible and focus on taking appropriate actions. 2. Alert others: If there are other people in the building, immediately notify them of the fire. Yell, knock on doors, or activate fire alarms to alert others and ensure they are aware of the danger. 3. Escape if possible: If the fire is small and contained, and you can safely escape, do so immediately. Follow your predetermined escape plan and evacuate the building as quickly as possible. Crawl low to the ground where the air is less smoke-filled. 4. Check doors for heat: Before opening any doors, check them for heat with the back of your hand. If a door is hot, do not open it as it could indicate fire on the other side. Find an alternative route or remain in a safe area and seal the door with towels or clothing to prevent smoke from entering. 5. Stay low in smoke-filled areas: Smoke is the leading cause of fire-related deaths. If you encounter smoke during your escape, stay low to the ground where the air is clearer. Cover your nose and mouth with a cloth or a damp piece of clothing to reduce smoke inhalation. 6. Use exits and fire escapes: Follow designated exit routes and use stairwells, fire escapes, or designated emergency exits to evacuate the building. Avoid using elevators, as they can malfunction during a fire. 7. Communicate with firefighters: Once outside, if emergency responders are on the scene, inform them of anyone who may still be inside the building. Provide them with accurate information to assist in rescue efforts. 8. Don't re-enter the building: Once you have safely escaped a burning building, do not attempt to re-enter for any reason. Let the firefighters handle the situation and provide them with any pertinent information you have about the building or occupants. Additional tips for fire safety: - Develop a fire escape plan: Create a detailed escape plan for your home or workplace and practice it regularly with all occupants. - Install and maintain smoke alarms: Ensure that smoke alarms are installed in every room and on every level of your home or workplace. Test them regularly and replace batteries as needed. - Stay low in smoke: Remember that smoke rises, so staying close to the ground during a fire can improve your chances of breathing cleaner air. - Preventative measures: Take precautions to prevent fires, such as keeping flammable materials away from heat sources, not leaving candles or cooking unattended, and having fire extinguishers readily available. - Educate yourself: Familiarize yourself with fire safety procedures and learn how to use a fire extinguisher properly. Remember, the most important priority in a fire emergency is your personal safety. If in doubt, evacuate the area and seek professional help.

Question 28

Proof: Science of Alcohol

Answer 28

Here are some key take-outs from Proof: The Science of Booze. Did you know that: * Yeast is key in making booze, it converts sugar into ethanol and carbon dioxide * Yeast is a single-celled organism, it’s neither plant nor animal, neither bacteria nor virus, it’s a fungus * Yeast is the first creature to have its genome sequenced * Alcohol gets absorbed better when injected into the intestines, imagine how this study was performed… * Hangovers are still a mystery, and nobody has a cure for it * Distillation was discovered over 2000 years back * Scientists and Engineer discovered many things while studying alcohol * There is a lot of research done on booze, not with (that’s for philosophers ;))

Question 29

Hyperthyroidism

Answer 29

Hyperthyroidism is a condition characterized by the overproduction of thyroid hormones by the thyroid gland. Thyroid hormones regulate various functions in the body, including metabolism, heart rate, and body temperature. When there is an excessive production of thyroid hormones, it leads to an accelerated metabolism and a range of symptoms. The most common cause of hyperthyroidism is an autoimmune disorder called Graves' disease. Symptoms of hyperthyroidism may include: 1. Weight loss despite increased appetite 2. Rapid or irregular heartbeat 3. Tremors or shaking 4. Increased sensitivity to heat 5. Excessive sweating 6. Nervousness, anxiety, or irritability 7. Fatigue or muscle weakness 8. Changes in bowel patterns, such as frequent bowel movements 9. Changes in menstrual patterns in women 10. Enlarged thyroid gland (goiter) 11. Eye problems (Graves' ophthalmopathy) like bulging eyes, eye irritation, or vision changes. The treatment of hyperthyroidism aims to reduce the production of thyroid hormones and manage the symptoms. Common treatment options include: 1. Antithyroid medications: Medications like methimazole or propylthiouracil (PTU) can help reduce the production of thyroid hormones. These medications are typically taken for a specified period, and their effectiveness is monitored through regular blood tests. 2. Radioactive iodine therapy: Radioactive iodine is administered orally, and it selectively destroys the cells of the thyroid gland that produce thyroid hormones. Over time, this leads to a decrease in hormone production. This treatment is often a long-term solution but may lead to hypothyroidism (underactive thyroid) in some cases. 3. Beta-blockers: Medications such as propranolol or atenolol are used to manage the symptoms of rapid heartbeat, tremors, and anxiety associated with hyperthyroidism. These medications do not directly affect thyroid hormone levels but provide symptomatic relief. 4. Surgery (thyroidectomy): In some cases, surgical removal of all or a portion of the thyroid gland may be necessary, especially if antithyroid medications and radioactive iodine therapy are not suitable or effective. After a thyroidectomy, lifelong thyroid hormone replacement medication is necessary to maintain normal hormone levels. The choice of treatment depends on various factors, including the underlying cause, the severity of symptoms, the individual's age, and any associated health conditions. It is important for individuals with hyperthyroidism to work closely with their healthcare provider to determine the most appropriate treatment plan and to receive regular follow-up care to monitor thyroid hormone levels and manage symptoms effectively.

Question 30

Heart Attacks

Answer 30

􀁸􀀃 Almost all causes of sudden collapse are from the heart, from some condition that suddenly stops the heart from beating. The most common cause of this is what is colloquially called a heart attack, or myocardial infarction (MI). This is when a lack of blood ow to the heart muscle itself causes the death of heart muscle cells. It’s often accompanied by a sudden change in the heart rhythm, a so-called arrhythmia. Instead of the heart beating in an organized way that effectively pumps blood, it just kind of quivers. 􀁸􀀃 No blood ow to the brain means that the body will collapse and die quickly. Sudden arrhythmias can also occur because of other conditions, including genetic predispositions to sudden death that can run in families. 􀁸􀀃 Historically, heart attacks have been thought of as a disease of a certain kind of person: usually, a successful, driven, type A kind of man. However, heart attacks are in fact the leading cause of death among women. 􀁸􀀃 Although our ability to deal with and treat a heart attack has become increasingly effective, we’re still seeing an increasing impact of heart disease. This is mostly because it is so dif cult to effectively modify well-known risk factors for atherosclerotic heart disease. 􀁸􀀃 The heart is, essentially, a muscle—a not-too-large muscle, but one that has to contract and relax and contract and relax, continuously, without a rest. Like any other muscle or living tissue, the heart needs oxygen, carried by blood though the coronary arteries that course along the surface of the heart. If these coronary arteries get blocked, there won’t be enough blood ow or oxygen, and parts of the heart muscle itself will be damaged or killed. 􀁸􀀃 The most common reason for blockage of ow though the coronary arteries is atherosclerosis: the buildup of plaques along the walls of the coronary blood vessels. A similar process can occur in blood vessels leading to the brain, causing stroke, or to other blood vessels affecting other organs. Therefore, the risk factors for stroke and heart attack overlap in many ways. 􀁸􀀃 It’s commonly thought that atherosclerotic plaques are made of fatty deposits, but that is an oversimpli cation. Although fats, or lipids, do contribute to these plaques, there are also in ammatory cells, scarring, and clotting cells and proteins that contribute to the plaques. 􀁸􀀃 These so-called atheromas start to develop in the teens and twenties and slowly proliferate. Longstanding, stable blockages can lead to the natural development of collateral vessels—new vessels that can bypass the blockage to deliver blood. Atherosclerotic plaques can lead to symptoms in several different ways.

Question 31

Treating Cancer

Answer 31

􀁸􀀃 Surgery is the primary, main therapy for breast cancer, and surgery alone can be curative when breast cancer is caught early. After surgery, many women with early cancer pursue what’s called adjunctive therapy, which refers to things done in addition to the primary therapy—surgery—to increase the chance of cure or longterm survival. 􀁸􀀃 Although theoretically an early cancer shouldn’t have spread to outside tissue, we can’t know if a few cancer cells have snuck out— and even a few cells, or one cell, can continue to grow and allow cancer to spread. Adjunctive therapy for breast cancer includes mainly chemotherapy, hormonal therapy, and radiation. 􀁸􀀃 Chemotherapy refers to drugs given to kill cancer cells or halt their spread. It’s most effective on rapidly dividing cells, and different kinds of breast cancer may be more or less sensitive to chemo. The chemotherapy drugs are often more effective when used in combinations. Although side effects may be very dif cult, we have gotten better at managing many of them. 􀁸􀀃 Many, but not all, breast cancer cells have receptors for female hormones. If they do, medications to block hormones can prevent cancers from spreading. 􀁸􀀃 Radiation therapy can also be used to destroy rapidly dividing cancer cells, though there are side effects and dose limitations. These adjunctive therapies can be used to increase the chance of long-term survival or as palliative therapy to extend life and provide comfort, even in patients who cannot be cured.

Question 32

Talking to paramedics about burns

Answer 32

More ambulances have pulled up, there’s plenty of help on the scene, and it’s time to arrange transport. The paramedic asks you about your patient’s status. This is your quick summary, just the facts: “Vitals normal, she’s ambulatory and talking, her voice is hoarse and she’s coughing. She was in an enclosed room with smoke. One large second- to third- degree burn on her leg, estimate 6% BSA.” The paramedic nods and instructs you to get her on an ambulance and ride with her. •• Let’s go through that quick summary—what you reeled off to the paramedic, the most essential things she needed to know. You started with, “Vitals normal”—that reflects those crucial ABCs. Then the phrase, “she’s ambulatory and talking” describes her overall functioning and mental status. Ambulatory and talking is much more reassuring than comatose or unable to speak. •• You also mentioned that she’s hoarse and coughing—that was to express the findings that make you worry about potential smoke inhalation. You also mentioned the large burn, and the location. Location is important, because burns on the neck, chest, or face can lead to additional complications from problems with breathing and circulation. Then you said an estimate of the burn size, saying, “6% BSA,” or 6% body surface area. •• That estimate is based on the “rule of 9s,” a shorthand way of estimating burn size. It breaks an adult’s body up into percentage zones, each of which is a multiple of 9 to add up to 100%. The head, front and back, is 9%; each arm is 9%; each leg is 18%; and the entire torso is 36%. Our patient had a large burn of the lower extremity, on her thigh and leg. The whole lower extremity would be 18%, and we figured her burn covered about a third of that, for an estimated burn size of 6% of her total body surface area. •• An accurate burn size estimate is important. Larger burns are more likely to lead to big inflammatory changes requiring advanced support, and larger burns will require more-aggressive fluid management. Burns always lead to a loss of fluids, both directly from the exposed burn but also from fluid seeping out of the circulation into the tissues around the burn. So an accurate estimate of burn size helps with triage—who needs what level of care the fastest?—and with starting appropriate fluid management.

Question 33

Proof Conclusions

Answer 33

* During a study of blind smelling odors, amateur drinkers got on average 7.5 out of 10 odors right and pros got 8.6 out of 10 right * Power of suggestion plays a role in the tasting, you will taste what others suggest or because you already know your drink * Our senses are limited, we can smell a single flavor excellent, but it becomes hard when we mix flavors * The shape, size, and visuals of the glass influence your taste * The color of your drink influences your taste * Study shows that adding tasteless artificial colors makes the drink taste different * Taste and smell aren’t well-defined and they’re hard to describe * Professor Noble invented a flavor map, the “[Noble Wine Aroma Wheel](https://en.wikipedia.org/wiki/Ann_C._Noble#The_Aroma_Wheel)” to describe flavor easier and faster for her research * Tasting gets influenced by your environment or setting, your wine tasted so much better at the vineyard on your holiday… * A flavor smells or tastes like something, it doesn’t mean it’s in there * When you taste, you remember a flavor that is stored in your memory and your brain links to it * Everyone taste different, a drink can taste fantastic to one person but shitty to another

Question 34

cellulitis symptoms and treatments

Answer 34

Cellulitis is a bacterial skin infection that typically affects the deeper layers of the skin and the underlying tissues. Here are the symptoms and treatments for cellulitis: Symptoms of Cellulitis: - Redness: The affected area may appear red, swollen, and warm to the touch. - Pain and tenderness: The area can be painful and tender, especially when touched or pressed. - Swelling: Swelling may occur around the affected area. - Skin changes: The skin may become tight, shiny, or stretched, and there may be a change in texture. - Skin rash: Some people may develop a rash that spreads and blisters. - Fever and chills: In more severe cases, individuals may experience fever and chills. Treatment of Cellulitis: 1. Antibiotics: - Oral antibiotics: Mild to moderate cases of cellulitis can often be treated with oral antibiotics. Commonly prescribed antibiotics include cephalexin, dicloxacillin, or clindamycin. It's important to complete the full course of antibiotics as prescribed. - Intravenous (IV) antibiotics: If the infection is severe, spreading rapidly, or if oral antibiotics are not effective, hospitalization may be required, and antibiotics may be administered through an IV. 2. Wound care: - Cleaning: Keep the affected area clean by washing it gently with mild soap and water. - Moisturizing: Apply a mild moisturizer to prevent excessive dryness and cracking of the skin. - Bandaging: In some cases, a sterile bandage or dressing may be recommended to protect the affected area. 3. Elevating the affected area: Elevating the affected limb or area can help reduce swelling and promote better circulation. 4. Pain management: Over-the-counter pain relievers, such as acetaminophen or ibuprofen, can help alleviate pain and reduce inflammation. Follow the recommended dosage and consult with a healthcare professional if needed. 5. Follow-up and monitoring: It's important to follow up with a healthcare professional to ensure proper healing and monitor for any complications. They may need to reassess the infection and adjust the treatment if necessary. In some cases, cellulitis can lead to complications such as the spread of infection to the bloodstream or the development of an abscess. If you suspect you have cellulitis or if the symptoms worsen despite treatment, it is crucial to seek medical attention promptly. A healthcare professional will provide an accurate diagnosis and recommend the most appropriate treatment based on the severity and location of the infection.

Question 35

Arnold - Belly Pain

Answer 35

Arnold •• The last case on our shift today is a 55-year-old man, Arnold, with a chief complaint of belly pain. Arnold says his pain started a few days ago and is now constant. It’s on the right side, up high in the belly. He also thinks he’s been running a fever today—he’s felt at times sweaty or chilled. We need more story; the OLD CAAAR mnemonic can help: ○○ Onset: a few days ago. ○○ Location: the right upper belly. ○○ Duration, this pain is pretty much constant now. ○○ Character: a sharp sort of pain. ○○ Alleviators: none. He tried antacid and that didn’t work. ○○ Aggravators: It hurts to breathe in, especially to breathe in deeply. ○○ Activity at onset: Arnold doesn’t remember what he was doing when this started. ○○ Radiation: none. The pain doesn’t move or shoot or point anywhere else. •• It’s abdominal pain, but the story doesn’t fit—it doesn’t sound like there’s anything wrong in the abdomen. Let’s see what the physical exam shows. His heart rate and respiratory rate are fast, though those might be abnormal because of his elevated temperature. One simple and reasonable step worth taking is to give Arnold a dose of ibuprofen. That will safely reduce his fever, and we’ll be able to reassess those vitals. •• Otherwise, on Arnold’s physical exam, everything seems normal. His belly is not at all tender, and his lungs are clear and unlabored— he’s breathing a little fast, the vital signs say, but he’s not having any difficulty breathing. •• Arnold mentioned that his pain worsens with breathing. Is there something wrong in his lungs, or with his diaphragm—something pressing there that hurts more when he moves it? We need a look at his lungs, and the test we need is a chest X-ray. •• The chest X-ray shows an area of increased density, called a consolidation, right at the bottom of his right lung, up against the diaphragm. That’s pneumonia, an infection of the lung, and the consolidation we see on X-ray is infected fluid, or pus. That’s what hurts, and that’s what hurts more when he breathes in. Arnold feels the pain in his belly, but the disease process is at the bottom of his chest. That’s not so unusual. You might expect pain to reliably happen exactly where the pathology is. But pain sensations don’t always correlate exactly with where the pain originates.

Question 36

Beer to Whiskey

Answer 36

In a basic sense, all whiskey begins life as beer. Whiskey distillers start by fermenting grains (just like beer brewers do) to release sugars that yeast will eventually convert into alcohol. But, the primary difference with whiskey is that this fermented product is never intended to be drank. So, producers never refine the mixture with additional ingredients, like hops. What sets all beer spirits apart is that, before distillation, the beer has been finished in a way that makes it drinkable—identical to the kind of brew you’d find in a six-pack on store shelves. And there’s a reason most beer rarely becomes a spirit. Working with a finished beer product is what makes beer spirits so unique, but it’s also what makes them more costly, both to produce and, ultimately, to buy. "You get a 6,000 gallon tanker of delicious gold medal-winning IPA. That’s a huge expense," Karakasevic explains. "And then you have to sit on it for like two, three, four, six, 10, 12 years and watch it evaporate away. You’re losing three to four gallons a year, and after 10 years, fuck, there’s 40 gallons gone out of one barrel. So your yield goes down and your cost goes up, and it’s harder to sell a $75 bottle of whiskey because everyone likes to spend $35."

Question 37

Treat Eye Infection

Answer 37

The treatment of an eye infection depends on the specific type and severity of the infection. However, here are some general guidelines for treating common eye infections: 1. Maintain good hygiene: Wash your hands thoroughly with soap and water before touching your eyes or applying any medications. 2. Warm compresses: Applying a warm compress to the affected eye can help soothe the symptoms and reduce inflammation. Dip a clean cloth or cotton pad in warm water, wring out excess moisture, and gently place it over the closed eyelid for a few minutes. Repeat this several times a day. 3. Eye drops or ointments: Over-the-counter or prescription eye drops or ointments may be recommended to treat the infection. These medications can help relieve symptoms and fight the underlying infection. Follow the instructions provided by your healthcare provider or the product label for proper usage. 4. Avoid wearing contact lenses: If you wear contact lenses, it's best to avoid wearing them until the infection clears up. Contact lenses can worsen eye infections and prolong the healing process. Replace your contact lenses and lens case to prevent reinfection. 5. Avoid rubbing or touching your eyes: Rubbing or touching your infected eye can further irritate the area and spread the infection. Try to resist the urge to touch your eyes and avoid any activities that may introduce dirt or bacteria into the eyes. 6. Practice good eye hygiene: Keep your eyes clean by gently washing them with a clean cloth and warm water. Avoid sharing towels, pillows, or other personal items that may come into contact with your eyes. 7. Seek medical attention: If your symptoms worsen, persist, or if you have severe pain, blurred vision, or discharge that is thick, pus-like, or bloody, it's important to seek medical attention promptly. Your healthcare provider can diagnose the specific type of eye infection and prescribe appropriate medications or treatments. It's crucial to remember that these guidelines are general and may not be suitable for all eye infections. It's best to consult with a healthcare professional for an accurate diagnosis and personalized treatment plan based on your specific condition.

Question 38

Diabetes treatment and weight control

Answer 38

􀁸􀀃 The treatment of diabetes is primarily concerned with achieving euglycemia—that is, a normal blood sugar during, after, and between meals. In type 2 diabetes, first-line therapy is losing weight and improving exercise habits. Sometimes, these steps alone can be sufficient to essentially “cure” diabetes. 􀁸􀀃 More typically, though, medications are necessary. These include oral medicines—so-called oral hypoglycemics—that increase insulin sensitivity, increase insulin release, or both. 􀁸􀀃 In many patients with type 2 diabetes, insulin must also be administered, typically by one or more daily injections. Type 1 diabetics, who lack any of their own insulin, must rely on injections. The treatment of diabetes also requires frequent home glucose monitoring with finger sticks. 􀁸􀀃 A more advanced treatment strategy, more typically used for type 1 diabetics, is an insulin pump to administer a constant ow of insulin to the body, similar to the way a healthy pancreas secretes insulin. There’s also technology available to continuously monitor blood sugar. 􀁸􀀃 Though tight control—that is, using intensive therapy to keep blood sugar close to normal—has been shown to best prevent the longterm complications of diabetes, it comes at a price. Deciding how tightly to control blood sugar depends on such factors as the life expectancy of the patient, the overall health and other risk factors, and an honest assessment of compliance and a patient’s ability to self-medicate. 􀁸􀀃 With the exception of a few patients with new-onset type 2 diabetes who successfully lose weight and improve their exercise habits, most patients with diabetes require lifelong active management. 􀁸􀀃 Diabetes is a good example of a disease whose treatment requires not just taking pills and visiting the doctor, but also taking charge of your health and making changes in your life. 􀁸􀀃 Effective weight control involves primarily changing the diet to consume fewer calories. Many different styles of diet have been proposed and studied, including ones that especially discourage carbohydrates or that stress consuming more foods with lower energy content. The best predictor of success isn’t which diet is followed, but whether changes in habits can be sustained for years. 􀁸􀀃 Although exercise alone is usually ineffective in leading to weight loss, exercise combined with dietary changes works better than diet alone. Medications can sometimes be an additional part of a weight loss program, but none are really ideal or particularly effective. 􀁸􀀃 Objectively, the most effective therapy for weight loss for obese patients is surgery. This is a fast-growing field called bariatrics, and it involves a variety of surgical options to lower the stomach volume or bypass some of the digestive and absorptive parts of the intestine—or both. 􀁸􀀃 Although the results of bariatric surgery can be impressive, surgery will not be successful without the patient committing and following through with lifestyle changes as well. Bariatric surgery also entails considerable risks, so it’s really only offered to people with severe obesity or who are already suffering from health consequences of their weight.

Question 39

Influenza Pneumonia

Answer 39

􀁸􀀃 Pneumonia is commonly understood as a bacterial infection in the lungs, but it can be caused by viral or fungal or other kinds of infections, or sometimes by noninfectious things like chemical irritants or an immune-mediated inflammatory reaction. 􀁸􀀃 In most circumstances, though, pneumonia is caused by infection of the lung tissue—infection that causes an accumulation of fluid and debris that leads to coughing and fever. 􀁸􀀃 Lung tissue itself is particularly prone to infection, because we’re constantly breathing in air and bringing in whatever we breathe. Also, the air sacs in the lungs are normally a little moist, and that warm, moist mucus is a breeding ground for microorganisms. 􀁸􀀃 Fortunately, we have immune systems to keep infection away. There are also little hair cells that beat up and down to keep mucus moving around and out so that it won’t get infected easily. But advancing age, lung damage from mild infections, asthma, and many other conditions can compromise lung integrity, increasing the risk of pneumonia. 􀁸􀀃 Influenza, the infection itself, causes fever and cough, so how can we tell it has turned into pneumonia? The time course of the symptoms is a crucial clue. Influenza usually includes about five days of fever that gradually decline. Increasing fevers after a few days often indicates a second, superimposed infection like pneumonia. Cough that’s getting much worse is another clue. 􀁸􀀃 On the physical exam, a patient with pneumonia—influenza pneumonia or any pneumonia—will often be breathing rapidly. There may be signs of increased difficulty breathing, such as pulling in the ribs with each breath, and the breath sounds themselves heard through a stethoscope will sound crackly and abnormal. 􀁸􀀃 Sometimes, a chest X-ray is done to confirm pneumonia. It will show an area of brightness where the X-ray beam is blocked by the accumulated infected fluid. The bigger the area of brightness, the worse the pneumonia (though there isn’t a 100 percent correlation). 􀁸􀀃 X-rays can also be done to monitor therapy for pneumonia to ensure improvement. However, chest X-rays aren’t perfect. The findings on the lm can lag a day or so behind what’s going on with the patient, so very early pneumonias may not be seen yet. 􀁸􀀃 Although pneumonia in young, healthy patients can usually be treated as an outpatient, in older or ill people, it may require hospitalization and extra support with oxygen. Pneumonia remains a significant cause of death in the developed world, often contributing to illness and decline in people with other health problems but occasionally killing someone who was otherwise well. 􀁸􀀃 In the case of influenza pneumonia, the secondary pneumonia itself can be caused by the flu virus invading the lung tissue or by secondary bacterial infections by bacteria that happened to be nearby and have taken advantage of the patient’s illness to cause another infection.

Question 40

Celiac Disease

Answer 40

Celiac disease is a chronic disorder that causes malabsorption of nutrients from the gut, leading to a myriad of symptoms that can include fatigue, anemia, and almost any GI symptom. In celiac disease, malabsorption of nutrients can also affect the bones— decreased absorption of dietary Vitamin D, phosphorus, and calcium can cause decreased bone density. 􀁸􀀃 With celiac disease, the lining of the gut—the small, ngerlike projections where absorption of food nutrients occurs—is damaged, and the net effect is that nutrients are not absorbed across the gut wall into the blood for use by the body. 􀁸􀀃 The primary symptoms of celiac disease are caused by inadequate nutrient availability and also by the GI effects of having, essentially, food staying in the gut instead of moving into your body. This includes diarrhea, bloating, and abdominal pain. 􀁸􀀃 Sometimes, constipation can be more of a problem than diarrhea, or—as in the case of the 55-year-old patient—there can be periods of time when these seemingly opposite symptoms go back and forth. Many celiac symptoms also occur outside of the gut. 􀁸􀀃 Celiac disease was known to the ancient Greeks, who referred to a condition called koiliakos, meaning “suffering of the bowels.” A patient case written in the second century described a man with stomach pain who was underweight, pale, weak, and incapable of working—which is still a pretty good description of a severe case in modern times. The Greek term was translated to the term “celiac” in 1856. 􀁸􀀃 Around that time, it was recognized that this was a disease that could be managed by diet. In 1954, Dutch pediatrician Willem Dicke linked the disease to the ingestion of wheat protein. It’s speculated that his experience seeing patients improve during the famine of 1944, when wheat was scarce, may have helped him recognize the critical role of wheat in this illness. 􀁸􀀃 Though the symptoms of celiac disease are varied and affect many organ systems, it only has one cause: ingesting certain proteins found in wheat, barley, and rye. These are natural proteins from a family called gluten proteins. Celiac disease is sometimes called “gluten enteropathy” or “celiac sprue.” 􀁸􀀃 When gluten-containing foods are eaten by people with celiac disease, these proteins are modi ed or processed so that they trigger a cross reaction with gut tissue. Basically, the body’s own immune system is tricked into attacking healthy cells in the gut (and probably elsewhere, too). 􀁸􀀃 Celiac disease is in a sense an autoimmune disease—the body attacks itself—but it’s an autoimmune disease that has speci c and avoidable trigger. It’s the gluten proteins that trigger the reaction, and once gluten is no longer part of the diet, the disease itself can almost always be reversed. TREATMENT & DIAGNOSIS Treatment and Diagnosis of Celiac Disease 􀁸􀀃 The treatment of celiac disease is, simply enough, a gluten-free diet. However, because wheat-based products are very common in a typical Western diet, a gluten-free diet might not be so simple in practice. Though wheat is the main food to avoid, people with celiac should also not eat barley or rye, and it’s often suggested that oat products be avoided, too, because typically harvested oats are often contaminated with wheat grains that presumably blow across the crops. 􀁸􀀃 At this time, there are no medications to prevent or treat the autoimmune damage that occurs when wheat is ingested, and people with celiac need to avoid eating gluten-containing products for the rest of their lives. Avoiding wheat not only helps relieve the immediate symptoms of celiac disease but also reduces the risk of long-term complications of untreated celiac disease, including osteoporosis and an increased risk of cancer. 􀁸􀀃 For many years, the only way to diagnose celiac disease was by small intestinal biopsy. Dr. Dicke, who made the link with wheat after World War II, also rst described the “villous atrophy” characteristic of celiac disease when biopsies are examined under the microscope. Biopsies are still used to de nitively diagnose celiac and to monitor patient’s progress. 􀁸􀀃 However, the availability of reliable, relatively inexpensive blood tests to diagnose celiac has changed our approach to this disease.

Question 41

Hepatitis and Cirrhosis

Answer 41

Cirrhosis and hepatitis are two related conditions that can affect the liver. Hepatitis refers to inflammation of the liver, while cirrhosis is a progressive and irreversible condition characterized by scarring and liver damage. Hepatitis can be a cause of cirrhosis, particularly when left untreated or chronic. Here are the symptoms and treatments for each condition: Hepatitis: 1. Symptoms: - Fatigue and weakness - Jaundice (yellowing of the skin and eyes) - Abdominal pain or discomfort - Loss of appetite - Nausea and vomiting - Dark urine - Pale or clay-colored stools - Joint pain - Fever 2. Treatments: - Antiviral medications: For viral hepatitis (such as hepatitis B or C), antiviral medications may be prescribed to reduce viral replication and prevent further liver damage. - Supportive care: Rest, maintaining hydration, and a healthy diet are important for supporting the liver's recovery. Avoiding alcohol and certain medications that can further harm the liver is also crucial. - Vaccinations: Vaccinations are available for hepatitis A and hepatitis B, which can help prevent these infections. Cirrhosis: 1. Symptoms: - Fatigue and weakness - Jaundice - Itchy skin - Abdominal pain and swelling - Easy bruising and bleeding - Weight loss and muscle wasting - Nausea and vomiting - Changes in appetite and taste - Confusion or mental changes (in later stages) - Fluid retention and swelling in the legs (edema) or abdomen (ascites) 2. Treatments: - Management of underlying causes: Treating the underlying causes of cirrhosis, such as chronic hepatitis, alcohol abuse, or nonalcoholic fatty liver disease, is crucial to prevent further progression. - Lifestyle changes: Avoiding alcohol consumption is essential, as alcohol can worsen liver damage. A healthy diet, weight management, and regular exercise are recommended to support liver health. - Medications: Medications may be prescribed to manage specific symptoms or complications of cirrhosis, such as diuretics to control fluid retention or medications to manage hepatic encephalopathy (mental changes). - Liver transplantation: In advanced cases, liver transplantation may be considered as a treatment option. It's important to note that these conditions can have overlapping symptoms and may require medical evaluation for accurate diagnosis and appropriate treatment. Chronic hepatitis can progress to cirrhosis if left untreated, emphasizing the importance of early diagnosis and management of hepatitis infections. If you suspect you may have hepatitis or cirrhosis, it is essential to consult with a healthcare professional for proper evaluation and guidance.

Question 42

Before Travelling

Answer 42

Learn about Terrain Learn about cultural abnormalities

Question 43

HIV - Testing and Treatment

Answer 43

􀁸􀀃 The most commonly used test for HIV is a blood test for antibodies to the virus, which usually becomes positive 3 to 12 weeks after infection during seroconversion (which is when the serological tests—the serum tests for antibodies—become positive). This delay in positivity means that someone with acute HIV, a new infection with symptoms, may still have a negative HIV test. 􀁸􀀃 In cases of suspected acute HIV, before seroconversion, a test for HIV genetic material in the blood using the polymerase chain reaction (PCR) technique can show infection. This same test, sometimes called the viral load, can also be used to see how heavily the blood is infected and, thus, how contagious a person might be. 􀁸􀀃 Another test commonly used in the evaluation and follow-up of an HIV patient is a CD4 count, a count of the T helper lymphocytes that are destroyed by HIV infection. A normal CD4 count is around 800 to 1,200; in advanced HIV and AIDS, this trends into the 100s or eventually down to zero. 􀁸􀀃 The most effective treatment of HIV starts early. There are medicines that can prevent the initial transmission of HIV—this can be used during the birth of a baby to an HIV-positive mom, after an inadvertent needlestick blood exposure for a health-care worker, or after an unsafe sexual encounter. 􀁸􀀃 When an HIV infection is diagnosed, there are about 30 different anti-HIV medications to stop the spread of the virus. These are used in a variety of combinations to make them more effective and also to prevent the virus from developing resistance. Current HIV medications need to be taken every day for the rest of a patient’s life. 􀁸􀀃 We also have a number of medications to prevent and treat the opportunistic infections that cause a lot of the suffering in AIDS patients. Again, these need to be taken long term. Medication regimens for AIDS and HIV patients can be complex and expensive and may lead to signi cant side effects. It’s also crucial to help people with HIV infections maintain good overall health and nutrition and to take steps to prevent transmission to other people.

Question 44

Steps of security E & E

Answer 44

What to do in disaster: 1. Immediate Security 2. Self check./ Medical Attention 3. Protection - Find a gun or a weapon. 4. Physical Needs - Shelter, Water, Fire, Food. 5. Communication - More for moral. Call people to reassure them 6. Transit to safety

Question 45

Endometriosis

Answer 45

Endometriosis is common. Probably about 15 percent of women have some degree of endometriosis, though the extent and severity of symptoms vary greatly. The normal endometrium is the lining of the uterus—tissue comprised of glands, blood vessels, and connective tissue that thickens and is then shed during each monthly cycle. 􀁸􀀃 In some circumstances, this endometrial tissue is found outside of the uterus—on the inside wall of the abdomen, on the ovaries, or nearby. It’s unclear how this tissue gets there. It could spread during menstruation, or cells could spread though lymphatic or blood vessels. The cells of endometriosis are normal cells, just in the wrong place; this is referred to as “ectopic” tissue. 􀁸􀀃 These misplaced areas of endometrial tissue are what cause the symptoms of endometriosis. Pain is caused in part from bleeding, which may be cyclical. Recurring bleeding cycles can lead to scarring, especially because unlike bleeding in the uterus, the blood from endometriosis cannot be expelled from the body. However, the extent of endometriosis, the amount of ectopic tissue observed, doesn’t always correlate with the degree of pain women experience. 􀁸􀀃 Dyschezia, or painful passage of stool, is a characteristic symptom of endometriosis, and it is also caused directly by the presence of endometrial tissue near the distal colon and by resulting scarring and adhesions. Women with endometriosis may experience painful symptoms intermittently, and they may or may not vary with their menstrual cycle. 􀁸􀀃 About 30 to 40 percent of women with endometriosis have problems with impaired fertility, perhaps also related to scarring and adhesions that alter the positioning of the ovary and fallopian tubes. However, even mild degrees of endometriosis, without signi cant scarring, can lead to infertility. 􀁸􀀃 The treatment of endometriosis needs to be tailored to the individual case. Medical options include the use of a variety of hormone strategies to reduce the development of endometrial tissue, or to stop menses altogether. There are also surgical approaches to removing or destroying the ectopic endometrial tissue through minimally invasive, laparoscopic procedures. While this can be effective in reducing pain and restoring fertility, the degree of success can be dif cult to predict. 􀁸􀀃 Laparoscopic approaches have the advantage of a much quicker recovery, less pain, less scarring, and a reduced risk of bleeding than traditional abdominal surgery. However, they may take a little longer, and not all procedures can be done using small laparoscopic tools. The surgeon also loses the ability to feel and use his or her hands directly. 􀁸􀀃 There are also even more advanced minimally invasive techniques, using devices to robotically assist the surgeon through even smaller or fewer openings, or even by using openings through normal body ori ces, such as through the wall of the esophagus.

Question 46

A Legend

Answer 46

Cover for your actions. As a CIA operative it. This includes a story, papers, facts and documents. Be congruent with your actions/story. Use a scepter of authority to blend in with any crowd. Anonymously anothority symbols are keys, clipboards, nametags and keycards. Fedex is also a good sceptor. You can also be untouchable/invisible - If you're homeless you cant go inside anywhere. Watch your shoes and watches.

Question 47

When should you leave a wound open vs close it.

Answer 47

The decision to close a soft tissue wound or leave it open depends on several factors, including the type, location, size, and severity of the wound. Here are some general guidelines: 1. Closure (stitches, staples, adhesive strips): - Clean, minor wounds with straight, well-aligned edges. - Wounds in areas that are prone to movement and require good cosmetic results (e.g., face). - Wounds that are less than 6-8 hours old (to reduce the risk of infection). - Deep wounds that require support to heal properly. - Wounds that have a higher risk of infection if left open. 2. Leaving the wound open (secondary intention healing): - Large, gaping wounds that are difficult to close primarily. - Wounds with a high risk of contamination or infection. - Wounds with significant tissue damage or signs of infection. - Wounds that are more than 6-8 hours old and carry a higher risk of infection. - Infected wounds or wounds that have foreign bodies or extensive tissue loss. It's important to note that these are general guidelines, and the decision to close or leave a wound open should ultimately be made by a healthcare professional. They will evaluate the specific characteristics of the wound and consider other factors such as the individual's overall health, risk of infection, and potential complications. Prompt medical attention is advised for deep, large, or contaminated wounds, as they may require professional evaluation and appropriate wound management to prevent complications and promote proper healing.

Question 48

Treating Migraines

Answer 48

Dealing with migraines should always start with prevention. Many (though not all) migraines have speci c triggers. These can include lack of sleep, hunger, dehydration, stress or illness, or sometimes bright lights or reading while in a car. 􀁸􀀃 People who have migraines should track their episodes and see if some of these common triggers seem to be part of the problem. Not all migraine sufferers have all of these triggers, but many have at least some, and some of these can be avoided through lifestyle modi cation, stress reduction, yoga, getting a good night’s sleep, and other nonmedical steps. It’s also very important for people with migraines to avoid falling into the trap of medication overuse and to modulate their caffeine intake. 􀁸􀀃 Beyond these preventive lifestyle strategies, migraine sufferers need an action plan to start as soon as possible when a migraine begins. For people who do have a warning aura, the migraine action plan needs to start as soon as the aura begins—which may be well before the actual headache. A migraine caught early is much more likely to be stoppable. 􀁸􀀃 A migraine action plan should include both medical and nonmedical steps. Usually, the patient will bene t from getting to a dark, quiet environment quickly. Sometimes a small snack, including some sugar, will help, perhaps even including some soda or coffee with caffeine. Although habitual caffeine use can lead to migraines, when taken at the start of a migraine, caffeine can help reduce its severity. 􀁸􀀃 Medicines can help, especially if taken at the start. These can include over-the-counter pain relievers like ibuprofen or acetaminophen. There are also very effective prescription migrainestopping medicines. The best of these are in a family called the triptans. They all work similarly to block the brain receptor that is central to migraine development. 􀁸􀀃 All migraine sufferers who don’t get full relief from over-thecounter products should have one of these triptans available for immediate use when a migraine begins. They come as pills and nasal sprays and in auto-injector devices that are especially useful for the many migraine patients who have vomiting with their headaches. Triptans, though very effective, can trigger rebound headaches if used too frequently. 􀁸􀀃 If, despite trigger avoidance and a good action plan, migraines are still occurring frequently, we ought to consider starting a daily migraine prevention strategy. This can involve adding a daily medication that can act as a migraine preventer. There are several of these available, though some can have side effects. 􀁸􀀃 There are also some more natural and potentially safer approaches to daily migraine prevention, including daily vitamin B2 or magnesium supplements. Some studies have shown these to be quite effective in preventing migraines.

Question 49

Stroke symptoms

Answer 49

•• Gabriel’s likely diagnosis is a stroke, also called a cerebral infarction, on the left side. A stroke results from an impaired blood supply to an area of brain. This causes an onset of focal neurologic deficits, corresponding to the loss of function of that brain area. Usually, the blood supply is interrupted by an occluded or closed-up vessel—typically from a blood clot or plaque. Sometimes, strokes can be caused by a ruptured blood vessel, causing bleeding and a loss of blood supply to one area. •• The key to stroke management is to quickly reestablish blood flow, minimizing cellular death. Early steps in management include the ABCs, and treating life-threatening complications like brain swelling or prolonged seizures. An emergency CT is needed to exclude bleeding in the brain. •• Once you know there’s no bleeding, clot-busting therapy can be offered if appropriate. However, breaking down the clot medically with a clot buster will only help if there is still viable brain tissue there. •• In most circumstances, we have three hours to reestablish blood flow to a brain area if we hope to prevent cellular death. But what about Gabriel—how long does he have? ○○ Your nurse suggests Gabriel’s wife call one of his coworkers to find out when he was last seen. It turns out that Gabriel left work late today, and was in perfectly good health when he left about 90 minutes ago. So he had to have had his stroke between his arrival home, about 60 minutes ago, and when his wife found him—certainly less than three hours ago.

Question 50

How to stitch a wound

Answer 50

Stitching up a wound should ideally be performed by a healthcare professional. However, here are the general steps involved in stitching up a wound: 1. Preparation: - Wash your hands thoroughly with soap and water or use hand sanitizer. - Put on sterile gloves and other appropriate personal protective equipment (PPE) if available. 2. Cleanse the wound: - Gently clean the wound with sterile saline solution or clean water to remove dirt, debris, and bacteria. - Use sterile gauze or a clean cloth to gently pat the wound dry. 3. Anesthesia (if necessary): - Apply a local anesthetic, such as lidocaine, to the surrounding area of the wound to numb the area. This step is typically performed by a healthcare professional. 4. Wound closure: - Use sterile instruments (e.g., forceps, scissors) to carefully align the wound edges. - Depending on the size and location of the wound, choose the appropriate closure method, such as sutures (stitches), staples, or adhesive strips. - Place the sutures, staples, or adhesive strips in a manner that brings the wound edges together securely but not too tight. - Tie or secure the sutures, or properly place and secure the staples or adhesive strips, ensuring proper wound alignment and closure. - Trim any excess suture material, if applicable. 5. Dressing and wound care: - Apply a sterile dressing or bandage over the closed wound to protect it from contamination. - Follow any additional instructions from a healthcare professional regarding wound care, such as applying antibiotic ointment or changing the dressing. 6. Post-procedure instructions: - Provide the patient with instructions on how to care for the wound at home, including any specific wound care instructions, signs of infection to watch for, and when to seek medical follow-up. It's important to note that these steps are a general overview, and the specifics may vary depending on the type and severity of the wound. Seeking professional medical attention for wound closure is recommended to ensure proper evaluation, treatment, and prevention of complications.

Question 51

Frequent Cough

Answer 51

􀁸􀀃 Our patient in the general medicine outpatient clinic is Margo, a 49-year-old woman who has come in with her husband with a chief complaint of “I’ve got this cough again.” Margo says that she gets a cough frequently, a bad cough that lingers for weeks, and she keeps seeing doctors, and it gets better, and then it comes back. She thinks this time it’s her allergies, because it’s the fall, and she always gets this cough in the fall. 􀁸􀀃 A cough is one of the most common symptoms that drive visits to doctors. Of course, most coughs are brief, self-limited diseases that people recover from without any specific evaluation or therapy at all. Coughing is a normal protective reflex that clears the lungs of secretions and mucus and inhaled dust. But of course, too much of a cough itself is distracting and aggravating, and it can lead to impaired sleep for both the patient and family. ``` 􀁸􀀃 Some of the most common causes of chronic, prolonged, or recurrent coughing include smoking; both active smoking and passive, secondhand smoke exposure can cause cough. Long-term smokers can develop chronic obstructive pulmonary disease with permanent destructive changes in the lungs. 􀁸􀀃 Asthma is also very common and can cause coughing as a main symptom, sometimes along with wheezing, noisy breathing, or shortness of breath. Prolonged cough can also be caused by environmental or occupational pollution. Any cause of chronic postnasal drip (including allergies or sinusitis) can cause an ongoing cough. ``` 􀁸􀀃 Reflux—meaning gastroesophageal reflux, from stomach contents coming back up—can cause cough, as can some medications (especially ACE inhibitors, a class of blood pressure medications). Whooping cough, also called pertussis, is probably one of the most common infectious causes of prolonged coughs in adults. 􀁸􀀃 Frequent, ordinary coughs—just from common cold viruses—can kind of stack up, one after another, and seem like a chronic ongoing cough. We see this in children, sometimes, when they start day care, in young pediatricians starting training, or in teachers or daycare workers. Children or those who work around children can be victimized by very frequent viral infections. 􀁸􀀃 Less commonly, prolonged coughing can be from heart disease, chronic lung infections, or tumors or cysts in the lungs or bronchial tubes. Problems outside of the chest have to be considered, too— such as something in the larynx or throat, or neurological conditions that lead to excessive secretions or an impaired ability to keep the airways clear. 􀁸􀀃 Also, any sort of immune-compromising condition can lead to recurring or persistent coughing. Occasionally, we see what’s called a psychogenic cough, sometimes related to stress. 􀁸􀀃 We can ask about the quality of the cough, to try to nail down exactly what it sounds like. There are a few specific coughs that do have very characteristic sounds. Croup is an illness of children— young children and babies mostly—with a cough that sounds like the bark of a seal or a dog. But croup is very uncommon in adults. 􀁸􀀃 Another characteristic cough is the cough of pertussis, or whooping cough. Classically, this is a staccato, one-after-another cough that goes on for a minute or more, followed by one big inspiration—a whoop. But many people with whooping cough don’t actually sound like that and don’t make that whoop. 􀁸􀀃 There’s also a distinction that can be made between a wet and dry cough. A dry cough is likely related to irritation, or some condition without a lot of excess phlegm; a wet, phlegmy cough is likely related to infection or inflammation, perhaps caused by sinus disease or allergies. 􀁸􀀃 But there’s a lot of overlap. Pneumonia can sound to some people wet or dry, and so can asthma. And two people listening to the same cough often disagree on whether it’s wet or dry. Cough descriptions are not very reliable or helpful, and they certainly shouldn’t be something that leads you to narrow down the diagnosis without corroborating information. 􀁸􀀃 The physical exam reveals that Margo is a healthy woman, overall, but she has an annoying, severe, recurring cough. She also wheezes, at least sometimes, on the physical exam. A wheeze is an almost musical whistling noise that is classically caused by narrowing of the airways in the chest. That can be from a one-time illness—such as pneumonia, where mucus in the airways causes narrowing— or by some kind of tumor or mass that’s pressing on one or more airways. 􀁸􀀃 From Margo’s history, this is a recurrent, come-and-go cough that is associated with a wheeze that comes and goes. That’s very suggestive of one single, common diagnosis: asthma. In fact, many of the medications Margo’s been using on and off for years are actually asthma medications, so doctors have been thinking about asthma before. But apparently this has never been communicated clearly to Margo.

Question 52

Spiderbite treatments

Answer 52

Symptoms of spider bites can vary depending on the type of spider and individual reactions. However, most spider bites result in localized symptoms that can include: 1. Redness and swelling: The bite area may become red, swollen, and inflamed. 2. Pain or discomfort: Spider bites can cause pain or a stinging sensation at the site of the bite. The severity of pain can vary depending on the type of spider and individual sensitivity. 3. Itching or rash: Some spider bites can lead to itching or the development of a rash around the bite area. 4. Puncture marks or blisters: Depending on the spider species and the bite, puncture marks or small blisters may be present at the site of the bite. 5. Development of a necrotic wound: In rare cases, certain spiders, such as the brown recluse or black widow, can cause tissue damage and the formation of a necrotic wound (a wound that turns black and becomes dead tissue). 6. Systemic symptoms: Although uncommon, some individuals may experience systemic symptoms such as fever, headache, muscle pain, or abdominal pain. These symptoms are more likely with bites from certain species like the black widow spider. It's important to note that not all spider bites cause significant symptoms, and the majority of spider bites are harmless and resolve on their own without medical intervention. However, if you suspect a spider bite from a venomous spider or if you develop severe symptoms, such as widespread rash, difficulty breathing, or muscle cramps, seek immediate medical attention. Identifying the specific spider responsible for the bite can be challenging, so it's always a good idea to seek medical evaluation if you're unsure or concerned about a spider bite. Most spider bites are harmless and can be treated at home with simple measures. However, if you're uncertain about the type of spider or if symptoms worsen or persist, it's important to seek medical attention. Here are general steps for treating spider bites: 1. Wash the area: Clean the bite area gently with mild soap and water to reduce the risk of infection. Pat it dry with a clean cloth. 2. Apply a cold compress: Place a cold compress or ice pack wrapped in a thin cloth on the bite area for about 10-15 minutes. This can help reduce swelling and provide temporary relief from pain or itching. 3. Use over-the-counter creams or ointments: Apply an over-the-counter hydrocortisone cream or antihistamine cream to help alleviate itching and inflammation. Follow the instructions on the product label. 4. Take over-the-counter pain relievers: If you experience pain or discomfort, you can take over-the-counter pain relievers like acetaminophen or ibuprofen, following the recommended dosage instructions. 5. Keep the bite area elevated: If possible, elevate the affected limb to help reduce swelling. 6. Avoid scratching: It's important to avoid scratching the bite area to prevent skin breakdown and potential infection. 7. Watch for signs of infection or allergic reaction: Monitor the bite area for any signs of infection, such as increased pain, redness, warmth, swelling, or the presence of pus. Additionally, watch for signs of an allergic reaction, including difficulty breathing, dizziness, or widespread rash. If any of these symptoms occur, seek medical attention promptly. It's important to note that these measures are general recommendations and may not be suitable for all types of spider bites. If you suspect the bite is from a venomous spider or if you develop severe symptoms, such as muscle pain, abdominal pain, sweating, or difficulty breathing, seek immediate medical attention. Preventing spider bites is the best approach. Take precautions such as wearing protective clothing, using insect screens, and avoiding areas where spiders are commonly found.

Question 53

sprain vs break

Answer 53

Distinguishing between a broken bone (fracture) and a sprain can be challenging without medical imaging, but there are some signs and symptoms that can help differentiate between the two. Here are some indicators: Broken Bone (Fracture): 1. Deformity: Visible deformity, such as a misalignment, angulation, or an abnormal shape of the affected area. 2. Intense pain: Severe and persistent pain, especially with movement or pressure on the area. 3. Swelling and bruising: Swelling that develops rapidly around the injured site, often accompanied by bruising. 4. Limited range of motion: Difficulty or inability to move the affected area normally. 5. Grating or popping sensation: Sometimes, a fracture may produce an audible or palpable sensation at the site of the injury. 6. Crepitus: A crunching or crackling sound or feeling when the broken ends of the bone rub against each other. Sprain: 1. Swelling and bruising: Swelling that develops gradually around the injured joint or area, often accompanied by bruising. 2. Pain and tenderness: Pain that is localized to the injured joint or area, which may worsen with movement or pressure. 3. Limited range of motion: Difficulty moving the affected joint or area due to pain and swelling. 4. Instability: Feeling of joint instability or a sense that the joint is "giving way." 5. Popping or tearing sensation: Sometimes, a sprain may be associated with a popping or tearing sensation at the time of injury. It's important to note that these are general guidelines, and the only way to definitively diagnose a fracture or sprain is through medical evaluation, which may involve physical examination, X-rays, or other imaging tests. If you suspect a broken bone or sprain, it is recommended to seek medical attention for proper diagnosis and appropriate treatment. Prompt medical evaluation is particularly important for suspected fractures to ensure proper alignment and healing.

Question 54

Symptoms of Concussion

Answer 54

Symptoms of a concussion, a mild traumatic brain injury, can vary from person to person. Some common symptoms include: 1. Headache or pressure in the head 2. Dizziness or feeling off-balance 3. Nausea or vomiting 4. Sensitivity to light or noise 5. Blurred vision or double vision 6. Confusion or feeling foggy 7. Memory problems or difficulty concentrating 8. Fatigue or feeling tired 9. Sleep disturbances (sleeping more or less than usual) 10. Mood changes, irritability, or anxiety 11. Slurred speech 12. Ringing in the ears (tinnitus) If you suspect a concussion, it's important to seek medical attention. A healthcare professional can evaluate your symptoms and provide appropriate treatment recommendations. In general, the treatment for a concussion involves the following: SLEEP IS GOOD! 1. Rest: Rest is crucial for allowing the brain to heal. Physical and mental rest may be recommended, which may include avoiding physical exertion, reducing screen time, and limiting activities that can worsen symptoms. 2. Medications: Over-the-counter pain relievers, such as acetaminophen, may be recommended for headaches. However, it's important to consult a healthcare professional before taking any medications, as some medications can increase the risk of bleeding or interact with other treatments. 3. Cognitive and physical rest: Activities that require concentration and physical exertion should be gradually reintroduced as symptoms improve. It's important to follow the guidance of a healthcare professional to prevent worsening of symptoms. 4. Symptom management: Specific symptoms, such as headaches or sleep disturbances, may be addressed individually with appropriate interventions and strategies. 5. Monitoring: Regular follow-up appointments may be scheduled to monitor your progress and ensure that symptoms are improving. If symptoms worsen or new symptoms develop, it's important to seek medical attention. It's important to note that every concussion is unique, and treatment recommendations may vary depending on the individual and the severity of the injury. Following medical advice and allowing adequate time for recovery is crucial for optimal healing and minimizing potential complications.

Question 55

Tornado Prep

Answer 55

Preparing for tornadoes involves taking proactive steps to ensure your safety and minimize potential damage. Here are some important measures to consider: 1. Stay informed: Stay updated on weather conditions by monitoring local news, weather apps, or a NOAA Weather Radio. Be aware of tornado watches (conditions are favorable for tornadoes) and tornado warnings (a tornado has been spotted or indicated by radar). 2. Develop an emergency plan: Create a detailed plan with your household members to know what to do in case of a tornado. Identify a safe shelter location within your home, such as a basement, storm cellar, or an interior room on the lowest level without windows. Discuss the plan with everyone and practice tornado drills regularly. 3. Prepare an emergency kit: Assemble an emergency kit with essential supplies that can sustain you and your family for at least 72 hours. Include items such as non-perishable food, water, medications, a flashlight, batteries, a first aid kit, a battery-powered weather radio, a whistle, cash, and important documents. 4. Secure your home: Reinforce your home's structural integrity by ensuring it is well-maintained. Secure loose objects outside, such as patio furniture, that could become dangerous projectiles in high winds. Consider installing impact-resistant windows or shutters, and reinforce garage doors to withstand strong winds. 5. Create a communication plan: Establish a communication plan with your family and friends, designating an out-of-area contact person. This person can serve as a central point of contact to relay information and check on each other's safety during and after the tornado. 6. Stay aware of warning signs: Learn to recognize the signs of an approaching tornado, such as dark, greenish skies; a rotating, funnel-shaped cloud; a loud, continuous roar similar to a freight train; or debris being lifted into the air. If you observe any of these signs, take immediate action to seek shelter. 7. Stay tuned to alerts: Listen to local authorities and follow their instructions during tornado warnings. Take shelter immediately if a tornado warning is issued for your area. 8. Practice situational awareness: Be observant of your surroundings and the weather conditions. If you see a tornado or its funnel cloud, take cover immediately. 9. Have a plan for community shelters: Familiarize yourself with community tornado shelters or safe locations, such as designated storm shelters, schools, or public buildings. Identify their locations in advance and know how to access them if necessary. 10. Review and update your insurance: Review your homeowner's insurance policy to ensure you have adequate coverage for tornado damage. Consider adding coverage for specific hazards, such as wind or hail, if necessary. Remember, tornadoes can be unpredictable and develop quickly. It's crucial to stay vigilant, have a plan in place, and take immediate action to protect yourself and your loved ones when a tornado threat arises.

Question 56

altitude Sickness

Answer 56

Altitude sickness, also known as acute mountain sickness (AMS), can occur when traveling to high-altitude locations where the air pressure is lower and the oxygen levels are reduced. Here are the symptoms of altitude sickness and some home remedies that may help alleviate mild symptoms: Symptoms of Altitude Sickness (Acute Mountain Sickness): - Headache (usually the primary symptom) - Fatigue or weakness - Dizziness or lightheadedness - Nausea or vomiting - Loss of appetite - Shortness of breath - Difficulty sleeping - Rapid heartbeat - Swelling of the hands, feet, or face (in severe cases) Home Remedies for Altitude Sickness (Mild Symptoms): 1. Rest and acclimatize: Allow your body time to adjust to the high altitude by taking it easy and avoiding strenuous activities for the first day or two. Gradually increase your activity level as your body adjusts. 2. Stay hydrated: Drink plenty of fluids, preferably water, to stay hydrated. Avoid excessive caffeine and alcohol consumption, as they can contribute to dehydration. 3. Avoid overexertion: Pace yourself and avoid pushing your physical limits. Listen to your body and rest when needed. 4. Eat light meals: Consume smaller, more frequent meals that are easy to digest. Avoid heavy, greasy foods that can contribute to nausea or digestive discomfort. 5. Use over-the-counter medications: Non-prescription pain relievers, such as acetaminophen or ibuprofen, may help alleviate headaches or body aches associated with altitude sickness. However, consult with a healthcare professional before taking any medication, especially if you have underlying medical conditions or take other medications. 6. Drink coca tea or chew coca leaves (where legal): Coca tea or leaves, commonly used in some high-altitude regions, are believed to have mild stimulant effects and may help alleviate symptoms of altitude sickness for some individuals. However, it's important to respect local laws and regulations regarding the use of coca products. While these home remedies may provide some relief for mild altitude sickness symptoms, it's important to note that severe or worsening symptoms should not be ignored. If symptoms become severe or if you experience symptoms of high-altitude pulmonary edema (HAPE) or high-altitude cerebral edema (HACE), which are more serious conditions, it is crucial to seek immediate medical attention. Additionally, if you know you will be traveling to high altitudes and are concerned about altitude sickness, consider discussing preventive medications, such as acetazolamide (Diamox), with a healthcare professional. These medications can help prevent or reduce the severity of altitude sickness symptoms, but they require a prescription and should be used under medical supervision. Remember, the best way to prevent altitude sickness is to ascend to high altitudes gradually, allowing your body time to acclimate. If you have concerns or a history of severe altitude sickness, consult with a healthcare professional before traveling to high-altitude destinations.

Question 57

Diabetes and treatments

Answer 57

Diabetes is a chronic condition characterized by high blood sugar levels due to either inadequate insulin production (Type 1 diabetes) or the body's inability to effectively use insulin (Type 2 diabetes). The symptoms and treatment options for diabetes differ based on the type of diabetes: Type 1 Diabetes: Symptoms: 1. Frequent urination 2. Excessive thirst 3. Unexplained weight loss 4. Increased hunger 5. Fatigue and weakness 6. Blurred vision 7. Slow healing of wounds 8. Frequent infections Treatment: 1. Insulin therapy: People with Type 1 diabetes require lifelong insulin therapy. Insulin is administered through injections or an insulin pump to regulate blood sugar levels. 2. Blood sugar monitoring: Regular monitoring of blood sugar levels helps in determining the appropriate insulin dosage. 3. Healthy diet: Following a balanced diet that includes carbohydrate counting and portion control is important to manage blood sugar levels. 4. Regular exercise: Engaging in regular physical activity can help control blood sugar levels and improve overall health. 5. Education and support: Diabetes education and support groups can provide guidance on managing the condition and coping with the challenges associated with Type 1 diabetes. Type 2 Diabetes: Symptoms: 1. Frequent urination 2. Excessive thirst 3. Increased hunger 4. Fatigue and weakness 5. Blurred vision 6. Slow healing of wounds 7. Recurring infections, such as urinary tract infections Treatment: 1. Lifestyle changes: Making healthy lifestyle modifications such as adopting a balanced diet, engaging in regular physical activity, maintaining a healthy weight, and managing stress can help control blood sugar levels. 2. Oral medications: In some cases, oral medications may be prescribed to help lower blood sugar levels and improve insulin sensitivity. 3. Insulin therapy: If lifestyle changes and oral medications are insufficient, insulin therapy may be required to manage blood sugar levels effectively. 4. Blood sugar monitoring: Regular monitoring of blood sugar levels is important to track progress and adjust treatment accordingly. 5. Education and support: Diabetes education programs and support groups can provide valuable information and guidance on managing Type 2 diabetes effectively. It is important for individuals with diabetes to work closely with their healthcare provider to develop a personalized treatment plan that addresses their specific needs and goals. Regular medical check-ups, blood tests, and ongoing management are crucial for successfully managing diabetes and preventing complications.

Question 58

Poison Ivy, Oak and Sumac treatment

Answer 58

While there are various folk remedies that people claim to be effective for treating poison ivy, poison sumac, and poison oak, it's important to note that scientific evidence supporting their efficacy is limited. It's always advisable to consult with a healthcare professional for appropriate treatment. However, here are a few folk remedies that some individuals have reported to provide relief: 1. Cold compress: Applying a cold compress or ice pack to the affected area can help reduce itching and inflammation. Wrap the ice pack in a thin cloth to prevent direct contact with the skin and apply it for short intervals at a time. 2. Oatmeal baths: Taking a bath with colloidal oatmeal can help soothe itching and provide temporary relief. You can find colloidal oatmeal in many drugstores, or you can grind regular oats into a fine powder and add it to your bathwater. 3. Baking soda paste: Mixing baking soda with water to create a paste and applying it to the affected area may help alleviate itching and dry out the blisters. Leave the paste on for a few minutes before rinsing it off. 4. Aloe vera gel: The cooling and soothing properties of aloe vera gel may provide temporary relief from itching and inflammation. Apply a thin layer of pure aloe vera gel to the affected area as needed. 5. Witch hazel: Witch hazel is a natural astringent that may help relieve itching and dry out blisters. Apply witch hazel to a cotton ball and gently dab it onto the affected skin. 6. Jewelweed: Some people believe that jewelweed, a plant commonly found in the same areas as poison ivy, poison sumac, and poison oak, can provide relief. Crushing the plant and applying the juice or using jewelweed soap or lotion may help alleviate itching. However, scientific evidence supporting its effectiveness is lacking. It's important to note that these remedies may provide temporary relief from symptoms but may not effectively treat the underlying allergic reaction. If you have a severe reaction or if the rash covers a large area, it's best to seek medical advice for proper diagnosis and treatment. Additionally, avoid scratching the affected area to prevent further irritation and the potential for infection.

Question 59

Dont be dependant on gear.

Answer 59

You should be able to do anything without any piece of gear. All gear should be duplicated at any tier. All gear should be practical and have multiple uses.

Question 60

Appendicitis

Answer 60

􀁸􀀃 The appendix is a small, hollow tube—really more like a small pouch, about four inches long—that comes off the beginning of the large intestine, in the lower right of the abdomen. Sometimes it’s referred to as the “vermiform” appendix, meaning that it is shaped like a worm. 􀁸􀀃 It’s thought that the appendix in humans is a vestigial organ—a vestige of a structure that’s perhaps important for the digestive processes of other animals, but not for us. There are immune cells in the appendix, so some have speculated that the organ serves to help the immune system develop in the fetus before birth. Removal of the appendix at any age doesn’t lead to any loss of function. 􀁸􀀃 Inflammation of the appendix occurs if anything obstructs its opening. About 30 percent of the time, there is what’s called a fecalith, a stonelike piece of stool that you could see on a plain X-ray, but more commonly, it’s not specifically known why the opening to the appendix became blocked. 􀁸􀀃 Whatever blocks that opening, once it’s blocked, normal mucus secretions cannot drain, and the appendix swells and becomes distended. Swelling of any of the hollow organ causes pain, which is first sensed by the nerves within the gut itself. This pain is kind of crampy and usually not severe at first. It’s usually first felt in the middle or upper belly, near the belly button. 􀁸􀀃 Continued swelling leads to a decreased blood supply within the wall of the appendix and invasion of normal gut bacteria, which can now multiply unchecked. The in ammation then spreads through the wall of the appendix and presses on the side of the inside of the abdominal cavity—which is when the pain becomes more sharp and focused and intense, localized over the right lower quadrant of the belly. 􀁸􀀃 There are usually signs of peritonitis, including marked tenderness. Without treatment, perforation of the wall of the appendix will occur, spilling infected contents into the abdomen. In the past, this was often fatal, but modern surgical techniques and antibiotics mean that the overall mortality even after a perforated appendix is low. Still, it is best to diagnose and treat appendicitis before the appendix ruptures. 􀁸􀀃 Almost all patients with appendicitis have pain. The classic story (which does not always occur) is pain that begins suddenly in the middle of the abdomen and then, 6 to 24 hours later, moves to the lower right, becoming sharper and more focused. 􀁸􀀃 The pain, especially once it has moved, is made worse by movement of the patient or tapping on the abdominal wall, so patients with appendicitis, classically, want to lie very still, or if they do walk, they walk slowly, hunching over to their right. 􀁸􀀃 There is also often nausea, and less often, there is vomiting. Anorexia—that is, a lack of desire to eat—is nearly universal and can even be the very rst symptom, especially in children. Fever is seen sometimes, most typically low grade. Fever is more common and sometimes higher if the appendix has ruptured. 􀁸􀀃 Appendicitis doesn’t follow the typical pattern of presentation in young children or babies or in elderly people, so those ages have a much higher rate of delayed diagnosis and perforation. 􀁸􀀃 The diagnosis can also be especially challenging in women, who can have similar symptoms with pelvic conditions including tubal pregnancy, ovarian rupture or torsion, or complications from pelvic infections. Also, some people have somewhat unusual anatomy. Although appendiceal pain is usually in the lower right, the appendix can sometimes refer pain more to the back or on the side—or even be located on the left side in rare cases.

Question 61

Climbing fences

Answer 61

Use corners if you can. The Kali stick method. Weave a stick in and out on the fence. The fence is now easier to climb.

Question 62

Types of Headaches nd Treatments

Answer 62

Symptoms and treatments for tension headaches, migraines, and sinus headaches can vary. Here's a breakdown of each: Tension Headaches: Symptoms: 1. Dull, aching pain or pressure on both sides of the head. 2. Tenderness in the scalp, neck, or shoulders. 3. Mild to moderate pain intensity. 4. No accompanying symptoms such as nausea or sensitivity to light or sound. Treatment: 1. Over-the-counter pain relievers: Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or acetaminophen, can help alleviate pain. 2. Applying heat or cold: Placing a warm compress or cold pack on the head or neck may provide relief. 3. Relaxation techniques: Practicing relaxation exercises, such as deep breathing or meditation, can help reduce stress and relieve tension. 4. Improved posture and ergonomics: Maintaining good posture and ergonomics can help prevent tension headaches caused by muscle strain. 5. Stress management: Identifying and managing stress triggers through techniques like exercise, counseling, or stress reduction strategies may help reduce the frequency and intensity of tension headaches. Migraines: Symptoms: 1. Moderate to severe pulsating or throbbing pain, often on one side of the head. 2. Nausea, vomiting, or stomach upset. 3. Sensitivity to light, sound, or smells. 4. Visual disturbances, such as seeing flashes of light or blind spots (aura). 5. Increased pain with physical activity. Treatment: 1. Over-the-counter pain relievers: Non-prescription NSAIDs or specific migraine medications, such as ibuprofen, aspirin, or acetaminophen combined with caffeine, may provide relief for mild migraines. 2. Prescription medications: If over-the-counter options are ineffective, a healthcare provider may prescribe specific migraine medications, including triptans or ergotamines. 3. Rest in a quiet, dark room: Finding a calm environment and resting in a dark room may help alleviate symptoms. 4. Avoiding triggers: Identifying and avoiding triggers that contribute to migraines, such as certain foods, stress, or lack of sleep, can help prevent or minimize episodes. 5. Relaxation techniques: Practicing relaxation exercises, such as deep breathing or progressive muscle relaxation, can help manage stress and reduce migraine symptoms. 6. Prevention medications: In some cases, daily medications may be prescribed to prevent migraines for those with frequent or severe episodes. Sinus Headaches: Symptoms: 1. Pain and pressure in the forehead, cheeks, or around the eyes. 2. Nasal congestion or stuffiness. 3. Thick, discolored nasal discharge. 4. Postnasal drip. 5. Pain worsens with head movement or bending forward. Treatment: 1. Over-the-counter pain relievers: NSAIDs or decongestants can help alleviate pain and reduce inflammation. 2. Nasal irrigation: Using a saline solution or nasal rinse to flush out the sinuses can provide relief. 3. Warm compress: Applying a warm compress to the face may help relieve sinus pain and congestion. 4. Steam inhalation: Inhaling steam from a hot shower or a bowl of hot water with a towel over the head can help open the sinuses and reduce pressure. 5. Allergy medications: If the sinus headache is caused by allergies, over-the-counter or prescription allergy medications may be helpful. It's important to note that these suggestions are general and may not apply to every individual. If you experience severe or recurring headaches, it is recommended to consult with a healthcare provider for an accurate diagnosis and personalized treatment plan.

Question 63

AVPU Scale of Alertness

Answer 63

•• Our first patient today is Gabriel, a 51-year-old man brought in by ambulance. He was found by his wife unconscious on the floor of his garage, with a puddle of blood under his head. It’s not known how long he was there—he usually gets home from work about an hour before his wife. •• When you talk to him, Gabriel wakes up. You ask him a few questions, and he tries to answer them, but seems to be having trouble mouthing words. Additionally, he cannot squeeze his right hand. Gabriel’s eye exam for pupil reactions and eye movements are normal, and you find nothing wrong with his lungs, heart, or belly. There’s a big laceration on the back of his head, matted with blood. •• We’ll describe his overall mental status using a simple scale that’s abbreviated AVPU: ○○ A for an alert patient. ○○ V for a patient who responds only to voice. ○○ P for a person who responds only to painful stimuli. ○○ U for an unresponsive patient, or someone who does not respond to anything. •• For now, Gabriel responds to voice, so he is a V on the AVPU scale. What we’ve got here, in summary, is an adult with altered mental status—in this case depressed consciousness, responding only to voice. •• He also has what are called focal neurologic findings. That phrase refers to anything that suggests a possible specific place for a neurologic lesion—an anatomic location where an injury or illness could account for the clinical picture. Gabriel is weak on the right side of his body, in his right arm. This corresponds to a lesion on the left side of the brain, because the left motor cortex on the left side of the brain controls the right side of the body. Gabriel also seems to be having trouble speaking, which could also reflect damage on the left side of the brain. •• Because of the possibility that increased pressure in the brain may account for Gabriel’s decreased level of consciousness, you decide to sedate and intubate him, placing Gabriel on a mechanical ventilator. This is a step especially necessary now because you need to make sure Gabriel is safe to head over to radiology for a head CT scan.

Question 64

Treatment and Prevention

Answer 64

􀁸􀀃 There’s quite a bit of research going on into brain recovery after stroke, looking for ways to maximize what’s called the plasticity of the brain—the ability of the brain to recover function. Children, especially the youngest children, have the best ability to recover after a stroke, probably because their brains are still growing and developing. Even a massive stroke in a young child can end up leading to minimal long-term disability. 􀁸􀀃 There seem to be important genetic switches on neurons that control their growth and development and, therefore, the ability of brain tissue to recover. A goal of research is in turning these switches back on, effectively making an adult brain, or parts of an adult brain, think it’s young again so that it can better grow and recover. 􀁸􀀃 For the time being, though, the best stroke treatment is stroke prevention. Control high blood pressure, high cholesterol, diabetes, and overweight; eat a healthy diet with plenty of fruits and vegetables; quit tobacco use; and exercise regularly. People at high risk should consider taking anti-stroke medications, typically medicines that prevent clotting, including aspirin or prescription both bene ts and risks, so their use should be discussed with a doctor. 􀁸􀀃 Another potential preventive therapy for stroke is an omega-3 supplement—a supplement of so-called healthy fats, often derived from sh oils. Some studies have shown that sh oil taken as a supplement can reduce strokes, but other studies haven’t been as persuasive. 􀁸􀀃 People who experience early signs of stroke or TIA need to be evaluated as quickly as possible, but there is sometimes a delay. Any sudden symptom of neurological dysfunction—including weakness, speech problems, altered sensations, loss of consciousness, trouble seeing or walking—is a potential stroke symptom that needs to be evaluated very urgently. 􀁸􀀃 Sometimes an individual experiencing a stroke seems to not notice the symptoms or deny symptoms that are really obvious to other people, so it may be up to friends or loved ones to insist that people with stroke symptoms seek care.

Question 65

Monitor the Baseline.

Answer 65

See if behavior deviates from the baseline. Watch people who are different from the baseline. Watch for circles of people. Move before bombshells go off.

Question 66

Travel problems

Answer 66

•• Our next patient is Jason, a 50-year-old who returned from Mexico a few days ago. His chief complaint is “rash,” but it turns out he’s got a few other things on his mind. He also has traveler’s diarrhea, for which you prescribe an antibiotic. •• The rash is on his feet. It’s pink and swirly. He went walking barefoot on a beach, so the explanation for the rash is that there are worms under the skin, called cutaneous larval migrans. They penetrate through the soles of bare feet, especially in sand where animals defecate. You can treat it with a topical or oral anti parasitic medication, though it takes a while for the intense itching to subside. •• Jason also reveals he had unprotected sex with prostitutes. He is paying the price for not taking some simple precautions, and not using common sense. We’ll test him for gonorrhea, chlamydia, and syphilis—but more worrisome are Hepatitis B, Hepatitis C, and HIV. If these tests are negative, he’ll have to repeat them in a few months to ensure he’s really in the clear. •• After an unprotected sexual encounter, there are few ways to prevent most of these infections. There are regimens available for anti-viral medications to prevent HIV infection, though in Jason’s case it’s probably too late. We’ll refer Jason to our HIV clinic’s hotline for their specific recommendations.

Question 67

Ménière’s Disease

Answer 67

􀁸􀀃 For Tina, it sounds like Ménière’s disease fits best because it causes attacks of vertigo that come and go, like Tina reports, and also affects hearing. Other diagnoses, such as a tumor or multiple sclerosis, seem much less likely, but after discussing these possibilities with Tina, she decides that she would like to pursue a very thorough workup. 􀁸􀀃 To definitively rule out a tumor, we need a brain scan—one that looks along the entire pathway, from the sense organs along the nerve to the brain. A CT scan is a very good study; it’s relatively quick to get and can show pretty good detail, especially of bones. 􀁸􀀃 However, there are drawbacks. CT scans are basically a series of plain X-rays that are stitched together by computers to make composite images. Like other X-rays, they rely on ionizing radiation to get an image. Though the risk is small, any study involving radiation will expose the patient to some risk of damage from the radiation itself, increasing the lifetime risk of cancer. 􀁸􀀃 In contrast, an MRI scan of the brain doesn’t use any ionizing radiation. It also has the advantage of imaging soft tissues like the brain with much more precision than a CT scan. MRIs are also better able to get images through the dense bones of the base of the brain, where CT scans don’t penetrate as well—and, with balance problems, we need to look at the base of the brain, where the balance and sense organs are. 􀁸􀀃 The main disadvantages of MRI compared to CT are that they take much longer to do, and they are more expensive. In Tina’s case, we decided to get an MRI to rule out even a small tumor, and it was normal. The MRI scan also showed that there were no brain lesions to suggest multiple sclerosis. 􀁸􀀃 After the MRI, we referred Tina to an ENT specialist, who reviewed the clinical exam and MRI and did a hearing test (which did confirm some low-frequency hearing loss). The ENT evaluation confirmed that Tina does indeed have Ménière’s disease. 􀁸􀀃 The specific cause of Ménière’s disease isn’t completely understood. There is increased endolymph fluid, as well as differences in the glycoprotein content of the fluid; there’s also evidence for alterations in the way that the fluid flows through the canals and is reabsorbed. Some studies have supported an infectious agent, genetic influences, or allergies—or a combination of these factors. 􀁸􀀃 Whatever the cause, the main symptom is episodic attacks that last for one or more hours. During attacks, there is vertigo, often accompanied by a ringing, rushing, or buzzing sort of sound (called tinnitus). There may also be a feeling of pressure or fullness in the ear. 􀁸􀀃 Accompanying these attacks is a gradual, fluctuating level of low frequency hearing loss that can become severe and is only reversible if caught early. The pressure feeling and hearing loss usually affects only one ear, but it can affect both. 􀁸􀀃 Ménière’s disease is a clinical diagnosis; there is no one specific test that confirms it. Tests are done, sometimes, to rule out other diagnoses (like the MRI Tina had). Blood tests are really of limited usefulness in the workup, though they can again rule out other problems if there are suggestive symptoms. Doing a thorough hearing evaluation is essential, and hearing will need to continue to be monitored during treatment. 􀁸􀀃 There are also high-tech tests that can support the diagnosis or monitor treatment. These include tests that directly monitor the electrical output of the organs and nerves of the inner ear when they’re triggered by sounds or nearby reflex muscle contractions.

Question 68

Beer

Answer 68

Beer is the most popular alcoholic beverage worldwide. In fact, after water and tea, beer is the most commonly-consumed drink in the world. Beer is also most likely the oldest alcoholic drink in history. A standard beer, whether it be a lager or an ale, has between 4% to 6% ABV, although some beers have higher or lower concentrations of alcohol. For example, “light beers” only have between 2% to 4% ABV while “malt liquors” have between 6% to 8%.

Question 69

Gunshot Wounds

Answer 69

•• We’re interrupted by a knock on the door, and whisked to the trauma room. An ambulance is on the way; the victim has a gunshot wound to the chest. Emergency care is triage, and Christina and her blanket are going to have to wait. •• In the trauma room, the new patient is covered in blood. Start with the ABCs. ○○ Airway: He has an artificial airway, an endotracheal (ET) tube, but blood is bubbling up into it. Your respiratory therapist thinks fast, and uses a small suction catheter through the ET tube to suck out the blood, fixing the problem. ○○ Breathing: Blood and air have filled the space around his lungs, and that’s preventing the lungs from filling. Quickly, you insert chest tubes between the ribs on both sides of the chest. When you pop them in, a gush of blood pours out. With the tubes in, his chest begins rising and falling with each breath, and his breath sounds become stronger. ○○ Circulation: His pulses are thin and weak. His hands and feet feel cool, and his capillary refill is sluggish—all indications of inadequate circulation. The blood bank has sent up universal donor blood to run in quickly along with other fluids and medications to increase the blood pressure and restore normal circulation. •• The next letter in major trauma is D, for disability—a reminder to check neurologic status. Your patient is entirely unresponsive. But you open his eyelids, and shine in a light—his pupils do constrict, so there’s at least some brain functioning there. •• Next up is the letter E, for exposure. In major trauma, you have to expose your patient. After the trauma team removes the patient’s clothes, you discover that your patient was also shot in the thigh, up high, near the groin. The amount of blood coming out suggests an arterial high-pressure wound. The thigh and chest bleeding need to stop if this patient is to survive. •• But you’ve done your job: Your patient’s ABCs are covered, and he’s reasonably stable. In a few minutes, the operating room is ready, and your patient is whisked off.

Question 70

Alcohol types

Answer 70

Gin ## Footnote Gin is a spirit made from juniper berries. It can have anywhere from 35% to 55% ABV. Brandy Brandy is distilled wine. The concentration of alcohol in brandy ranges from 35% to 60%. For example, one famous brandy, Cognac, has 40% ABV. Whiskey Whiskey is a spirit made from fermented grain. The ABV of whiskey ranges from 40% to 50%. Rum Rum, a distilled drink made from fermented sugarcane or molasses, has a typical alcohol concentration of 40% ABV. Some rum is “overproof,” meaning that it has alcohol concentration of at least 57.5% ABV. Most overproof rum exceeds this minimum, usually reaching 75.5% ABV, which is equivalent to 151 proof. Tequila Tequila is a type of liquor. The main ingredient of tequila is the Mexican agave plant. The alcohol concentration of tequila is typically about 40% ABV. Vodka Vodka, a liquor usually made from fermented grains and potatoes, has a standard alcohol concentration of 40% ABV in the United States. Absinthe Absinthe is a spirit made from a variety of leaves and herbs. There is no evidence for the idea that absinthe is a [hallucinogen](https://www.alcoholrehabguide.org/alcohol/drinking-drugs/hallucinogens/), but it does have a high alcohol concentration. Some forms of absinthe have about 40% ABV, while others have as much as 90% ABV. Everclear Everclear, a grain-based spirit, is another drink with a heavy concentration of alcohol. The minimum ABV of Everclear is 60%, but Everclear can also have 75.5% and 95% ABV.

Question 71

Post Event

Answer 71

Have a bias for action. Run, hide fight, die vs push or hold but ACT

Question 72

Alcoholism

Answer 72

􀁸􀀃 Alcoholism can also contribute to gastric ulcers, which led to Sally’s abrupt deterioration. There can be multiple, overlapping factors; alcohol itself can damage the stomach lining and prevent healing. Alcoholics may not consume regular meals, including fat and protein that protect the stomach. 􀁸􀀃 And if cirrhosis has begun, the liver disease can lead to a decrease in clotting proteins, so the ulcers bleed more. Liver disease can also lead to increased pressure in the blood vessels in the stomach and esophagus, which may further increase bleeding. 􀁸􀀃 The effect of alcohol consumption on heart disease and stroke is still being researched. It appears that moderate alcohol consumption, about one drink per day, may improve cardiac risk factors, perhaps by its effect on cholesterol metabolism. But excessive drinking directly damages the heart muscle and increases the risk of heart attacks and stroke. 􀁸􀀃 People with alcoholism also have an increased risk of some cancers, pneumonia, osteoporosis, diabetes, neuropathy, and mental illness. There are also increased risks of death by suicide and motor vehicle accidents, domestic violence, and other addictions. 􀁸􀀃 Alcoholism is frequently associated with obesity, too; alcohol is a signi cant source of calories, though it doesn’t offer much in the way of actual nutrition, and it will make you fat. And, of course, obesity then contributes to liver disease, heart disease, diabetes, and everything else that’s already going wrong.

Question 73

Diabetes complications

Answer 73

􀁸􀀃 These complications of diabetes include the following. 􀅼􀀃 Heart disease, including an increased risk of heart attack and stiffening of the heart wall, leading to chronic heart failure 􀅼􀀃 Other arterial disease, which can cause stroke or a loss of circulation in the extremities that may lead to amputation 􀅼􀀃 Kidney disease – in fact diabetes is the most common cause of kidney failure in the developed world; 􀅼􀀃 Neuropathy, or nerve damage, that can lead to abnormal or decreased sensation or weakness 􀅼􀀃 Retinopathy, or eye damage—this can cause severe vision loss or blindness 􀁸􀀃 There is also an increased risk of dementia, chronic lung disease, frequent infections, and skin ulcers. All of these complications develop after many years of disease, typically 10-20 years, though there’s quite a bit of variability. Though better glucose control decreases the likelihood of complications, it is dif cult to predict which patients remain at the most risk.

Question 74

Asthma

Answer 74

􀁸􀀃 Asthma is very common. It affects about 25 million people in the United States, including 7 million children. It causes symptoms by two interrelated mechanisms in the lungs: Part one is inflammation— swelling and mucus accumulation in the airways. Part two is what’s called bronchoconstriction, where muscles that wrap around the airways constrict, causing narrowing. 􀁸􀀃 The main symptoms of asthma, when it’s aring up, are coughing, shortness of breath, and a feeling of chest tightness. Sometimes there can be chest or, more rarely, abdominal pain as well. Symptoms can range from mild to quite severe or even life threatening, and they very characteristically wax and wane, getting better or worse depending on triggers. 􀁸􀀃 However, many people with asthma have at least some amount of chronic inflammation and symptoms as a baseline, though they may not complain about daily problems. 􀁸􀀃 People with asthma can have triggers that lead to a are-up of symptoms, sometimes called an asthma attack. Common triggers can be exercise, cold air, respiratory infections (including common cold viruses), tobacco smoke, or allergies. 􀁸􀀃 These triggers lead to cough even in people without asthma, which can be a source of diagnostic confusion. For example, allergies themselves cause cough, but usually, there are other symptoms of allergies, such as a runny or congested nose or itchy eyes—or a common cold. Everyone gets some cough with their colds, but when someone’s colds often lead to a prolonged, severe cough, that also suggests the possibility of underlying asthma.

Question 75

CPR Steps

Answer 75

When you come across someone who appears to be dead, follow these steps. 1. Make sure the person isn’t just sleeping or lying still. Give him or her a shake. Yell, “Are you okay?” In our example, this person just collapsed in front of our eyes. You can probably skip step 1. 2. Yell for help. Call out, “Someone call 911.” If there are people nearby, point to one person speci cally and tell him or her to make that call. 3. If you’re in a public place, such as a mall or sporting event, and someone is around to help you, tell someone to go get you an automated external de brillator (AED). Many places— including gyms, department stores, schools, and churches—now have these devices available. If one of these is available, using one as quickly as possible is the single best way to improve survival. 4. While waiting for someone to call 911 and get the AED, start rescue CPR. Roll the person onto his or her back. Start pushing right in the middle of the chest, hard and fast. Use two hands, one on top of the other, and after every push, relax so that the chest can bounce back up. You shouldn’t stay leaned into the chest—it’s down, up, down, up. A good rhythm is the beat from the song “Stayin’ Alive” by the Bee Gees (think “push, push, push, push, stayin’ alive, stayin’ alive”). 5. Keep going, pushing hard and fast, until either trained emergency rescue personnel show up or someone runs over with the AED. 6. If you have an AED, follow the instructions on the device. Studies have shown that even school-aged children can use these correctly. There will be a cartoon on the front showing the steps and a big “ON” button—pushing that is the rst step. After that, the machine will have voice prompts to tell you exactly what to do. You will put a big sticky pad on the front of the chest; then, make sure no one is touching the victim. The computerized device will monitor what the heart is doing, and if appropriate, the device will tell you to push the “shock” button to deliver a jolt of electricity to start the heart beating again. An AED is a smart and safe device—it will not suggest giving a shock to a normally beating heart, and in fact, the “shock” button won’t do anything if you push it unless it’s safe to give a shock to the victim. After the shock, the machine will analyze the heart rhythm again and continue to tell you what to do. 􀁸􀀃 If at any time during the rescue process the victim starts to respond— that is, starts to move or takes breaths—stop what you’re doing, roll the patient to lie on his or her side, and wait for rescue personnel. 􀁸􀀃 The newest guidelines for bystander CPR have de-emphasized some of the traditional parts of CPR that had been taught. Rescuers are no longer encouraged to even check for an open airway and breathing; that used to be the rst step, but that’s been dropped, because it turns out that the faster you start pumping by pressing on the chest, the better chance the victim has. Don’t check pulses; don’t mess with the airway. Don’t even bother with mouth-tomouth resuscitation or rescue breaths. Just jump in, push hard, and push fast—while calling for help and for someone to get you an AED. 􀁸􀀃 There are some situations where other approaches to CPR are needed. First, you have to be safe yourself to do CPR. If a victim is in a busy street or is drowning, it may not be safe for you to approach. Do not endanger yourself to do CPR.

Question 76

Surviving Frostbite

Answer 76

Surviving frostbite requires prompt action and proper care. Here's what you can do if you or someone else is experiencing frostbite: 1. Get to a warm environment: Move indoors or to a sheltered area away from the cold. Avoid further exposure to freezing temperatures. 2. Remove wet clothing: Take off any wet clothing or accessories. Wet clothing can further contribute to heat loss and increase the risk of frostbite. 3. Gradually warm the affected area: Immerse the frostbitten area in warm (not hot) water, ideally at a temperature of around 104°F (40°C). Avoid using direct heat sources like heating pads, stoves, or fires, as they can cause burns. If warm water is not available, use body heat by placing the frostbitten area against warm skin, such as the armpit. 4. Avoid rubbing or massaging the affected area: Rubbing or massaging frostbitten skin can cause further damage. Instead, gently support the affected area with a warm towel or clothing. 5. Protect unaffected areas: If you have frostbite in your fingers or toes, for example, use blankets or clothing to keep the unaffected areas warm. 6. Don't use dry heat sources: Avoid using hair dryers, heating pads, or direct heat from fires or radiators to warm the frostbitten area, as these can cause burns. 7. Seek medical attention: Frostbite requires medical evaluation and treatment, even if you have already started the rewarming process. While waiting for medical help, keep the frostbitten area elevated to reduce swelling. 8. Prevent refreezing: Once frostbitten tissue has thawed, it can easily refreeze and cause additional damage. Take precautions to prevent refreezing by keeping the affected area warm and protected. It's important to note that severe cases of frostbite can lead to tissue damage and complications, such as infection or gangrene. Therefore, it is essential to seek medical attention promptly for proper evaluation, treatment, and management of frostbite. To prevent frostbite in the first place, it's important to dress warmly in layers, wear appropriate cold-weather gear (such as hats, gloves, and insulated footwear), and limit your exposure to extreme cold temperatures. Stay hydrated and avoid alcohol and tobacco, as they can increase the risk of frostbite.

Question 77

4 Causes of fever

Answer 77

Almost all fevers are caused by one of four broad categories of illness: infection, cancer, autoimmune disease, and miscellaneous. Of these, infections are by far the most common, especially for relatively brief fevers. But the longer the fever persists, the less likely it’s going to be an infection—at least not a straightforward infection.

Question 78

Ménière’s Treatment

Answer 78

􀁸􀀃 There are several treatment options for Ménière’s disease, though none is really ideal. The main first therapy is dietary—restricting sodium—sometimes along with taking a diuretic to reduce body water. This simple treatment can reduce vertigo attacks but may not effectively slow hearing loss. 􀁸􀀃 Medications can be used during acute attacks to reduce the uncomfortable sensations of vertigo and nausea, but these don’t reduce hearing loss, and they are also ineffective in preventing further attacks. Still, conservative management and monitoring of hearing is probably good enough therapy for many people with Ménière’s disease. 􀁸􀀃 Another option for treatment is the use of steroids, which may reduce the pressure in the endolymph fluid. These can be given orally, by injection, or even by injection through the eardrum into the middle ear. There are some serious potential side effects of steroid use, especially if they’re needed for a long course. 􀁸􀀃 More aggressive therapy, especially for frequent and severe vertigo attacks, can include direct injections of medicine into the middle ear. An antibiotic called gentamicin is used—not because it is an antibiotic, but because it can decrease the number of vestibular hair cells that are sending the incorrect balance information to the brain. Although it can effectively reduce or eliminate vertigo attacks, gentamicin can actually make the hearing loss worse, so this therapy isn’t suitable for everyone. 􀁸􀀃 There are some surgical options for therapy as well. A shunt can be placed in the inner ear to drain some of the excess fluid; however, how well this works is controversial. This kind of surgery is nondestructive and can at least theoretically preserve hearing. 􀁸􀀃 Another surgical technique is to divide and destroy part of the vestibular nerve. This can achieve good control of vertigo in most patients, and usually hearing is preserved, but it is irreversible. 􀁸􀀃 The most aggressive approach of all is to remove the entire labyrinth on one side, permanently stopping symptoms of vertigo and tinnitus from one ear, but also eliminating hearing from that side. This may still be appropriate for patients with severe unilateral disease, especially if hearing is already severely affected. 􀁸􀀃 However, loss of the balance sense can affect gait in many patients, and about 30 percent of patients with unilateral disease will later develop Ménière’s disease in the other ear. 􀁸􀀃 Ménière’s disease is often characterized by fluctuating symptoms, with remissions and exacerbations, so it’s difficult to predict the longterm prognosis. In most patients, the vertigo attacks subside within 10 to 20 years, and hearing loss remains in the moderate range.

Question 79

To treat a nosebleed:

Answer 79

To treat a nosebleed: 1. Stay calm and sit up straight. 2. Lean slightly forward and pinch the nostrils together. 3. Maintain firm pressure for 10-15 minutes. 4. Breathe through the mouth. 5. Apply a cold compress to the bridge of the nose. 6. Release pressure after 10-15 minutes to check if bleeding has stopped. 7. Avoid nose blowing or picking. 8. Moisturize nasal passages with petroleum jelly or saline spray. 9. Seek medical attention if bleeding persists or is severe. Remember, seek immediate medical attention if the bleeding doesn't stop after 20-30 minutes, or if it's accompanied by severe symptoms or a severe injury.

Question 80

Surveillance detection

Answer 80

Stop multiple times and see if you can see people in 3 locations. Watch for changes from the baseline. Cruising the area Broken down vehicles parked vehicles with people in them. people taking excessive pictures

Question 81

Physical Exam

Answer 81

Pulse Rate: The pulse rate indicates the heart rate and can provide insight into the person's circulatory status. To measure the pulse, place your index and middle fingers on the radial artery (located on the wrist, just below the base of the thumb) or the carotid artery (located on the neck, to the side of the windpipe). Count the number of beats you feel in one minute. A normal resting pulse rate for adults is typically between 60 and 100 beats per minute, but this can vary based on age and overall health. Respiratory Rate: The respiratory rate reflects the number of breaths a person takes per minute. Observe the rise and fall of the chest or abdomen and count the breaths. Normal adult respiratory rates usually range from 12 to 20 breaths per minute. Blood Pressure: Blood pressure measures the force exerted by blood against the walls of the arteries. It consists of two values: systolic pressure (the top number) and diastolic pressure (the bottom number). Blood pressure is typically measured using a blood pressure cuff and a stethoscope. Normal blood pressure for adults is generally around 120/80 mmHg. Skin Assessment: Evaluate the person's skin for signs of injury, such as wounds, bruising, or burns. Additionally, assess the skin's color, temperature, and moisture. Pale or clammy skin could indicate poor circulation or shock, while flushed or hot skin might be a sign of fever or inflammation. Pupillary Response: Assess the person's pupils by shining a light into their eyes. Observe how the pupils react to changes in light. Normally, the pupils should constrict when exposed to bright light and dilate in dim lighting. Level of Consciousness: Evaluate the person's mental status and level of consciousness. Assess if they are alert, responsive, and oriented to person, place, time, and situation. Note any signs of confusion, disorientation, or loss of consciousness.

Question 82

Misc Booze

Answer 82

Hard Cider ## Footnote Hard cider is fermented apple juice. It usually has about 5% ABV. Mead Mead, a blend of water and fermented honey, has between 10% to 14% ABV. Saké Saké*,* a well-known Japanese drink made from fermented rice, has an alcohol concentration of about 16% ABV.

Question 83

OLD CARR diagnosis

Answer 83

○○ O is onset. When did it start? ○○ L stands for location. Where does it hurt? ○○ D is duration. When it hurts, how long does it last? ○○ C is character. What does it feel like? ○○ A number 1 is for aggravators. What makes the pain worse? ○○ A number 2 is for alleviators. What makes the pain better? ○○ A number 3 is activity. What were you doing when the pain started? ○○ R is for radiation. Where does the pain go? That is, if it starts at one point, does it move anywhere else?

Question 84

Yeast Infections / Diaper Rash

Answer 84

Yeast infections, also known as candidiasis, are caused by an overgrowth of Candida fungus, particularly Candida albicans. They can occur in various parts of the body, but the most common type is vaginal yeast infection. Here are the symptoms and treatments for yeast infections: Vaginal Yeast Infection: - Symptoms: Itching, burning sensation, redness, swelling of the vulva, white, thick, clumpy vaginal discharge (resembling cottage cheese), pain or discomfort during sexual intercourse, and sometimes a mild, yeasty odor. - Treatment: - Over-the-counter antifungal creams, ointments, or suppositories: These typically contain active ingredients like miconazole, clotrimazole, or tioconazole. They are inserted into the vagina and used for 1 to 7 days, depending on the product and severity of the infection. - Prescription antifungal medications: In cases of severe or recurring infections, your healthcare professional may prescribe stronger antifungal medications in the form of oral tablets or longer courses of topical treatments. - It's important to complete the full course of treatment, even if symptoms improve. Other Types of Yeast Infections: - Oral thrush: Symptoms include white, creamy patches in the mouth or throat, difficulty swallowing, and a cotton-like feeling in the mouth. Antifungal medications in the form of oral rinses or lozenges are typically prescribed. - Skin and nail infections: Symptoms include red, itchy, and inflamed skin with a rash, scaling, or cracking. Antifungal creams, ointments, or powders are commonly used for treatment. - Diaper rash: A yeast infection can cause a persistent, red, and inflamed rash in the diaper area. Keeping the area clean and dry and using antifungal creams or ointments specifically designed for infants can help treat and prevent diaper rash. General measures for managing yeast infections include: - Good hygiene: Keep the affected area clean and dry. - Avoid irritants: Avoid using harsh soaps, perfumed products, or douches in the affected area. - Cotton underwear: Wear breathable cotton underwear and avoid tight-fitting clothing. - Dietary adjustments: Some individuals find that reducing their intake of sugar and refined carbohydrates can help prevent recurrent yeast infections. It's important to consult a healthcare professional for an accurate diagnosis and appropriate treatment plan, especially if you experience recurring or severe yeast infections. They can provide guidance and prescribe the most suitable treatment for your specific situation.

Question 85

Influenza

Answer 85

􀁸􀀃 Influenza strikes millions of Americans each year and remains a very significant cause of death, directly killing about 35,000 in the United States each year and probably contributing to the ill health and decline of many more, especially elderly adults. 􀁸􀀃 Influenza is more common in the winter—in the cold months. This may be because people congregate indoors, passing their germs around more efficiently, or perhaps in part because damage to the lining of the nose by cold air makes it easier to catch influenza (and other viruses as well). 􀁸􀀃 The typical course of influenza begins with exposure to the virus, followed by a brief incubation period of one to four days. People become contagious the day before symptoms begin. Symptoms are typically sudden and include fever and aches and chills, often with some respiratory symptoms, such as cough and runny nose, and sometimes with GI symptoms, including nausea and vomiting. The disease typically lasts about five to seven days. 􀁸􀀃 Many people mistakenly think that influenza is just a bad cold, but it really is a distinct, different disease, caused by the specific influenza virus. Influenza causes much higher fevers, plus characteristic body aches that aren’t seen with ordinary colds. 􀁸􀀃 The treatment of most cases of influenza is mostly supportive. Medicines like acetaminophen or ibuprofen—more widely known by their brand names, Tylenol or Advil or Motrin—will help reduce fevers and relieve the achy feelings. Extra fluids are also needed during fevers to prevent dehydration. Rest, stay away from other people, and stay in bed until you feel well. 􀁸􀀃 There are medicines that can be used to specifically fight the flu. The most widely prescribed one is oseltamivir, which is sold as the brand Tamiflu. It can help some, but it’s no wonder drug. It works best when started very early in the infection, within 48 hours— or, better yet, within 24. After that, it doesn’t help much. It can modestly reduce symptoms and the duration of the infection, but it’s not overall very effective in reducing serious complications. 􀁸􀀃 It is the complications of influenza that we fear. Myositis, like Christopher experienced, can be painful and even debilitating, but with supportive care, full recovery is expected. The most serious complication of influenza, which contributes to most of the deaths, is pneumonia. 􀁸􀀃 We’ve talked about pneumonia some before, but it’s such a common condition both as a primary infection and as a complication of other illnesses that we ought to cover it more thoroughly. Pneumonia comes from the Greek, meaning inflammation of the lungs; the word is probably related to older root words that refer to fluid or owing in the chest. Even the ancients knew that fluid in the lungs, leading to a wet cough, wasn’t a good thing.

Question 86

Concussion

Answer 86

This is a concussion, a word meaning a minor traumatic brain injury. After a concussion, the key to a successful recovery is rest—both physical rest, and brain rest. Clinically, a concussion is diagnosed any time there’s been head trauma followed by a period of altered brain functioning. •• Symptoms like headache, mood changes, foggy thinking, and poor sleep often occur after a concussion. Resting after a concussion prevents an even worse second concussion. Current guidelines suggest resting until all symptoms are gone, followed by a gradual return to activity and normal life. •• Thirty minutes later Brad still seems OK, certainly not worse, and you reassure him that no imaging is needed. He can go home, and his girlfriend promises to keep him resting. He can follow up with his own primary doctor in a week or so.

Question 87

Diabetes Mellitus

Answer 87

􀁸􀀃 The term “diabetes” comes from a Greek word referring to a siphon or something that passes a great deal of water. The term “mellitus” refers to the sweet taste of the urine, as if it is sweetened with honey. In 1776, the glucose concentration of the urine of diabetic patients was first measured, confirming the central role of so-called glucosuria—glucose in the urine—as a defining feature of diabetes. 􀁸􀀃 Understanding diabetes means understanding glucose and carbohydrate metabolism and how altered glucose metabolism causes illness. All foods contain one or more of the three so-called macronutrients—the common molecules that we eat and absorb for energy. These three macronutrients are carbohydrates, fat, and protein. 􀁸􀀃 Carbohydrates are further divided into the simple sugars—small molecules of one or two sugar units each—and complex sugars, also called polysaccharides, which are essentially chains of smaller sugar units linked together. Polysaccharides are commonly called starches, and in the gut, these long carbohydrates and smaller two-unit carbohydrates are chopped into single simple sugar units called monosaccharides for absorption. The main monosaccharide absorbed from food is glucose, and for practical purposes, the terms “blood glucose” and “blood sugar” refer to the same thing. 􀁸􀀃 Glucose is crucial at many levels of metabolism. It is the essential energy source for many body tissues and can be converted to a variety of forms, including the building blocks of fat, by processes in the liver. The level of blood sugar is tightly controlled by several overlapping homeostatic mechanisms to ensure good health and energy availability. 􀁸􀀃 The word “homeostasis” is a central way that living organisms maintain health. Homeostasis is an active process that regulates the internal environment, keeping essential parameters like pH, temperature, electrolytes, and metabolic substrates all in a normal range. Once homeostasis is disturbed, all sorts of problems ensue. 􀁸􀀃 Diabetes comes in two types. Type 1 diabetes used to be called juvenile diabetes, and though it usually occurs in children, it can begin in adulthood. In type 1 diabetes, the beta cells of the pancreas are destroyed by the body’s own immune system, eliminating the body’s ability to secrete insulin. This condition had been uniformly and rapidly fatal prior to the development of insulin injections in the 1920s. 􀁸􀀃 In contrast to type 1 diabetes, type 2 diabetes more commonly begins in adulthood, usually in people who are overweight. Although the exact mechanisms aren’t completely understood, many overweight people will eventually seem to develop resistance to insulin; even though their pancreas can produce plenty of it, the circulating insulin becomes ineffective in driving down blood sugar. 􀁸􀀃 Eventually, in type 2 diabetes, there is decreased insulin secretion as well (though insulin isn’t typically completely gone, as it is in type 1 diabetes). The combination of insulin resistance and relative insulin insufficiency leads to high blood sugar, or hyperglycemia, in type 2 diabetes. And it’s the hyperglycemia that causes most of the mischief. 􀁸􀀃 Although they can be life threatening, acute complications of high blood sugar are not very common in type 2 diabetics. The main goals of therapy are to prevent the very significant, late effects of long-term hyperglycemia. These late effects can affect almost every organ system of the body. Although treatment and good control of blood sugar will prevent or delay most of these complications, even with very good therapy, patients with diabetes remain at risk.

Question 88

Candida.

Answer 88

Thrush is commonly seen in newborns and young babies, but really should not occur in healthy, young men. The appearance of thrush suggests that something has gone wrong with his immune system. He also has some swollen lymph nodes, which are most commonly seen during infections.

Question 89

Treating Abscesses

Answer 89

Treating abscesses typically involves a combination of at-home care and medical intervention. Here are the general steps for treating abscesses: 1. Do not attempt to pop or drain the abscess yourself: It's important to avoid squeezing, puncturing, or opening the abscess at home, as this can lead to further infection or complications. Instead, seek medical attention for proper evaluation and treatment. 2. Clean the affected area: Gently clean the area around the abscess with mild soap and water. This helps to prevent further infection and keeps the area clean. 3. Apply warm compresses: Use warm compresses on the abscess for about 10-15 minutes several times a day. The warmth can help increase blood flow to the area, promote circulation, and encourage the abscess to come to a head. 4. Seek medical attention: It is important to consult a healthcare professional, such as a doctor or a dermatologist, for proper evaluation and treatment of the abscess. They may perform the following: - Incision and drainage: In many cases, the abscess will need to be incised and drained by a healthcare professional. They will make a small incision in the abscess to allow the pus to drain out. This helps relieve pain, promote healing, and prevent the infection from spreading. - Antibiotics: Depending on the severity of the abscess and the presence of an underlying infection, your healthcare professional may prescribe oral or topical antibiotics to help fight the infection. - Follow-up care: After the abscess is drained, your healthcare professional may provide instructions for at-home care. This may include applying antibiotic ointment, changing dressings, or taking oral antibiotics. It's important to follow their guidance for proper healing and to prevent recurrence or complications. 5. Keep the area clean and monitor for signs of infection: Follow the instructions provided by your healthcare professional for cleaning and dressing the abscess. Watch for any signs of worsening infection, such as increased pain, redness, swelling, or the development of a fever. If you notice any concerning symptoms, contact your healthcare professional promptly. It's important to note that the specific treatment approach for abscesses may vary depending on the location, size, and severity of the abscess. It is always recommended to seek medical advice and follow the instructions of a healthcare professional for proper evaluation and treatment.

Question 90

Treat Hemorrhoids

Answer 90

To treat hemorrhoids, you can try the following measures: 1. Manage symptoms with over-the-counter creams or ointments: Topical creams containing hydrocortisone or witch hazel can help reduce itching, inflammation, and discomfort associated with hemorrhoids. Follow the instructions on the packaging for proper usage. 2. Apply cold compresses: Placing a cold compress or ice pack wrapped in a cloth on the affected area can provide temporary relief from pain and swelling. Apply it for about 15 minutes at a time, several times a day. 3. Take warm baths: Soaking in a warm tub of water for about 10-15 minutes a few times a day can help alleviate discomfort and promote relaxation of the anal muscles. Adding Epsom salts to the bathwater may also provide additional relief. 4. Keep the area clean: Clean the affected area gently with warm water and mild soap after each bowel movement. Avoid using harsh or scented soaps, as they can irritate the hemorrhoids. 5. Increase fiber intake: Consuming a diet rich in fiber can help soften stools and ease bowel movements, reducing strain on the hemorrhoids. Include high-fiber foods such as fruits, vegetables, whole grains, and legumes in your diet. You can also consider taking fiber supplements or using stool softeners if recommended by your healthcare provider. 6. Stay hydrated: Drink an adequate amount of water throughout the day to maintain hydration and promote softer stools. 7. Avoid prolonged sitting or straining: Try to avoid sitting or standing for long periods, as this can increase pressure on the hemorrhoids. When using the toilet, avoid straining and consider using a stool to elevate your feet, which can help with better bowel movements. 8. Practice good hygiene: After bowel movements, pat the anal area gently with a moistened tissue or use unscented, alcohol-free wipes. Avoid rubbing or using rough toilet paper, as it can irritate the hemorrhoids. 9. Consult a healthcare professional: If home remedies don't provide sufficient relief or if your symptoms worsen, it's advisable to consult a healthcare professional. They can evaluate your condition and provide additional treatment options, including prescription medications or procedures if necessary. It's important to note that these measures are general recommendations and may not be suitable for everyone. The severity of hemorrhoids can vary, and it's best to consult with a healthcare professional for an accurate diagnosis and personalized treatment plan based on your specific situation.

Question 91

Skin Cancer or not?

Answer 91

There are five characteristics of skin cancers that are easy to remember from the mnemonic ABCDE: ○○ A stands for asymmetry—meaning that a skin lesion suspicious for cancer may look asymmetric. ○○ B stands for border. A benign lesion has smooth, even borders; a cancerous lesion may have borders or edges that are uneven, notched, or in a scalloped pattern. ○○ C, for color, emphasizes that benign lesions are usually the same color throughout, while cancerous lesions often have variable colors, or coloring that changes with time. ○○ D is for diameter—larger lesions are more likely to be cancer, or contain cancer. ○○ E is for evolving— meaning that any mole or mark that’s changing in color, size, elevation, or borders is more suspicious than a mole that stays the same from year to year.

Question 92

Snake Bites

Answer 92

If you or someone else has been bitten by a venomous snake, it is crucial to take immediate action. Here's what you should do: 1. Stay calm and call for help: Contact emergency medical services or local emergency response immediately. Provide them with information about the snake bite and your location. 2. Keep still and immobilize the affected limb: Restrict movement as much as possible. Immobilize the bitten limb using a splint or any available means (e.g., a stick, rolled-up newspaper) to minimize the spread of venom. 3. Position yourself properly: If possible, keep the bitten limb below heart level. This can help slow the spread of venom. 4. Remove constrictive items: Remove any tight clothing, jewelry, or constrictive items near the bite area before swelling occurs. This can help prevent complications if swelling occurs. 5. Clean the wound: If you have access to clean water and soap, gently clean the bite wound with mild soap to minimize the risk of infection. Avoid scrubbing the wound, as it may cause further damage. 6. Do not: - Cut the wound or attempt to suck out the venom. - Apply a tourniquet or constrictive bandage. - Apply ice or immerse the wound in cold water. - Use alcohol or any substances topically on the wound. 7. Monitor vital signs: If possible, keep track of the bitten person's vital signs, such as pulse rate, breathing, and blood pressure, until medical help arrives. It's essential to seek medical attention as soon as possible following a venomous snake bite. Antivenom treatment and additional medical interventions may be required. Remember, do not attempt to capture or kill the snake for identification purposes, as it can increase the risk of further bites. Prevention is the best approach, so it's important to take precautions to avoid encounters with venomous snakes and seek professional guidance on snakebite prevention and management in your specific region.

Question 93

Awareness

Answer 93

Awareness is simply the DECISION to pay attention to ones surroundings. Stay LEFT of the event. Leave before the explosion goes off.

Question 94

Seizure disorders

Answer 94

Seizure disorders, also known as epilepsy, are neurological conditions characterized by recurrent seizures. Seizures occur due to abnormal electrical activity in the brain. Here are the symptoms and treatments for seizure disorders: Symptoms: 1. Uncontrolled jerking movements of the limbs or body. 2. Loss of consciousness or awareness. 3. Staring spells or repetitive movements, such as lip smacking or hand fidgeting. 4. Sensations of tingling, dizziness, or unusual smells or tastes. 5. Confusion or disorientation after a seizure. 6. Fatigue or weakness. Treatment: 1. Medications: Antiepileptic drugs (AEDs) are the most common treatment for seizure disorders. These medications help control seizures by stabilizing the electrical activity in the brain. The specific medication and dosage will depend on the type of seizures and individual response. 2. Lifestyle modifications: Certain lifestyle changes can help manage seizure disorders, such as: - Getting enough sleep and maintaining a regular sleep schedule. - Minimizing stress and practicing relaxation techniques. - Avoiding triggers that may provoke seizures, such as flashing lights or certain foods. 3. Vagus nerve stimulation (VNS): This treatment involves implanting a device that delivers electrical impulses to the vagus nerve, which can help reduce the frequency and severity of seizures. 4. Ketogenic diet: In some cases, a ketogenic diet, which is high in fats and low in carbohydrates, may be recommended for children with severe seizure disorders that do not respond well to medications. 5. Responsive neurostimulation (RNS): RNS is a newer treatment option that involves implanting a device in the brain to detect and respond to abnormal electrical activity, potentially preventing seizures. 6. Epilepsy surgery: In certain cases where seizures are localized and not well controlled with medication, surgery may be considered to remove or separate the affected brain tissue. It's important for individuals with seizure disorders to work closely with a neurologist or healthcare provider specializing in epilepsy. Regular follow-up appointments, medication management, and monitoring of seizure activity are crucial for effective treatment. In addition, creating a supportive environment and educating family members, friends, and colleagues about seizure first aid can help ensure safety and proper care during a seizure episode.

Question 95

Vince Low Blood cell count

Answer 95

It’s time to check in on Vince. We’re going to focus now on the most important lab for Vince: the CBC, or complete blood count. It’s an analysis of the three main kinds of blood cells: red blood cells, platelets, and white blood cells. •• Vince’s proportion of red cells, which carry oxygen, is very low. That can account for his exercise intolerance. Vince’s count of platelets—repair cells—is very low, too. Not good. Vince’s white cells—part of the immune system—are also very low. •• His bone marrow, where these cells are made, has stopped working. Given the overall picture, you’re concerned that the likely diagnosis is something quite bad, either cancer or bone marrow failure from aplastic anemia.

Question 96

Altitude Sickiness

Answer 96

Let’s change venues, heading to a clinic at a ski resort. Our first patient calls himself Turbo. He’s a 31-year-old ski instructor coming in with a chief complaint of: “Man, I’m hung over, and I need a vitamin shot.” •• Turbo has a pounding headache, feels like he might throw up, and feels dizzy. In truth, there is no vitamin shot, and there is no quick hangover cure—the only treatment is rest, fluids, maybe aspirin or acetaminophen, and no more alcohol. •• Turbo has no past medical history. On your exam, he looks comfortable, but you notice a wet, crackly sound over his chest. This is more than just a hangover: Turbo has altitude sickness. •• Altitude sickness is caused by a relative lack of oxygen in the air as you ascend. If someone goes up too quickly, symptoms begin. The mildest symptoms include headache, nausea, and dizziness. If untreated, or if the person ascends further, high-altitude pulmonary edema can begin, with fluid accumulating in the lungs. That’s what Turbo has. If he continued to ascend, he would be at risk for the worst form of altitude sickness, which can cause brain swelling, confusion, coma, and death. •• You make arrangements for Turbo to be taken down the mountain for treatment. He’ll also need extra oxygen and diuretics. The recovery is usually quick once the patient descends, and Turbo may be able to come back in a few days—just slower, next time, and probably on medication to prevent altitude sickness from returning.

Question 97

Types of headaches

Answer 97

The classification of headaches starts with one question: Is this a primary or a secondary headache? Primary headaches are ones that occur without any other abnormality or speci c pathology. These include migraine, tension, and cluster headaches. Although these kinds of headaches can be very painful and disruptive to life and work, they’re sometimes thought of as “benign” headaches because they don’t get worse and worse, and no one dies because of them. In contrast, secondary headaches are headaches caused by something else—something else that can be directly identi ed and treated. These include headaches from a brain tumor, an intracranial bleed, an abscessed tooth, meningitis, or—as our patient suspects—a sinus infection. Sudden or severe high blood pressure can also cause headaches. 􀁸􀀃 The secondary headache category also includes headaches that accompany many viral or bacterial infections, such as in uenza or strep throat, or headaches caused by trauma. They can also be caused by metabolic disturbances, including low oxygenation or low blood sugar or from substance abuse or withdrawal.

Question 98

UTIs

Answer 98

Symptoms of a urinary tract infection (UTI) can vary depending on which part of the urinary system is affected. Common symptoms include: 1. Lower urinary tract infection (cystitis): - Frequent urge to urinate - Pain or a burning sensation during urination - Cloudy or bloody urine - Strong-smelling urine - Pelvic pain or pressure - Mild fever or fatigue 2. Upper urinary tract infection (pyelonephritis): - Symptoms of lower urinary tract infection, plus: - High fever (often above 101°F or 38.3°C) - Flank pain (pain in the back or side, below the ribs) - Nausea and vomiting - Additional symptoms of systemic infection, such as chills and shaking Treatment for a UTI typically involves the following: 1. Antibiotics: The primary treatment for a UTI is a course of antibiotics to eliminate the bacterial infection. The specific antibiotic prescribed will depend on factors such as the type of bacteria involved and its sensitivity to different medications. Commonly prescribed antibiotics for UTIs include trimethoprim-sulfamethoxazole, nitrofurantoin, or fluoroquinolones. It's important to complete the full course of antibiotics as prescribed, even if symptoms improve. 2. Increased fluid intake: Drinking plenty of water and staying hydrated can help flush out bacteria from the urinary system. This can also help alleviate symptoms and promote healing. 3. Urinary pain relief: Over-the-counter pain relievers, such as phenazopyridine, can help alleviate the discomfort or pain associated with UTI symptoms. However, they do not treat the underlying infection and should not be used as a substitute for antibiotics. It's important to follow the recommended dosage and consult with a healthcare professional if needed. 4. Prevention measures: After a UTI, it's important to take preventive measures to reduce the risk of recurrence. This may include: - Drinking plenty of water to maintain good hydration. - Urinating frequently and fully emptying the bladder. - Wiping from front to back after using the toilet. - Avoiding irritants such as harsh soaps or feminine hygiene sprays. - Urinating before and after sexual activity. - Proper hygiene practices, including regular bathing and wearing breathable underwear. It's crucial to seek medical attention if you suspect a UTI, as untreated or recurrent infections can lead to complications. A healthcare professional will provide an accurate diagnosis and recommend appropriate treatment based on your specific condition.

Question 99

MI symptoms

Answer 99

•• Myocardial infarctions (MI) can vary greatly. For example: ○○ The worsening chest pain over the center or left chest, arising over 10 or 15 minutes, should last for 20 minutes to 2 hours. It can be longer or shorter, though. ○○ Classically, patients are said to report a “crushing” type of pain. There’s even a specific hand gesture for it, a closed fist held over the left chest, called Levine’s sign. The pain can vary in character and location, though, and sometimes there is no pain at all. Any pain ought to be improved by sitting down or resting, and it should worsen with exertion. ○○ Expected associated symptoms can include shortness of breath, nausea, vomiting, sweating, belching, or lightheadedness. The pain often radiates to the left arm, but can also radiate into the right arm or both arms. ○○ Most commonly, chest pain from an MI begins during exertion, but it can also start during periods of emotional stress. MIs can also start while eating, or during sex, or during sleep, or any time.

Question 100

Dizziness

Answer 100

􀁸􀀃 In our general medicine clinic, a 42-year-old woman named Tina says that for the last few months, she gets these “attacks” where all of a sudden she gets dizzy. She can’t stand up straight, and sometimes she hears a buzzing or high-pitched sort of noise. She says that she sort of staggers around and has to eat a candy bar. Once she has some sugar, in about a half of an hour, she starts to feel better. 􀀃 These episodes are getting more intense, more frequent, and are lasting longer—now, she says, sometimes she has to eat two candy bars. Her friends have told her that she’s either having hypoglycemia or that she’s just crazy. 􀁸􀀃 Dizziness can be a challenging symptom because different people use that term to refer to different things. Dizziness can mean vertigo—which is a sensation of spinning, as if the environment is moving around you. True vertigo is usually caused by problems with the inner ear, where the sense organs of balance are. 􀁸􀀃 Dizziness can also refer to a lightheaded feeling, like you’re going to faint. That’s a completely different problem, with different physiology to think about. Dizziness in this sense is usually caused by insuf cient blood ow to the brain. 􀁸􀀃 Less frequently, a feeling of dizziness can be related to feeling unsteady or off balance, caused by problems with the brain, nerves, or muscle. This can be related to a loss of either nerve input to the brain—conditions where there’s a loss of sensory input, so a person can’t sense, essentially, where their feet are; or a condition that affects motor function, causing weakness and unsteadiness. These are neurological problems and are most often present in elderly people. 􀁸􀀃 Finally, dizziness can be a psychological or psychophysiological effect, when a person feels kind of disconnected or disassociated with the world’s sensory signals. In that case, a psychological assessment is most helpful. 􀁸􀀃 Tina clari es by saying that the feeling she keeps having is a spinning feeling—like the room is spinning, round and round. She says she doesn’t feel faint, and she’s never passed out, but she is afraid she’ll fall down. This is true vertigo. 􀁸􀀃 Because she also mentioned that she hears an unexplained buzzing or high-pitched sound, we can be pretty sure that this is an ear problem, speci cally with the inner ear, where hearing and balance sense organs are located. That would explain the combination of vertigo and a hearing issue. 􀁸􀀃 Tina’s history and physical exam support a clinical diagnosis of episodic vertigo. The main symptom of problems along the pathways of the balance system, from the balance organs through the nerves to the brain area that interprets the data, is vertigo—a sensation of movement in space when there is in fact no movement. 􀁸􀀃 The most common cause of vertigo is called benign paroxysmal positional vertigo (BPPV). It causes brief (less than one minute) episodes of vertigo triggered by a position change, such as turning over in bed or quickly looking up. 􀁸􀀃 It’s caused by a problem in the balance sense organs themselves, by debris in the semicircular canals. The symptoms and nystagmus can be recreated in the of ce by moving the head in the plane of the effected canal. Tina’s vertigo attacks last too long to be typical of BPPV. 􀁸􀀃 Labyrinthitis refers to in ammation in the balance and hearing organs. The vertigo can be made worse by positional changes and usually last days to weeks. Tina’s symptoms have come in recurrent, isolated attacks that have come and gone repeatedly—which really doesn’t t the typical presentation of labyrinthitis. 􀁸􀀃 Another problem that can occur in the sense organs of balance is called Ménière’s disease. Although we don’t know exactly why it occurs, it seems to be caused by excessive endolymph uid that interferes with the functioning of the balance organs. Ménière’s patients, in addition to having periods of intense vertigo, often also suffer from hearing problems, because that same excessive endolymph affects the functioning of the cochlea.

Question 101

Hyperthyroidism

Answer 101

Hypothyroidism is a condition characterized by an underactive thyroid gland, which leads to insufficient production of thyroid hormones. Thyroid hormones play a vital role in regulating various bodily functions, including metabolism, energy production, and the functioning of organs and tissues. Hypothyroidism can occur due to various causes, such as autoimmune disease (Hashimoto's thyroiditis), certain medications, radiation therapy, or surgical removal of the thyroid gland. The symptoms of hypothyroidism can vary, but commonly include: 1. Fatigue and weakness 2. Weight gain or difficulty losing weight 3. Cold intolerance 4. Dry skin and hair 5. Constipation 6. Depression or mood swings 7. Memory problems or difficulty concentrating 8. Muscle aches and stiffness 9. Menstrual irregularities in women 10. Elevated cholesterol levels 11. Swelling of the face, hands, or legs (edema) Treatment for hypothyroidism typically involves lifelong thyroid hormone replacement therapy, which aims to restore normal thyroid hormone levels in the body. The most common medication used is synthetic thyroxine (levothyroxine), which is identical to the hormone produced by the thyroid gland. The dosage of medication is determined based on individual needs and is adjusted through regular monitoring of thyroid hormone levels. It is important to follow the prescribed medication regimen consistently and undergo regular blood tests to ensure that the thyroid hormone levels remain within the appropriate range. Adjustments to the medication dosage may be made over time to optimize treatment effectiveness. It may take several weeks or months to find the right dosage that effectively relieves symptoms and restores normal hormone levels. In addition to medication, it's important to maintain a healthy lifestyle that includes a balanced diet, regular exercise, and stress management. This can help support overall well-being and may improve symptoms associated with hypothyroidism. If left untreated, hypothyroidism can lead to complications and adversely affect various body systems. Therefore, it is crucial to receive an accurate diagnosis, follow the prescribed treatment plan, and maintain regular communication with your healthcare provider to effectively manage hypothyroidism.

Question 102

Robert’s Swarm

Answer 102

•• Another patient is coming back, a 45-year-old man named Robert. He was at a picnic and got stung by bees or wasps, and then he passed out. His friends drove him over to the ED. •• Robert’s back in a room; he’s awake, but doesn’t look good. ABCs first: His airway is open, and he’s breathing on his own. But his pulse is fast, he looks pale, and he doesn’t open his eyes when you ask him to. You can see several sting marks on his left arm, and the area is red and swollen. His lips are swelling, and he’s starting to get raised red welts on his chest and belly, too. •• Could Robert be having a severe allergic reaction, called anaphylaxis, to the stings? It’s best to assume he is in fact allergic, and begin immediate therapy. •• You begin giving oxygen, epinephrine, and extra fluids to support his blood pressure and circulation; additional medications, including an antihistamine, are added to his IV meds, and a second IV is placed. That gives you extra access for medicines and fluids, and also provides a backup if the first IV becomes dislodged. •• Bees, wasps, and hornets usually just cause painful stings. In the field, try to remove the stinger, if it’s still embedded, with a sharp card or side of a blade—don’t try to squeeze it, or more venom can be introduced. Routine care should include a cool pack, elevation, and pain medication. •• Dangerous reactions usually start within minutes of the sting, though they can be delayed by up to a few hours. Worrisome symptoms include hives, shortness of breath, swelling of the tongue or lips, weakness, vomiting, dizziness, or fainting. If it’s available, give epinephrine immediately, and either transport the victim to emergency care or call 911, whichever is faster. People who are known to be allergic, who’ve had a sting reaction before, should always carry an epinephrine auto-injector when outdoors. •• After epinephrine is given, even if the sting victim feels better, they should be brought in for emergency care—allergic reactions can persist or progress. •• Robert’s vital signs are improving, and he’s waking up; he confirms he is allergic. He’ll need to be monitored longer, and weaned off the epinephrine, so it’s an ICU admission for Robert.

Question 103

Pain Complications

Answer 103

•• Tom and Allen received two different medicines because they have different kinds of pain. We think of pain as something that happens totell us when there is damage or illness. Pain receptors detect damage and send signals through nerves, up the spinal cord, to the brain. •• But pain also includes a sensory experience. People who are fearful, say of an immunization or a bee sting, feel far more pain from the exact same injury than people who are calm. •• With persistent chronic pain, there is a re-regulation of the way that the body senses pain. A condition called hyperalgesia develops, where the sensation of pain becomes more sensitive to weaker stimuli. •• The bottom line for treatment is that though opiate-based compounds—the narcotics—work well for acute pain in the setting of an acute illness or injury, these medicines do not work well for chronic pain. In fact, opiates themselves can induce hyperalgesia. People who take opiate-based pain medicines long term will start to become more sensitive to pain. They’ll naturally want to take more of their medication—with diminishing returns as their tolerance increases. •• All potentially addictive substances, including opiates, also affect powerful pathways in the brain. Opiates short-circuit the brain’s reward system, which may be why addicted people stop doing the behaviors they ought to be doing—like going to work, maintaining friendships, or looking after their spouse. •• When patients take a dose of narcotics, they feel better; when it wears off, they feel worse. Worrying about when the next dose will come will increase pain, reinforcing the need for more medication. •• The line between chronic and acute pain is often difficult to determine. Mental illness can also complicate matters. The emergency department is not the best place to untangle and address these issues—but if they’re not addressed, our patients will have an even more difficult time finding relief.

Question 104

Urticaria

Answer 104

􀁸􀀃 There are a few conditions that can kind of mimic chronic idiopathic urticaria, but it’s easy enough to tell the difference. Allergic contact dermatitis occurs only where a contact allergen touches the skin, so it’s in the same place every time. A so-called foxed drug eruption can be a recurring swollen area, but it’s in the same place every time, and as it heals, it leaves a dusky area. 􀁸􀀃 The only rash that occurs like Leslie’s, popping up quickly anywhere on the body and then disappearing quickly, is urticaria. 􀁸􀀃 At least 30 to 50 percent of chronic idiopathic urticaria is autoimmune—that is, there are antibodies against our own tissues that trigger the reaction. It’s likely that perhaps the other 50 percent is autoimmune, too, but we haven’t been able to test for the antibodies yet. So perhaps that term “idiopathic,” meaning “of unknown cause,” is misleading. 􀁸􀀃 Food allergies can cause acute episodes of urticaria, but it’s very unlikely that foods will cause longstanding, chronic urticaria without clear correlation. Some people with chronic urticaria can have hives triggered by physical things, such as pressure on the skin, warmth, or cold. These triggers are usually clear from the history. 􀁸􀀃 Many patients with chronic urticaria, like Leslie, have thyroid antibodies, but these don’t seem to be the actual trigger. Usually, thyroid functioning is normal, and these antibodies require no treatment. Even if thyroid functioning is abnormal, treating the thyroid condition doesn’t help resolve the urticaria. 􀁸􀀃 There is good therapy available for chronic idiopathic urticaria. It’s crucial that patients are taught how to use the medicines correctly. Daily use of antihistamines at relatively high doses, every day, can help suppress the rash. It’s important that these antihistamines not be stopped on days when the rash is absent—staying on them daily, long term, even on days without rash, helps keep the rash suppressed. Sometimes, multiple antihistamines that work via different receptors are used simultaneously. 􀁸􀀃 If maximal, regular, scheduled use of antihistamines is ineffective, daily or every-other-day oral steroids can be used, though side effects of this strategy can be significant. To avoid long-term steroids, other immune-modifying medications, such as cyclosporine, can be useful. Even more aggressive strategies can include the administration of intravenous immunoglobulin or plasmapheresis, a method of filtering out immune molecules from the blood. 􀁸􀀃 Ironically, Leslie was prescribed the correct medications, but because multiple doctors had given her different instructions, she didn’t understand how to use these medications correctly. In our clinic, no further tests were done, and written instructions were provided for the use of two simultaneous antihistamines. 􀁸􀀃 Leslie, as is typical for most people with chronic urticaria, did not have any food allergies, but food allergies are a signi cant problem for many people, and they’re often misunderstood. It’s important to make a distinction between an adverse reaction to food—something like the bloating and diarrhea that goes with lactose intolerance— and a true food allergy, because only real food allergies can progress to life-threatening reactions. 􀁸􀀃 Most food allergies cause only mild symptoms. The best predictor of who is at risk for serious food reactions is what has happened with that food exposure in the past. Anyone who has had a life-threatening or severe reaction to a specific food is at risk for that happening again. 􀁸􀀃 Also, some foods, especially peanuts and tree nuts, are more likely to cause more severe reactions than other food allergens. In addition, any person who has a history of asthma or recurrent wheezing who also has food allergies is more likely to experience a severe reaction to foods. These are generalities. If you have food allergies or a suspicion of food allergies, work with your own doctor for specific recommendations.

Question 105

TIA versus Stroke

Answer 105

􀁸􀀃 The risk factors for TIA and stroke are the same, and they overlap with the risks for coronary artery disease and blockages in other blood vessels. All of these are related to age; the risk of stroke doubles every decade of life, starting at 55. 􀁸􀀃 Men are at higher risk than women, and there are inherited risk factors as well. African Americans, Hispanics, and Asians are all at higher risk than Caucasians (perhaps because they all have higher rates of hypertension). 􀁸􀀃 Stroke risk is increased not only by high blood pressure, but also by obesity, diabetes, and high cholesterol. Lifestyle choices like smoking, staying sedentary, and excessive alcohol consumption all increase the risk of stroke, as do some medications. Taking oral contraceptives, especially when combined with smoking in women over 35, can further increase stroke risk. 􀁸􀀃 The symptoms of a TIA or stroke can start out exactly the same, but the risk of a stroke within seven days of a TIA is doubled among those who don’t seek treatment. 􀁸􀀃 Aftercare of a stroke, after clot-busting medicine or treatment of hemorrhage, often includes prolonged rehabilitative care and supportive care. Some functioning can return. 􀁸􀀃 Immediately after a stroke, there is a window of a few days or weeks where there can be a fairly rapid recovery of function, at least partially. More functioning is more likely to return with a stroke that affected a smaller area of brain and in people who got medical care quickly. 􀁸􀀃 The location of the stroke is also a predictor; some areas of the brain seem to be more or less fragile than other parts. Improvement will also depend on the overall health of the patient and whether there were complications. 􀁸􀀃 The recovery period immediately after a stroke occurs when cells near the area of ischemia start to recover. These are cells that were damaged, but not killed, by the stroke. 􀁸􀀃 After this initial period, there can still be improvement and recovery—though recovery becomes slower after the rst few weeks. After that initial period, brain recovery probably isn’t related to individual cells recovering their function, but from other mechanisms. 􀁸􀀃 To some extent, the brain can rewire connections around an area of damage. Past six months after a stroke, though, there is typically not a lot of further recovery possible. The exact extent of recovery within that six-month window is difficult to predict, but it can be substantial. However, 100 percent recovery is rare.

Question 106

Lauras Fever

Answer 106

•• Our first patient is Laura; she’s three weeks old, with a chief complaint given by her mom of “fever.” Today, she seemed less energetic and less interested in nursing. Her parents checked her temperature, and it was 101° Fahrenheit. Laura’s mom and dad have been fine, but there is a three-year-old sister in the house with cold symptoms. •• The physical exam is normal, with entirely normal vital signs. Laura has a normal temperature now of 99.1°. In this case, Laura’s measured temperature of 99.1 is well within the normal range, which is up to 100.4. But with a newborn, we’re very careful about taking any fever very seriously. •• Even though Laura now looks well, the evaluation was undertaken quickly. The best way to know if a bacterial infection is present is with tests called cultures. Though cultures are accurate, they take a few days to complete, so in the meantime we need surrogate, quicker tests to help decide what to do today. For Laura, those quick screens included a CBC (complete blood count), plus a urinalysis and analysis of the cerebrospinal fluid. Though the CBC was normal, the urine contained white cells suggesting a possible urinary tract infection. •• Laura was admitted to the hospital and started on IV antibiotics. The next day, both her urine and blood cultures grew out the same bacteria—an infection had probably started in her urinary tract, and spread to her blood. She remained well, and was sent home in a few days to complete a course of antibiotics. We caught the infection just based on that one symptom, fever—and treated Laura successfully even before she got sick. Fever, in this case, was helpful.

Question 107

Faiting

Answer 107

○○ If you start to feel like you’re going to faint, the best thing to do is to lie down. That will immediately increase blood flow to the brain. ○○ The worst thing to do is to try to get somewhere private by walking away—you’ll still faint, but you might hit your head on the way down, and it’s better to have someone nearby. ○○ If you ever come across someone who says they feel like they’re going to faint, help them lie down so they don’t hurt themselves—or at least stay close so you can catch them and ease them down when they pass out.

Question 108

Triage

Answer 108

Triage is a process used in emergency situations to prioritize the medical care of patients based on the severity of their condition. Smart tags, also known as triage tags or color-coded tags, are tools used to assist in the triage process. They provide a quick visual indicator of the patient's priority level and help healthcare providers allocate resources efficiently. While the specific details of smart tag systems may vary, here are some general guidelines for triaging and using smart tags: 1. Assess the Situation: Evaluate the overall situation to determine the available resources, number of patients, and the severity of the incident. This initial assessment will help you understand the scope of the situation and guide your triage decisions. 2. Establish Triage Categories: Determine the triage categories to classify patients based on the severity of their injuries or medical conditions. The commonly used categories are: - Immediate/Red: Patients with life-threatening conditions who require immediate medical attention to survive. Examples include severe bleeding, obstructed airway, or cardiac arrest. - Delayed/Yellow: Patients with injuries or illnesses that are significant but not immediately life-threatening. They require medical care but can wait a short while before receiving it. Examples include fractures, moderate bleeding, or respiratory distress. - Minimal/Green: Patients with minor injuries or illnesses that do not require immediate medical attention. They can often care for themselves or receive assistance from non-medical personnel. Examples include minor cuts, sprains, or cold symptoms. - Expectant/Black: Patients who are unlikely to survive due to the severity of their injuries or the lack of available resources. These patients are typically provided with comfort measures and palliative care. 3. Assign Smart Tags: Once the triage categories are established, assign the appropriate smart tag to each patient. The smart tags are usually color-coded or labeled to correspond with the triage categories. Make sure the tag is visible and easily identifiable. 4. Prioritize Care: Based on the assigned triage category, prioritize the medical care and allocate resources accordingly. Immediate/Red patients should receive immediate life-saving interventions, while Delayed/Yellow patients may need treatment as soon as possible but can wait briefly. Minimal/Green patients can be treated after the more severe cases have been addressed, and Expectant/Black patients may require comfort measures and emotional support. 5. Reassess and Re-Triage: In dynamic situations, continuously reassess patients and adjust their triage category if their condition changes. Re-triage may be necessary to ensure that resources are allocated appropriately as the situation evolves. It's important to note that specific triage protocols and smart tag systems may vary depending on the healthcare facility, region, or type of incident. Medical professionals receive training in triage techniques and may adapt their approach based on the circumstances at hand. During emergencies, it is recommended to follow the guidance of trained healthcare providers or emergency response personnel who are familiar with the specific triage protocols and smart tag systems in use.

Question 109

Amy’s Raccoon

Answer 109

Another patient is on her way back. This is Amy, a 22-year-old graduate student who’s studying raccoons. She spends a lot of her time outdoors, watching raccoons and other creatures, and this one bit her. •• Wound care comes first. Amy has been bitten twice on the leg, and your nurse will get to work irrigating out the area as well as possible. In the field, use whatever clean water you’ve got; it works better under pressure. •• Amy is up to date on her tetanus shots, but what about rabies? Rabies is a viral infection, called a zoonotic infection, caught from infected animals, from their bites or saliva. It is virtually impossible to treat once symptoms start. •• In the U.S., most domesticated animals are vaccinated. There are occasional transmissions to humans from wild mammals, particularly bats. Animals with rabies do not behave normally—and that’s a concerning clue here. The one that bit Amy was not acting like an ordinary raccoon. Rabid animals can be overly aggressive,or at other times can act listless and tired. Amy is going to need rabies prophylaxis, a series of injections that will prevent her from catching rabies from this bite.

Question 110

Cynthia - Is it a heart attack

Answer 110

•• Our next patient is Cynthia, 22 years old. She’s had intermittent chest pain for about a week. At first it wasn’t too bad, but today it’s especially severe. Cynthia also says this week she’s felt exhausted, like she can’t do anything, and today it was hard to even get out of bed. She says she’s been short of breath, too. •• First impressions? She’s younger than the vast majority of people having cardiac chest pain. And the history doesn’t sound like a typical MI, where you expect a single pain complaint that lasts 20 minutes to a few hours. But, again, an MI isn’t the only worrisome cause of chest pain. This exhaustion, this inability to get out of bed, what’s that all about? •• Her vital signs are not normal. Her heart rate is too fast, her blood pressure is low, and her breathing is fast. Her pulse ox checks out normal at 95%, but let’s give her some extra oxygen, anyway—it’s almost always a good thing to do to help save lives. •• For Cynthia’s exam, let’s just focus on the abnormals. Through your stethoscope, her breaths have a wet and crackly quality. This sound is called rales or crackles, and it’s caused by fluid in the lungs. Cynthia’s heart tones sound distant and soft. •• The workup from here is fast. We do an EKG, which shows several abnormalities; a quick chest X-ray confirms hazy fluid in the lung fields, and it also shows that the silhouette of her heart is large. Her heart is not beating effectively—it’s squeezing, but not as well as it should, and blood isn’t exiting the heart as forcefully and quickly as it needs to. •• Cynthia probably has myocarditis, a disease of the heart muscle itself. In the U.S., this is most commonly caused by a viral infection. Though many patients recover completely, this disease has a high mortality, about 20% within one year of presentation. In the ED, the most important steps are to give oxygen, manage the patient’s fluids status appropriately (this is a case where too much IV fluid will make things worse), and continue to look for other, more immediately treatable causes of heart dysfunction. •• For now, though myocarditis fits the picture well, we haven’t fully excluded myocardial ischemia as a possible cause or contributor to her symptoms. Cynthia will need to be admitted, probably to a cardiac ICU, and continue to receive serial blood tests and EKGs while medical support of her heart function continues.

Question 111

Look for threats.

Answer 111

Look for people going against baselines. Find the exits. What structures can be used as cover. Find obvious threats in the room. What are the more subtle treats.

Answer 112

Cold: Symptoms: Mild symptoms such as a runny or stuffy nose, sneezing, sore throat, and cough. Fever: Rare, and if present, typically low-grade. Duration: Symptoms usually resolve within a week. Influenza (Flu): Symptoms: Similar to a cold but more severe. Symptoms may include fever, chills, muscle aches, fatigue, cough, sore throat, runny or stuffy nose, headache, and sometimes gastrointestinal symptoms. Fever: Common and often higher (above 100.4°F or 38°C). Duration: Symptoms typically last about one to two weeks, with fatigue and weakness lasting longer. Upper Respiratory Illnesses: Examples: These can include various viral or bacterial infections like sinusitis, pharyngitis (sore throat), or laryngitis. Symptoms: Symptoms depend on the specific illness but may include nasal congestion, runny nose, sore throat, cough, hoarseness, or postnasal drip. Fever: May or may not be present, depending on the specific illness. Duration: Duration varies depending on the cause and treatment but typically lasts a week or longer. Bronchitis/Lower Respiratory Infections: Examples: These can include bronchitis or pneumonia, which primarily affect the lungs. Symptoms: Symptoms may include persistent cough, production of discolored or bloody mucus, shortness of breath, chest pain, and wheezing. Fever: Common, especially in pneumonia. Duration: The duration can vary. Bronchitis symptoms may last for a few weeks, while pneumonia can last for several weeks or longer and requires medical attention.

Question 113

tachycardia

Answer 113

Fast heart rate.

Question 114

Dealing with Attack Dogs

Answer 114

Stay on your feet no matter what. Side step initial attack Wrap your arm in a jacket. Strick snout and eyes.

Question 115

Eye Sores

Answer 115

Dangerous Darts •• Our next patient is one of two brothers who found darts in the garage. Mark is the older boy at 8; his 7-year-old brother is cowering somewhere with his mom on the other side of the room. The dad’s with Mark. Mark’s face is covered with blood, and a bright blue dart is sticking out of his eye. •• If something like this happens when you’re nearby, it’s best to leave the thing in, whatever it is. Removal can cause more damage, and can trigger even more bleeding. •• It might be that the lawn dart actually landed just inside his eye, against his nose—it’s hard to tell if it’s punctured his cheek or eye socket. You make sure the dart itself is stable and not moving, adding a little tape across it so it won’t dislodge, and have an IV started for pain medicine and to give antibiotics; then you arrange for a CT scan, and have your staff contact both the ophthalmologist and ENT surgeon on call. •• If something small can be rinsed out of the eye, that probably doesn’t need an ED evaluation; but if there’s persistent pain or significant trauma, or any hint that vision has been affected by an injury, that needs to be seen right away. An injured eye can be protected during transport by taping a disposable cup over the eye, and keeping both eyes in the dark. •• Chemicals splashed into the eye can cause some of the most damaging injuries. The important thing is to start irrigating right away, and continue irrigating while getting the victim to the ED. •• We have Mark’s CT result now. The lawn dart didn’t puncture his eyeball, but it did go through the bones under the eye. He’ll be taken to surgery, and a specialist will remove the dart, clean out the wound, and put things back together.

Question 116

Some facts from the book The Science of Booze:

Answer 116

To conclude, I have learned that a lot is unknown in this area. Scientists are still figuring out how it works. We do make alcohol but important parts we don’t understand: * We are still figuring out about yeast and fermentation * We try to understand aging * We do our best to understand how our tasting works * Every day we learn more about the influences of alcohol on the human body * There is a world to discover to understand and cure hangovers. Isn’t it surprising that we know so less considering our relationship with booze? Humans have made and consumed alcohol since the beginning of civilization! People even claim that civilization started with alcohol. Stored fruit started to ferment and humans wanted to settle because that drink gave joy.

Question 117

Lice

Answer 117

Confirm lice presence: Look for lice and eggs near the scalp. Treat affected individuals: Use an over-the-counter lice treatment shampoo or lotion as directed. Comb hair: Use a fine-toothed comb to remove lice and eggs. Wash items: Launder clothes, bedding, and towels in hot water or seal them in bags for two weeks. Clean the environment: Vacuum furniture and clean combs/brushes.

Question 118

Fever tactics

Answer 118

Fever Tactics •• What are the best clues to help risk-stratify a patient with fever, to separate out the people who have a viral infection that’s going to get better whatever you do versus the much smaller proportion of people who have a something more serious? •• The most important consideration is the overall health, age, and status of the patient. A newborn has a very poor immune system, so is at higher risk. The same goes for elderly people; those with compromised immune systems, including people on chemotherapy; and those with HIV infections or diabetes. •• Similarly, children who are not vaccinated are another high-risk group—riskier both in terms of their getting serious infections like meningitis and bacteria in the blood, and suffering more harm more quickly from those infections if they’re unrecognized and untreated. •• The other most reliable sign to help risk-stratify people with fever is their current clinical condition. People with fever who feel overall OK, who are eating and drinking and feel reasonably well after fever-reducing medications, are overall at low risk of having some kind of serious underlying infection. •• Now for some less helpful measures: The height of a fever is only weakly correlated with the risk of a serious infection, especially in an era with widespread vaccinations against invasive bacterial infections. Also, the response of that number to fever-reducing medicine is not a good predictor.

Question 119

Blood Loss

Answer 119

1. Mild blood loss (up to 15% of blood volume): - Slightly increased heart rate - Mild fatigue or weakness 2. Moderate blood loss (15-30% of blood volume): - Increased heart rate - Mild to moderate drop in blood pressure - Pale or cool skin - Increased respiratory rate - Fatigue and weakness - Dizziness or lightheadedness 3. Severe blood loss (over 30% of blood volume): - Rapid, weak pulse - Very low blood pressure - Pale, cold, or mottled skin - Rapid and shallow breathing - Profound fatigue and weakness - Dizziness or lightheadedness - Confusion or disorientation - Loss of consciousness or fainting Remember, if severe blood loss is suspected or encountered, immediate medical assistance should be sought.

Question 120

HIV/AIDS

Answer 120

Acquired immunode ciency syndrome (AIDS) is caused by the human immunode ciency virus (HIV). HIV is a roughly spherical virus that is about 60 times smaller than a human red blood cell (which is actually rather large for a virus). It’s one of a kind of viruses called retroviruses, which have their own unique enzymes and proteins that can insert their own genetic material into that of the infected host cells. 􀁸􀀃 Viruses are, in a way, not really living organisms. They don’t have any way to extract energy from their environment and can’t reproduce on their own. What they do is infect the cells of living organisms and use their own genetic instructions to take over the cell’s machinery. The HIV virus takes the idea of controlling a cell one step further. As a retrovirus, HIV contains a special enzyme called reverse transcriptase that turns the virus RNA into DNA that is directly inserted into the DNA of the host cell. 􀁸􀀃 Furthermore, the HIV virus preferentially infects our own immune cells—the cells that are supposed to be ghting off infections. The host’s own immune- ghting apparatus, instead of defending the body against HIV, is tricked into damaging our own cells and making more HIV virus to infect more of our cells. 􀁸􀀃 HIV doesn’t necessarily make the host immediately ill. It can replicate and spread in a relatively small number of cells, leaving plenty of normal immune cells to do their job. It can take years for people with HIV infection to develop signs of serious illness. 􀁸􀀃 The diagnosis of AIDS is made when a person with HIV infection has clinical manifestations of disease, either caused by the virus itself or by an opportunistic infection. Without treatment, about 50 percent of people infected with HIV will develop AIDS within 10 years (though a small number of people seem to remain healthy inde nitely). 􀁸􀀃 In addition to destroying the host immune system, HIV infects cells in the brain (causing, eventually, a form of dementia) and perhaps cells in the gut and other tissues. 􀁸􀀃 Without a functioning immune system, serious illness can occur from out-of-control, ordinary infections. A fairly ordinary, innocuous infection can be much harder to clear and can have severe or prolonged symptoms. There are also less-ordinary infections, sometimes called opportunistic infections—which are caused by organisms that couldn’t cause any problems for a healthy individual at all. 􀁸􀀃 Though we can still use antibiotics, antivirals, antiparasitics, and antifungal drugs to some bene t in AIDS patients, none of these

Question 121

Mental prep E&E

Answer 121

NEVER LET THE SITUATION WEAR YOU DOWN. Work the problem. Ooda loops - Its about initiative. Force them to react to you. Don't be a sitting target. Movement is life. Maintain situational awareness. Control panic. Have realistic optimism. Be relentless. Be Resilient.

Question 122

Lesson from medical practice

Answer 122

There are some good lessons from our patient’s prolonged diagnostic journey. It took several years for the correct diagnosis to be made, which is especially discouraging because there was effective therapy available. What went wrong, and what lessons should doctors and patients learn? 􀁸􀀃 Our first mistake was that there was an incomplete history. We knew that gynecological issues were a potential cause of symptoms, but we didn’t ask about her sexual history. Knowing about one symptom, that intercourse had become painful, was a crucial diagnostic clue. It was overlooked perhaps in part because of embarrassment. 􀁸􀀃 Even doctors don’t necessarily like to talk about these things. Still, if you’re the patient, keep in mind that you need to speak up about symptoms that are bothering you. Don’t wait for the doctor to ask, and don’t assume that if the doctor didn’t ask, he or she doesn’t need to know. 􀁸􀀃 Another mistake was overlooking the necessity for a thorough and complete exam. Louisa was uncomfortable about anyone performing a rectal exam—probably because she knew it would be painful. But a gentle rectal exam could have revealed speci c ndings that could have helped the medical team reach the correct diagnosis sooner. A gynecological exam would have been diagnostic—but our patient had stopped seeing her gynecologist. 􀁸􀀃 Another issue was a lack of good collaboration on the part of the doctors involved. We’re supposed to be a team, working together. But unfortunately, the ball got dropped, and more than once. Sometimes, the best diagnostic tool isn’t a blood test or an MRI— it’s just doctors talking to each other about the case so that everyone on the team knows what’s going on. 􀁸􀀃 Another lesson is that we’ve all got our favorite tools and our favorite ways of looking at things. Our patient had been referred to a gastroenterologist early on, but the GI doctor was looking for GI diagnoses. In fact, the psychiatrist that the patient saw later was looking, mostly, for psychiatry diagnoses. An open mind, from all of the doctors on the team, helps avoid our putting on mental blinders that prevent us from seeing the correct diagnosis.

Question 123

Opiate addiction

Answer 123

􀁸􀀃 Painkillers are the most often abused prescriptions. It turns out that there are really only three medications that are commonly used to treat pain—or at least three groups of medications, and within each group, they’re all similar. 􀁸􀀃 The first group only contains one medicine: acetaminophen, or Tylenol. It’s an effective medicine for mild to moderate pain, with minimal side effects when used correctly. It is not addictive. 􀁸􀀃 The second group, which also has many brands available over the counter, is the nonsteroidal anti-inflammatory drugs (NSAIDs). The most common ones are ibuprofen and aspirin; there are many others available by prescription. They all work in a very similar way. They are also effective for mild to moderate pain and have no addiction potential, and they’re pretty safe. Occasionally, and more often with regular use, they can cause GI upset. 􀁸􀀃 The problem is that neither of these kinds of medicine, alone, is effective for the most severe pain. For the worst pains, the only effective medicines in general use are narcotics and narcotic derivates. They’re all essentially based on an extract of the poppy plant, the precursor to opium. 􀁸􀀃 These medications range from morphine to codeine with many in between; the group also includes heroin, which is another opium derivative. They can all be used to effectively treat even the most severe pain, but all of them are potentially addictive when used inappropriately. When abused, they not only relieve pain, but they also get the user high. 􀁸􀀃 Still, for the many people who suffer from pain, especially chronic pain, narcotics are essential for providing relief. One of the biggest obstacles for these patients is misunderstanding the nature of drug tolerance, dependence, and addiction. This leads to the frequent undertreatment of pain, which itself, ironically, can actually contribute to the development of addictive behavior. 􀁸􀀃 To prevent, recognize, and treat addiction, we rst have to make sure we understand what’s happening physically and psychologically. Tolerance is a normal physiological change, when the body adapts to, or seems to “get used to,” a certain dose of a medication, such as an opioid. 􀁸􀀃 When tolerance develops, the drug becomes less effective at a given dose, and to get the desired effect, the dose will have to be increased. Tolerance is an inevitable, predictable phenomenon that will occur in anyone who regularly uses certain medications. 􀁸􀀃 Dependence is different. In modern medical contexts, dependence refers to physical changes in the body as we adapt to regularly taking certain drugs. Biochemical changes take place mainly in the brain, as the body gets used to regular doses of these medications— and if the medication is stopped or reduced quickly, physical symptoms of withdrawal will take place. 􀁸􀀃 Symptoms of opiate or narcotic withdrawal can include sweatiness, agitation, aches, insomnia, cramping, diarrhea, nausea, and vomiting. These can be very unpleasant or severe, but they are not life threatening. 􀁸􀀃 Other kinds of medication can cause dependence and withdrawal symptoms, including steroids, antidepressants, anxiety medication, and some heart medicines (such as beta-blockers). 􀁸􀀃 Addiction, the way that doctors use the term, means psychological symptoms like compulsive drug use and craving for drugs. People who are addicted to drugs will continue to seek and use the drug despite worsening physical, social, and mental harm. 􀁸􀀃 In a sense, while the term “dependence” refers to the physical symptoms of withdrawal, the term “addiction” refers to a maladaptive psychological need to consume a drug. This definition of addiction is also used in other contexts, such as people addicted to gambling, sex, or Internet use. 􀁸􀀃 People with addiction may or may not have physical dependencies and may or may not suffer from physical withdrawal symptoms, but they will crave and seek the addiction even at the expense of their jobs or relationships, risking arrest and social isolation to satisfy their cravings. 􀁸􀀃 Another term that’s sometimes used is “pseudoaddiction,” which is seen only in people with chronic pain that is inadequately treated. These patients are desperate for effective pain relief and very fearful of worsening pains, so they watch the clock closely and may take steps that could be considered to be drug-seeking behaviors, such as filling prescriptions early or hoarding pills. 􀁸􀀃 The behaviors associated with pseudoaddiction stop completely when the pain itself is adequately treated. The key to treating pseudoaddiction (and preventing it from developing into true addiction) is in treating pain correctly. 􀁸􀀃 Not all chronic pain patients become addicted to opioids. In fact, the vast majority will never have addictive symptoms. Most, if not all, patients who use narcotics regularly will develop tolerance, physical dependence, and the potential for withdrawal, but that’s different from the craving and compulsive drug-seeking behavior seen with addiction. 􀁸􀀃 Although it is possible, addiction is not a common problem among those treated for pain, and a fear of encouraging addiction should not prevent doctors from treating pain and relieving suffering. 􀁸􀀃 Although we don’t know the exact contribution of genetics, it’s definitely true that some people seem to have a higher built-in risk for addiction than others. Beyond that, the most important factor in predicting addiction is the reason the drug is taken. People who take drugs to get high or avoid life (as opposed to people who take medication to treat pain or other medical problems) are much more likely to develop addiction.

Question 124

Autism Spectrum Disorder

Answer 124

􀁸􀀃 Autism—or, as it’s now more formally called, autism spectrum disorder (ASD)—is a complex neurodevelopmental disorder that’s characterized by three distinct though overlapping problems impairments in social interactions; impairments in communication; and a pattern of repetitive, stereotyped behaviors. 􀁸􀀃 One of the earliest and most characteristic indicators of autism is a failure of the development of what’s called joint attention, which is a child’s ability to share interests and experiences or to request things from others using gestures, eye contact, and verbal communication. 􀁸􀀃 For example, children without autism (called “neurotypical”) will point at things, usually by 12 to 15 months. They’ll point when they want you to look at something, or they’ll point when they want something. They’ll also understand when other people point to look at the thing that someone else is interested in, to share that experience. 􀁸􀀃 There are other ways to share like this, too. Neurotypical children will bring toys to caretakers to show them what they’re interested in, and during play, neurotypical toddlers will frequently look at their parents to make sure that they’re paying attention, and they’ll deliberately sort of “show off” to get attention. 􀁸􀀃 There is some research that shows that failure of joint attention in autism isn’t just characteristic, but that it may be the essential early step that leads to other eventual symptoms. Joint attention—paying attention to what parents are paying attention to and enjoying positive feedback for doing this—is exactly how babies learn to communicate and interact. If that shared attention isn’t working correctly early on, it may lead to missing out on the learning of all sorts of social and behavioral skills. 􀁸􀀃 Later on, other typical symptoms of autism develop. These frequently include repetitive, stereotyped behaviors, such as head banging, rubbing, or spinning. Routines can become very rigid, and children with ASDs (and, thus, their parents) may find breaks in routine very difficult. 􀁸􀀃 Children with autism like to play, and they find their play soothing, but their play tends to be different from that of neurotypical children. They’ll perhaps be fascinated by the details of an object or find ways to use an object that’s not based on pretending or on what the object was meant to be used for. Rather than throw a ball, they’ll stare at it as it reflects colors, or rather than push a toy car, they’ll spin the wheels. 􀁸􀀃 There’s a tremendous range of autism, which is why we now refer to an “autism spectrum,” and not all children with autism will show all of the symptoms. Complicating the picture is that many children with autism will also have genetic disorders (such as Down syndrome) or a history of other medical problems (including fetal alcohol exposure or cerebral palsy), and many also develop psychiatric disorders, including anxiety disorders or obsessive compulsive disorder. 􀁸􀀃 There’s a lot of overlap, and the picture changes as a child develops. One thing is for sure, and it’s crucial to communicate this to parents: No two children with autism are the same, and the most important challenges to tackle will depend on the individual child.

Question 125

sommelier and an amateur

Answer 125

Factors like environment, setting, temperature, and color of light have an influence. The example where he meets a master sommelier makes it clear that the crowd’s opinion on tasting does matter. It discussed the difference between an experienced sommelier and an amateur in blind tastings. Here the sommelier will do slightly better in identifying drinks than an amateur drinker. A blind tasting is that you don’t see what you drink, including the color. The difference is in the taster’s experience. Expertise is determined by knowing how to describe a drink and to remember it based on experience. Sommeliers get training to describe drinks and a good one has tasted a lot and stored it in his or her memory.

Question 126

Ulcers vs Acid Reflux

Answer 126

Ulcers and acid reflux are two different conditions that can affect the digestive system. Here are the symptoms and treatments for each: Ulcers: Symptoms: 1. Burning or gnawing pain in the stomach, often between meals or at night. 2. Nausea or vomiting. 3. Feeling of fullness or bloating. 4. Belching or burping. 5. Unintentional weight loss. 6. Dark, tarry stools (indicating bleeding in the digestive tract). 7. Fatigue or weakness. Treatment: 1. Medications: Ulcers caused by Helicobacter pylori (H. pylori) bacteria are treated with a combination of antibiotics to eradicate the infection. Acid-reducing medications, such as proton pump inhibitors (PPIs) or H2 blockers, may also be prescribed to reduce stomach acid production and promote healing. 2. Antacids: Over-the-counter antacids can provide temporary relief from ulcer symptoms by neutralizing stomach acid. 3. Lifestyle changes: Avoiding foods that irritate the stomach lining, such as spicy or acidic foods, and reducing stress can help manage ulcer symptoms. 4. Avoiding nonsteroidal anti-inflammatory drugs (NSAIDs): If NSAIDs are contributing to ulcer formation, your healthcare provider may recommend alternative pain medications. 5. Follow-up care: Regular follow-up appointments are important to monitor healing, adjust medications, and check for any complications. Acid Reflux (Gastroesophageal Reflux Disease - GERD): Symptoms: 1. Heartburn or a burning sensation in the chest, often after eating or when lying down. 2. Regurgitation of stomach acid or sour-tasting liquid into the throat or mouth. 3. Difficulty swallowing or a sensation of a lump in the throat. 4. Chronic cough or hoarseness. 5. Asthma symptoms, such as coughing or wheezing. Treatment: 1. Lifestyle modifications: Making changes to diet and habits can help manage acid reflux symptoms. These include: - Avoiding trigger foods, such as fatty or fried foods, chocolate, caffeine, citrus fruits, spicy foods, and carbonated beverages. - Eating smaller, more frequent meals. - Avoiding lying down or sleeping immediately after meals. - Elevating the head of the bed while sleeping. 2. Medications: - Antacids: Over-the-counter antacids can provide temporary relief by neutralizing stomach acid. - H2 blockers: These medications reduce stomach acid production and provide longer-lasting relief. - Proton pump inhibitors (PPIs): These medications are stronger acid reducers and are typically prescribed for more severe or persistent acid reflux. 3. Surgery: In severe cases of acid reflux that do not respond to medication or lifestyle changes, surgery may be considered as a last resort. It's important to consult with a healthcare provider for an accurate diagnosis and appropriate treatment options based on individual symptoms and medical history.

Question 127

Fixing Sprains vs Breaks

Answer 127

The treatment for sprains and bone breaks (fractures) can vary, but here are general guidelines for each: Sprains: 1. Rest: Avoid putting weight or excessive strain on the injured area. Use crutches or other assistive devices if necessary. 2. Ice: Apply ice packs wrapped in a cloth to the injured area for about 15-20 minutes at a time, several times a day. This helps reduce swelling and pain. 3. Compression: Use an elastic bandage or compression wrap to provide support and minimize swelling. Make sure not to wrap it too tightly to avoid cutting off circulation. 4. Elevation: Keep the injured area elevated above heart level as much as possible to reduce swelling. 5. Pain relief: Over-the-counter pain relievers, such as acetaminophen or ibuprofen, can help alleviate pain and reduce inflammation. Follow the recommended dosage instructions. 6. Rehabilitation exercises: Once the acute phase has passed, a healthcare professional may recommend specific exercises and physical therapy to restore strength, flexibility, and function to the injured area. Bone breaks (Fractures): 1. Immobilization: Stabilize the injured area to prevent further damage and promote proper healing. This may involve the use of splints, casts, or braces. 2. Pain management: Over-the-counter or prescription pain medication may be recommended to manage pain and discomfort. 3. Surgery: In some cases, surgery may be necessary to realign and stabilize the broken bones, especially for complex fractures. 4. Rehabilitation: After the initial healing phase, a healthcare professional may recommend physical therapy exercises to restore range of motion, strength, and function to the affected area. 5. Follow-up care: Regular follow-up appointments with a healthcare professional are important to monitor healing progress and make any necessary adjustments to the treatment plan. It's important to note that the specific treatment approach may depend on the severity and location of the injury, as well as individual factors. Consulting a healthcare professional is crucial for an accurate diagnosis and appropriate treatment recommendations for sprains and fractures.

Question 128

Gallstones

Answer 128

Gallstones are solid deposits that form in the gallbladder, a small organ located beneath the liver. They can cause pain and other digestive symptoms when they block the bile ducts. Here are the symptoms and treatments for gallbladder stones: Symptoms: 1. Abdominal pain: The most common symptom is sudden and intense pain in the upper right abdomen, which may radiate to the back or right shoulder. 2. Nausea and vomiting. 3. Indigestion or bloating after meals. 4. Jaundice (yellowing of the skin and eyes) if a gallstone blocks the bile ducts. 5. Clay-colored stools and dark urine. Treatment: 1. Symptomatic management: Over-the-counter pain relievers, such as nonsteroidal anti-inflammatory drugs (NSAIDs), can help alleviate the pain associated with gallstones. However, this only provides temporary relief and does not address the underlying issue. 2. Medications: - Ursodeoxycholic acid (UDCA): This medication can be used to dissolve cholesterol gallstones in some cases, but it is typically not effective for larger or calcified stones. - Oral bile acid supplements: These supplements may be prescribed to help dissolve gallstones, particularly cholesterol stones. 3. Cholecystectomy: The most common and definitive treatment for gallstones is surgical removal of the gallbladder, known as cholecystectomy. This can be done through open surgery or minimally invasive laparoscopic surgery. After the gallbladder is removed, bile flows directly from the liver to the small intestine. 4. Endoscopic removal: In cases where gallstones have migrated into the bile ducts, an endoscopic procedure called endoscopic retrograde cholangiopancreatography (ERCP) may be performed to remove the stones. 5. Shock wave lithotripsy (SWL): This non-invasive procedure uses shock waves to break up gallstones into smaller pieces that can be passed through the bile ducts. 6. Observation: In some cases, if gallstones are small and not causing symptoms, a "wait and watch" approach may be adopted. Regular monitoring and lifestyle modifications may be recommended. Prevention: 1. Healthy diet: Adopting a balanced diet that is low in fat and cholesterol can help reduce the risk of gallstone formation. 2. Gradual weight loss: Rapid weight loss and yo-yo dieting can increase the risk of gallstones. If weight loss is necessary, it should be achieved gradually and in a healthy manner. 3. Regular physical activity: Engaging in regular exercise can help maintain a healthy weight and reduce the risk of gallstone formation. It's important to consult with a healthcare provider for proper diagnosis and appropriate treatment options based on individual symptoms and medical history.

Question 129

Maria - Is it a UTI?

Answer 129

•• Our first case today is Maria. She’s 48 years old, and she is not happy. She was here in this very ED yesterday, and now she’s back and not feeling better. Maria’s visit yesterday was, we thought, fairly routine. Her chief complaint was: “I have a bladder infection.” The story, or the history of present illness, was that she had one day of increasing pain on the side of her belly, kind of the flank area on the right, along with frequent urination. The recorded vital signs and physical exam were normal. •• It was noted that Maria looked comfortable and well, and that she had had no fever. Her urine tests showed first that she was not pregnant, and second that her urine contained white blood cells. She was sent home with a prescription for an antibiotic to cover a presumed urinary tract infection, and told to follow-up with her own doctor or return to the ED if symptoms didn’t improve soon. A fairly routine encounter, though in retrospect, now, you’re wondering if something was missed. •• The best way to know if there’s a urinary tract infection is a test called a urine culture. Someone with urinary symptoms and an abnormal urine dipstick is presumed to have a urinary tract infection, and often starts therapy before the urine culture comes back. Maria’s urine culture from yesterday is still pending. •• Her chief complaint today is: “My side hurts.” She has a fever now of 100.9, and her heart rate is a little fast. She says, “Doctor, this hurts, I think I have a kidney stone,” and she points to the side of her abdomen, on her right flank. •• Maria says she started taking the antibiotics yesterday, and she doesn’t really notice that she’s urinating frequently any more. The pain is pretty much constant, now, on the right, and is worse than yesterday. She’s never had painful urination, and says she’s had no vomiting or diarrhea. Maria is holding very still; she looks uncomfortable, and she doesn’t seem to want you to touch her at all. She’s tender all over her belly, but especially so on the right side. •• Is this a urinary tract infection? Probably not—it didn’t improve with antibiotics, and her pain really isn’t down low, over her bladder, and it isn’t over her kidneys in the back. It’s on the right side. Also, though you can get abdominal pain with a urinary tract infection, she shouldn’t be so tender to touch. She also never had the classic urinary tract symptom of painful urination—even at the first encounter, she never said that it hurt to urinate. You’re starting to question whether she ever had a bladder infection at all. •• What about a kidney stone, as Maria suggested today? That doesn’t quite fit the story, either. A stone will usually cause at least a little blood in the urine, and Maria didn’t have that. But even more compelling is today’s exam—she’s lying very still, and trying not to move. People with kidney stones don’t act like that. They writhe around, squirm, and flop back and forth trying to find a comfortable position. A kidney stone does not cause a tender belly, or a belly that hurts to touch or hurts when the patient moves. •• Maria’s tender belly, along with the discomfort that she feels when she moves, is evidence of a condition called peritonitis, or inflammation of the peritoneum, referring to the lining inside the abdomen. Untreated, peritonitis will continue to spread and can be fatal. In this case, the right-sided abdominal pain, white cells in the urine, and now signs of peritonitis point to only one likely diagnosis: appendicitis. •• You draw some blood, and there is a high white cell count. The white cells in the urine are from the inflamed appendix, pushed against her right ureter; the high white cell count in the blood is from her immune system gearing up to fight infection. You give Maria IV fluids and tell her she’s not allowed to eat, now, because the surgeon is coming to meet her. Anyone who might need sedation or surgery needs to keep their stomach empty. •• In a presentation like this, where the story and physical exam and limited labs fit well, it would be reasonable for the surgeon to take Maria straight to the operating room, which is what he did. Within a few hours of her second presentation to the ED, her appendix is out, and she’s recovering upstairs. She’ll probably go home tomorrow in good shape. •• What can we learn from Maria’s case? The first visit, where she was diagnosed with a urinary tract infection (UTI), wasn’t a mistake. At that point she didn’t have peritonitis, and the white cells in the urine were suggestive of a UTI. Nine times out of ten, that would have been the correct diagnosis. Maria was told to come back to the ED if her symptoms didn’t improve, and that’s what happened, and by then her story and exam had changed to make the true diagnosis clear.

Question 130

Types of disguise

Answer 130

Type A - To conceal the specific idetedy (stocking cap, mask, etc) Type B - Blend in to a crowd. Look like a native. use stereotypes Type C - To look like specific person

Answer 131

Appendicitis is the inflammation of the appendix, a small pouch-shaped organ located in the lower right abdomen. The symptoms of appendicitis can vary but commonly include: 1. Abdominal pain: The most characteristic symptom of appendicitis is abdominal pain that typically starts around the belly button and then moves to the lower right side of the abdomen. The pain often becomes sharp and intense. 2. Loss of appetite: Many people with appendicitis experience a decreased desire to eat. 3. Nausea and vomiting: Nausea and vomiting are common symptoms that may accompany appendicitis. 4. Low-grade fever: Some individuals may develop a mild fever, usually not exceeding 100.4°F (38°C). 5. Change in bowel habits: Appendicitis can cause changes in bowel movements, such as diarrhea or constipation. It is essential to differentiate appendicitis from other conditions that can mimic its symptoms. Some conditions that may present similar symptoms include: 1. Gastroenteritis: This is inflammation of the stomach and intestines, often caused by a viral or bacterial infection. Symptoms include abdominal pain, nausea, vomiting, and diarrhea. 2. Urinary tract infection (UTI): UTIs can cause abdominal pain, pelvic discomfort, and urinary symptoms such as frequent urination or pain during urination. 3. Ovarian cyst or torsion: These conditions can cause lower abdominal pain, often on one side, along with menstrual irregularities and pelvic discomfort. 4. Inflammatory bowel disease (IBD): Conditions like Crohn's disease or ulcerative colitis can cause abdominal pain, diarrhea, and other gastrointestinal symptoms. To differentiate appendicitis from these conditions, it is important to consider the following factors: - Location of pain: Appendicitis typically involves pain in the lower right abdomen. - Migration of pain: Appendicitis pain tends to start around the belly button and then moves to the lower right side of the abdomen. - Worsening symptoms: Appendicitis pain tends to worsen over time, becoming sharper and more intense. - Rebound tenderness: Applying pressure to the abdomen and then quickly releasing it may cause increased pain in appendicitis. - Imaging tests: Imaging studies such as ultrasound or computed tomography (CT) scan can help identify appendicitis or rule out other conditions. However, it is important to note that diagnosing appendicitis requires a medical evaluation by a healthcare professional. If you suspect appendicitis or experience severe abdominal pain, it is recommended to seek immediate medical attention for proper evaluation and treatment.

Question 132

Travel and Mosquitos

Answer 132

In the ED, we have to stay especially vigilant when working with patients who’ve been traveling or living overseas, especially in areas of the developing world. They may have illnesses we’re unfamiliar with in our own population—uncommon here doesn’t mean uncommon everywhere. Domestic travel—say, to a higher-altitude area—can also pose some surprising health risks. This lecture examines cases of international travel– borne illness before closing with a pair of unique situations at a ski resort. Anjali’s Adoption •• Our first patient today is Anjali, a 13-month-old girl who has just arrived here from India. In fact, she has just been adopted, and her adoptive parents have brought her straight from the airport. Her chief complaint is: “fever.” She also has loose stools. This illness began in India. By far, the most likely cause of fever at this age is an infection, but what kind of infection? •• A urinary tract infection will cause prolonged fevers, and they’re especially common in girls. She could also have a prolonged viral infection, or a deep or hidden infection without clear symptoms to give us a clue. Tuberculosis, malaria, typhoid, dengue, and many other infections are still prevalent in India. Let’s see if our physical exam gives us any clues. •• Anjali has many mosquito bites, especially on her legs and arms, on areas of skin that aren’t typically covered with clothes. It’s difficult to do a good ear exam because she fights it, but you think that looks OK, and her throat looks normal. Her lungs sound clear, and her heart is probably OK. You can’t really palpate her belly well—she’s really screaming now—but you don’t get a sense that her abdomen is tender. •• Because of her seven-day fever, you’re going to have to work her up. That’s going to involve some unpleasantness and pain for Anjali. It’s unfortunate that so many of the things that happen in the ED can be painful or scary, especially for little kids. Families can help out by staying calm and offering distraction rather than reassurance. Watching a video or reading a book together is more effective at relieving anxiety than saying things like, “You’ll be OK,” or, “It will be over soon,” or, “It isn’t going to hurt.” •• There were two useful clues from Anjali’s physical exam. One was in the vital signs, and the other was all of those mosquito bites. ○○ The three most concerning mosquito-borne illnesses in India are malaria, dengue fever, and a relatively new infection called Chikungunya fever. All can be and should be prevented in international travelers by using mosquito repellents, netting, and by staying indoors when possible. People traveling to areas of the world with malaria should take oral medications to prevent this infection, in addition to taking other steps to prevent mosquito bites. ○○ There are other mosquito-borne infections worldwide, including yellow fever, and several mosquito-associated encephalitis viruses that cause inflammation of the brain.

Question 133

Taking Temperature

Answer 133

Normal body temperature varies slightly depending on the method of measurement and individual factors. Generally, a normal body temperature for adults ranges between 97°F (36.1°C) and 99°F (37.2°C) orally. However, temperatures can fluctuate throughout the day and may be influenced by factors such as physical activity, environmental conditions, and individual health. A high body temperature, known as fever or pyrexia, usually indicates an underlying illness or infection. Fevers can help the body fight off infections by stimulating the immune system. Common causes of fever include respiratory infections, urinary tract infections, influenza, and other viral or bacterial infections. Extremely high temperatures (above 104°F or 40°C) can be serious and require medical attention. Conversely, low body temperatures, known as hypothermia, can occur when the body loses heat faster than it can produce it, leading to a drop in core temperature. Hypothermia can be caused by exposure to cold environments, prolonged immersion in cold water, or certain medical conditions. Severe hypothermia is a medical emergency and requires immediate attention.

Question 134

Clean dog bite

Answer 134

If you or someone else has been bitten by a dog, it's essential to take the following steps for treatment: 1. Ensure safety: Move to a safe location away from the dog to prevent further bites or injury. 2. Control bleeding: If the bite has caused bleeding, apply gentle pressure using a clean cloth or sterile gauze to control the bleeding. Elevate the affected area if possible. 3. Clean the wound: Wash the wound thoroughly with mild soap and warm water. Gently remove any dirt, debris, or saliva from the area. Avoid scrubbing the wound, as it may cause further damage or increase the risk of infection. 4. Apply an antiseptic: After cleaning the wound, apply an antiseptic solution or hydrogen peroxide to help reduce the risk of infection. Avoid using alcohol, iodine, or harsh chemicals, as they can be irritating to the tissues. 5. Cover the wound: Use a sterile bandage or clean cloth to cover the wound. This will help protect it from further contamination. 6. Seek medical attention: It's important to seek medical evaluation, especially for deep, puncture wounds or bites on the face, hands, feet, or genital area. Medical professionals can assess the severity of the bite, evaluate the risk of infection, and determine if additional treatment, such as antibiotics or a tetanus shot, is necessary. 7. Report the incident: Contact local animal control or your local health department to report the dog bite. They may need to investigate the situation or provide guidance on necessary precautions, such as rabies vaccination. Remember, dog bites can carry a risk of infection, so it's crucial to seek medical attention, even for seemingly minor bites. Prompt treatment and appropriate wound care can help prevent complications and promote proper healing.

Question 135

Cancer

Answer 135

􀁸􀀃 Our nal diagnosis is breast cancer with metastatic spread to the local lymph nodes and bone, both near the hip and other sites. Sharing news like this isn’t a one-time event; it isn’t one big talk at which all questions are answered. Discussions like this should always end with plans for the next discussion and open-ended time for families and doctors to share how they feel. 􀁸􀀃 Cancer, at its core, is a genetic disease—that is, it’s a disease that affects the genetic material of the cells. Every cell is governed by the instructions carried on its chromosomes, the genes that encode the proteins that control every function of every cell. Cancer cells are cells that have lost the ability to control their own growth and differentiation, and they grow and spread far beyond the tissues that they ought to call home. 􀁸􀀃 There are two kinds of genetic changes that can lead to cancer. First, there are germ line mutations, which are genes that are present way back in the embryo, passed on from mother or father, and are present in every cell in the body. These mutations are hereditary, meaning that you’re born with them. Hereditary mutations account for about 10 percent of all cancers. 􀁸􀀃 The second kind of genetic change occurs only in a single cell—a mutation or mistake that’s created when the cellular genetic material is copied to make new cells. Sometimes this happens just randomly, but for many kinds of cancers, we know what things cause at least some or most of these cellular changes. 􀁸􀀃 Radiation, including solar radiation, can disrupt or damage DNA, as can environmental toxins or smoking. Certain infections can also directly cause certain cancers, or chronic infections can lead to chronic cell damage that can eventually lead to cancer. 􀁸􀀃 Although there are both somatic and germ line kinds of mutations, many cancers are related to not one genetic change, but several overlapping conditions. Although cancer is always genetic, it usually arises from a combination of contributions from multiple genes, sometimes (but not always) including hereditary genes carried in families. 􀁸􀀃 One very common risk factor for almost all cancers is age. The longer our cells have been alive, the more years they’ve had to sustain the damaging hits on their genetic material that lead to cancer. Almost all cancers increase in frequency with age, and in fact, it may be true that if we live long enough, eventually we will all get some kind of cancer. 􀁸􀀃 Cancer isn’t one disease. Any tissue can develop cancer, and often, there are potentially multiple types of cancer even in one kind of body tissue, all of which have different health consequences and treatments. But whatever the initial cause and whatever the kind of cancer, what all cancers have in common is that the genetic mechanism that should have controlled the growth and spread of the cell fails, and the cell keeps dividing and growing and spreading. 􀁸􀀃 The signs and symptoms of cancer can be almost anything. They depend on where the cancer is, how fast it’s growing, and whether it’s pushing on blood vessels, nerves, or other crucial tissues. Some cancers themselves release chemicals into the blood that cause symptoms in any part of the body. Cancers can also cause symptoms if they spread or metastasize to other areas. 􀁸􀀃 There are sometimes constitutional symptoms of cancer. There may be prolonged and dif cult-to-explain fever, weight loss, or marked fatigue. These symptoms may occur because of the metabolic demands of the growing cancer tissue or in part because of the body’s immune system trying to attack and ght off the cancer. However, breast cancer often occurs with none of these constitutional symptoms. 􀁸􀀃 Immunity, or a lack of immunity, is an important part of cancer biology. Our immune systems are there to ght off foreign invaders, and we think of invaders as infections like bacteria or viruses that barge into our bodies from outside. But cancer cells are also, in a sense, foreign invaders—invaders from the inside. 􀁸􀀃 Our immune systems have developed to be very good at snif ng out and destroying these cancer cells. People with immune de ciencies, or altered immune systems for other reasons, are at higher risk for developing many kinds of cancer.

Question 136

Sarah -- Is it a heart Attack?

Answer 136

•• Another patient is ready for evaluation. Her name is Sarah, and she’s very uncomfortable. Sarah is 60 years old, and is undergoing chemotherapy for lung cancer. She has come in because of an abrupt onset of chest pain and difficulty breathing. After the ABCs and extra oxygen, her vital signs show that she’s breathing rapidly, and has a very fast pulse. Her pulse ox (blood oxygen level) remains low, despite the extra oxygen by mask, and Sarah looks scared and anxious. •• Your team is working on IV access and getting an EKG while you complete the first exam. Sarah’s breath sounds—what you hear over her chest with a stethoscope as she breathes—are very decreased on the left side. Ordinarily, breath sounds should be the same on both sides. •• The most likely cause of those decreased breath sounds in a patient with the sudden onset of chest pain and difficulty breathing is a pneumothorax. That’s when air escapes from the lungs into the space between the lung and the chest wall. Air trapped there will block sound transmission, so the breath sounds are decreased. •• More important for Sarah, if there’s a lot of air trapped there, it will prevent the lungs from expanding well. And, if there’s a lot of air there under pressure, it can even prevent blood flow from returning to the chest and the heart. That’s exactly what’s going on here. •• A chest X-ray confirms the diagnosis. After an injection of local anesthesia, a tube is inserted into her chest, between the chest wall and the lung, to deflate that space and let the air escape. This quickly improves Sarah’s symptoms. She’s then admitted to the hospital upstairs for further observation, where specialists will try to determine the pneumothorax’s cause.

Question 137

Pregnancy complications

Answer 137

During pregnancy, some common complications that may occur include: 1. Gestational diabetes: This is a type of diabetes that develops during pregnancy. It affects the body's ability to regulate blood sugar levels and can increase the risk of complications for both the mother and the baby. 2. Pre-eclampsia: This condition is characterized by high blood pressure and damage to organs, such as the liver and kidneys. It typically occurs after the 20th week of pregnancy and can lead to complications if left untreated. 3. Miscarriage: Miscarriage refers to the loss of a pregnancy before the 20th week. It can occur due to various reasons, including genetic abnormalities, hormonal imbalances, or certain medical conditions. 4. Ectopic pregnancy: An ectopic pregnancy happens when the fertilized egg implants outside the uterus, usually in the fallopian tube. This can lead to complications and requires immediate medical attention. 5. Placenta previa: Placenta previa occurs when the placenta partially or completely covers the cervix, which can cause bleeding during pregnancy. It may require careful monitoring and potentially a cesarean delivery. 6. Preterm labor: Preterm labor refers to the onset of labor before 37 weeks of pregnancy. It can result in premature birth, which may increase the risk of health issues for the baby. 7. Fetal growth restriction: This occurs when the baby doesn't grow at the expected rate during pregnancy. It can be caused by various factors, including placental problems, maternal health issues, or genetic factors. 8. Infections: Certain infections, such as urinary tract infections, bacterial vaginosis, or sexually transmitted infections, can pose risks to both the mother and the baby during pregnancy if left untreated. 9. Multiple pregnancies: Carrying multiple babies (twins, triplets, etc.) increases the risk of complications, including preterm birth, preeclampsia, and fetal growth issues. It's important to note that while these complications can occur, many pregnancies progress without any major problems. Regular prenatal care, early detection, and proper management of complications can help mitigate risks and ensure a healthy pregnancy outcome. If you have any concerns about your pregnancy, it's best to consult with your healthcare provider for guidance and appropriate care.

Question 138

Stroke Symptoms

Answer 138

•• Next up is a woman who came in by ambulance. She’s Maryann, and is 51 years old. When you meet her, it’s hard to understand her speech, but she says, “They think I’m having a stroke.” A few minutes later, Maryann’s husband arrives, and it’s a little easier to understand him. •• They were at a picnic, he says, and his wife wasn’t feeling well. She started to complain about a sore throat, and dizziness, and she wanted to go home. But then she started having trouble talking normally. He thought she was having a stroke, so he called 911—a smart move when stroke symptoms are present. •• Remember, in almost all medical encounters, the history of the illness gives you the most important clues. She started with vague symptoms, like a sore throat and dizziness, and then had trouble speaking. But typically a stroke is a rapid, sudden wave of symptoms, all hitting at once. •• The CT scan is ready. But you want a few minutes for a physical exam and to think about what’s best for Maryann. Healthy paranoia has kicked in: Something isn’t right here, and sending this patient to CT when you don’t know what’s going on may be a bad idea. •• Your physical exam begins with vital signs, and they’re normal. But Maryann has a weak face (she’s droopy and can’t speak properly) and trouble with her eyes (she has problems following a pen light, plus double vision). •• Is Maryann having a stroke? A stroke can cause muscle weakness, but much more typically on one side of the body. A huge stroke could do it, but Maryann seems mentally sharp (she asked for a notepad to write communications on). Alternatively, a small stroke in the base of the brain or spinal cord could cause widespread weakness, but that would also affect her breathing centers and vital signs.

Question 139

High Blood Pressure

Answer 139

High blood pressure, also known as hypertension, is a condition in which the force of blood against the walls of the arteries is consistently too high. It is often referred to as the "silent killer" because it usually has no symptoms but can lead to serious health complications if left untreated. Here are the symptoms and treatments for high blood pressure: Symptoms: 1. Most people with high blood pressure do not experience any noticeable symptoms. However, in some cases, individuals may experience symptoms such as headaches, shortness of breath, nosebleeds, dizziness, or chest pain. These symptoms may occur during extremely high blood pressure episodes or in cases of severely uncontrolled hypertension. Treatment: 1. Lifestyle modifications: Making healthy lifestyle changes can be an effective way to manage high blood pressure. These include: - Adopting a balanced diet rich in fruits, vegetables, whole grains, and lean proteins while limiting sodium (salt) intake. - Engaging in regular physical activity, such as aerobic exercises, for at least 150 minutes per week. - Maintaining a healthy weight or losing weight if overweight or obese. - Reducing alcohol consumption and avoiding tobacco use. - Managing stress through techniques like relaxation exercises, meditation, or counseling. 2. Medications: In some cases, lifestyle changes alone may not be sufficient to control high blood pressure. Healthcare providers may prescribe medications to help lower blood pressure. These medications may include diuretics, beta-blockers, ACE inhibitors, angiotensin II receptor blockers (ARBs), calcium channel blockers, or other types of medications that work to relax blood vessels or reduce fluid volume. 3. Regular monitoring: It is important to regularly monitor blood pressure at home or through regular medical check-ups to track progress and ensure that blood pressure is within the target range. Monitoring helps in adjusting treatment if necessary. 4. Management of underlying conditions: High blood pressure can be associated with other underlying conditions, such as diabetes or kidney disease. Treating and managing these conditions effectively can help control blood pressure. 5. Ongoing care: Individuals with high blood pressure should continue to work closely with their healthcare provider to monitor blood pressure, adjust medications if needed, and receive regular check-ups to prevent complications. It is important to note that managing high blood pressure is a lifelong commitment, and treatment may need to be adjusted over time. Regular communication with healthcare providers, adherence to prescribed treatments, and a healthy lifestyle are key to successfully managing high blood pressure and reducing the risk of complications.

Question 140

Triage Image

Answer 140

Question 141

Hyperthermia

Answer 141

Hypothermia is a condition characterized by a dangerously low body temperature, typically below 95°F (35°C), due to prolonged exposure to cold temperatures. Here's some information on hypothermia: Hypothermia: Hypothermia occurs when the body loses heat faster than it can produce it, leading to a drop in core body temperature. It can happen in cold weather conditions, especially when the body is not adequately protected or when clothing is wet. Symptoms of hypothermia may vary depending on the severity of the condition and can include: - Shivering - Cold, pale, or bluish skin - Numbness or loss of sensation - Slurred speech - Confusion or difficulty thinking clearly - Fatigue or drowsiness - Weak pulse - Slow or shallow breathing - Loss of consciousness (in severe cases) Treatment for hypothermia involves taking immediate steps to raise the body temperature and prevent further heat loss. Here are some important measures to take: - Move to a warm environment: Get out of the cold and seek shelter indoors if possible. If indoors is not an option, find a protected area away from wind and precipitation. - Remove wet clothing: Wet clothing can exacerbate heat loss, so remove any wet garments and replace them with dry, warm clothing or blankets. - Gradually warm the body: Use external heat sources to warm the body slowly. Wrap the individual in blankets or use warm packs or heating pads on the neck, chest, and groin areas. You can also use skin-to-skin contact with another person, if available. - Offer warm liquids: If the person is conscious and able to swallow, provide warm liquids, such as warm water or warm sweetened drinks, to help increase the body temperature from within. - Seek medical attention: Even if the person's condition improves, it's important to seek medical evaluation to assess for any underlying complications or to provide additional treatment if necessary. Preventing hypothermia is crucial in cold environments. Here are some preventive measures: - Dress appropriately: Wear layered clothing and choose materials that insulate well and wick moisture away from the body. Use hats, scarves, and gloves to cover exposed areas. - Stay dry: Avoid wet clothing and keep your body dry. Change out of wet clothes as soon as possible. - Stay hydrated: Drink plenty of fluids, as dehydration can increase the risk of hypothermia. - Be aware of warning signs: Pay attention to signs of shivering, discomfort, or confusion, and take action to warm up if necessary. If you encounter someone with severe hypothermia or who is unconscious, call emergency services immediately for professional medical assistance.

Question 142

CBC

Answer 142

One of the most common blood tests done is a complete blood count (CBC), which counts the quantities of the three basic types of blood cells: the red cells, which carry oxygen; the white cells, which ght disease; and the platelets, which help blood clot when it needs to. In addition, a CBC usually includes a differential (or “diff”), which breaks down the white cells into subtypes.

Question 143

Types of headaches

Answer 143

In Gordon’s case, there are no red ags, so this is very likely to be one of the primary headaches. There really are only a small handful of common primary headache types; these are almost always migraine, tension, or cluster headaches. 􀁸􀀃 Tension headaches are common. They can last from 30 minutes to 7 days and have a pressing or tightening quality; they’re not throbbing. The pain is bilateral—which means that it occurs on both sides of the head—and of mild to moderate intensity. They’re not aggravated by activity and lack nausea and vomiting. Typically, they’re not made worse with lights or loud sounds. Our patient isn’t having tension headaches. 􀁸􀀃 Cluster headaches are less common, but they’re really quite characteristic. The pain is brief—from 15 minutes to 3 hours, without treatment. They begin and stay unilateral and are accompanied by one-sided facial symptoms on the same side as the pain: a red or watery eye, congestion or watery nose, one-sided sweating, or one-sided pupil or eyelid changes. The thing to keep in mind about cluster headaches is how these symptoms are so striking and unilateral and that the headaches are really quite brief. Our patient isn’t having cluster headaches.

Question 144

Antiseptic plants

Answer 144

There are several natural antiseptic oils that have been used traditionally for their antimicrobial properties. These oils may help inhibit the growth of bacteria, fungi, and other microorganisms. Here are some examples: 1. Tea tree oil: Tea tree oil, derived from the leaves of the Melaleuca alternifolia tree, is known for its potent antiseptic and antimicrobial properties. It can be used topically to cleanse and disinfect minor cuts, scrapes, and skin infections. 2. Lavender oil: Lavender oil has both antiseptic and soothing properties. It can be applied topically to minor wounds, burns, or insect bites to help prevent infection and promote healing. 3. Eucalyptus oil: Eucalyptus oil has strong antiseptic qualities and is commonly used to help relieve respiratory congestion. It can also be used as a topical antiseptic for minor cuts and wounds. 4. Rosemary oil: Rosemary oil possesses antimicrobial properties and can be used as a natural antiseptic. It may help prevent infection in minor cuts and abrasions. 5. Thyme oil: Thyme oil is known for its antimicrobial and antifungal properties. It can be used topically as an antiseptic for skin infections or diluted in water as a mouthwash for oral hygiene. 6. Lemon oil: Lemon oil has antimicrobial properties and can be used as a natural disinfectant. It can be added to homemade cleaning solutions or diluted and applied topically for minor wounds or insect bites. It's important to note that these natural oils should be used with caution and in appropriate dilutions. Some individuals may have skin sensitivities or allergies to certain oils. It's always advisable to perform a patch test before applying any oil to a larger area of the skin. If you have a severe or persistent infection, it's best to seek medical advice for proper diagnosis and treatment.

Question 145

Drowning Events

Answer 145

Naveen •• There’s a call coming in from an ambulance on the way; a teenage boy was rescued from a near-drowning event. He’s immobilized on a backboard and breathing through an oxygen mask, but can talk and tell you what happened. His parents are on the way. •• Naveen is 17 years old. He and some friends were jumping into a lake; he hit the water hard, and may have hit the bottom of the lake or a rock. His friends dragged him out and then the ambulancecame. He says he’s been drinking, but not that much, and asks that you don’t tell his dad. •• Naveen, at least now, is thinking pretty clearly. But he’s probably intoxicated, so his exam is less reliable. After confirming a normal neurologic and general exam, you order the appropriate X-rays to confirm there’s no spine injury. Naveen will stay immobilized until that’s done for his own safety. •• Meanwhile: If you’re a bystander and someone may be drowning, don’t just jump into the water—a panicking swimmer can drag you down. Lifeguards have special training to deal with this. If possible, throw a float tied to a line, or extend a pole or other object for the victim to grab while you stay on solid ground. Always call for more help. As long as it’s safe, try to drag the victim onto land or back into a boat—don’t try to do CPR or other rescue maneuvers in the water. •• Once the victim is out of the water, the usual ABC steps apply. Don’t try to squeeze the victim to get water out—that doesn’t work and can cause more problems. If the victim starts vomiting up water, help turn him on his side. •• One other consideration: Cold or icy water immersions are a unique circumstance. There are cases where a person has been pulled out of cold water who seems dead—with no respiratory effort and no heartbeat. But once the body warms, life sometimes returns. Don’t stop CPR on a cold-water immersion victim until the person has been warmed up.

Question 146

Jake’s Snakebite

Answer 146

•• “I picked him up, but he bit me, so I dropped him. Then I tried to pick him up again, with my other hand, and he bit me there too.” So starts your conversation with Jake, a 10-year-old boy and your neighbor. His panicked dad brought him to your house after a rattlesnake bit him twice. •• There are puncture wounds on both wrists, and the one on the right side looks like it’s becoming swollen. Snakebites, especially venomous snakebites, can cause pain, tissue damage, an immune response, neurologic symptoms, and infections. •• If Jake seemed very ill or in tremendous pain, it would be good to first call 911 or head directly to the hospital. But since he seems well, you’ll spend a quick moment trying to wash out the wounds, with the hose sprayer in your kitchen sink. •• There’s a myth that snakebites ought to be treated with the “cut and suck” method. You’re supposed to, it is said, cut open the wound and suck on it. This is a terrible idea. It will only increase tissue damage and further contaminate the wound. •• Jake’s dad goes to check in on the rest of the family when Jake’s mom arrives. Together, you and the mom take him to the ED, coinciding with the start of your shift. Jake’s vital signs are normal. an IV. •• In the United States, most venomous snakes are from a family called pit vipers, which includes cottonmouths, copperheads, and rattlesnakes. Even though these kinds of snakes have venom, most bites don’t actually result in envenomation. The definitive treatment for a serious envenomation is often thought to be the administration of antivenin, sometimes pronounced antivenom. But antivenin can cause a lot of very serious side effects. •• For now, we’ll use a pen to mark the edges of the swelling on Jake’s wrists, and monitor his vital signs. We’ve given him some pain medication and antibiotics through the IV, and you’ve asked a clerk to see if you can confirm whether Jake has had a tetanus vaccine lately. You reassure his mom, and tell her you’ll be back later. What is of concern is that his right hand is becoming more and more painful and swollen. His vital signs remain normal, and he’s otherwise well, but he’s in a lot of pain. •• You’ll put in a call to a toxicology expert to help decide if antivenin is warranted, and Jake will be admitted for close monitoring in the ICU. He may need to go to the operating room to relieve the

Question 147

Multiple Sclerosis

Answer 147

􀁸􀀃 Multiple sclerosis is the most common debilitating neurological disease that affects young adults. Most cases manifest between the ages of 20 and 40, and women are far more likely to be affected than men. There is a strong genetic component to MS: People from certain ethnic groups, especially Caucasians who may have had roots in Scandinavia, seem to be most vulnerable, and MS is 20 times more common in close relatives of people with MS than in the general population. 􀁸􀀃 But there is more than genetics. Identical twins have only about a 30 percent concordance, meaning that 70 percent of identical twins of people with MS do not themselves develop MS, despite having identical genetic material. 􀁸􀀃 In addition to a genetic vulnerability, there must be important environmental factors at work. MS is more common in communities farther from the equator, perhaps because of reduced sunlight exposure, leading to lower vitamin D. People who move from an area of high risk to an area of low risk before puberty, but not afterward, seem to have their lifetime risk reduced. 􀁸􀀃 There have also been multiple outbreaks or clusters of MS, suggesting a possible infectious contributor; there have been many proposed possible infections, though none seems to be the single cause. Smoking, diet, occupation, and socioeconomic status all may also contribute. The cause of MS, as with many other health problems, likely relates to multiple overlapping genetic and environmental factors. 􀁸􀀃 MS causes damage to the central nervous system (CNS), meaning the brain and spinal cord. There are two major pathological features; one is the destruction of myelin, the insulation around nerve fibers. Myelin makes a sheath around nerve fibers that dramatically increases the speed and efficiency of the transmission of nerve impulses. Without myelin, basically, nerves don’t work at all or might be slow and unreliable. This demyelination had been thought of as the main, characteristic pathological feature of MS. 􀁸􀀃 However, damage can also occur from injury to nerve cells themselves. The affected areas of brain tissue are called the lesions of MS, and at least some of them can be seen on MRI scans; however, the correlation between what’s seen on the scan and the clinical effect of the lesion isn’t exact. Small lesions can cause significant symptoms, large lesions can cause minimal or zero symptoms, and sometimes symptoms can occur with no visible lesion at all. 􀁸􀀃 Lesions in MS can come and go, with apparent healing of affected areas while other areas develop new lesions. That’s very characteristic of most MS patients: waxing and waning symptoms as different areas of the CNS become more or less affected. 􀁸􀀃 MS is thought of as an autoimmune disorder, because there is activation of the immune system and inflammation leading to damage in the brain. Also, like other autoimmune diseases, it affects women more than men and starts relatively early in life. 􀁸􀀃 However, potent anti-inflammatory medicines that suppress flareups of MS don’t necessarily prevent the long-term progression of MS, leading some to think that there is more to MS than autoimmunity. There’s a lot of research going on, and there is certainly more to learn. 􀁸􀀃 The symptoms of MS depend on where the lesions are. Vision problems are quite common, usually caused by inflammation in the optic nerve. There can be sensory symptoms, including tingling, numbness, or pain; muscle weakness or spasms; or problems with balance and orientation that may contribute to difficulty walking. Fatigue is also a very common and significant symptom of MS, and fatigue can worsen all of the other neurological manifestations. 􀁸􀀃 Other common symptoms that can progress or wax and wane over time can include bladder and bowel problems, sexual dysfunction, problems with speech and swallowing, cognitive and memory issues, and depression or other psychiatric problems that can be very debilitating. 􀁸􀀃 MS symptoms can flare up at any time but often seem to have certain triggers. These can include infections. Even relatively ordinary, mild infections, such as a bladder infection or strep throat, can exacerbate underlying MS symptoms. Environmental stresses like heat, cold, or dehydration can be very problematic, and many patients also find that emotional stress can lead to worsening symptoms of MS. 􀁸􀀃 MS, itself, is not a fatal disease; most people with MS have a normal or nearly normal life span. But the effects of MS on quality of life can be very substantial. Twenty years after diagnosis, most patients remain independent and ambulatory, though some will use a cane for balance or an electric scooter to help prevent fatigue. 􀁸􀀃 Some patients, maybe 20 percent, will actually have very little progression after their initial presentation; on the other end of the spectrum, about 20 percent may have rapidly progressive disease.