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Nutritional Factors Affecting Health Meal Planning Applications There are a number of health-related applications that can be used for meal planning, including the United States Department of Agriculture (USDA) Food Patterns, the DASH (Dietary Approaches to Stop Hypertension) Eating Plan, MyPlate, food exchanges, and the glycemic index. USDA Food Patterns There are three USDA Food Patterns included in the 2015-2020 Dietary Guidelines: Healthy U.S. Style Eating, Healthy Mediterranean Style Eating, and Healthy Vegetarian Style Eating. One eating pattern is not necessarily superior to another, but rather more of a preference; however, a vegetarian lifestyle has been associated with a decreased risk for some chronic diseases such as heart disease and certain cancers. The USDA Food Patterns are all based on systematic review from scientific research, food pattern modeling, and analysis of intake of the U.S. population. Each USDA Food Pattern is based on the five food groups—vegetables, fruits, grains, dairy, and protein—and can be customized to meet an individual’s needs based on age, sex, height, weight, and level of physical activity. The Healthy U.S. Style Eating Pattern is based on typical foods consumed in Americans’ diets with a focus on nutrient-dense foods in portions that are appropriate for the desired caloric intake. The Healthy Mediterranean Style Eating Pattern is based on the Healthy U.S. Style Eating Pattern but adjusted to align with the eating patterns of the Mediterranean diet, which have been associated with positive health outcomes. Specifically, the Healthy Mediterranean Style Eating Pattern has more fruit and seafood, but less dairy, than the U.S. Style Eating Pattern. The Healthy Vegetarian Style Eating Pattern is also based on the Healthy U.S. Style Eating Pattern, but is adjusted to reflect the eating habits of self-reported vegetarians, as identified in the National Health and Nutrition Examination Survey (NHANES). DASH Eating Plan The DASH Eating Plan is based on clinical research trials, which found that the plan helped individuals lower their blood pressure and low-density lipoprotein (LDL) cholesterol and improve heart health, while meeting nutrient requirements. The DASH Eating Plan emphasizes whole grains, poultry, fish, and nuts, along with food sources of potassium, calcium, and magnesium. Individuals are encouraged to consume as much as seven to eight servings of grains and four to five servings of fruits and vegetables per day on a 2000-calorie diet. Individuals using the DASH Eating Plan may need to gradually increase the intake of whole grains, fruits, and vegetables, since the increased fiber of these foods can lead to bloating and diarrhea. MyPlate MyPlate is a tool developed by the USDA based on the five food groups and healthy eating, focused on variety, appropriate portion sizes, nutrient-dense foods, and low saturated fat, sodium, and added sugar intake. The MyPlate Daily Checklist and the SuperTracker are two specific online tools that allow individuals to customize nutrition planning for their specific needs. Food Exchanges Food exchanges are used for meal planning purposes, especially for those with diabetes and/or seeking weight loss. Food exchanges divide food into six categories based on the amount of carbohydrate, fat, and protein they contain: starches/breads, fruits, milk, vegetables, meat, and fat. - Starches and breads contain 15 grams of carbohydrate and 3 grams of protein per exchange with 80 calories. - Fruits contain 15 grams of carbohydrate per exchange with 60 calories. - Milk exchanges contain 12 grams of carbohydrate; 8 grams of protein; 3-8 grams of fat depending on whether the milk exchange is a low-, medium-, or high-fat choice; and 90-150 calories, depending on the fat content. - Vegetable exchanges contain 5 grams of carbohydrate per serving with 25 calories. - Meat exchanges contain 7 grams of protein per ounce and 0-8 grams of fat, depending on whether the source of the meat exchange is very lean, lean, medium fat, or high fat, with a range of 35-100 calories. - Fat exchanges provide 5 grams of fat and 45 calories. Glycemic Index Finally, the glycemic index and glycemic load offer insight as to how foods affect blood glucose and insulin levels. Glycemic index and load can be useful tools in meal planning to help individuals better understand the impact specific foods may have on their blood sugar. Carbohydrate counting may also be a useful tool in helping individuals monitor and understand the impact various carbohydrates have on their blood sugar. Nutritional Needs Carbohydrates Carbohydrates provide 4 kilocalories per gram and are a major source of fuel for the body, particularly during moderate- and high-intensity exercise, up to 2 hours in duration. Beyond approximately this duration, stores deplete, and the body relies on fatty acid metabolism for sustained energy. Carbohydrates are used for energy immediately, if needed, but excess carbohydrates are converted to glycogen and stored in skeletal muscles and the liver or converted to fat if the body’s glycogen stores are full. The amount of glycogen the body can store is influenced by a variety of factors including physical training status, basal metabolic rate, body size, and eating habits, but in general, the body can store about 15 grams per kilogram of body weight. In general, athletes should consume about 6-10 grams of carbohydrate per kilogram of body weight daily, depending on the intensity, duration, and frequency of their training, as well as their current health and physical goals. This is somewhat higher than recommendations for minimally-active individuals. The standard recommendation for the general population is to consume 45-65% of daily caloric intake from carbohydrates. Protein Like carbohydrates, protein provides 4 kilocalories per gram. Protein, which consists of amino acids, is used to support the body in the development of tissues, enzymes, and hormones, and to rebuild and repair muscles after exercise. In general, protein recommendations for athletes fall in the range of 1.5-2.0 grams per kilogram of body weight daily, depending on the type, duration, and frequency of exercise. For the general public, the recommendation is much lower, at 0.8 grams per kilogram of body weight daily. Excessive consumption of protein does not lead to increased muscle mass because protein in excess of physiologic needs is converted and stored as fat. Protein is essential in the diet and is needed to support the building of connective tissue, cell membranes, and the development of muscle. Protein consists of amino acids, and there are 22 amino acids used in the body. EAAs are required through the diet, since they cannot be synthesized in the body, and the eight of them include isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine. There are also seven conditional amino acids that cannot be sufficiently produced in the body, so they should come from the diet: arginine, cysteine, glutamine, histidine, proline, taurine, and tyrosine. There are seven non-EAAs: alanine, asparagine, aspartic acid, citrulline, glutamic acid, glycine, and serine. These amino acids can be produced by the body so are not required in the diet. Protein can be categorized as complete or incomplete. Complete proteins contain all of the EAAs, while incomplete proteins do not. Protein that comes from animal sources is usually complete and contains all of the EAAs, while incomplete proteins typically come from plant sources and do not contain all the EAAs. Proteins that have a higher amount of the EAAs are considered to have a higher amino acid profile. Good sources of animal protein include meat (beef, chicken, turkey, pork, and lamb), eggs, fish/seafood (tuna, crab, shrimp, lobster), and dairy (milk, yogurt, and cheese). Sources of plant-based protein include grains (brown rice, spelt, quinoa, amaranth, oatmeal), legumes (beans, peas, and lentils—pinto, black kidney, garbanzo, edamame, and tofu), and nuts and seeds (peanut butter, almond butter, peanuts, almonds, pistachios, walnuts, pecans, pumpkin seeds, and sunflower seeds). Fat Fat provides 9 kilocalories per gram and contributes significantly to resting energy requirements, as well as requirements during low-intensity and long-duration exercise. Fats can be divided into two basic categories: saturated and unsaturated. Saturated fats, which are primarily found in animal sources, include butyric, lauric, myristic, palmitic, and stearic acid, while unsaturated fats typically come from plant sources, such as soybeans, nuts, seeds, olives, and avocados. Fats should comprise at least 15% of the total caloric intake; as much as 30%-40% can be acceptable, depending on the health, age, and needs of the individual. An intake of 30% fat (10% saturated, 10% polyunsaturated, and 10% monounsaturated) aligns with dietary guidelines and should ensure an adequate—but not excessive—dietary intake. Vitamins and Minerals Vitamin and mineral needs vary throughout the lifespan and between sexes, but typically can be met if a balanced, varied diet is consumed with foods such as lean meats/protein, fruits, vegetables, whole grains, and dairy. B vitamins such as thiamin, riboflavin, and niacin are required to support metabolic processes; vitamin D is required for calcium absorption, and vitamins C and E are required to mitigate stress oxidation in the body. Fat-soluble vitamins (A, D, E, and K) are stored in the body, so they should not be consumed in excessive quantities. If an individual is not meeting their vitamins and minerals requirements through diet, a multivitamin-mineral supplement or specific supplementation is needed. Supplementation is also necessary at certain times. For example, a folic acid supplement is recommended to women hoping to conceive as deficiencies in folic acid have been linked to spinal malformations. Sweating can lower electrolytes and minerals such as sodium, potassium, chloride, iron, calcium, phosphorus, and magnesium. Sodium and potassium help to regulate the body’s water balance and also play a significant role in muscle contraction. Chloride also helps with fluid balance and nerve conductions. Iron plays an important role in the body’s ability to transport and use oxygen, and calcium is critical for bone formation, nerve conduction, and muscle contraction. Phosphorus is involved in intramuscular oxidation processes, and magnesium helps support energy metabolism. Electrolytes (sodium, potassium, and chloride) and water need to be replaced during extended exercise, particularly in hot and humid environments, because they are excreted in sweat. Health Risk Factors Associated with Dietary Choices Dietary choices affect health risks associated with some chronic health conditions. Saturated fats Saturated fat is associated with an increased risk for cardiovascular disease, so the Dietary Guidelines for Americans recommends consuming no more than 10% of caloric intake from saturated fats. An emphasis should be made on replacing saturated fats with unsaturated fats, especially polyunsaturated, as this substitution is associated with improved total and LDL cholesterol. Triglycerides Circulating triglycerides are also affected by diet. Limiting refined, sugary foods; replacing saturated fats with unsaturated fats; and increasing fiber intake can help to keep triglycerides in the normal range of less than 150 milligrams per deciliter. High triglycerides can lead to increased risk of heart disease and diabetes. Trans fats Trans fats are produced through a process called hydrogenation, which makes packaged foods (such as coffee creamer, snack foods, store-bought baked goods, vegetable shortening, stick margarines, fast foods, and refrigerated dough products) more shelf stable. In recent years, manufacturers have begun limiting or removing trans fats, per the Food and Drug Administration regulatory requirements, because these fats have been shown to pose a significant risk for heart disease and should be eliminated from the diet. Cholesterol Cholesterol is required for various physiological and structural functions, such as the production of cells and hormones. However, these requirements are met by the cholesterol produced in the body; little to no additional dietary cholesterol is needed. The upper limit for healthy levels of cholesterol is 200 milligrams per deciliter; high cholesterol is a risk factor for heart disease. Because recent research has failed to find a significant correlation between dietary intake and circulating cholesterol, the 2015-2020 Dietary Guidelines no longer contain recommendations that limit cholesterol intake to 300 milligrams per day. The Institute of Medicine (IOM) still recommends limiting the intake of cholesterol-laden foods such as high-fat meats and dairy, which also contain high amounts of saturated fat. Calcium Calcium plays important physiologic roles including vascular contraction, vasodilation, muscle contraction, and nerve impulse transmission. The majority of calcium in the body is stored in bones and teeth. To support bone mineral deposition and avoid bone resorption, it is important to have adequate calcium intake. This is especially true at certain stages of the life cycle, when bones are forming or have the tendency to demineralize, as well as for athletes, who may lose additional calcium through perspiration. Postmenopausal women, especially, need to obtain adequate amounts of calcium in the diet to decrease the risk for osteoporosis. Signs and symptoms of calcium deficiency may be absent or may include muscle weakness, cramping, and increased susceptibility to fractures. Recommended intake varies by gender and throughout the lifespan, with increases for females, adolescents, lactating mothers, and postmenopausal women. Iron Iron in the body is primarily combined with hemoglobin, in an iron-protein compound that increases the blood’s oxygen-carrying capacity 65 times, as well as in muscle myoglobin. Intensive workout programs put individuals at risk for developing iron-deficiency anemia, which decreases aerobic capacity, since less oxygen can circulate to working tissues, leading to fatigue and reduced athletic performance. Other symptoms of iron-deficiency anemia include brittle nails, sluggishness, headaches, pale skin, and dizziness. Iron recommendations are 1.3-1.7 times higher for athletes than nonathletes and another 1.8 times higher for vegetarian athletes in comparison to those who consume animal protein, due to the lower bioavailability of nonheme iron sources in the vegetarian diet. The Recommended Dietary Allowance (RDA) for iron for men over the age of 18 is 8 milligrams per day; for women ages 19-50, 18 milligrams; for women ages 51 and older, it is also 8 milligrams per day. Females of childbearing age are at a higher risk for iron-deficiency anemia due to red blood cell loss during menstruation. Females often tend to consume less dietary iron as well. Endurance athletes may require additional iron due to foot-strike hemolysis, loss of hemoglobin in urine from strenuous training, and the small amount of iron lost in sweat. Heme sources of iron are more easily absorbed and include beef, pork, and beef liver. Nonheme sources include oatmeal, lentils, dark green leafy vegetables, and fortified cereals. Vitamin C intake can increase the absorption of iron in the small intestine; a glass of orange juice increases nonheme iron bioavailability by three times. It should be noted that excessive iron intake, especially in males, can be toxic. Hydration and Electrolytes The adult male body is about 60% water, while the female body is about 50%-55% water. As a result, less than optimal hydration status can affect health. Dehydration can cause headaches, sluggishness, mood changes and loss of cognitive functioning, and muscle cramping. Decreased athletic performance can occur with just a 3% loss in body weight from dehydration. During exercise, perspiration helps mitigate the increase in body temperature. During strenuous activity, individuals can lose as much as 6%-10% of their body weight via sweating, depending on the type and duration of the activity. It is important to maintain adequate hydration before, during, and after exercise; the recommendation is 8-12 cups of water per day plus replacement of fluid loss during exercise. Individual needs may vary, but during exercise, about 6-8 ounces of fluid are usually needed every 15-20 minutes of activity. Within the context of adequate hydration, electrolyte balance must also be preserved. The five major electrolytes that are important to health are sodium, potassium, chloride, calcium, and magnesium. Sodium, which is needed to help maintain fluid balance, nerve function, muscle contractions, and acid-base balance, is the primary electrolyte lost in sweat and must be replaced. It is important to include sodium in fluids or food as part of the rehydration process after exercise so that overhydration, or hyponatremia, does not occur as a result of drinking water alone. Adding sodium to fluids also helps to improve the absorption of water and carbohydrates. Most commercial sports drinks are formulated to provide the optimal levels of sodium and carbohydrates in solution. Nutrient-dense versus caloric-dense foods Nutrient-dense foods are rich in essential nutrients, vitamins, and minerals but low in calories, especially in comparison to calorically-dense or energy-dense foods. Calorically-dense foods provide few essential nutrients relative to the number of calories they provide. When focusing on weight loss or optimal health, it is important to focus on nutrient-dense foods. Sources of nutrient-dense foods include fresh vegetables and fruits, specifically dark green leafy vegetables like kale, spinach, and collard greens and fruits like berries, melon, mangoes, and citrus. Other nutrient-dense foods include lean sources of protein, dairy, legumes, and whole grains that have been enriched with vitamins and minerals. Calorically-dense foods include cookies, cakes, pastries, soda, chips, high-fat meats, and fast foods and other highly processed, highly caloric foods. Diseases Coronary Artery Disease (CAD) According to the World Health Organization (WHO), coronary artery disease, or CAD, is the deadliest disease in the world, accounting for 15.5% of all deaths worldwide in 2015. CAD, also known as ischemic heart disease, is a narrowing of the blood vessels that supply blood, oxygen, and nutrients to the heart muscle. This narrowing is usually caused by the buildup of cholesterol-containing plaques along the arterial walls, which then reduces blood flow. Decreased coronary blood flow can cause angina (chest pain) and dyspnea (shortness of breath). Left untreated, overtime, arrhythmias, heart failure, and heart attacks can result, particularly if the blockage completely occludes blood flow. CAD develops gradually over time, and is often considered insidious in nature because patients can be asymptomatic for years while the plaques are slowly building up in the coronary arterial walls. In these cases, patients may be entirely unaware of their condition until it becomes severe enough to trigger symptoms, at which point, the disease can be fairly progressed. Oftentimes, patients first experience angina and dyspnea during heavy exertion (for example, during exercise), but these symptoms subside with rest. As the disease progresses and the buildup more significantly narrows the arteries, symptoms can appear with routine activities and even rest. Plaques are composed of low-density lipoprotein (LDL) cholesterol, damaged endothelium cells, white blood cells, calcium, and inflammatory cells. The buildup is called atherosclerosis and it can occur in any artery throughout the body, though CAD specifically refers to atherosclerosis of the coronary arteries. The smooth inner walls of arteries are lined with a thin layer of cells called the endothelium. Smoking, hypertension, hypocholesteremia, and other such risk factors can damage the endothelium. This thin layer of cells has a protective function for the arteries and it helps ensure smooth, low-friction blood flow so that the blood can pump through with minimal effort. As the endothelium incurs damage, LDL cholesterol can cross the damaged barrier and enter the arterial walls, which leads to an influx of white blood cells to the area to digest and process the LDL. This causes further inflammation and plaque buildup, both which slow blood flow by reducing the diameter for flow and increasing friction and resistance. Atherosclerosis thus narrows, hardens, and stiffens arteries. Risk factors for CAD include a family history of the disease, smoking, advanced age, hypertension, hypocholesteremia, high triglycerides, a sedentary lifestyle, diabetes, a poor diet that is high in processed foods, obesity, metabolic syndrome, and certain inflammatory conditions. These risk factors are considered along with a physical exam and diagnostic tests, such as an exercise stress test, echocardiogram, EKG, and a cardiac catherization, to diagnose a patient with CAD and determine the best treatment. Treatment often focuses on lifestyle modifications, including obtaining regular aerobic exercise, smoking cessation, blood sugar control, and adopting a healthy diet with minimal processed foods. Medications, such as statins and aspirin, may be prescribed. Depending on the severity and extent of the blockages and symptoms, surgeries may be indicated. Common procedures for CAD include the insertion of stents, balloon angioplasties, and coronary artery bypass surgeries. Stroke The WHO reports that strokes are the second leading cause deaths worldwide, accounting for 11.1% of the total in 2015. Moreover, they are the leading cause of long-term disability. A stroke is defined as the death of brain tissue due to ischemic or hemorrhagic injury. Ischemic strokes are more common than hemorrhagic strokes; however, the differential diagnosis of these conditions requires careful attention to the patient’s history and physical examination. In general, an acute onset of neurological symptoms and seizures is more common with hemorrhagic stroke, while ischemic stroke is more frequently associated with a history of some form of trauma. The National Institutes of Health (NIH) Stroke Scale represents an international effort to standardize the assessment and treatment protocols for stroke. The scale includes detailed criteria and the protocol for assessment of the neurological system. The stroke scale items are to be administered in the official order listed and there are directions that denote how to score each item. Ischemic Stroke Ischemic strokes result from occlusion of the cerebral vasculature as a result of a thrombotic or embolic event. At the cellular level, the ischemia leads to hypoxia that rapidly depletes the ATP stores. As a result, the cellular membrane pressure gradient is lost, and there is an influx of sodium, calcium, and water into the cell, which leads to cytotoxic edema. This process creates scattered regions of ischemia in the affected area, containing cells that are dead within minutes of the precipitating event. This core of ischemic tissue is surrounded by an area with minimally-adequate perfusion that may remain viable for several hours after the event. These necrotic areas are eventually liquefied and acted upon by macrophages, resulting in the loss of brain parenchyma. These affected sites, if sufficiently large, may be prone to hemorrhage, due to the formation of collateral vascular supply with or without the use of medications such as recombinant tissue plasminogen activator (rtPA). The ischemic process also compromises the blood-brain barrier, which leads to the movement of water and protein into the extracellular space within 4 to 6 hours after the onset of the stroke, resulting in vasogenic edema. Nonmodifiable risk factors for ischemic stroke include age, gender, ethnicity, history of migraine headaches with aura, and a family history of stroke or transient ischemic attacks (TIAs). Modifiable risk factors include hypertension, diabetes, hypercholesterolemia, cardiac disease including atrial fibrillation, valvular disease and heart failure, elevated homocysteine levels, obesity, illicit drug use, alcohol abuse, smoking, and sedentary lifestyle. The research related to the occurrence of stroke in women indicates the need to treat hypertension aggressively prior to and during pregnancy and prior to the use of contraceptives to prevent irreversible damage to the microvasculature. In addition, it is recommended that to reduce their risk of stroke, women with a history of migraine headaches preceded by an aura should ameliorate all modifiable risk factors, and all women over seventy-five years old should be routinely assessed for the onset of atrial fibrillation. Heredity is associated with identified gene mutations and the process of atherosclerosis and cholesterol metabolism. Hypercholesterolemia and the progression of atherosclerosis in genetically-susceptible individuals are now regarded as active inflammatory processes that contribute to endothelial damage of the cerebral vasculature, thereby increasing the risk for strokes. There are also early indications that infection also contributes to the development and advancement of atherosclerosis. The presenting manifestations of ischemic stroke must be differentiated from other common diseases, including brain tumor formation, hyponatremia, hypoglycemia, seizure disorders, and systemic infection. The sudden onset of hemisensory losses, visual alterations, hemiparesis, ataxia, nystagmus, and aphasia are commonly, although not exclusively, associated with ischemic strokes. The availability of reperfusion therapies dictates the emergent use of diagnostic imaging studies, including CT and MRI scans, carotid duplex scans, and digital subtraction angiography to confirm the data obtained from the patient’s history and physical examination. Laboratory studies include CBC, coagulation studies, chemistry panels, cardiac biomarkers, toxicology assays, and pregnancy testing as appropriate. The emergency care of the patient who presents with an ischemic stroke is focused on the stabilization of the patient’s ABCs, completion of the physical examination and appropriate diagnostic studies, and initiation of reperfusion therapy as appropriate, within 60 minutes of arrival in the emergency department. Reperfusion therapies include the use of alteplase (the only fibrinolytic agent that is approved for the treatment of ischemic stroke), antiplatelet agents, and mechanical thrombectomy. Emergency providers must also be alert for hyperthermia, hypoxia, hypertension or hypotension, and signs of cardiac ischemia or cardiac arrhythmias. Hemorrhagic Stroke Hemorrhagic strokes are less common than ischemic strokes; however, a hemorrhagic stroke is more likely to be fatal than an ischemic stroke. A hemorrhagic stroke is the result of bleeding into the parenchymal tissue of the brain due to leakage of blood from damaged intracerebral arteries. These hemorrhagic events occur more often in specific areas of the brain, including the thalamus, cerebellum, and brain stem. The tissue surrounding the hemorrhagic area is also subject to injury due to the mass effect of the accumulated blood volume. In the event of subarachnoid hemorrhage, ICP becomes elevated with resulting dysfunction of the autoregulation response, which leads to abnormal vasoconstriction, platelet aggregation, and decreased perfusion and blood flow, resulting in cerebral ischemia. Risk factors for hemorrhagic stroke include older age; a history of hypertension, which is present in 60 percent of patients; personal history of stroke; alcohol abuse; and illicit drug use. Common conditions associated with hemorrhagic stroke include hypertension, cerebral amyloidosis, coagulopathies, vascular alterations including arteriovenous malformation, vasculitis, intracranial neoplasm, and a history of anticoagulant or antithrombotic therapy. Although the presenting manifestations for hemorrhagic shock differ in some respect from the those associated with ischemic stroke, none of these such manifestations is an absolute predictor of one or the other. In general, patients with hemorrhagic stroke present with a headache that may be severe, significant alterations in the level of consciousness and neurological function, hypertension, seizures, and nausea and vomiting. The specific neurological defects depend on the anatomical site of the hemorrhage and may include hemisensory loss, hemiparesis, aphasia, and visual alterations. A common site for an aneurysm, or bulging or ballooning in a blood vessel within the brain is where the internal carotid artery (ICA) enters the cranium; it branches into a system of arteries that provide blood flow to the brain, known as the circle of Willis. Most small brain aneurysms do not rupture and are found during various tests. An aneurysm may press on brain tissue and present with ocular pain or symptoms. However, a rupture is a medical emergency that can lead to stroke or hemorrhage. The most common symptom described by patients is “the worst headache of my life.” A sudden, severe headache, stiff neck, blurred or double vision, photophobia, seizure, loss of consciousness, and confusion may also be reported. Diagnostic studies include CBC, chemistry panel, coagulation studies, and blood glucose. Non-contrast CT scan or MRI are the preferred imaging studies. CT or magnetic resonance angiography may also be used to obtain images of the cerebral vasculature. Close observation of the patient’s vital signs, neurological vital signs, and ICP is necessary. The emergency management of the patient with hemorrhagic shock is focused on the ABC protocol, in addition to the control of bleeding, seizure activity, and increased ICP. There is no single medication used to treat hemorrhagic stroke; however, recent data suggests that aggressive emergency management of hypertension initiated early and aimed at reducing the systolic BP to less than 140 millimeters of mercury may be effective in reducing the growth of the hematoma at the site, which decreases the mass effect. Beta-blockers and ACE inhibitors are recommended to facilitate this reduction. Endotracheal intubation for ventilatory support may be necessary. Patients who present with manifestations of hemorrhagic stroke with a history of anticoagulation therapy present a special therapeutic challenge due to the extension of the hematoma formation. More than 50 percent of patients taking warfarin who suffer a hemorrhagic stroke will die within thirty days. This statistic is consistent in patients with international normalized ratio (INR) levels within the therapeutic range, with increased mortality noted in patients with INRs that exceed the therapeutic level. Emergency treatment includes fresh frozen plasma, IV vitamin K, prothrombin complex concentrates, and recombinant factor VIIa (rFVIIa). There are administration concerns with each of these therapies that must be addressed to prevent any delays in the reversal of the effects of the warfarin. Transient Ischemic Attack A transient ischemic attack (TIA) is defined as a short-term episode of altered neurological function that lasts for less than one hour; it may be imperceptible to the patient. The deficit may be related to speech, movement, behavior, or memory and may be caused by an ischemic event in the brain, spinal cord, or retina. The patient’s history and neurological assessment according to the NIH Stroke Scale establish the diagnosis. Additional diagnostic studies include CBC, glucose, sedimentation rate, electrolytes, lipid profile, toxicology screen, 12-lead ECG, and CSF analysis. Imaging studies include non-contrast MRI or CT, carotid Doppler exam, and angiography. The ABCD2 stroke risk score calculates the patient’s risk for experiencing a true stroke within two days after the TIA based on five factors (see the table below). Interventions aimed at stroke prevention in relation to the risk stratification as calculated by the ABCD2 score are specific to underlying comorbidities; however, treatment with ASA and clopidogrel is commonly prescribed.
Cancer Cancer is a general term that refers to a disease characterized by abnormal cells that can development in any number of body tissues, organs, or systems that divide uncontrollably and that can infiltrate, crowd out, and kill healthy body cells. Cancer of the lung, pancreas, testicles, cervix, brain, and blood are just a few of the many tissues that may incur cancerous growth. Regardless as to the initial site of the development of cancer cells, cancer, unlike benign tumors, can usually spread throughout one's body. There are over 100 distinct types of recognized cancers and when all types are aggregated, cancer is the second-leading cause of death in the United States. Signs and symptoms vary widely, depending on the specific cancer; however, common symptoms include unexplained weight loss, the presence of a palpable lump or mass, notable changes in bowel habits or appetite, abnormal bleeding, and persistent cough or fever. Tobacco use, including smoking, is the single greatest risk factor for the development of most cancers. Family history, obesity, exposure to ionizing radiation and certain chemicals and environmental pollutants, poor diet, sedentary lifestyle, drug or alcohol abuse, and infections such as hepatitis and HPV can also increase one's risk of developing cancer. Any of these factors or others may initiate genetic changes that precede and place the individual at risk for the development of abnormal cell growth. Cancer may be suspected from laboratory results, patient symptoms, and a physical exam and then detected through imaging studies, such as CT scans and MRIs. These scans may also be used to assess the spread of the malignancy. Biopsies are often used to confirm the diagnosis. Treatment typically involves surgery to remove malignant tissue, chemotherapy, radiation therapy, targeted cell therapy, and supportive palliative care for pain reduction, disease- and treatment-symptom management, restoration of overall health, and emotional care. Survival rates depend on several factors, mainly the specific type of cancer, the extent to which it is confined or spread, and the patient's age and general health status. Early detection is critical for the most favorable treatment outcomes. Diabetes Mellitus This is a condition that affects how the body responds to the presence of glucose. Glucose is needed for cell functioning, and all consumable calories eventually are converted to glucose in the body. A hormone produced by the pancreas, called insulin, is needed to break down food and drink into glucose molecules. In patients with type 1 diabetes, the pancreas fails to produce insulin, leading to high levels of glucose in the bloodstream. This can lead to organ damage, organ failure, or nerve damage.
Patients with type 1 diabetes receive daily insulin injections or have a pump that continuously monitors their blood insulin levels and releases insulin as needed. These patients need to be careful to not administer excess insulin, as this will cause their blood sugar to become too low. Low blood sugar can lead to fainting and exhaustion and may require hospitalization. In patients with type 2 diabetes, the pancreas produces insulin, but the body is unable to use it effectively.
Patients with type 2 diabetes typically need to manage their condition through lifestyle changes, such as losing weight and eating fewer carbohydrate-rich and sugary foods. There are also some medications that help the body use the insulin that is present in the bloodstream. Gestational diabetes is a form of diabetes that some women develop during the second to third trimester of pregnancy, when their systems temporarily become resistant to insulin. High blood sugar in a pregnant woman can affect fetal growth and influence the baby’s risk of becoming obese. Pregnant women with gestational diabetes are encouraged to exercise daily, avoid excessive weight gain, and carefully monitor their diet. Gestational diabetes is similar to type 2 diabetes in the way symptoms present and in treatment options. Diabetic Ketoacidosis This is an acute complication that primarily occurs in patients with type 1 diabetes who lack adequate insulin. When the body does not have enough insulin in the blood to break down macronutrients into glucose, it defaults to breaking down fatty acids into ketones for energy. This typically does not cause major issues in a person who does not have diabetes, as eventual insulin production and uptake will balance the level of ketones in the blood. In a patient with diabetes who cannot produce enough insulin, the body will continue to release fatty acids into the bloodstream. Eventually, this will result in too many ketones in the blood and will shift the body’s pH level to an excessively acidic one. This is a crisis situation, and the patient may eventually go into a coma if left untreated. Symptoms include dehydration, nausea, sweet-smelling breath, confusion, and fatigue. Treatment includes oral or IV electrolyte and insulin administration. Diabetic ketoacidosis can occur with type 2 diabetes but occurs more frequently with type 1 diabetes. Often, a ketoacidosis event is the first indicator that a person may have diabetes. Metabolic Syndrome/Syndrome X Metabolic syndrome, or Syndrome X, refers to the presence of comorbid cardiovascular and insulin-related conditions. Patients diagnosed with metabolic syndrome must have three or more of the following conditions: hypertension, elevated fasting blood glucose levels, low HDL cholesterol, high triglycerides, and excess belly fat. This syndrome is believed to result from insulin resistance, causing high blood glucose, insulin, and lipid levels. Patients with metabolic syndrome tend to be overweight or obese and at an increased risk of organ failure, heart attacks, and strokes. They often suffer from another underlying condition, such as diabetes or polycystic ovary syndrome, that leads to metabolic syndrome. Metabolic syndrome is often treated with prescription medications that lower cholesterol and blood pressure, but diet and exercise changes are strongly recommended. Weight loss is a key component in managing metabolic syndrome. Chronic Obstructive Pulmonary Disease (COPD) Chronic Obstructive Pulmonary Disease (COPD) is characterized by an airflow obstruction that’s not fully reversible. It’s usually progressive and is associated with an abnormal inflammatory response in the lungs. The primary cause of COPD is exposure to tobacco smoke, and is one of the leading causes of death in the United States. COPD includes chronic bronchitis, emphysema, or a combination of both. Though asthma is part of the classic triad of obstructive lung diseases, it is not part of COPD. However, someone with COPD can have an asthma component to their disease. Chronic bronchitis is described as a chronic productive cough for three or more months during each of two consecutive years. Emphysema is the abnormal enlargement of alveoli (air sacs) with accompanying destruction of their walls.
Signs and symptoms of COPD can include: - Dyspnea - Wheezing - Cough (usually worse in the morning and that produces sputum/phlegm) - Cyanosis - Chest tightness - Fever - Tachypnea - Orthopnea - Use of accessory respiratory muscles - Elevated jugular venous pressure (JVP) - Barrel chest - Pursed lip breathing - Altered mental status
A diagnosis of COPD can be made through pulmonary function tests (PFTs), a chest x-ray, blood chemistries, ABG analysis, or a CT scan. A formal diagnosis of COPD can be made through a PFT known as spirometry, which measures lung function. PFTs measure the ratio of forced expiratory volume in one second over forced vital capacity (FEV1/FVC) and should normally be between 60% and 90%. Values below 60% usually indicate a problem. The other diagnostic tests mentioned are useful in determining the acuity and severity of exacerbations of the disease. In acute exacerbations of COPD, ABG analysis can reveal respiratory acidosis, hypoxemia, and hypercapnia. Generally, a pH less than 7.3 indicates acute respiratory compromise. Compensatory metabolic alkalosis may develop in response to chronic respiratory acidosis. A chest x-ray can show flattening of the diaphragm and increased retrosternal air space (both indicative of hyperinflation), cardiomegaly, and increased bronchovascular markings. Blood chemistries can suggest sodium retention or hypokalemia. A CT scan is more sensitive and specific than a standard chest x-ray for diagnosing emphysema. Treatment for acute exacerbations of COPD can include oxygen supplementation, short-acting Beta-2 agonists, anticholinergics, corticosteroids, and antibiotics. Acute Respiratory Tract Infections Acute Bronchitis Acute bronchitis is inflammation of the bronchial tubes (bronchi), which extend from the trachea to the lungs. It is one of the top five reasons for visits to healthcare providers and can take from ten days to three weeks to resolve. Common causes of acute bronchitis include respiratory viruses (such as influenza A and B), RSV, parainfluenza, adenovirus, rhinovirus, and coronavirus. Bacterial causes include Mycoplasma species, Streptococcus pneumoniae, Chlamydia pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Other causes of acute bronchitis are irritants such as chemicals, pollution, and tobacco smoke.
Signs and symptoms of acute bronchitis can include: - Cough (most common symptom) with or without sputum - Fever - Sore throat - Headache - Nasal congestion - Rhinorrhea - Dyspnea - Fatigue - Myalgia - Chest pain - Wheezing
Acute bronchitis is typically diagnosed by exclusion, which means tests are used to exclude more serious conditions such as pneumonia, epiglottitis, or COPD. Useful diagnostic tests include a CBC with differential, a chest x-ray, respiratory and blood cultures, PFTs, bronchoscopy, laryngoscopy, and a procalcitonin (PCT) test to determine if the infection is bacterial.
Treatment of acute bronchitis is primarily supportive and can include: - Bedrest - Cough suppressants, such as codeine or dextromethorphan - Beta-2 agonists, such as albuterol, for wheezing - Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain - Expectorants, such as guaifenesin
Although acute bronchitis should not be routinely treated with antibiotics, there are exceptions to this rule. It’s reasonable to use an antibiotic when an existing medical condition poses a risk of serious complications. Antibiotic use is also reasonable for treating acute bronchitis in elderly patients who have been hospitalized in the past year, have been diagnosed with congestive heart failure (CHF) or diabetes, or are currently being treated with a steroid. Pneumonia Pneumonia is an infection that affects the functional tissue of the lung. Microscopically, it is characterized by consolidating lung tissue with exudate, fibrin, and inflammatory cells filling the alveoli (air sacs). Pneumonia can represent a primary disease or a secondary disease (e.g., post-obstructive pneumonia due to lung cancer), and the most common causes of pneumonia are bacteria and viruses. Other causes of pneumonia include fungi and parasites. Pneumonia can be categorized according to its anatomic distribution on a chest x-ray or the setting in which it is acquired. Pneumonia categorized according to its anatomic distribution on chest x-ray can be: - Lobar: Limited to one lobe of the lungs. It can affect more than one lobe on the same side (multilobar pneumonia) or bilateral lobes (“double” pneumonia). - Bronchopneumonia: Scattered diffusely throughout the lungs - Interstitial: Involving areas between the alveoli
Pneumonia categorized according to the setting in which it is acquired can be: - Community-Acquired Pneumonia (CAP): Pneumonia in an individual who hasn’t been recently hospitalized, or its occurrence in less than 48 hours after admission to a hospital. - Hospital-Acquired (Nosocomial) Pneumonia: Pneumonia acquired during or after hospitalization for another ailment with onset at least 48 hours or more after admission. - Aspiration Pneumonia: Pneumonia resulting from the inhalation of gastric or oropharyngeal secretions. Community-Acquired Pneumonia (CAP) Common causes of community-acquired pneumonia (CAP) include: - Streptococcus pneumoniae - Haemophilus influenzae - Moraxella catarrhalis - Atypical organisms (such as Legionella species, Mycoplasma pneumoniae, and Chlamydia pneumonia) - Staphylococcus aureus - Respiratory viruses Streptococcus Pneumoniae Streptococcus pneumonia (also known as S. pneumonia or pneumococcus) is a gram-positive bacterium and the most common cause of CAP. Due to the introduction of a pneumococcal vaccine in 2000, cases of pneumococcal pneumonia have decreased. However, medical providers should be aware there is now evidence of emerging, antibiotic-resistant strains of the organism.
Signs and symptoms of pneumococcal pneumonia can include: - Cough productive of rust-colored sputum (mucus) - Fever with or without chills - Dyspnea - Wheezing - Chest pain - Tachypnea - Altered mental status - Tachycardia - Rales over involved lung - Increase in tactile fremitus - E to A change - Hypotension - Lung consolidation
Diagnosis of pneumococcal pneumonia can include: - CBC with differential - Chest x-ray - CT scan (if underlying lung cancer is suspected) - Sputum gram stain and/or culture - Blood cultures - Procalcitonin and C-reactive protein blood level tests - Sputum, serum, and/or urinary antigen tests - Immunoglobulin studies - Bronchoscopy with bronchoalveolar lavage (BAL)
Treatment of pneumococcal pneumonia can include: - Antibiotics, such as ceftriaxone plus doxycycline, or azithromycin - Respiratory quinolones, such as levofloxacin (Levaquin®), moxifloxacin (Avelox®), or gemifloxacin (Factive®) - Supplemental oxygen - Beta-2 agonists, such as albuterol via nebulizer or metered-dose inhaler (MDI), as needed for wheezing - Analgesics and antipyretics - Chest physiotherapy - Active suctioning of respiratory secretions - Intubation and mechanical ventilation Mycoplasma Pneumoniae Mycoplasma pneumonia, also known as M. pneumoniae, is a bacterium that causes atypical CAP. It is one of the most common causes of CAP in healthy individuals under the age of forty. The most common symptom of mycoplasmal pneumonia is a dry, nonproductive cough. Other signs and symptoms can include diarrhea, earache, fever (usually < 1020F), sore throat, myalgias, nasal congestion, skin rash, and general malaise. Chest x-rays of individuals with mycoplasmal pneumonia reveal a pattern of bronchopneumonia. Cold agglutinin titers in the blood can be significantly elevated (> 1:64). Polymerase chain reaction (PCR) is becoming the standard confirmatory test for mycoplasmal pneumonia, though currently it is not used in most clinical settings. Treatments for mycoplasmal pneumonia are no different than for CAP, except for the specific antibiotics used in treatment are usually different. Methicillin-Resistant Staphylococcus Aureus Community-Acquired Methicillin-Resistant Staphylococcus Aureus (CA-MRSA) has emerged as a significant cause of CAP over the past twenty years. It also remains a significant cause of hospital-acquired pneumonia. The majority (up to 75%) of those diagnosed with CA-MRSA pneumonia are young, previously healthy individuals with influenza as a preceding illness. Symptoms are usually identical to those seen with other causes of CAP. Chest x-ray typically reveals multilobar involvement with or without cavitation/necrosis. Gram staining of sputum and/or blood can reveal gram-positive bacteria in clusters. Treatment of CA-MRSA should be prompt as it has a high mortality rate. Supportive measures are needed as in other cases of CAP. CA-MRSA is notoriously resistant to most antibiotics with the exception of vancomycin and linezolid, but even aggressive courses of these drugs can be unsuccessful. Viral Pneumonia Viral pneumonia is more common at the extremes of age (young children and the elderly). It accounts for the majority of cases of childhood pneumonia. Cases of viral pneumonia have been increasing over the past decade, mostly as a result of immunosuppression (weakened immune system). Common causes of viral pneumonia in children, the elderly, and the immunocompromised are the influenza viruses (most common), RSV, parainfluenza virus, and adenovirus.
Signs and symptoms of viral pneumonia largely overlap those of bacterial pneumonia and can include: - Cough (nonproductive) - Fever/chills - Myalgias - Fatigue - Headache - Dyspnea - Tachypnea - Tachycardia - Wheezing - Cyanosis - Hypoxia - Decreased breath sounds - Respiratory distress
Viral pneumonia is diagnosed via a chest x-ray and viral cultures. The chest x-ray usually reveals bilateral lung infiltrates, instead of the lobar involvement commonly seen in bacterial causes. Viral cultures can take up to two weeks to confirm the diagnosis. Rapid antigen testing and gene amplification via polymerase chain reaction (PCR) have been recently incorporated into the diagnostic mix to shorten the diagnosis lag.
Treatment of viral pneumonia is usually supportive and can include: - Supplemental oxygen - Rest - Antipyretics - Analgesics - Intravenous fluids - Parenteral nutrition - Intubation and mechanical ventilation
Specific causes of viral pneumonia can benefit from treatment with antiviral medications. Influenza pneumonia can be treated with oseltamivir (Tamiflu®) or zanamivir (Relenza®). Ribavirin® is the only effective antiviral agent for the treatment of RSV pneumonia. Meningitis Meningitis is defined as the infection and resulting inflammation of the three layers of the meninges, the membranous covering of the brain and spinal cord. The causative agent may be bacterial, viral, parasitic, or fungal. The most common bacterial agent is S. pneumoniae. Meningococcal meningitis is common in crowded living spaces. However, the development and use of the meningococcal vaccine (MCV 4) has reduced the incidence in college students and military personnel. The Haemophilus influenza vaccine (Hib) has decreased the incidence and morbidity of the HI meningitis in infants, and the pneumococcal polysaccharide vaccine (PPSV) is being used to prevent meningitis in at-risk populations, such as immunocompromised adults, smokers, residents in long-term care facilities, and adults with chronic disease. General risk factors for bacterial infection of the meninges include loss of, or decreased function of, the spleen; hypoglobinemia; chronic glucocorticoid use; deficiency of the complement system; diabetes; renal insufficiency; alcoholism; chronic liver disease; otitis media; and trauma associated with leakage of the CSF. Bacterial meningitis is infectious, and early diagnosis and treatment are essential for survival and recovery. Emergency providers understand that even with adequate treatment, 50 percent of patients with bacterial meningitis will develop complications within two to three weeks of the acute infection, and long-term deficits are common in 30 percent of the surviving patients. The complications are specific to the causative organism, but may include hearing loss, blindness, paralysis, seizure disorder, muscular deficiencies, ataxia, hydrocephalus, and subdural effusions. In contrast, the incidence of viral meningitis is often associated with other viral conditions such as mumps, measles, herpes, and infections due to arboviruses such as the West Nile virus. The treatment is supportive, and the majority of patients recover without long-term complications; however, the outcome is less certain for patients who are immunocompromised, or less than two years old or more than sixty years old. The classic manifestations of bacterial meningitis include fever, nuchal rigidity, and headache. Additional findings may include nausea and vomiting, photophobia, confusion, and a decreased level of consciousness. Patients with viral meningitis may report the incidence of fatigue, muscle aches, and decreased appetite prior to the illness. Infants may exhibit a high-pitched cry, muscle flaccidity, irritability, and bulging fontanels. The diagnosis of meningitis is determined by lumbar puncture; CSF analysis; cultures of the blood, nose, and respiratory secretions and any skin lesions that are present; complete blood count (CBC); electrolytes; coagulation studies; serum glucose to compare with CSF glucose; and procalcitonin to differentiate bacterial meningitis from aseptic meningitis in children. There is a small risk of herniation of the brain when the CSF is removed during the lumbar puncture, but effective antibiotic treatment must be initiated as quickly as possible to prevent the morbidity associated with bacterial meningitis. The results of the Gram stain of the CSF and blood will dictate the initial antibiotic therapy, which will be modified when the specific agent is identified. Additional interventions include seizure precautions, cardiac monitoring, and ongoing assessment of respiratory and neurological function. Patients with bacterial meningitis may require long-term rehabilitation. Seizure Disorders A seizure is defined as a chaotic period of uncoordinated electrical activity in the brain, which results in one of several characteristic behaviors. Although the exact cause is unknown, several possible triggers have been proposed as noted below. The recently revised classification system categorizes seizure activity according to the area of the brain where the seizure initiates, the patient’s level of awareness during the seizure, and other descriptive features such as the presence of an aura. The unclassified category includes seizure patterns that do not conform to the primary categories. Seizures that originate in a single area of the brain are designated as focal seizures, while seizures that originate in two or more different networks are designated as generalized seizures. The remaining seizures in the onset category include seizures without an identified point of onset and seizures that progress from focal seizures to generalized seizures. Risk factors associated with seizures include genetic predisposition, illnesses with severe temperature elevation, head trauma, cerebral edema, inappropriate use or discontinuance of antiepileptic drugs (AEDs), intracerebral infection, an excess or deficiency of sodium and glucose, toxin exposure, hypoxia, and acute drug or alcohol withdrawal. Patients are encouraged to identify any conditions that may be triggers for their seizure activity. Although the triggers vary greatly from one patient to another, commonly identified events include increased physical activity, excessive stress, hyperventilation, fatigue, acute ETOH (ethyl alcohol) ingestion, exposure to flashing lights, and inhaled chemicals, including cocaine. The tonic phase presents as stiffening of the limbs for a brief period, while the clonic phase is evidenced by jerking motions of the limbs. These manifestations may be accompanied by a decreased level of consciousness, respiratory alterations and cyanosis, incontinence, and biting of the tongue. Absence seizures are manifested by a decreased level of awareness without abnormal muscular activity. The manifestations of the postictal phase include alterations in consciousness and awareness and increased oral secretions. Seizure disorders are diagnosed by serum lab studies to assess AED levels and to identify excess alcohol and recreational drugs, metabolic alterations, and kidney and liver function. Electroencephalography (EEG) and the enhanced magnetoencephalography are used to identify the origin of the altered electrical activity in the brain, and MRI, skull films, and CSF analysis are used to rule out possible sources of the seizure disorder such as tumor formation.
Dementia Dementia is a general term used to describe a state of general cognitive decline. Although Alzheimer’s disease accounts for up to 80 percent of all cases of dementia in the United States, the remaining two million cases may result from any one of several additional causes. The destruction of cortical tissue resulting from a stroke, or more commonly from multiple small strokes, often results in altered cognitive and physical function, while repetitive head injuries over an extended period also potentially result in permanent damage, limiting normal brain activity. Less common causes of dementia include infection of the brain by prions (abnormal protein fragments) as in Creutzfeldt-Jakob disease or the human immunodeficiency virus (HIV) as in AIDS, deposition of Lewy bodies in the cerebral cortex as in Parkinson’s disease, and reversible conditions such as vitamin B-12 deficiency and altered function of the thyroid gland. The onset and progression of the disease relate to the underlying cause and associated patient comorbidities.
Alzheimer’s Disease Alzheimer’s disease is a chronic progressive form of dementia with an insidious onset that is caused by the abnormal accumulation of amyloid- plaque in the brain. The accumulation of this plaque eventually interferes with neural functioning, and the progressive manifestations of the disease. Although the exact etiology is unknown, environmental toxins, vascular alterations due to hemorrhagic or embolic events, infections, and genetic factors have all been proposed as the triggering mechanism for the plaque formation. The progression of the disease and the associated manifestations are specific to the individual; however, in all individuals, over time, there is measurable decline in cognitive functioning, including short-term and long-term memory, behavior and mood, and the ability to perform activities of daily living (ADLs). The diagnosis is based on the patient’s presenting history and manifestations, imaging studies of the brain, protein analysis of the cerebrospinal fluid (CSF), and cognitive assessment with measures such as the Mini-Mental State Exam. Current treatments are only supportive, although cholinesterase inhibitors and N Methyl D aspartate receptor antagonists may slow the progression of the manifestations for a limited period if administered early in the course of the disease. All patients will suffer an eventual decline in all aspects of cognitive functioning, with the average survival rate dependent on the presence of comorbidities and the level of care and support available to the patient. Multiple Sclerosis Multiple sclerosis (MS) is a chronic disease manifested by progressive destruction of the myelin sheath and resulting plaque formation in the central nervous system (CNS). The precipitating event of this autoimmune disease is the migration of activated T cells to the CNS, which disrupts the blood-brain barrier. Exposure to environmental toxins is considered to be the likely trigger for this immune response. These alterations facilitate the antigen-antibody reactions that result in the demyelination of the axons. The onset of this disease is insidious, with symptoms occurring intermittently over a period of months or years. Sensory manifestations may include numbness and tingling of the extremities, blurred vision, vertigo, tinnitus, impaired hearing, and chronic neuropathic pain. Motor manifestations may include weakness or paralysis of limbs, trunk, and head; diplopia; scanning speech; and muscle spasticity. Cerebellar manifestations include nystagmus, ataxia, dysarthria, dysphagia, and fatigue. The progress of the disease and presenting clinical manifestations vary greatly from one individual to another; however, there are common forms of the disease that relate to the expression of the clinical manifestations or disability and the disease activity over time. An initial episode of neurological manifestations due to demyelination that lasts for at least 24 hours is identified as a clinically-isolated episode of MS. The potential for progression of the disease to the relapsing-remitting form of MS is predicted by magnetic resonance imaging (MRI) studies indicating the presence or absence of plaque formation. The remaining forms of MS are all associated with increasing disability related to the disease over time. The relapsing-remitting form is common to 85 percent of all patients diagnosed with MS and presents a variable pattern of active and inactive disease. The manifestations may resolve, decrease in severity, or become permanent after a relapse. In the primary-progressive form of MS that affects 10 percent of patients diagnosed with MS, the disease is constantly active without periods of remission. The secondary- progressive form of MS is identified as the progression of the relapsing-remitting form to a state of permanently active disease without remission. Myasthenia Gravis Myasthenia gravis is also an autoimmune disease of the CNS that is manifested by severe muscle weakness resulting from altered transmission of acetylcholine at the neuromuscular junction due to antibody formation. Relapses and remissions are common, and these relapses may be triggered by infection, stress, pregnancy, and increases in body temperature (such as those induced by immersion in hot water). Subjective manifestations include weakness, diplopia, dysphagia, fatigue on exertion, and bowel and bladder dysfunction. Objective manifestations include unilateral or bilateral ptosis of the eye, impaired respiratory function, impaired swallowing, and decreased muscle strength. Tensilon testing and electromyography, which measure muscle activity over time, are used to diagnose this disorder, while anticholinesterase agents and immunosuppressant agents are the mainstays of treatment. Additional treatments include plasmapheresis to decrease circulating antibodies and removal of the thymus gland to slow T-cell production. Guillain-Barré Syndrome The most common form of Guillain-Barré syndrome (GBS) is acute immune-mediated demyelinating polyneuropathy. This rare syndrome may develop two to four weeks after a bacterial or viral infection of the respiratory or GI systems or following surgery. The most common causative organisms are C. jejuni and cytomegalovirus that may produce a subclinical infection that occurs unnoticed by the patient prior to the development of the acute onset of GBS. Other causative agents that are associated with GBS include the Epstein-Barr virus, Mycoplasma pneumoniae, and varicella-zoster virus. There is also an association between GBS and HIV. Current research is focused on investigating any association between the Zika virus and GBS; however, to date, there is little evidence of that relationship because there are few laboratories in the United States with the technology needed to identify the virus. The incidence of GBS has also been associated with vaccine administration; however, accumulated data does not support these claims. The manifestations present as an acute onset of progressive, bilateral muscle weakness of the limbs that begins distally and continues proximally. The syndrome is the result of segmental demyelination of the nerves with edema, resulting from the inflammatory process. Additional presenting manifestations include pain, paresthesia, and abnormal sensations in the fingers. The progressive muscle weakness peaks at four weeks and potentially involves the arms, the muscles of the core, the cranial nerves, and the respiratory muscles. Involvement of the cranial nerves may result in facial drooping, diplopia, dysphagia, weakness or paralysis of the eye muscles, and pupillary alterations. Alterations in the autonomic nervous system also may result in orthostatic hypotension, paroxysmal hypertension, heart block, bradycardia, tachycardia, and asystole. Respiratory manifestations include dyspnea, shortness of breath, and dysphagia. In addition, as many as 30 percent of patients will progress to respiratory failure requiring ventilatory support due to the demyelination of the nerves that innervate the respiratory muscles. The syndrome is diagnosed by the patient’s history and laboratory studies to include electrolytes, liver function analysis, erythrocyte sedimentation rate (ESR), pulmonary function studies, and the assessment of CSF for the presence of excess protein content. In addition, electromyography and nerve conduction studies are used to identify the signs of demyelination, which confirms the diagnosis. Gastritis Gastritis may be acute or chronic, and acute gastritis is further differentiated as erosive or nonerosive. Involvement of the entire stomach lining is termed pangastritis, while regional involvement is termed antral gastritis. Acute gastritis may be asymptomatic or may present with nonspecific abdominal pain, nausea, vomiting, anorexia, belching, and bloating. The most common causes of acute gastritis include use of NSAIDs and corticosteroids and infection by the H. pylori bacteria. Acute gastritis may also be associated with alcohol abuse. Double-contrast barium studies, endoscopy, and histological examination of biopsy samples most often confirm the diagnosis and the causative agent. Treatment includes normalization of fluid and electrolyte balance, discontinuance of causative agents such as NSAIDs, and corticosteroids, H2 blockers, PPIs, and appropriate antibiotic therapy in the event of H. pylori infection. Chronic gastritis is an inflammatory state that has not responded to therapy for acute gastritis. Chronic H. pylori infection is associated with the development of peptic ulcers, gastric adenocarcinoma, and mucosal-related lymphoid tissue (MALT) lymphoma. In addition to endoscopy and barium studies, gastric biopsy for assessment of antibiotic sensitivity is done because the initial antibiotic therapy was unsuccessful in eradicating the organism. Autoimmune gastritis is related to vitamin B-12 deficiency due to intrinsic factor deficiency and is associated with megaloblastic anemia and thrombocytopenia. Chemical or reactive gastritis is due to chronic NSAID and steroid use and is manifested by mucosal epithelial erosion, ulcer formation, and mucosal edema and possible hemorrhage. Chronic gastritis is diagnosed by endoscopy, biopsy, and histological studies. Treatment is specific to the causative agent, and in the instance of H. pylori infection, a course of three antibiotics will be administered. H. pylori infection also requires long-term surveillance for reoccurrence of infection. Hepatitis Hepatitis is an inflammatory condition of the liver, which is further categorized as infectious or noninfectious. Causative infectious agents for hepatitis may be viral, fungal, or bacterial, while noninfectious causes include autoimmune disease, prescription and recreational drugs, alcohol abuse, and metabolic disorders. More than 50 percent of the cases of acute hepatitis in the United States are caused by a virus. Transmission routes include fecal-oral, parenteral, sexual contact, and perinatal transmission. There are four phases of the course of viral hepatitis. During phase 1, which is asymptomatic, the host is infected, and the virus replicates; the onset of mild symptoms occurs in phase 2; progressive symptoms of liver dysfunction appear in phase 3; and recovery from the infection occurs in phase 4. These phases are specific to the causative agent and the individual. The most common viral agents are hepatitis A (HAV), hepatitis B (HBV), and hepatitis C (HCV). Less commonly, hepatitis D (HDV), hepatitis E (HEV), CMV, Epstein-Barr virus, and adenovirus may cause hepatitis. HAV and HBV often present with nausea, jaundice, anorexia, right upper quadrant pain, fatigue, and malaise. HCV may be asymptomatic or, alternatively, may present with similar symptoms. Approximately 20 percent of acute infections with HBV and HCV result in chronic hepatitis, which is a risk factor for the development of cirrhosis and liver failure. The care of the patient with acute hepatitis due to HAV and HCV is focused on symptom relief, while the antiviral treatment for HBV is effective in decreasing the incidence of adenocarcinoma. Chronic hepatitis is a complication of acute hepatitis and frequently progresses to hepatic failure, which is associated with deteriorating coagulation status and the onset of hepatic encephalopathy, due to alterations in the blood-brain barrier that result in brain cell edema. Inflammatory Bowel Disease Inflammatory bowel disease (IBD) is an idiopathic disease that results from a harmful immune response to normal intestinal flora. Two types of IBD include Crohn’s disease and ulcerative colitis (UC). Crohn’s disease is characterized by inflammatory changes in all layers of the bowel. Although the entire length of the GI tract may be involved, the ileum and colon are affected most often. The inflamed areas are commonly interrupted by segments of normal bowel. Endoscopic views reveal the cobblestone appearance of these affected segments. UC is characterized by inflammatory changes of the mucosa and submucosa of the bowel that affect only the colon. There is a genetic predisposition for Crohn’s disease, and there is also an increased incidence of cancer in patients with either form of IBD. Additional risk factors include a family history of IBD or colorectal cancer, NSAID and antibiotic use, smoking, and psychiatric disorders. IBD is diagnosed by a patient’s history, including details of any recent foreign travel or hospitalization to rule out tuberculosis or C. difficile as the precipitating cause, in addition to endoscopy, CT and magnetic resonance imaging (MRI), serum and stool studies, and histologic studies. Manifestations are nonspecific and are most often associated with the affected bowel segment. Common manifestations of IBD include diarrhea with blood and mucous and possible incontinence; constipation primarily with UC that is associated with progression to obstipation and bowel obstruction; rectal pain with associated urgency and tenesmus; and abdominal pain and cramping in the right lower quadrant with Crohn’s disease, and in the umbilical area or left lower quadrant with UC. In addition, anemia, fatigue, and arthritis may be present. The treatment of IBD focuses on attaining periods of remission and preventing recurrent attacks by modifying the inflammatory response. The stepwise treatment protocol begins with aminosalicylates and progresses to antibiotics, corticosteroids, and immunomodulators. Ulcers Ulcers of the GI tract are categorized as to the anatomical site of injury. Gastric ulcers are located in the body of the stomach, and peptic ulcers are located in the duodenum. The presenting symptom is abdominal pain 2 to 4 hours after eating for duodenal ulcers, in addition to hematemesis and melena. The defect is due to erosion of the mucosal lining by infectious agents, most commonly H. pylori; extreme systemic stress such as burns or head trauma; alcohol abuse; chronic kidney and respiratory disease; and psychological stress. Untreated, the mucosal erosion can progress to perforation, hemorrhage, and peritonitis. Laboratory studies include examination of endoscopic tissue samples for the presence of the H. pylori organism, urea breath test, CBC, stool samples, and metabolic panel. Endoscopy, which is used to obtain tissue samples and achieve hemostasis, and double barium imaging studies made be obtained. The treatment depends on the extent of the erosion and will be focused on healing the ulcerated tissue and preventing additional damage. The treatment protocol for H. pylori infection includes the use of a PPI, amoxicillin, and clarithromycin for a minimum of seven to fourteen days. Subsequent testing will be necessary to ensure that the organism has been eradicated. Patients infected with H. pylori also must discontinue the use of NSAIDs or continue the long-term use of PPIs. Surgery may be indicated for significant areas of hemorrhage that were not successfully treated by ultrasound, and the procedure will be specific to the anatomical area of ulceration. Tuberculosis (TB) Tuberculosis (TB) is a highly communicable disease caused by the infectious bacteria Mycobacterium tuberculosis. M. tuberculosis is an acid-fast rod that secretes niacin; when the bacteria reach a vulnerable site, they multiply quickly. Because it is an aerobic bacterium, meaning it grows in the presence of oxygen, it principally affects the upper lobes of the lungs where the O2 concentration is the greatest. It can also affect the brain, intestines, peritoneum, kidneys, joints, and liver. It is transmitted via the airborne route by droplet infection, with the primary source of the virus being saliva and lung secretions. TB has a dangerous onset, and many individuals are not aware of infection until it is well advanced.
TB infection progresses as follows: - Infected droplets enter the lungs, and the bacteria form a tubercle lesion. - The body’s defense systems capture the tubercle, leaving a blemish. - If capture does not occur, the bacteria may enter the lymph system and travel to the lymph nodes, causing an inflammatory response called granulomatous inflammation. - Initial lesions form and may become dormant, but can be revived and become a secondary infection when re-exposure to the bacterium occurs. - Once active, TB is known to cause necrosis and cavitation (formation of a hole) in the lesions, which leads to rupture, the spread of necrotic tissue, and destruction to various areas of the body.
Rapid identification of those in close contact with the infected individual is important so that they may be tested and receive necessary treatment, and once identified, they will be assessed with a tuberculin skin test and chest x-rays to determine if they have been infected with TB. The risk of transmission of the infection is significantly decreased once the infected individual has been taking TB medication for two to three weeks. TB infection generally manifests as fatigue, lethargy, anorexia, weight loss, low-grade fever, chills, night sweats, incessant cough with the production of mucoid and mucopurulent sputum (sometimes blood streaked), chest tightness, and chest pain that is dull and achy. In the advanced stages of the illness, dullness with percussion over affected parenchymal areas, bronchial breath sounds, rhonchi, and crackles will be present. Partial obstruction of a bronchus caused by endobronchial disease or compression by edematous lymph nodes may create localized wheezing and dyspnea.
The main goals of treatment involve preventing transmission, managing symptoms, and inhibiting progression of the disease. Diagnosis consists of many factors, including collection of an all-inclusive patient history, which will detail the following: - History of TB exposure - Country of origin and travel to regions in which the incidence of TB is increased - Recent history of flu, pneumonia, febrile illness, or foul-smelling sputum production - Previous tests performed to determine the presence of M. tuberculosis in the body and the results of those tests - Recent bacilli Calmette-Guerin vaccine, a vaccine that contains attenuated (dead) tubercle bacilli and is usually administered to those who reside in foreign countries or are traveling to foreign countries to create increased resistance to TB
Diagnostic efforts will also revolve around results of a physical examination of the chest, auscultation of breath sounds, and inquiring about chest tightness or a dull, achy chest pain. A chest x-ray is not considered a definitive diagnostic tool, but the presence of multinodular infiltrates with deposits of calcium phosphate in the upper lung lobes is suggestive of TB. If the disease is active, it will appear on a chest x-ray as lung inflammation, and it will form a TB-specific necrosis, in which diseased tissue devolves into a firm, dry mass (caseation), also apparent on an x-ray. Additionally, the attending physician will most likely order a specific blood analysis test to determine the presence of TB in the body (QuantiFERON-TB Gold). This test is quite sensitive and rapid, and results can be available in as little as 24 hours. Sputum cultures positive for M. tuberculosis are considered confirmatory of the diagnosis, and after the administration of medications has begun, sputum samples are obtained again to establish the effectiveness of therapy. A positive TB skin test does not mean that active TB is present, but it is indicative of previous exposure or the presence of inactive disease. Once it is positive, it will remain so throughout an individual’s lifetime. Once diagnosis has confirmed infection, the patient with active TB infection is admitted and placed under airborne isolation precautions in a negative-pressure room (to maintain this, the room door must be tightly closed). The room should have at least six exchanges of fresh air per hour and be ventilated to the outside, if possible. The patient’s nurse wears a particulate respirator (special individually fitted mask) and a gown when the probability of clothing contamination exists. Thorough handwashing is required before and after caring for the patient, as well as after leaving his or her room. The patient should be required to wear a surgical mask if he or she needs to leave the room for a test or procedure. Respiratory isolation is discontinued after the patient is no longer considered contagious. The medications used for active TB infection consist of first-line and second-line drugs. First-line medications include isoniazid, rifampin, ethambutol, pyrazinamide, rifabutin, and rifapentine. These medications provide the most effective anti-TB activity. Second-line agents (amikacin, ciprofloxacin, and kanamycin) are used in conjunction with first-line agents but are more toxic to the body’s systems. Active TB is treated with a combination of medications to which it is vulnerable, and this approach is instituted because of resistant strains of the organism.
Education upon discharge consists of the following: - Providing the patient and caregivers with information about TB and allaying concerns about the contagious aspect of the illness - Encouraging the patient to follow the medication regimen exactly as prescribed - Advising the patient that the medication regimen is continued over a six- to twelve-month period, depending on the situation - Informing the patient of the side effects/adverse effects of the medications and ways to minimize them to maintain compliance - Instructing the patient to resume activities gradually, as he or she is still in the recovery period - Instructing the patient to cover his or her mouth and nose when coughing/sneezing and to place used tissues into plastic bags for disposal - Informing the patient that a sputum culture is necessary every two to four weeks once medication therapy is initiated, and once the results of three consecutive cultures (about three months of treatment) are negative, he or she is no longer considered infectious - Advising the patient to avoid excessive exposure to silicone or dust because these materials can cause further lung damage - Informing the patient of the importance of compliance with treatment, follow-up care, and collection of sputum cultures as prescribed Mononucleosis Mononucleosis is a common infection caused by the Epstein-Barr virus. It is transferrable via direct intimate contact; its most customary source is oral secretions, but it can also be spread through the secretions from the nasal cavity and oropharynx, and sometimes tears. Incubation may be anywhere from four to six weeks, and the communicable period is unknown. It is most often assessed in teenagers and young adults, particularly those who are sexually active. It is important to remember that those who have been exposed to mononucleosis will always carry the virus, even after infection indicators have resolved. Signs and symptoms usually manifest as a high fever, severe sore throat, swollen lymph nodes/tonsils, nausea, abdominal pain, weakness, and fatigue. Hepatosplenomegaly (enlargement of the liver and spleen) may occur, and the patient may also present with a distinct macular rash that is most prominent over the trunk. Childhood Diseases Rubeola (measles), mumps, pertussis (whooping cough), chicken pox (varicella), and diphtheria are all common, contagious viruses that usually strike during childhood. Measles Measles (rubeola) is caused by the infectious agent paramyxovirus. It is transmitted via airborne particles and direct contact with infectious droplets, and it also crosses the placental barrier to the fetus. The highest concentration of the measles virus resides in the respiratory tract secretions, blood, or urine of an infected individual. It has an incubation period of ten to twenty days but is considered communicable between four days before the rash appears to five days after. Signs and symptoms of measles virus are fever, malaise, coryza (head cold with a runny nose), cough, conjunctivitis, and a rash that is red, erythematous, and maculopapular. These eruptions normally start on the face and spread downward to the feet and will gradually turn a brownish color. The individual may also display “Koplik’s spots,” which are small red spots with a bluish-white center and red base, commonly located in the mouth. Mumps Mumps is another infection caused by paramyxovirus. It is transmitted the same way as measles, with the highest concentration of the virus existing in an infected individual’s saliva or urine. The incubation period is fourteen to twenty-one days, and mumps is communicable immediately before and after the beginning of parotid gland swelling. The patient presenting with mumps will have a fever, headache and malaise, anorexia, jaw or ear pain aggravated by chewing, followed by parotid gland swelling, and orchitis (inflammation of one or both testicles), as well as aseptic meningitis. Pertussis Pertussis, otherwise referred to as “whooping cough,” is caused by the infectious agent Bordatella pertussis. It is spread through direct contact or droplets from an infected person and incidental contact with recently tainted items of clothing and bedclothes; the main source of the virus is discharge from the respiratory tract of the infected individual. Incubation can be anywhere from five to twenty-one days but is generally ten days. The communicable period is greatest during the time when discharge from respiratory secretions ensues. Physical indicators of pertussis include symptoms of respiratory infection followed by increased severity of cough, with a loud “whooping” respiration, possible cyanosis, respiratory distress, restlessness, irritability, and anorexia. Implementation of care focuses on compliance with strict airborne and droplet precautions during the catarrhal stage (when respiratory secretion discharge is present), especially if the individual is hospitalized. Administration of antimicrobial therapy as prescribed, reduction of cough-causing environmental factors (dust, smoke, sudden alterations in temperature), and encouragement of adequate hydration/nutrition. Monitoring of vital signs, cardiopulmonary status, and pulse oximetry are other interventions involved. Chicken Pox Chicken pox (varicella) is a result of the highly contagious varicella-zoster virus. It is transferred via direct contact, droplet (airborne), and contaminated items. The concentration is greatest in the respiratory tract secretions and skin lesions of the infected individual. Incubation is anywhere from thirteen to seventeen days and is transmissible from one to two days before the onset of the rash to six days after the first vesicles appear and when skin lesion crusts have formed. Signs and symptoms of infection include slight fever, malaise, and anorexia, followed by a macular skin outbreak that first develops on the trunk and scalp and then moves to the face and extremities. The rash may also appear in the mouth and genital and rectal areas. Lesions become eruptions, begin to dry out, and create a crust. The antiviral agent acyclovir (Zovirax®) may be used to treat chicken pox in vulnerable, immunocompromised individuals to lessen the number of lesions, shorten fever time, and decrease itching, lethargy, and anorexia. The use of VCZ immune globulin (VariZIG®) or IV immune globulin (IVIG) is suggested for immunocompromised children who have no previous history of varicella and are most susceptible to contracting the virus and have complications as a result. Diphtheria Diphtheria is caused by the contagious Corynebacterium diphtheriae and is virulent during direct contact with the infected person, carrier, or contaminated articles. Its source is the discharge from the mucous membrane of the nose and nasopharynx, skin, and other lesions of the infected. The incubation period is between two and five days, with the transferrable period being variable and dependent on the absence of virulent bacilli (three cultures of discharge from the nose, nasopharynx, skin, and other lesions must be negative), usually two to four weeks. The person presenting with diphtheria infection will experience a low-grade fever; malaise; sore throat; foul-smelling, mucopurulent nasal discharge; lymphadenitis (inflammation of lymph gland); and neck edema. Care consists of isolation of the hospitalized individual, administration of antibiotics and diphtheria antitoxin as prescribed (after a skin or conjunctival test to rule out sensitivity to horse serum), and tracheostomy care if a tracheotomy is required. Herpes Zoster Herpes zoster, also referred to as shingles, normally attacks individuals with a history of chicken pox infection. It usually occurs in adulthood and is a result of the reactivation of the varicella-zoster virus. The possibility of infection is especially likely in persons who are immunocompromised. Flare-ups occur in a segmental distribution pattern on the skin area along the infected nerve (the once-dormant virus is located in the dorsal nerve root ganglia of the sensory cranial and spinal nerves) and will appear after several days of irritation in the area. It is contagious to those who have never had chicken pox and have not been vaccinated against the virus. The patient with shingles will present with unilaterally clustered skin lesions along peripheral sensory nerves on the trunk, thorax, or face. The person will generally be suffering fever, malaise, burning and pain in the affected area(s), paresthesia (numbness and tingling), and pruritus. Diagnosis is determined by visual evaluation, Tzanck smear, and a viral culture that is specific to the identification of the causative agent. Fever Normal body temperature averages around 98.6 degrees Fahrenheit. A fever is an increase in body temperature. It is often the first indicator that the body is fighting an infection or injury, as most bacteria and viruses cannot survive high temperatures. Mild fevers can be treated with over-the-counter pain and fever relievers, such as ibuprofen or acetaminophen. Increased risks for more serious fevers include hospitalization, surgery, travel to high-risk countries, a suppressed immune system, drug abuse, and some medications. These are risk factors due to the increase in exposure to viruses and bacteria that can cause a fever. Drugs The following section will discuss different classes of medications. It is important to recognize that drugs with a similar therapeutic effect might have different mechanisms/modes of action. For example, ACE inhibitors (e.g. ramipril), calcium channel blockers (e.g. amlodipine), and antihypertensive agents have similar therapeutic effects, but their mechanisms of action are different. When filling a prescription, it is important for pharmacists understand how a drug works. Not only does knowledge about the pharmacology of a medicine help to identify possible drug interactions, but it also helps to facilitate patients’ understanding of why medications are prescribed for them. Medications Acting on the Nervous System Antidepressants and Anxiolytics Antidepressants are used to treat different mood disorders including depression, anxiety, phobias, and obsessive-compulsive disorder (OCD). Treatment for depression includes various medications, in addition to cognitive behavioral therapy (e.g. counseling).
The following are some of the symptoms frequently observed with depression: - Difficulty concentrating - Decreased interest or no interest in activities that used to be enjoyable - Fatigue or lack of energy - Sense of worthlessness or hopelessness - Difficulty sleeping - Changes in appetite - Suicidal thoughts
Antidepressants exert their therapeutic effects by modulating the release or action of various neurotransmitters in the brain. Neurotransmitters are chemical messengers that transmit signals from one neuron to another. The common side effects of antidepressants are serotonin syndrome (headache, agitation, tremor, hallucination, tachycardia, hyperthermia, shivering and sweating), sexual dysfunction, weight changes, gastric acidity, diarrhea, sleep disturbances, and suicidal ideation.
Commonly prescribed antidepressant medications include: - Sertraline - Fluoxetine - Paroxetine - Citalopram - Escitalopram - Venlafaxine - Desvenlafaxine - Duloxetine - Trazodone - Bupropion - Amitriptyline - Nortriptyline
Benzodiazepines are a class of medications used for the short-term treatment of anxiety. They are often combined with antidepressants during initial treatment to increase treatment compliance. Benzodiazepines have the potential for significant physical dependence and withdrawal symptoms. These drugs can be used as sedatives and hypnotics and are also utilized as an add-on therapy with anti-convulsant medications. Benzodiazepines are often used to treat symptoms from alcohol withdrawal. The majority of benzodiazepines are labeled as Class IV controlled substances. The common side effects of these medications include physical dependence, sedation, drowsiness, dizziness, and lack of coordination.
The following are commonly prescribed benzodiazepines: - Diazepam - Lorazepam - Clonazepam - Alprazolam - Midazolam - Temazepam Antipsychotics Antipsychotics are used to treat psychosis, including schizophrenia and bipolar disorder. Psychosis is often characterized by a cluster of symptoms including delusions (false beliefs), paranoia (fear or anxiety), hallucinations, and disordered thoughts. The most common side effects of antipsychotics are dyskinesia (movement disorder), loss of libido or sex drive, gynecomastia (breast enlargement) in males, weight gain, heart diseases (QT prolongation), and metabolic disorders, including type 2 diabetes.
The following are examples of commonly prescribed antipsychotics: - Chlorpromazine - Fluphenazine - Haloperidol - Aripiprazole - Olanzapine - Risperidone - Ziprasidone - Clozapine Stimulant Medications Stimulant medications are also called sympathomimetic agents, as they work by augmenting the sympathetic neurotransmitter activity (e.g. epinephrine and norepinephrine). These drugs are often used during emergencies to treat cardiac arrest and shock. Stimulant medications are more commonly used to treat attention-deficit hyperactivity disorder (ADHD). The common side effects of such medications include irritability, weight loss, insomnia, dizziness, agitation, headache, abdominal pain, tachycardia, growth retardation, hypertension, and cardiovascular disturbances, and death.
The following are examples of sympathomimetic drugs that are used in the treatment of ADHD: - Methylphenidate - Dextroamphetamine - Lisdexamfetamine - Mixed salts of amphetamine - Atomoxetine Anticonvulsant Medications Anticonvulsants are also called antiepileptic or anti-seizure medications. They are used in the treatment of epileptic seizures. They suppress excessive firing of neurons and therefore, prevent the initiation and spread of seizures. This class of medications is often used to stabilize mood in bipolar disorder or for the treatment of neuropathic pain. The common side effects are dizziness, sedation, weight gain, hepatotoxicity, hair loss, blood disorders, etc. Anticonvulsants are teratogenic and can cause significant harm to a fetus and result in birth defects. Therefore, female patients on anticonvulsant therapy should consult with their physicians before planning pregnancy.
The common medications in this class include the following: - Carbamazepine - Oxcarbazepine - Phenytoin - Valproic acid - Divalproex - Levetiracetam - Lamotrigine - Topiramate - Clobazam Medications Acting on the Cardiovascular System Lipid-Lowering Medications Lipid-lowering medications are used for the treatment of high blood lipids (hyperlipidemia), including high cholesterol (hypercholesterolemia) and high triglycerides (hypertriglyceridemia). Although a patient with hypercholesterolemia typically will not experience symptoms, the condition leads to the accumulation of fatty deposits, called atherosclerotic plaques, in the blood vessels and liver. As time progresses, the deposits slow, impede, or block the flow of blood through the vessels. When blood flow is compromised to the heart muscle, ischemic heart disease can result. If the blood flow to the brain decreases, there is a possibility of ischemic stroke. Compromised blood supply in peripheral tissues and limbs can cause the development of peripheral vascular diseases (PVD). Lifestyle changes, such as a healthy diet and regular exercise, can significantly reduce the risk of hypercholesterolemia, even in the presence of predisposing genetic risk factors. Total cholesterol is determined from two components: high-density lipoproteins (HDL) cholesterol, considered the “good” cholesterol, and low-density lipoproteins (LDL) cholesterol, considered the “bad” cholesterol. Although it is helpful to keep a lower total cholesterol level for health and reduced disease risk, it is more critical to keep the ratio of HDL to LDL elevated.
Examples of lipid-lowering agents include: - Statins: pravastatin, simvastatin, atorvastatin, rosuvastatin - Cholesterol absorptions inhibitors: ezetimibe, cholestyramine, colestipol - Fibrates: gemfibrozil, fenofibrate Antihypertensive Medications Antihypertensive medications are used to treat high blood pressure. Although hypertensive individuals generally do not have symptoms, some people experience headaches, blurred vision, and dizziness. When high blood pressure is left untreated, it can lead to different clinical conditions including coronary artery disease, heart failure, kidney failure, or stroke. There are two values that comprise a blood pressure measure. The top number is the systolic pressure (the pressure exerted on the arterial walls when the heart muscle contracts) and the bottom number is the diastolic pressure (the pressure on the arterial walls when the heart muscle relaxes). Normal, healthy blood pressure in adults should be a systolic reading less than 120 mmHg and a diastolic pressure less than 80 mmHg.
There are three stages of high blood pressure, as outlined below: - Prehypertension is characterized by systolic pressure between 120-139 mmHg and diastolic pressure between 80-89 mmHg - Stage 1 hypertension is characterized by systolic pressure between 140-159 mmHg and diastolic pressure between 90-99 mmHg - Stage 2 hypertension is characterized by systolic pressure of 160 mmHg and higher and diastolic pressure of 100 mmHg and higher
ACE Inhibitors (ACEIs): “ACE inhibitors,” or angiotensin-converting enzyme inhibitors, are used to treat hypertension and cardiovascular diseases. The most common side effect of ACE inhibitors is a chronic dry cough, which, in many cases, is so annoying for a patient that it results in switching the medication to a different class. Other frequent side effects are low blood pressure (hypotension), dizziness, fatigue, headache, and hyperkalemia (increased blood potassium levels).
Examples of some ACE Inhibitors include: - Ramipril - Enalapril - Lisinopril - Captopril - Quinapril - Perindopril
Angiotensin Receptor Blockers (ARBs): ARBs have similar therapeutic effects as ACE Inhibitors; however, they tend to have better compliance, due to their lower incidence of persistent cough. They block the effect of angiotensin at the receptor site and are widely used for hypertension and cardiovascular disease. The common side effects are hypotension, fatigue, dizziness, headache, and hyperkalemia.
Examples of ARBs include: - Losartan - Irbesartan - Valsartan - Candesartan - Telmisartan - Olmesartan
Calcium Channel Blockers (CCBs): CCBs work by decreasing calcium entry through calcium channels. By regulating the movement of calcium, contraction of vascular smooth muscle is controlled, which causes blood vessels to dilate. This reduces blood pressure and workload on the heart, so this type of medication is used to treat hypertension and angina, and to control heart rate. Common side effects of CCBs include dizziness, flushing of the face, headache, edema (swelling), tachycardia (fast heart rate), bradycardia (slow heart rate), and constipation. In combination with other medications that treat hypertension, calcium channel blocker toxicity is possible. Combinations, like verapamil with beta-blockers, can lead to severe bradycardia.
The following are examples of common calcium channel blockers: - Amlodipine - Nifedipine - Felodipine - Verapamil - Diltiazem
Beta Blockers: Beta blockers are an important class of antihypertensive medications, and are widely used to treat hypertension and cardiovascular disease. Some of them are also used to treat migraines, agitation, and anxiety. The side effects of beta blockers include hypotension, dizziness, bradycardia, headache, bronchoconstriction (trouble breathing), and fatigue.
Commonly prescribed beta blockers include: - Atenolol - Metoprolol - Propranolol - Sotalol - Nadolol - Carvedilol - Labetalol
Vasodilators: Vasodilators cause blood vessels to dilate, lowering resistance to flow and reducing the workload on the heart. Vasodilators are used to treat hypertension, angina, and heart failure. The common side effects associated with their use include lightheadedness, dizziness, low blood pressure, flushing, reflex tachycardia, and headache. Vasodilators should not be combined with medications for erectile dysfunction, as this interaction can cause a fatal drop in blood pressure.
Examples of common vasodilators include: - Nitroglycerin (available as sublingual tablets, sprays, patches, and extended release capsules) - Isosorbide mononitrate - Isosorbide dinitrate - Hydralazine - Minoxidil (limited use)
Alpha-1 Receptor Blockers: Alpha-blockers decrease the norepinephrine-induced vascular contraction, causing relaxation of blood vessels and a resultant reduction in blood pressure. This type of medication is used to treat high blood pressure and benign prostatic hyperplasia (BPH). The common side effects of this class of medications include hypotension, dizziness, headache, tachycardia, weakness, and nausea.
Examples of alpha blockers include: - Prazosin - Doxazosin - Terazosin - Tamsulosin (primarily used to treat BPH) - Alfuzosin (primarily used to treat BPH)
Diuretics: Diuretics are used alone and in combination with other medications to treat hypertension. They are often used to eliminate excess body fluid to treat swelling/edema. Diuretics inhibit the absorption of sodium in renal tubules, resulting in increased elimination of salt and water. This action increases urine output, decreases blood volume, and lowers blood pressure. Side effects of diuretics include hypotension, dizziness, hypokalemia, dehydration, hyperglycemia, polyuria (frequent or excessive urination), fatigue, syncope (fainting), and tinnitus (ringing in ears).
Examples of commonly prescribed diuretics include: - Furosemide - Bumetanide - Hydrochlorothiazide - Spironolactone - Amiloride - Triamterene Medications Acting on the Respiratory System Antiasthmatics Antiasthmatics are used to prevent and treat the acute symptoms of asthma, which is a disease characterized by wheezing, cough, chest tightness, and shortness of breath. Acute asthma can be life-threatening and needs to be treated promptly. Asthma is caused by inflammation and constriction of the airways, which results in difficulty breathing. Acute asthma may be exacerbated by certain triggering factors including environmental allergens, certain medications (e.g. aspirin), stress or exercise, smoke, and lung infections. It is important to avoid the triggering factors to prevent acute symptoms. The common side effects of antiasthmatics are cough, hoarseness, decreased bone mineral density, growth retardation in children, mouth thrush, agitation, tachycardia, and a transient increase in blood pressure.
There are two categories to asthma medications that can be used alone or in combination: 1. Bronchodilators (dilate the airway to ease breathing) - Salbutamol - Formoterol (generally used in combination with inhaled corticosteroids) - Salmeterol (generally used in combination with inhaled corticosteroids)
2. Anti-inflammatory agents - Fluticasone (inhaled corticosteroid) - Budesonide (inhaled corticosteroid) - Beclometasone (inhaled corticosteroid) - Montelukast - Zafirlukast Medication to Treat COPD (Chronic Obstructive Pulmonary Disease) COPD is an obstructive airway disease that is characterized by coughing, wheezing, shortness of breath, and sputum production. COPD is a progressive disease and it worsens over time. COPD is a combination of two common conditions: chronic bronchitis and emphysema. Chronic bronchitis is inflammation of the smooth lining of bronchial tubes. These tubes are responsible for carrying air to the alveoli, which are the air sacs in the lungs responsible for gaseous exchange between the lungs and blood. Emphysema results from alveolar damage, reducing the ability for healthy gas exchange. These two pathologies cause breathing difficulties in patients with COPD. The contributing factors for the development of COPD include smoking, environmental pollutions, and genetic risk factors. The side effects of COPD medications are similar to that of antiasthmatics.
The medications commonly used to treat COPD include the following:
1. Bronchodilators (dilate the airway to ease breathing) - Salbutamol - Formoterol (generally used in combination with inhaled corticosteroids) - Salmeterol (generally used in combination with inhaled corticosteroids)
2. Anti-inflammatory agents - Ipratropium (Atrovent®) - Tiotropium (Spiriva®) - Fluticasone - Budesonide Medications Acting on the Digestive System Gastric acid Neutralizers/Suppressants Gastric acid neutralizers/suppressants either neutralize stomach acid or decrease acid production, and therefore, provide relief of symptoms associated with hyperacidity. They are also used to treat gastroesophageal reflux disease, or GERD. In GERD, the lower esophageal sphincter does not close properly, which causes the contents of the stomach to back up into the esophagus. This leads to irritation, which is why the common symptoms of GERD include heartburn, coughing, nausea, difficulty swallowing, and a strained voice. There are many factors that can cause or exacerbate GERD including obesity, pregnancy, eating a large meal, acidic foods, a hiatal hernia, and smoking. Lifestyle modifications such as avoiding trigger foods, losing weight (if obesity is a component), decreasing meal size, and trying not to lie down immediately after eating, can reduce symptoms.
The medications used to treat hyperacidity in stomach include the following: - Antacids (e.g. calcium carbonate) - Ranitidine - Famotidine - Omeprazole - Esomeprazole - Lansoprazole - Rabeprazole - Pantoprazole Medications Acting on the Endocrine System Anti-Diabetic Medications Anti-diabetic medications are used to treat diabetes, which is a chronic metabolic disease in which the body cannot properly regulate blood sugar levels. This dysregulation is caused by either inadequate or absent insulin production from the pancreas (Type 1 diabetes) or inadequate action of insulin in peripheral tissues (i.e. insulin resistance in Type 2 diabetes). Type 1 diabetes usually occurs in early childhood and is typically treated with insulin injections or medications. Type 2 diabetes generally develops later in adolescence or adulthood, and is related to poor diet, lack of physical activity, and obesity. Diabetes often does not to cause daily symptoms, but symptoms do arise when blood sugar is either too high (from inadequate control) or too low (from inappropriate dosing of hypoglycemic (antidiabetic) agents, including insulin). A few of the symptoms of diabetes include increased thirst and hunger, fatigue, blurred vision, a tingling sensation in the feet, and frequent urination.
Examples of some antidiabetic medications include: - Insulin - Metformin - Acarbose - Gliclazide, glyburide, glimepiride - Rosiglitazone, pioglitazone - Sitagliptin, saxagliptin
Drug and Non-Drug Therapy in Type 2 Diabetes: The most effective way of treating Type 2 diabetes is to combine both drug and non-drug therapies. As a part of the treatment, drug therapy can stimulate the pancreas to produce more insulin or help the body better use the insulin produced by the pancreas. As part of the non-drug therapy, counseling is necessary to help patients understand the important diet and lifestyle modifications. Patients with Type 2 diabetes should try to decrease their consumption of processed foods, simple carbohydrates and refined sugars, and overall caloric intake, while increasing physical activity. These interventions help to decrease the requirement of antidiabetic medications and prevent long-term diabetes-related complications. Glucometer: Patients with diabetes should test their blood sugar regularly to ensure that it is well-controlled. Glucometers are used to measure blood sugar. Patients insert a testing strip into the glucometer, prick a finger with a lancet, and then apply a drop of blood to the test strip. Upon applying the blood, the meter gives a blood sugar reading. Most modern machines need a very small amount of blood to obtain an accurate reading and can generate the result in seconds. Some more advanced meters can store readings for a period of time, so patients can present it to their physicians for review. Female Hormones Hormonal medications are generally used as oral contraceptives to prevent pregnancy. Female hormonal medications are also used to treat premenstrual symptoms (PMS), post-menopausal symptoms, acne, and endometriosis. They are also used as emergency contraceptives to prevent unwanted and accidental pregnancy. Oral contraceptives can provide hormones (estrogen and/or progestin), which suppress the egg maturation and ovulation process. Additionally, hormonal contraceptives prevent the endometrium from thickening in preparation to hold the fertilized egg. A mucus barrier is created by progestin, which stops the sperm from migrating to the fallopian tubes and fertilizing the egg. There are many side effects associated with oral contraceptives, including increasing the risk of fatal blood clots, especially in women older than 35 or in women who smoke.
More common and less severe side effects include: - Nausea and stomach upset - Headache - Weight gain - Spotting between periods - Mood changes - Lighter periods - Aching or swollen breasts
More serious side effects that need immediate emergency care include: - Chest pain - Blurred vision - Stomach pain - Severe headaches
Examples of some commercially available brands of contraceptive include: - Yasmin - Ortho Tri-Cyclen - TriNessa - Sprintec - Ovcon - Plan B (emergency contraceptive) Medications Acting on the Immune System Antivirals Antivirals are used to fight viruses in the body, by either stopping replication or blocking the function of a viral protein. They are used to treat HIV, herpes, hepatitis B and C, and influenza, among other viruses. Vaccines are also available to prevent some viral infections. Side effects of antivirals include headache, nausea, blood abnormalities including anemia and neutropenia (low neutrophil count), dizziness, cough, runny or stuff nose, etc.
Some examples of disease-specific antivirals include: - Acyclovir, valaciclovir: Herpes simplex, herpes zoster, and herpes B - Ritonavir, indinavir, darunavir: Protease inhibitor for HIV - Tenofovir (Viread®): Hepatitis B and HIV infection - Interferon: Hepatitis C - Oseltamivir (Tamiflu®): Influenza Antibiotics Antibiotics are antimicrobial agents that are used for treatment and prevention of bacterial infections. The mechanism of action of an antibiotic involves either killing bacteria or inhibiting their growth. Antibiotics are not effective against viruses, and therefore, they should not be used to treat viral infections. Antibiotics are often prescribed based on the result of a bacterial culture to ascertain which class of antibiotic(s) the respective strain will respond to. The common side effects of antibiotics include allergies, hypersensitivity reactions or anaphylaxis, stomach upset, diarrhea, candida (fungal) infections, and bacterial resistance (superinfection, in which a strain of bacteria develops resistance to a broad classes of antibiotics).
Commonly prescribed antibiotics include: - Penicillin V - Amoxicillin (with or without clavulinic acid) - Ampicillin - Cloxacillin - Cephalexin - Cefuroxime - Cefixime - Tetracycline - Doxycycline - Minocycline - Gentamicin - Tobramycin - Ciprofloxacin - Levofloxacin - Erythromycin - Azithromycin - Clarithromycin - Clindamycin Antimetabolites Antimetabolites are used to treat diseases including severe psoriasis, rheumatoid arthritis, and several types of cancer (breast, lung, lymphoma, and leukemia). The most commonly used medication of this class is methotrexate, which suppresses the growth of abnormal cells and the action of the immune system. Methotrexate is widely used to treat rheumatoid arthritis. This medication is typically prescribed as once a week dose, and it should not be prescribed for daily dosing because overdosing can be lethal. Pharmacists should be alerted to any prescriptions for daily methotrexate, as the doctor must be contacted to confirm and correct the dosing.
The following are the potential side effects of methotrexate: - Dizziness - Drowsiness - Headache - Swollen gums - Increased susceptibility to infections - Hair loss - Confusion - Weakness Steroids Steroids are used to treat allergies, asthma, rashes, swelling, and inflammation. These medications are available in different forms, such as oral tablets, nasal sprays, eye drops, topical creams and ointments, inhalants, and injections. The common side effects of steroids include insulin resistance and diabetes, osteoporosis, depression, hypertension, edema, glaucoma, etc.
The following are examples of commonly prescribed corticosteroids: - Prednisone - Hydrocortisone - Fluticason - Triamcinolone - Mometasone - Budesonide - Fluocinolone - Betamethasone - Dexamethasone
Total Parenteral Nutrition: Total parenteral nutrition is used in situations where a patient cannot orally ingest food or digest food through the stomach and intestines. In such cases, total parental nutrition is essential to maintain patient nourishment and to prevent wasting or malnutrition.
The clinical conditions requiring total parenteral nutrition include the following: - Any cause of malnourishment - Failure of liver or kidneys - Short bowel syndrome - Severe burns - Enterocutaneous fistulas - Sepsis - Chemotherapy and radiation - Neonates - Conditions requiring full bowel rest, such as pancreatitis, ulcerative colitis, or Crohn’s disease
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