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For patients with AT-III deficiency buy 25mg phenergan fast delivery, the risk of thrombosis increases with age Key Concept/Objective: To understand AT-III deficiency AT-III deficiency is an autosomal dominant trait that affects nearly 1 in 2 order phenergan 25mg on-line,000 people purchase phenergan 25mg. There are two types of AT-III deficiency: inherited and acquired. The inherited form has two subsets: quantitative deficiency and qualitative deficiency. In some cases, AT-III defi- ciency may be acquired, as with disseminated intravascular coagulation or severe liver dis- ease or through the administration of I. AT-III normally inactivates factor Xa and thrombin; patients with AT-III deficiency show evidence of continuous factor X acti- vation and thrombin generation. The typical presentation of AT-III deficiency is similar to that of other hypercoagulable states. There is no evidence that AT-III deficiency increases the risk of arterial thrombosis. The two hypercoagulable states more closely related to arte- rial thrombosis are the antiphospholipid syndrome and hyperhomocystinemia. A 26-year-old man presents with new-onset left lower extremity swelling and pain of 6 hours’ duration. He takes no medications and has no history of trauma, immobilization, or prior thrombosis. His family history is remarkable for two “blood clots” in his mother. Compression ultrasonography confirms occlu- sive thrombus in the left superficial femoral vein. Which of the following is the most appropriate sequence of interventions for this patient? Start heparin and warfarin immediately, send tests for the hypercoagu- lable state before warfarin reaches therapeutic levels, and discontinue heparin after the international normalized ratio (INR) reaches thera- peutic levels B. Send tests for the hypercoagulable state, then start heparin and war- farin concurrently, and discontinue heparin after 5 days’ overlap C. Send tests for the hypercoagulable state, then start heparin and war- farin concurrently, and discontinue heparin when the INR reaches therapeutic levels D. Start heparin and warfarin immediately, discontinue heparin after 5 days’ overlap, and evaluate for the hypercoagulable state after warfarin therapy is completed E. Evaluate for the hypercoagulable state, but no anticoagulation is indi- cated for superficial thrombophlebitis Key Concept/Objective: To understand the timing of workup and duration of therapy for patients presenting with a new DVT 5 HEMATOLOGY 39 A 26-year-old man presenting with new-onset thrombosis and a positive family history is highly suspicious for a hereditary hypercoagulable state and should be worked up for this. Because the levels of protein C and antithrombin III can be diminished in the setting of acute thrombosis and because heparin and warfarin also alter these levels, the optimal time for the workup is after the patient has completed therapy. Exceptions to this rule include the antiphospholipid antibody syndrome, in which early diagnosis can affect ther- apy and disorders for which specific genotypic tests are available (e. Because the INR (prothrombin time) is heavily depend- ent on factor VII, which has a short half-life, it rises fairly quickly after warfarin is begun. However, therapeutic anticoagulation may take several days longer because of the persist- ence of factor X and prothrombin. Overlapping heparin and warfarin by 5 days is thought to limit the risk of propagation of thrombus caused by delayed therapeutic anticoagula- tion. The confusingly named superficial femoral vein is in fact in the deep system and war- rants therapy. A 58-year-old woman is 2 days’ status post–total hip replacement. She has been receiving subcutaneous heparin as prophylaxis for DVT. You are asked to see the patient to evaluate new-onset dyspnea. On examination, the patient is tachypneic, tachycardic, and diaphoretic. She is agitated and complains of substernal chest pain. Cardiac, abdominal, and extrem- ity examinations are normal except for her surgical wounds, which seem to be healing well.

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To establish the flow along the meridians some Taoists con- centrated on easy-to-get energy points which were in accord with acupuncture points buy 25mg phenergan visa. By focusing on these specific power centers the Taoists realized that not only was chi released so that a warm current was felt purchase 25 mg phenergan fast delivery, but that the energy points were activated cheap 25 mg phenergan overnight delivery, effect- ing a whole set of mental and physical functions. Focusing on the navel, for instance, effects the entire gastro-intestinal system, and the increased chi aids in digestion and balances the appetite. The Microcosmic Orbit begins and ends at the navel, and the functional channel extends from the palate to the perineum. To open the front channel, we work from the navel to the perineum, and later, after opening the back channel, we open the remainder of the functional channel. Awaken the Individual Healing Points To awaken the energy in the individual points use your inner vision. Direct your vision inwardly to the point you wish to activate, and concentrate your mind on that point in your body. Do not create a visual image of the energy point in your mind. Rather bring your mind down from your head and put it in your body, e. The energy, or chi flow that eventually results will be experienced differently by people depending on physical, emotional, and psy- chological conditions. Genetic make-up, past history, diet, imme- - 52 - Chapter IV diate physical and mental stresses all contribute to the varying re- sults. Some might feel the power of the warm current in a few minutes or a few weeks, while others may take months to feel it. Some experience the energy as hot or cold, some report tingling sensations and some see colors. Pai-Hui Crown Ying-Tang GO-20 Yu-Chen BL-9 Hsuan-Ying Palate Hsuan-Chi Shuan-Chung Chuang-Kung Chi-Chung GO-6 CO-12 Tan-Tien Chi-Chung Ming-Men GO-4 CO-8 Kuan-Yuan Chang-Chiang Coccyx Ovarian Palace Jing- GO-1 Gong Sperm Palace Hui-Yin Perineum CO-1 Wei-Chung BL-40 Heding Extra-31 Yung-Chuan K1 Ta-Tun LI-1 Fig. Do not ignore the messages and sensations your body sends; if anything, listen more attentively and experience your body more fully. These messages are valuable signals that you are coming in tune with your etheric energy body that connects your physical body to your mind. Choosing your First Point: The Navel The first energy center is normally the navel, but it varies if you have problems such as high or low blood pressure, if you are old, or if you have chest problems. The navel serves as the generator of electricity which supplies all the other points. The Taoists considered the navel the earth or root of the body. It is the origin of energy: from the fertilized ovum the fetus is developed, linked to life by its umbilical cord. After birth the surrounding energy continues to enter through the same area. The navel also is the place where breath originates. As blood and chi are drawn to this point a deep rhythmic breathing is estab- lished, and the entire mid-section of the body becomes a huge pump, vigorously circulating the chi and blood throughout the or- ganism. This circulation distributes the life substances and relieves the heart of its heavy burden. Moreover, blood follows chi, and when vital power is distributed evenly throughout the body no energy accumulates at one point, thereby overheating or damaging the nearby vital organs. How- ever, if one is injured or ill, energy can be directed to a particular site, concentrating all one’s healing resource to the point where it is most needed. When the warm current has removed the impuri- ties, the blood follows to finish the job of restoration.

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Prednisone and cyclophosphamide therapy should be started as soon as possible Key Concept/Objective: To know the diagnosis and prognosis of Henoch-Schonlein purpura Henoch-Schonlein purpura is diagnosed on the basis of the classic tetrad of skin rash purchase phenergan 25 mg on-line, abdominal pain discount 25 mg phenergan with mastercard, arthralgias and arthritis 25 mg phenergan free shipping, and glomerulonephritis. The extent of renal involvement is the most important prognostic factor in Henoch-Schonlein purpura. Renal biopsy results are not diagnostic of Henoch-Schonlein purpura, as such results can be identical with the results obtained in cases of IgA nephropathy with IgA depo- sition in the mesangium and in cases involving severe crescent formation. Skin biopsy results also show IgA (not IgG) deposition on immunofluorescence. This patient does not have any risk factors or signs of sepsis; if there is any suspicion that gonococcal or rickettsial infection is causing the palpable purpura, empirical therapy should be start- ed immediately. Most cases of Henoch-Schonlein purpura resolve spontaneously, although prednisone and cyclophosphamide should be considered for use in the few patients with acute renal failure. A 67-year-old black man with a history of tobacco abuse and ethanol abuse is admitted for gradually worsening esophageal dysphagia complicated by a 1-day history of shortness of breath, productive cough, and fever. On examination, the patient has a temperature of 101. Chest radiography reveals a right lower lobe infiltrate consistent with aspiration pneumonia. He is placed on piperacillin-tazobactam and oxy- gen, and he gradually improves. By hospital day 3, he experiences defervescence, but on hospital day 10 he is noted to again have a fever (100. In addition, the patient has a rash, and peripheral blood eosinophilia and acute renal insufficiency are present. This patient will likely progress to end-stage renal disease 22 BOARD REVIEW B. Standard of care would include stopping the piperacillin-tazobac- tam and starting high-dose I. Another β-lactam antibiotic can be safely substituted for piperacillin D. Urinalysis will most likely reveal sterile pyuria, mild proteinuria, and hematuria E. Most patients with this disorder become oligoanuric Key Concept/Objective: To understand the clinical manifestations and management of acute interstitial nephritis (AIN) Virtually all β-lactam antibiotics (i. It usually occurs after several weeks of high-dose antibiotic therapy. Classically, patients exhibit a triad of hypersensitivity reactions: rash, fever, and eosinophilia. The second- ary fever associated with AIN usually occurs after defervescence from the original infec- tious disease and during the onset of the allergic reaction. Urinary findings in patients with AIN include the nonspecific findings of sterile pyuria and mild proteinuria, as well as the more significant finding of hematuria, which in some patients may be gross. Eosinophils may be found in the urine sediment on Wright or Hansel staining in over 75% of cases. The pathogenesis of β-lactam-associated AIN remains unknown. The dis- ease is not dose related and occurs in only a small number of the millions of people tak- ing β-lactam drugs each year. It can recur or be exacerbated on rechallenge with a sec- ond β-lactam drug. Most patients regain renal function, and many regain baseline renal function. The use of corticosteroids to treat renal failure associated with AIN remains controversial.

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Allopathic medical practitioners have been inject- ing cortisone for decades at different depths for a variety of inflammatory conditions 25 mg phenergan with visa, but the exact mechanism of action order 25 mg phenergan, optimal dose buy cheap phenergan 25mg line, and interval of injections for a given inflammatory condition in a specific location has never been scientifically proven. This does not mean that cortisone injections should be abandoned; rather caution is advised when using this substance until the careful practitioner gathers clinical experience and con- fidence with its use. Spending time with a medical practitioner experienced with the use of the injectable substance is invaluable for observing injection technique and clinical prac- tice. The same can be said for lipodissolve therapy at the present time.

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