By Z. Rune. New Jersey City University.

Gyneco- logical consultation is paramount since consideration should be given for endome- trial sampling when there is suspicion of endometrial hyperplasia or cancer order 80 mg innopran xl amex blood pressure causes. After intravenous estrogen such as conjugated equine estrogen (Premarin) 25 mg intravenously every 6 hours is given for 3 to 4 doses generic innopran xl 80 mg amex blood pressure drops after exercise, then the patient is usually transitioned to an oral contracep- tive agent and menses regulated with these medications. A patient who presents to the emergency center in frank shock due to excessive vaginal bleeding should have urgent management of hypovolemia and blood products en route while very basic diagnostic information is sought. Establishing whether the patient is pregnant is critical, and this should be determined by a reliable hospital/office test, and not by patient history (contracep- tion, abstinence, home pregnancy test). Screening questions and examination about amount of vaginal bleeding and presence or absence of clots, number of pads, and degree that each pad is soaked may be helpful, but multiple research studies have highlighted the unreliability of an individual’s assessment of their menstrual bleeding. Is there an obvious etiology for the vaginal bleeding (uterine fibroids, coagulopathy, cervical cancer, genital tract laceration)? A systematic assessment of volume status will prevent undue delay in these patients. Also, in older women, myocardial infarction and stroke should be considered if hypotension is prolonged. The treatment for hypovolemic shock is the same as that of other conditions, such as trauma. A complication of pregnancy usually indicates an incomplete abortion, such that a uterine dilation and curettage should be performed to stop the bleeding. Other conditions that should be considered include molar pregnancy, and ante- partum vaginal bleeding such as placenta previa or placental abruption. When the uterus is above the level of the umbilicus in a pregnant woman with vaginal bleed- ing, a speculum examination or digital examination should be avoided since these actions may exacerbate placenta previa. An ultrasound examination instead is help- ful in conditions of pregnancy-related vaginal hemorrhage. Upon exam- ining the woman, blood stains down the legs indicates significant bleeding, and the probable need for transfusion. The speculum examination should be performed to assess for degree of bleeding, lesions of the vagina or cervix, and ascertaining whether the bleeding is coming from within the uterus (supracervical) versus the cervix or vagina. A digital pelvic examination is performed to assess for cervical pathology, and also uterine size and shape. The bleeding is due largely to anovulation, that is, unopposed estrogen effect on the endometrium leading to overgrowth of the endometrium without progesterone to arrest the growth. In a woman older than age 35, or in a younger patient with persistent and prolonged unopposed estrogen, endometrium sampling should be performed to assess for endometrial hyperplasia or cancer. In most situations where there is less active bleeding, oral contraceptive agents can be used. Hormonal therapy should not be initiated until pregnancy and structural lesions of the uterus are ruled out. Endometrial sampling should be performed prior to initiation of hormonal treatment if possible. Notably, bleeding due to uterine fibroids will typically not respond to hormonal manipulation. In those women, inflation of a Foley balloon in the uterus has been described as a temporar- izing measure, and may be life-saving for those patients who cannot receive estrogen and also are not suitable surgical candidates. However, most of these patients will undergo uterine D and C, both for diagnostic purposes, and also to acutely arrest the hemorrhage. It is important to note that the underlying pathological process that induced the bleeding is not addressed with a D and C, and the patient may return to the emergency center in several months if the cause is not addressed. She states that she has had irregular menses for 3 years, and at times has “baseball-sized clots” pass vaginally. There are no abnormalities on pelvic examination including speculum examination of the cervix and vagina. Approximately 30 cc of dark blood is noted in the vaginal vault and a moderate flow of blood from the cervix.

They can be expected to last for 7 to 10 days if upper and somewhat longer if lower cheap 40 mg innopran xl visa prehypertension at 24. Influenza There are differences between the common cold and influenza that are helpful to make a diagnosis buy innopran xl 40 mg line blood pressure medication prices. The symptoms are similar, but are more likely and more severe in one or the other. Consult the list below to identify what you’re most likely dealing with: For influenza, the administration of antiviral medications such as Tamiflu or Relenza will shorten the course of the infection if taken in the first 48 hours after symptoms appear. For colds, concentrate your treatment on the area involved; nasal congestion medication for runny noses or sore throat lozenges for pharyngitis, for example. Various natural remedies are also useful to relieve symptoms, which we will discuss in the next section of this book. Although most upper respiratory infections are caused by viruses, some sore throats may be caused by a bacterium called Beta- Streptococcus (Also known as Strep Throat). These patients will often have small white spots on the back of their throat and/or tonsils, and are candidates for antibiotics. Amoxicillin (veterinary equivalent: Fish-Mox) or Keflex (Fish-Flex) are some of the drugs of choice in those not allergic to Penicillin drugs. Erythromycin (Fish-Mycin) family drugs are helpful in those who are Penicillin-allergic. In most cases, however, it is not appropriate to use antibacterial agents such as antibiotics for upper respiratory infections. Antibiotics have been overused in treating these problems, and this has led to resistance on the part of some organisms to the more common drugs. Resistance has made some of the older antibiotics almost useless in the treatment of many illnesses. Lower respiratory infections, such as pneumonia, are the most common cause of death from infectious disease in developed countries. The more serious nature of these infections leads many practitioners to use antibiotics more often to treat the condition. Most bronchitis is caused by viruses, however, and will not be affected by antibiotics. Antibiotics may be appropriate for those with a lower respiratory infection that hasn’t improved after several days of treatment with the usual medications for upper respiratory infections. The patients who are at-risk will appear to have worsening shortness of breath or thicker phlegm over the course of time despite the usual therapy. There is a school of thought that recommends more liberal use of antibiotics in sick persons over the age of 60 or those with other serious medical conditions. This population has a higher risk of death because of decreased resistance to secondary bacterial infections. Both upper and lower respiratory infections are different than asthma, which is a condition where the airways become constricted in a type of spasm, causing a particularly vocal kind of breathing called a “wheeze”. Asthma may occur as an allergic response, or may be associated with some respiratory infections, such as childhood “croup”. The treatment of asthma involves different medicines than colds or flus, such as certain antihistamines and epinephrine, than those used in treating respiratory infections. Good respiratory hygiene is important to prevent patients with respiratory infections from transmitting their infection to others. Practicing good hygiene is not only a good strategy for you and your family, but demonstrates social responsibility and could prevent a pandemic. This is what needs to be done: Sick individuals should cover their mouth and nose with tissues and dispose of those tissues safely. Although others caring for the sick individual may wear masks (N95 masks are best for healthcare providers), it is most important for the afflicted person to wear one. Wash with soap and warm water for 15 seconds or clean your hands with alcohol-based hand sanitizers if they do not appear soiled. Sick persons should keep at least 4 feet away from other persons, if possible, due to droplet spread. Wash down all possibly contaminated surfaces such as kitchen counters or doorknobs with an appropriate disinfectant (dilute bleach solution will do). Isolate the sick individual in a specific quarantine area, especially if he/she has a high fever. Don’t self-medicate, especially with antibiotics, unless modern medical care is not accessible for the foreseeable future; Many of the strategies and treatments described above will deal with respiratory infections quite well, but what is modern pharmaceuticals are not available or are no longer produced due to a major catastrophe?