By I. Tjalf. Southern Oregon University. 2019.

It can cause euphoria quality floxin 400mg, ataxia best 400mg floxin, dizziness buy generic floxin 400mg line, headache order 200 mg floxin, nausea, vomiting, haematemesis, nystagmus, confusion, coma, hypotension, and respiratory depression. Most cases respond to supportive measures; gastric lavage and haemodialysis are options. Ethylene glycol This is found in antifreeze, windshield washer fluid, and radiator coolants. There can be tachycardia, hypertension, pulmonary oedema, metabolic acidosis, hypocalcaemia, myositis, coma, and convulsions. Severe poisoning is an indication for haemodialysis (which means ethanol or fomepizole dose should be increased) or haemodiafiltration. Absinthe This is a green, distilled, highly alcoholic, anise-flavoured spirit derived from herbs (e. Opinion varies on its psychoactivity but it has been blamed for such phenomena as delirium and hallucinations. Rizvi ea (2010) have reported a case of acute suicidality that emerged during absinthe consumption. Vincent Van Gogh (1853-1890) 2507 Epidemiology: Not everyone who drinks (ethyl) alcohol will develop significant problems from its use. For a discussion on whether and how to collaborate with the tobacco industry see Gray. Absinthe is sometimes known as Green Fairy due to its colour and is said to have been a favourite of Oscar Wilde. Also, it is a mistake to view alcohol dependence as an all or none phenomenon – it comes in all grades. Alcohol limits for drivers in the Republic of Ireland, 2009 (from December 1994) 2511 80 mgs/100 mls of blood 35 micrograms/100 mls of breath 2512 107 mgs/100 mls of urine Alcohol limits for drivers in the Republic of Ireland from September 2011 Road Traffic Bill 2009 passed by Dáil in June 2010 20 mgs/100 mls of blood for learner and professional drivers 50 mg/100 mls of blood for other drivers European blood alcohol limits for drivers, 2009 (mgs/100 mls of blood) 0. The proportion of a population drinking excessively is largely determined by the average consumption of 2513 that population. The latter is determined by price,(Kendell ea, 1983; Purshouse ea, 2010) licensing laws , and customs and moral beliefs. Islamic countries, especially Saudi Arabia, do not officially allow alcoholic consumption. People whose jobs carry a high risk of alcoholism include those who have ready assess to alcohol (chefs, barmen, brewery workers, kitchen porters - even some laboratory workers), those on expense accounts (salesmen, executives), seamen, printers, vagrants, printers, ex-convicts, doctors, and patients in general. In England, 38% of men and 23% of women drank more 2515 than the upper recommended levels for the heaviest drinking day of the week. A fifth of British adults drank in excess of double the safe limit on their heaviest day of the week in 2007. The social stigma associated with the presence of women in pubs has largely disappeared and they have more money to spend. Barriers that may reduce likelihood of women seeking help for substance abuse/dependence Social stigma Too busy with offspring or elder care Fear of loss of children Fear of drug-using partner Lack of child care services Lack of transport Poverty/lack of health insurance Perception that drug services are not geared toward women Heavy, regular drinking occurs at a later age in women than in men but there is a shorter length of time before women develop problems: this ‘telescoping’ effect in women has been described for other drugs as well as alcohol. Over 4% of British government revenue derived from alcohol taxes in the mid-1980s during which 750,000 people worked in the British drink trade. The total annual economic, health and social costs associated with alcohol misuse in England is somewhere between £20-30 bn. Rates of first admission per 1000,000 for England for both sexes rose from 4 in 1970 to 9 in 1986. Both problems were more prevalent among young adults, especially males aged 16-24 years. Alcohol dissolves better in fat and women have a greater amount of fat and less body water relative men. In both Britain and Ireland national alcohol advisory and monitoring groups had to disband because of lack of central support. Follow up to 2005 confirmed that alcoholic disorders are a common reason for re-admission. Hospital-bed days due to alcohol-related disorders in Ireland increased from 55,805 in 1995 to 117,373 in 2004. Ireland topped the European list for binge drinking (> 5 pints or its equivalent/sitting) at 32 binges/year, Britain coming second with 28 binges. Also, Ireland spent more per household on alcohol (> 2521 €1,600/household/year) than anyone one else in Europe. According to the Office of Tobacco Control, Irish 16 and 17 year olds spend €145m on alcohol/year, i. The risk of accidental death in Taiwan is significantly associated with alcohol use disorder and with other common psychiatric disorders, especially when the two are combined. Aetiology of alcoholism: early findings and suggestions Danish adoption studies - increase in alcoholism among the sons of alcoholics Swedish studies - in some cases transmission is through the male line only but in others it affects both sexes Social factors/culture may account for some of the sex differences, e. However, not all studies support a relationship between life-long anxiety and alcoholism. In their review of the literature on the P300 in alcoholism, Gamma & Liechti 2524 (2002) conclude that a small/reduced P300 amplitude is an endophenotype in children and adolescents marking the risk for alcoholism/other substance abuse/various externalising (and perhaps internalising) disorders. However, they also admit that the similarity of P3 findings in smokers (nicotine) and alcohol- dependent people suggests that ‘a substantial part of the P3 amplitude reduction seen in alcoholics or other substance-dependent individuals’ might be explained by ‘uncontrolled nicotine co-dependence’! Somewhere between 40-60% of the variance in alcohol abuse/dependence is accounted for by genes. Alcoholism, sociopathy and depression may run in families but their interrelationship is complex – there may be a tendency for a greater incidence of the first two diagnoses in males and the last diagnosis in females, although social changes may modify this observation. Hasin and Grant (2002) found that past alcohol dependence increased the current risk of having major depression more than fourfold. Alcoholics have been shown to have a significantly reduced frontal blood flow (largely associated with duration of drinking) which is more marked if there is associated dissociality. Twin and adoption (and combined twin-adoption) studies support an inherited tendency to develop alcoholism in both sexes. Kendler ea, 1994) Children of alcohol-dependent parents who are reared by non-alcohol dependent adoptive parents have 3-4 times the risk of developing dependence on alcohol than do adopted children whose biological parents were non-alcoholic. People whose mothers drank when they were in the womb have increased chances of developing alcohol disorders themselves. The sons of alcoholics have shown abnormalities of the P300 visual evoked response (reduced amplitude and delayed latency), a measure of visual information processing. The exact relationship of the abnormal P3 to alcoholism is controversial, one suggestion being that it actually relates to conduct disorder/antisocial personality disorder. Some people may have a genetic propensity to alcoholic brain damage, possibly related to variants in enzymes involved in B1 metabolism. Alcohol is broken down mainly via the alcohol dehydrogenase/aldehyde dehydrogenase pathway. At relatively high levels of alcohol intake the cytochrome P450 enzyme system becomes involved in the metabolism of alcohol, and this factor may have a role in the development of physiological tolerance. Smaller amygdala volume in alcohol-dependent subjects appears to be associated with alcohol craving.

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Following Marín Arrese (2004) generic floxin 200mg, direct evidence (perceptual markers and beliefs) and indirect evidence (inference and reasoning) jointly express the speaker’s commitment to the truth of the utterance floxin 200mg fast delivery, both cognitively and perceptually buy 200 mg floxin otc, since references to sources of information have been linked closely to references to reliability of knowledge (Dendale/ Tasmowski 2001) Evidentiality markers are considered to be ‘percep- tual’ (expressed by verbs such as hear cheap 200 mg floxin with amex, see, etc. Another subdivision is provided by De Haan (2001), who puts forward the classifications of direct/indirect and first hand / second hand evidence, where indirect evidence incorporates that which is quoted, while inferential refers to personal but indirect access to information. Evidentiary validity and degree of certainty are two parameters to be analysed in order to find the dimension of author commitment to the validity of the information. Epistemic modality (Nuyts 2001) refers to the possibility or necessity of the truth of the utterance, and consequently indicates the speaker’s degree of commitment to his/her proposition in relation to his/her knowledge or belief within a high degree of certainty (one possible conclusion to be drawn from facts), and a low degree of certainty (facts lead to speculation). Markers of possibility are found in utterances like: “All of the symptoms you have could be a migraine”; markers of certainty can be found in expressions such as: “I’d definitely suggest […]”. The results indicate that users offer suggestions that are drawn from mental processes and general knowledge, as in the following examples: (8) I actually read once that B vitamins should be taken as a balanced thing, so if you’re taking one, you could balance it by taking a B-complex with it, so you get some of each. Credibility and Responsibility in User-generated Health Posts 205 (9) I assume there is a trigger in your food or combinations of food that combined with body rhythms trigger the migraines. In some (rare) occasions, in fact, the members report information obtained by their own doctors for other users’ specific health problem: (10) User1: I’ve read somewhere that the hormones in birth control pills mimic early pregnancy hormones. He said that multiple studies show that while natural menopause can make migraines either better or worse (just like estrogen-containing birth control) surgical menopause in 99% of the cases makes migraines much, much worse. As suggested by Fitneva (2001), cognitive resources cannot provide a solid certain background, so users tend towards a dimension based on possibility and probability. Use of health forums and negotiation of trust Health forums are a particularly intriguing space to consider with regard to information and source credibility, for several reasons. Although net users may be comfortable with technology and good at using it, they may lack the tools and abilities needed to effectively evaluate medical information. Such strategies are ‘analytic’ (people analyse information carefully), ‘heuristic’ (they use a more intuitive approach), or ‘social’ (they ask their social circle for advice). This section presents the findings of a small-scale survey of people in Italy aged 18-33 examining young adults’ beliefs about the credibility of information available on Italian health forums, and the reason why they choose to evaluate information as credible. Findings for the second research Credibility and Responsibility in User-generated Health Posts 207 question indicate that 75% of respondents use health forums but, among them, only 14. When asked why they do not trust information they find on health fo- rums, 75% of young adults reported doubts about the source of the in- formation (Table 3). In other words, as the analysis of these posts shows, the authorial presence is expressed only for support and is limited when expressing certainty and authority. Mental processes and general background knowledge, as well as mediated data, do not constitute a solid certain background on which the information may be expressed. To validate this, when people were asked why they do not trust information they find on health forums, 75% of young adults reported doubts about the source of the information. Final considerations The Internet offers confidential and convenient access to an unprece- dented level of information about a diverse range of subjects, and over time it has increased its perceived credibility. However, analysis of web pages raises significant questions about the relevance, coverage, and legitimacy of a lot of Internet health information (Rice/ Katz 2001: 31). Although content providers are expected to take steps to help control the most extreme content (Williams/Calow/Lee 2011), user agreements in the form of ‘terms of use’ are treated as membership contracts and in fact only protect one side’s rights, without assuming any responsibility for the content, for which the Credibility and Responsibility in User-generated Health Posts 209 users assume all the risk (Sözeri 2013). In healthcare environments, there is also concern that anonymity makes people likely to engage in antisocial behaviour and may promote misinformation and advice that runs contrary to clinical research. As suggested by Metzger and Flanagin (2013), the vast amount of information available online makes the origin of information, its quality, and its veracity less clear than ever before, shifting the burden on individual users to assess the credibility of information. In a time continuum that goes from temporary to permanent, in- formation is positioned on the temporary side, whereas knowledge is situated on the verge of permanent. On the other hand, research has shown that the degree to which adults believe information they find online varies according to the type or topic of information which they are searching for, and that assessments of credibility are related to the context in which the information is found (Flanagin/Metzger 2007; Hargittai et al. For example, people are less likely to find commercial information or information from special interest groups to be credible, probably because they recognize that these sources have a strong potential for 210 Marianna Lya Zummo bias (Flanagin/Metzger 2007). Research indicates that as people engage more, and more deeply, with the Internet, they may develop a healthy scepticism toward the believability of online information (Metzger/Flanagin 2013). In addition, Internet users know how to differentiate between the types of people they encounter online, even though those people are represented online by text (Lea/Spears 1992; Walther/Jang 2012). According to Fage-Butler and Nisbeth Jensen (2013), many posts have disclaimers, which underline that the advice given should not be deemed to be expert, and recommend that website users “see a qualified doctor before acting on any of the information on the forum” (2013: 27). Although previous studies show that the reader will change behaviour according to what is suggested online, it seems that a negotiation of trust is at play. In fact, a small-scale survey of Italian people aged 18-33 shows young adults’ beliefs about the credibility of information available on Italian health forums and the reason why they choose to evaluate information as credible. Patients Looking for Information on the Internet and Seeking Teleadvice: Motivation, Expectations, and Misconceptions as Expressed in E-mails Sent to Physicians. Ethical Challenges for User-Generated Content Publishing: Comparing Public Service Media and Commercial Credibility and Responsibility in User-generated Health Posts 215 Media. Introduction In the past two decades, the United States has experienced a rapid growth in the Hispanic population – increasing 233% since 1980 to reach a total of 37 million Spanish-speakers by 2012. A logical effect of this increase in population has been an increase in the use of Spanish in every service industry, of which health and human services is no exception. However, despite the significant diversity found inherent to this incoming population – which represents various countries, regions and backgrounds – many of the medical Spanish courses treat these immi- grants as a homogeneous group. Indeed, oftentimes in these courses, and in much of the learning and reference materials, the colloquial re- gister, which is not only the most common language register but also the one that takes into account this diversity, is absent. In contrast to the abundant information available on both standard and technical Spanish in the medical setting, it is quite difficult to find any materials that include or describe Latin American dialect variants. In this chapter, the variants that arise in the clinic setting and the impact that these can have on doctor-patient communication will 218 Ashley Bennink be described. Then, the communicative competence necessary to converse effectively in the medical interview given the appearance of these terms will be outlined along with a discussion of the challenges that they present to the attainment of this quality communication. However, it should be noted that the intention in this chapter is not to offer solutions to these problems but instead to create awareness around the issue of Spanish lexical variants in the United States medical setting. Spanish lexical variants in the United States medical setting In 2013, a preliminary study was conducted by Bennink (2013a) to research the presence and frequency of Spanish lexical variants in the medical setting in southeastern United States. The study was inspired, on one side, by her previous work with Latinos and with other bilingual professionals in healthcare clinics within that region and, on the other, by the fact that, prior to that study, there were no lists of frequent variants in the field of health and wellness. With the goal of starting to fill that gap, questionnaires were sent to clinics and medical interpreter organizations in order to collect data on which variants were encountered and at what frequency. It should be noted that in that study the denomination lexical variant was used to refer to words or phrases used by patients that were neither the technical term nor the ‘standard’. The responses received not only confirmed the extent to which lexical variants are employed in the healthcare setting, recovering a list of around 242 distinct variants, but also demonstrated a surprising diversity in terms of origin. The variants recorded in the survey by respondents as ‘lexical variants’ included ones with origins in other languages, including indigenous languages – such as cuate from the Nahua cóatl, meaning ‘twin’ – or the English language – for example, raite to mean ‘a ride as a form of transportation and rifill to mean a Dialect Variation and its Consequences on In-Clinic Communication 219 ‘medication refill’. However, it should be noted that most diatopic variants were found to be from Mexico, with high numbers also from El Salvador, Guatemala and parts of South America (Colombia and Peru). This concentration of variants from a handful of countries seems to reflect the composition of the non-English speaking Latino population in that region, which seems to logically imply that the variants most frequently employed are determined, in part, by the most common countries of origin for the Hispanic population in that region, leading us to hypothesize that care should be taken in generalizing these results to other sectors of the United States. Impact on care Given the presence and diversity of these variants in the clinic setting, the question is then raised as to if they have any impact on care.

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A raised blood level of ‘congugated’ bilirubin occurs in various liver and bile duct conditions buy 200 mg floxin mastercard. It is particularly high if the flow of bile is blocked cheap floxin 400mg overnight delivery, for example by a gallstone in the common bile duct or by a tumour in the pancreas floxin 200 mg fast delivery. Other blood tests must be used to confirm the diagnosis of a particular disorder and/or to monitor the activity of the disorder and response to treatment cheap floxin 200mg with amex. Since the liver synthesises many of the blood-clotting proteins, blood- clotting tests may be used as a marker of the severity of certain liver disorders. A high level of this enzyme is particularly associated with heavy alcohol drinking. Blood tests can detect viruses and antibodies to viruses, for example hepatitis A/B virus, or auto-antibodies from autoimmune disorders of the liver, for example primary biliary cirrhosis (associated with anti-mitochondrial antibodies), autoimmune hepatitis (asso- ciated with smooth muscle antibodies) and primary sclerosing cholangitis (associated with antinuclear cytoplasmic antibodies). Other types of protein in the blood can identify specific liver diseases, for example cerulo- plasmin is reduced in Wilson’s disease, lack of 1-antitrypsin is an uncommon cause of cirrhosis and high levels of ferritin is a marker of haemochromatosis. Most clinical tests use the plasma concentrations of the waste substances of creatinine and urea, as well as electrolytes, to determine renal function. Glomerular blood pressure provides the driving force for water and solutes to be filtered out of the blood and into the space made by Bowman’s capsule; the resulting glomerular filtrate is further processed along the nephron to form urine. Including erythropoietin, which regulates red blood cell production in the bone marrow, rennin, which is a key part of the rennin–angiotensin–aldosterone system, and the active forms of vitamin D (calcitriol) and prostaglandins. Maintaining a balance of several substances, some of which are summarised in Table 10. The kidney’s ability to perform many of its functions depends on the three fundamental functions of filtration, re-absorption and secretion: • Filtration is driven by both hydrostatic and oncotic (colloid osmotic pressure) transport. These transport processes are driven by hydrostatic, oncotic, diffusion and active transport. Some key regulatory hormones for re-absorption include aldosterone, which stimulates active sodium re-absorption (and water as a result), and antidiuretic hormone, which stimulates pas- sive water re-absorption. Usually only a few substances are secreted, unless they are present in great excess, or are natural poisons. There are several categories of diuretics, all of which increase the excretion of water, but in a distinct way: 1. Diuretics that cause a substantial diuresis, up to 20% of the filtered load of NaCl and water. Loop diuretics, such as furosemide, inhibit the re- absorbtion of sodium at the ascending loop, which leads to a retention of water in the urine. Other examples of high-ceiling loop diuretics include ethacrynic acid, torsemide and bumetanide. Diuretics that act on the distal convoluted tubule and inhibit the sodium chloride symporter, leading to retention of water in the urine. Aldosterone normally acts to add sodium channels in the principal cells of the collecting duct and late distal tubule of the nephron. Spironolactone prevents aldosterone from entering the principal cells, preventing sodium re-absorption. The thiazides and potassium-sparing diuretics are considered to be calcium-sparing diuretics. The thiazides cause a net decrease in calcium lost in urine; the potassium-sparing diuretics cause a net increase in calcium lost in urine, but the increase is much smaller than that associated with other diuretic classes. Their presence leads to an increase in the osmolarity of the filtrate; to maintain osmotic balance, water is retained in the urine. In diabetes mellitus, the concentration of glucose in the blood exceeds the maximum resorption capacity of the kidney; glucose remains in the filtrate, leading to the osmotic retention of water in the urine. Diuretics that have a rapidly flattening dose effect curve (in contrast to ‘high ceiling’, where the relationship is close to linear). However, there are certain classes of diuretic which usually fall into this category, such as the thiazides. Diuretics are used to treat oedema in heart failure, liver cirrhosis, hypertension and certain kidney diseases. Some diuretics, such as acetazolamide, make the urine more alkaline and are helpful in increasing excretion of substances such as aspirin in cases of overdose. Within hypothalamic neurons, the hormone is packaged in secretory vesicles together with a carrier protein called neurophysin; both are released upon secretion. The single most important effect of anti-diuretic hormone is to conserve body water, by reducing the loss of water in urine. In the absence of anti-diuretic hormone, the collecting ducts of the kidney are virtually impermeable to water. Anti-diuretic hormone stimulates water re-absorbtion through the insertion of ‘water channels’, or aquaporins (see Section 10. Aquaporins transport solute-free water through tubular cells and back into blood, leading to a decrease in plasma osmolarity and an increased osmolarity of urine. Regulation of anti-diuretic hormone secretion is primarily through the plasma osmolarity. Osmolarity is sensed in the hypothalamus by neurons known as osmoreceptors, which in turn stimulate secretion from those neurons that produce anti-diuretic hormone. Secretion of anti- diuretic hormone is also simulated by decreases in blood pressure and volume, conditions sensed by stretch receptors in the heart and large arteries. Changes in blood pressure and volume are not nearly as sensitive a stimulator as increased osmolarity, but are nonetheless potent in severe conditions. For example, loss of 15–20% of blood volume by haemorrhage results in a massive secretion of anti-diuretic hormone. Another potent stimulus of anti-diuretic hormone is nausea and vomiting, both of which are controlled by regions in the brain with links to the hypothalamus. The most common disease state related to anti-diuretic hormone is diabetes insipidus. This condition can arise from either of two situations: • Hypothalamic (‘central’) diabetes insipidus. This results from a deficiency in secretion of antidiuretic hormone from the posterior pituitary. The major indication of either type of diabetes insipidus is excessive urine production; as much as 16 l of urine per day. If adequate water is available for consumption, the disease is rarely life-threatening. Hypothalamic diabetes insipidus can be treated with exogenous anti-diuretic hormone. Water pores are however completely impermeable to charged species, such as protons. Aquaporins comprise six transmembrane α-helices, and five interhelical loop regions (A–E) that form the extracellular and cytoplasmic vestibules. There are 13 known types of aquaporin in mammals; six of these are located in the kidney. Haemostasis provides several important functions: it maintains blood in a fluid state while circulating within the vascular system; it arrests bleeding at the site of injury by formation of a haemostatic plug (clot); and it ensures the removal of the haemostatic plug once healing is complete. In which the blood vessels contract as a result of neurological reflexes and local myogenic (muscle) spasm.

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Some metabolic processes de- velop over minutes to hours purchase 400mg floxin with amex, while infectious and other metabolic disorders progress over hours to days cheap floxin 400 mg amex. A preceding state of confusion buy floxin 400mg amex, with- out focal neurologic symptoms purchase floxin 400 mg with visa, usually suggests a metabolic etiology. Hypothermia may be environmental, or accompany alcohol or sedative intoxication, hypoglyce- mia, sepsis, Wernicke’s or hepatic encephalopathy, or myxedema. Hyperthermia may be due to heat stroke, seizures, malignant hyperthermia, anticholinergic in- toxication, pontine hemorrhage, sepsis or thyroid storm. The patient’s breath may smell of acetone (in diabetic ketoaci- dosis) or alcohol. Does the patient have a surgical scar, suggesting a thyroidectomy (and pos- sible incidental removal of parathyroid glands)? However, despite its limitations, it is widely used in nontrauma settings as well. Scores range from 3 (worst) to 15, with coma defined as a score <8 (unless the patient has sponta- neous eye opening). Eyes Verbal Motor Score No opening No sounds No movement 1 Open to noxious stimulus Unintelligible sounds Extensor response 2 Open to verbal stimulus Nonsensical speech Flexor response 3 Open spontaneously Confused Flexion withdrawal 4 Oriented Localizes noxious stimulus 5 Follows commands 6 • Examine the eyes at rest. Small pupils suggest an interruption of the sympathetic pathway, organo- phosphate poisoning, opiate overdose, or a pontine lesion. Pupils that are normal in size but unreactive are seen with brainstem (midbrain) lesions. Extraocular movements can be assessed by eliciting the oculocephalic or oculovestibular re- flex. The oculocephalic (or doll’s eyes) maneuver should not be performed if the Neurologic Emergencies 91 patient is at risk for cervical injury; instead, the more sensitive oculovestibular (or cold-water calorics) reflex should be tested. Differential Diagnosis • Locked-in syndrome: syndrome of intact consciousness, with voluntary movement re- stricted to opening and closing the eyes and moving the eyes in the vertical plane. In addition, a low pO2 in the setting of a normal pulse oximetry value, as well as an elevated carboxyhe- moglobin level, are indicative of carbon monoxide poisoning. True coma is rarely caused by ethanol levels under 250 mg/dL; patients suspected of acute intoxication but with lower levels require further testing (e. Although some references recommend empiric administration of naloxone, selec- tive use guided by the history, vital signs, and physical exam is acceptable. Indiscriminate use may cause seizures in patients with cocaine or tricyclic toxicity or cause withdrawal seizures in chronic benzodiazepine users. Patients with no clear etiology for their altered mental status should be admitted, even if all symptoms have resolved. These meninges, from the outermost layer inward, are the dura mater, the arachnoid, and the pia mater. The dura adheres to the inner surface of the cranium; the arachnoid attaches to the inner surface of the dura; and the pia is attached to the brain, following all of its contours. The spinal epidural space is located between the periosteum of the vertebrae and the dura and is filled with fatty connective tissue and a vertebral venous plexus. Scope of the Problem • Meningitis • Meningitis is inflammation of the membranes of the brain or spinal cord, which may accompany an infectious, neoplastic, toxic, or autoimmune process. Because the precise etiology may not be evident in the emergency department, empiric treat- ment for bacterial meningitis is of utmost importance. However, with the decline in frequency of Haemophilus influenzae meningitis as a result of the H. It may coexist with viral meningitis or it may present as a distinct entity, caused most commonly by arbovi- ruses, herpes viruses, and rabies. Louis encephalitides) are associated with high mortality rates and severe neurologic sequelae. Patients at highest risk for symptomatic infection include persons over age 50 and the immunosuppressed. Associated symptoms may include fever, headache, nausea, vomiting, weakness, altered mental status, stiff neck, and an erythematous rash. Complications of intracranial abscess include epilepsy, focal motor or sensory deficits, and intellectual deficits. Patients with spinal abscesses may have residual motor or sensory deficits, or bowel or bladder dysfunction. Risk Factors • Meningitis • As mentioned above, the most common pathogens in patients over one month of age are S. Other risk factors include intravenous drug abuse, neurosurgical procedures, and penetrating head injury. The causative organ- isms vary according to the primary source of the infection and the immune status of the patient (Table 4D. Diagnosis History • The classic triad of fever, nuchal rigidity, and altered mental status is seen in ap- proximately two-thirds of patients with community-acquired bacterial meningitis. Other signs and symptoms which should cause one to suspect meningitis include headache, chills, vomiting, myalgias/arthralgias, lethargy, malaise, focal neurologic deficits, photo- phobia, and seizures. Elderly patients may present with subtle findings, frequently limited to an altered sensorium. Fungal meningitides present with an atypical constellation of symptoms, including headache, low-grade fever, weight loss, and fatigue; similarly, tuberculous meningitis may be associated with fever, weight loss, night sweats, and malaise, with or without headache and meningismus. Organisms causing meningitis Population Additional Potential Pathogens Neonate (<1 mo) Group B streptococci, E. Encephalitis, causative organisms Virus Route of Entry Arbovirus Mosquito bite; hematogenous spread (California, W. Louis, West Nile) Herpes virus Herpes simplex type 1 Skin lesions; retrograde neuronal spread Varicella zoster Skin lesions; retrograde neuronal spread E-B virus Mononucleosis Rabies Animal bite; retrograde neuronal spread Measles, mumps Post-infectious Table 4D. Examination • Meningitis • Evaluate the patient’s overall appearance and mental status. Note that papilledema takes time to develop, and this finding can be absent in the majority of patients with bacterial meningitis. In infants <12 mo of age, when meningeal signs are unreliable, the anterior fontanelle should be evaluated for bulging. Neck stiffness is often absent at the extremes of age, or in patients with altered levels of conscious- ness, immunosuppressed, or partially treated disease. Localizing signs are generally absent in bacterial meningitis; their presence suggests the possibility of a focal infection, such as an abscess. The level of consciousness may range from confusion or delirium to stupor or coma. Evaluation 4 • Delay in the diagnosis of bacterial meningitis in the elderly, especially with nonspecific symptoms, is responsible for the high mortality in this population. Normal adult pressures are 5-19 cm H2O, when the patient is in the lateral recumbent position. Empiric therapy should be based on the suspected patho- gen, taking into consideration the patient’s age and risk factors for specific organ- isms.

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