By O. Bandaro. Trinity College of Florida.

Intellectualizing for your own self-comfort or being drawn helping doctors cheap etodolac 400 mg line arthritis cats,” or “extending professional courtesy etodolac 300mg visa working with arthritis in back,” caring into talking shop is not in the best service of your pa- for colleagues is an important tradition in medicine. They may quoted maxim that “The physician who treats himself has a have specifc ideas or concerns that are not shared by other fool for a patient. What does it mean to “immi- Within our current medical culture there is clear endorsement grate to the nation of the sick? For • Physicians should have a family physician and an age- example, not all physicians are fnancially sound or have appropriate health assessment as an occupational overhead and/or disability insurance. Thoroughness, including a complete physical examination, • Physicians should not self-medicate through self- cannot be sacrifced. Physicians are observant and expect prescribing, the sample cupboard or workplace supplies. It provides comfort and trust in the physician– Robert Klitzman has invited physicians to be aware of “post- patient relationship. The demonstration of empathy is as important as in other and denying symptoms, worrying too little, self-diagnosing and physician–patient relationships. Physicians worry about the transforma- colleagues we need to be aware of our own reactions. At times, particularly if they our physician patient’s response to illness close to home? The end of the visit should involve more than education, Case resolution involvement in decision-making and enquiring whether The program director reviewed some of the key prin- your patient got what they needed. As treating physicians ciples involved in treating colleagues and the importance we need to be clear and explicit about our practice with of maintaining appropriate roles and boundaries in such regard to prescriptions, consultations and investigations. The resident acknowledged being irritable, not download the physician roles and responsibilities to fatigued and hungry that evening after being on call your physician patient. We all deserve confdentiality and privacy in our health ing in the emergency room for a second opinion refused. However, we may also need to refect with our physi- The resident and program director discussed a mutually cian patient on how privacy issues or maintaining secrets agreeable approach to address the complaint. This may be especially relevant when physician patients the frustration, fear, and disappointment the patient had are suffering from diseases of degeneration (including experienced. As a result, the resident gained a deeper aging), psychiatric illness or substance use disorders. We must be aware that illness is not unprofessional conduct and that there is a difference between illness and impairment. Physicians for physicians: when doctors be- treatment are as effective for physicians as they are for come patients. In caring for our colleagues we would do well to remember the words of Rabia Elizabeth Roberts: “We learn that our human- ity is more powerful than our expertise alone” (Hanlon 2008). Richard Gunderman would invite us to adopt our part of the highway and to care for one another as colleagues the best way we can. By practising the best kind of philanthropy; the result will beneft the health of all our patients. If a physician is diagnosed with a reportable condi- tory agency, tion, the treating physician is required to report the case to the • outline the consequences of a failure to report, and individual or offce designated in the legislation. Residents who • identify sources of support to guide decision-making in are being treated for serious health issues must also consider this area. A number of colleges include questions Case on licence applications or renewal forms pertaining to alcohol A third-year resident involved in treating a surgeon in or drug dependence and any physical or mental conditions Manitoba is aware that the surgeon suffers from alcohol that might affect ftness to practise.

The chairman of a large pathology department is planning for the personnel that he will need in the future etodolac 400 mg lowest price arthritis pain forecast. He is trying to decide whether his department will have more need for a dermatopathologist or a cytopathologist buy cheap etodolac 200 mg on-line arthritis blisters. He decides against the cytopathologist because he expects the number of Pap smears to fall off dramatically in the future. The development of which of the following is the most likely reason for this expected decrease in the number of Pap smears? A 22-year-old woman comes to the physician because of a 1-day history of fever and right flank pain. A previously healthy 30-year-old woman comes to the physician for a follow-up visit after a chest x-ray shows bilateral hilar adenopathy and a calcified 1-cm nodule in the periphery of the right lower lobe. Specially stained sections of a bronchial biopsy specimen show no acid-fast bacilli or fungi. A 3-year-old girl is brought to the emergency department 30 minutes after she tripped and fell. Physical examination shows blue sclera and edema and tenderness over the right proximal lower extremity. X-rays show a fracture of the right femur, as well as several fractures of varying ages of the left clavicle, right humerus, and right fibula. A 50-year-old man with type 2 diabetes mellitus has a 1-week history of swelling and a feeling “like electric shocks” in his right wrist and hand. He is a computer programmer, and the shock-like feeling is worse with activity and at the end of the day. With the hand hyperextended, pain radiates into the fingers when the examiner taps the flexor surface of the distal wrist. A 3-year-old boy is brought to the physician because of a 2-day history of fever and an itchy rash. Physical examination shows multiple red papules and vesicles over the face, trunk, and upper and lower extremities. E - 54 - Pharmacology Systems General Principles of Foundational Science 25%–30% Pharmacodynamic and pharmacokinetic processes Bacteria Antibacterial agents Viruses Antiviral agents Fungi Antifungal agents Parasites Antiparasitic agents Immune System 1%–5% Blood & Lymphoreticular System 1%–5% Behavioral Health 5%–10% Nervous System & Special Senses 5%–10% Skin & Subcutaneous Tissue 1%–5% Musculoskeletal System 1%–5% Cardiovascular System 5%–10% Respiratory System 5%–10% Gastrointestinal System 5%–10% Renal & Urinary System 5%–10% Pregnancy, Childbirth, & the Puerperium 1%–5% Female Reproductive & Breast 1%–5% Male Reproductive 1%–5% Endocrine System 5%–10% Multisystem Processes & Disorders 5%–10% - 55 - 1. Ten months after starting procainamide therapy for cardiac arrhythmias, a 56-year-old man develops arthritis and other symptoms consistent with drug-induced systemic lupus erythematosus. This finding is consistent with which of the following genetic polymorphisms in drug metabolism? He has been taking a drug for the past 7 years to control severe behavioral and psychiatric symptoms associated with dementia, Alzheimer type. Therapy is started with trimethoprim- sulfamethoxazole, and his pneumonia resolves. The pharmacotherapy was effective because of inhibition of which of the following? A 62-year-old man comes to the physician because of burning pain and tenderness of his right great toe 1 day after heavy ethanol consumption. Physical examination shows erythema, swelling, warmth, and tenderness of the right great toe. After a 2-week course of nonsteroidal anti-inflammatory drug treatment, his symptoms decrease in severity but do not completely resolve.

The rate at which these rise depends on a number of factors generic 200 mg etodolac otc painkillers for cats with arthritis, including how Clinical features catabolic the patient is cheap 300mg etodolac visa arthritis in fingers nodules, i. Complete anuria is only seen with bladder out- Oliguria (urine output <15 mL/hour or <400 mL/ flow obstruction, bilateral (or unilateral in a single 24hour) is common, but does not occur with all causes functioning kidney) ureteric obstruction. Water retention can lead to r Hyperventilationmaybeduetohypoxiaorrespiratory hyponatraemia. Hypovolaemia Bleeding, dehydration, r Urgent urinalysis, followed by microscopy (to look for and/or diuretics hypotension Sepsis, cardiac failure, drugs cells and casts) and culture. Acute glomeru- Primary and secondary causes r Bloods lonephritis of glomerular disease Acute interstitial Pyelonephritis, drugs 1 Anaemia (normochromic, normocytic if underly- nephritis ing disease or in chronic renal failure). These include autoantibody profile, com- It is important to assess the volume status by assess- plement levels, blood and urine tests for myeloma and ing blood pressure, jugular venous pressure, skin turgor, possibly a renal biopsy. Management Acute renal failure is an emergency, with possible life- threatening complications. Complications Reversiblecausesshouldbetreatedassoonaspossible; Hyperkalaemia may cause cardiac arrhythmias and sud- withdraw any potentially nephrotoxic drugs, treat sepsis, den death. Fluid overload may cause cardiac failure, malignant hypertension, and relieve any obstruction. Fluidchallengesmaybe 236 Chapter 6: Genitourinary system required with regular review to ensure that the patient Indications for urgent dialysis does not become fluid overloaded. Central venous r Persistent hyperkalaemia >6 mmol/L despite medical pressure measurement may be helpful, but should therapy not be relied upon over clinical assessment espe- r Severe acidosis cially in the presence of cardiac or pulmonary disease. If blood pressure remains low Prognosis despite filling (such as due to cardiac insufficiency, Depends on underlying cause and concomitant medical sepsis), then additional treatment, usually inotropic conditions. Definition r In fluid overload, or in oliguric renal failure high doses Necrosis of renal tubular epithelium as caused by hypop- of furosemide may be effective in causing a diuresis. However, there is no good evidence that furosemide speeds the recovery from renal failure, and it should Aetiology be avoided in those thought to have pre-renal failure. In addi- tion, in shock renal blood flow is particularly likely to Hyperkalaemia suffer because of constriction of renal vessels due to r Treatseverehyperkalaemia(K>6. Toxin induced r Endogenous Haemoglobinuria, myoglobinuria, Review all medication for dosages in renal failure. Chapter 6: Disorders of the kidney 237 sympathetic activity and the release of vasoconstrictive Table6. Glomerulonephritis 12% Toxinsmayhaveavarietyofmechanismssuchascaus- Pyelonephritis/reflux nephropathy 10% ing vasoconstriction, a direct toxic effect on tubular cells Renovascular disease 7% Hypertension 6% causing their dysfunction, and they may also cause the Adult polycystic kidney disease 6% death of tubular epithelial cells which block the tubules. Blockageoftherenaltubulescauses renal function requiring any form of chronic renal re- asecondary reduction in glomerular blood flow. The ep- Incidence ithelial cells take time to differentiate and develop their The exact number of people with chronic renal failure is concentrating function. This phase renal disease such as amyloid, myeloma, systemic lupus may last many weeks, depending on the initial severity erythematosus and gout. Initially there may be a phase of large Prognosis volumes of dilute urine production due to reduction In acute tubular necrosis the mortality is high but if in tubular reabsorption. The kidneys are usually small and shrivelled, with 3 The hormone functions of the kidney are also affected: scarring of glomeruli, interstitial fibrosis and tubular at- reduction of vitamin D activation causes hypocal- rophy. The onset of uraemia is insidious, but by the time vious historical urea and creatinine measurements are serum urea is >40 mmol/L, creatinine >1000 µmol/L, very useful. Late symptoms include r U&E to assess progress of the renal failure, ensure Na+ pruritis, anorexia, nausea and vomiting – very late and K+ are normal.

Research-orientated: development of therapeutic proteins Identification of The number of good molecular targets for new molecular therapeutic proteins is limited targets Assessment Pick the winners buy etodolac 400mg online arthritis vitiligo; assessment in cellular and animal of available models and new targets Design of therapeutic proteins buy 200mg etodolac free shipping arthritis x ray foot, e. Most important Modern medical biotechnology uses a wide range drug group: therapeutic of methods to diagnose and treat diseases – from proteins the biotechnological production of simple natu- ral products to gene therapy. The most important group of biotechnological drugs by far, however, are the thera- peutic proteins. Most therapeutic proteins are chemical mes- sengers, enzymes or, especially in recent times, monoclonal an- tibodies. Now these molecules can be produced in genetical- ly modified cells that carry the hereditary information for pro- ducing the human protein. Main avenues of research 41 In addition, new findings from basic research now allow thera- peutic proteins to be coupled with non-protein components to improve their efficacy and duration of action. Since the substance is produced mainly in the kidneys, patients with renal damage are prone to develop anemia. Those affected – often dialysis patients – generally feel weak and tired, because their red blood cells no longer carry sufficient supplies of oxygen to the body. Since the early 1990s recombinant erythropoietin has replaced time-consuming, costly and risky blood transfusions, previous- ly the standard treatment for anemic patients. Because the hor- mone is a glycoprotein (see illustration), it cannot be produced in bacterial or yeast-cell cultures: the erythropoietin molecule has several carbohydrate side chains that slow its breakdown in the body but also modify its intrinsic bioactivity. These side chains can be attached to proteins only by the synthe- Erythropoietin: the molecule sising apparatus found in carbohydrate chain mammalian cells. For this reason, only mammalian cells can be used to produce complex therapeutic pro- teins. In renal clinical trials untreated anemic patients can ex- perience a correction of their anemia with one injection twice a month. Patients who are in maintenance can be managed with a single monthly injection whether they have reached end stage renal disease (chronic kidney disease stage 5) or not (typically chronic kidney disease stages 3 and 4). Less frequent adminis- trations reduce the oscillation in hemoglobin levels outside the optimal range of hemoglobin as defined by best practice guide- lines, which is often seen with existing short-acting compounds (epoetin, darbepoetin). Such excursions are associated with ad- verse events and considered to contribute to further deterio- ration of cardiac and renal functions. It is believed that less fre- quent administrations represent a significant gain in quality of life for patients but also allow overworked nephrologists and nurses to concentrate on the other serious medical conditions affecting many of these patients such as hypertension, diabetes, chronic heart failure and obesity. The principle of Improved efficacy of proteins can be achieved pegylation: Pegasys with the help of specific modifications. It is essential to select the proper moiety that will confer Main avenues of research 43 to the active protein the de- A pegylated protein: Pegasys sired properties. The choice of linker is also very impor- tant as its rigidity (or lack thereof) will influence the ultimate properties of the new medicine. Roche has successfully applied this principle to develop a drug for the treatment of hepati- tis C and B. In this method the drug is enveloped in one or two highly branched molecules of polyethylene glycol. It has been used for de- cades for treating hepatitis C, a widespread infection which causes inflammation of the liver. To date no treatment exists that is able to eradicate the hepatitis C virus from the body. As a result, drug levels in the patients’ blood- stream undergo significant fluctuations in a two-day rhythm, giving rise to side effects and limit efficacy. It is also considered that fluctuation is instrumental promoting the appearance of resistant viruses.