Patient history, indications

Osteosarcoma has recently been diagnosed in a 12-year-old girl. Family history indicates that her paternal aunt died of breast cancer at age 29 after having survived treatment for an adrenocortical carcinoma. An uncle died of a brain tumor at age 38 and the patient s father, age 35, has leukemia. 

This patient was treated empirically with vancomycin alone because his physicians suspected that he had endocarditis, caused by Streptococcus of the viridans group. The history indicated that the origin of the infection was the patient s mouth. Three days later the results from the clinical microbiology laboratory showed that three blood cultures, taken at the time of admission, grew Enterococcus faecalis. susceptible to ampicillin, vancomycin, gentamicin, and streptomycin. 

As this patient s history indicated that his problems began soon after he started taking 2 cups of milk with lunch at school and his physical examination and stool examination findings suggested he had carbohydrate malabsorption, a diagnosis of lactose intolerance was made. It was recommended that his milk intake at lunch be decreased to half a cup (about 4 oz). His symptoms improved considerably and almost immediately. His milk intake was then gradually increased such that he was ultimately able to take up to 8 oz of milk without much complaint, especially when the milk was taken with other foods. 

This is the first case of this kind associated with ephedrine, and it seems plausible that the patient s previous history indicated a genetic predisposition to vascular disease. 

In 40 patients who had seizures while taking therapeutic dosages of mianserin it was concluded that mianserin is probably no more likely to produce convulsions in therapeutic dosages than tricyclic compounds (5). When it does so, seizures are more likely to occur in the first 2 weeks of treatment in patients with a family or personal history indicative of risk, and after a dosage increase. 

While the SSRIs are the most frequently used drugs for treatment of major depressions, the tricyclics remain valuable alternatives. In some patients a tricyclic may be the first choice, especially if the past history indicates a positive therapeutic response to such drugs. The sedative actions of tricyclics may be of value in depressed patients with insomnia or weight loss, since SSRIs tend to exacerbate such symptoms. Generic formulations of the tricyclics are much less costly than any of the other antidepressant drugs. 

Iodine-induced thyrotoxicosis in apparently normal thyroid glands has been reported in two patients after exposure to 2—10 mg iodine daily for 2—12 months before thyrotoxicosis was diagnosed. Although the pathogenesis of this kind of IIH remains obscure, the positive family history for thyroid disease in both patients may indicate a latent abnormality of their thyroid glands (Skare and Frey, 1980). Moreover, 10 further cases of iodine-induced thyrotoxicosis in apparently normal thyroid glands have been reported (Savoie et al, 1975). In contrast, a more-than-adequate or excessive iodine intake may lead to hypothyroidism and autoimmune thyroiditis, as shown in China in areas with more than adequate and excessive iodine consumption (Teng et al., 2006). 

III. Contraindications. Known hypersensitivity to the antivenom or to horse serum is a relative contraindication for the Wyeth product antivenom may still be indicated for severe envenomation despite a patient history of allergic reaction. Known hypersensitivity to sheep or sheep semm, or to papain or papayas, are contraindications tor the Protherics product (CroFab). 

The practical conclusion of these observations is if a patient starts with, for example, a maculopapular exanthema due to an important drug, it is probably less dangerous to continue the treatment under close observation, than to stop treatment and to start the next application of the drug in several days or weeks. Alternatively, if the case history indicates an adverse reaction in connection with an earlier treatment period with a given drug or group of drugs, the first new application should be preceded either by a small test dose or possibly by skin or laboratory tests. 

The extraction process begins with a full patient evaluation, including a review of medical history and current therapy, followed by a complete physical examination. Patient history assessment should include a review of the previous indication for device implantation, the indication for extraction procedure, and control of systemic signs of infection. In case of local or systemic infection, it is very important to verify when symptoms or signs appeared. Physical examination should focus on the pocket device. The pocket should be examined to detect pocket device location (prepectoral... 

First, I verify the indication for removal following current guidelines and recommendations [5]. Patient history, physical examination, comorbidities, cardiac function parameters, echocardiography evaluation, medical therapy (antibiotics and cessation of anticoagulants), laboratory tests, and indications for removal are checked to identify very sick and high-risk patients while planning... 

The patient s family history indicated that a maternal uncle had died of an identical disease. This suggested that this disorder was inherited as an X-linked recessive condition. 

Two further cases of hepatocellular carcinoma associated with anabolic steroid therapy have been reported. One was a child with Fanconi s anaemia, who was treated with anabolic steroids for 50 months (2 ). The other also occurred in a patient with Fanconi s anaemia following 4 years medication with androgenic, anabolic steroids (3 ). Examination of the livers of 2 patients with acquired aplastic anaemia who had been treated with similar compounds for 3 months prior to death revealed generalized parenchymal hyperplasia in one and widespread nodular hyperplasia in the other. Since 1971, 10 cases of hepatocellular carcinoma during medication with anabolic steroids have been reported in the literature. The prognosis is poor with a survival time of less than a year. The similar medical history indicates but does not prove a cause-effect relationship between disease and medication. The data must, however, be viewed alongside that pointing to hepatic tumours as complications of treatment with other types of steroids, notably the oral contraceptives. 

Penicillins should be used cautiously in patients witii renal disease, pregnancy (Pregnancy Category C), lactation (may cause diarrhea or candidiasis in die infant), and in tiiose witii a history of allergies. Any indication of sensitivity is reason for caution. The drug is also used witii caution in patients witii asthma, renal disease, bleeding disorders, and gastrointestinal disease. 

When severe anxiety is present, it is important to obtain the history from a family member or friend. During the time the history is taken, the nurse observes the patient for behavioral symptoms indicating anxiety (eg, psychomotor agitation [extreme restlessness], facial grimaces, tense posture). Physiologic manifestations of anxiety include increased blood... 

During tiie ongoing assessment, tiie nurse assesses the respiratory status every 4 hours and whenever tiie drug is administered. The nurse notes the respiratory rate, lung sounds, and use of accessory muscles in breathing, hi addition, tiie nurse keeps a careful record of the intake and output and reports any imbalance, which may indicate a fluid overload or excessive diuresis. It is important to monitor any patient with a history of cardiovascular problems for chest pain and changes in the electrocardiogram. The primary health care provider may order periodic pulmonary function tests, particularly for patients with emphysema or bronchitis, to help monitor respiratory status. 

Increasingly, detoxification is being done on an ambulatory basis, which is much less costly than inpatient detoxification (Hayashida et al. 1989). Inpatient detoxification is indicated for patients with serious medical or surgical illness and for those with a past history of adverse withdrawal reactions or with current evidence of more serious withdrawal reactions (e.g., dehrium tremens) (Feldman et al. 1975). 

Patients requiring detoxification from high or supratherapeutic dosages of benzodiazepines constitute a smaller number of patients, but they are at greater risk for life-threatening discontinuation symptoms, such as seizures, delirium, and psychoses. There has been more experience with inpatient detoxification in this group, but outpatient detoxification is possible if conducted slowly (5% reduction in dose per week), with frequent contact, and in the context of a therapeutic alliance with the patient. Often, such an alliance proves unworkable because the patient s impoverished control results in supplementation from outside sources or early exhaustion of prescribed supplies meant to be tapered. In these cases, as in the cases of patients with a history of seizures, delirium, or psychoses during previous detoxification attempts, inpatient detoxification is indicated. 

In the recently released book on worldwide compliance issues (Adherence to Long-term Therapies, Evidence for Action),7 published by the World Health Organization, researchers indicate that the problem of noncompliance is worse in countries in the developing world than in countries in the industrialized world. Many parts of the United States have similar morbidity and mortality rates as countries in the Third World.8 Specific disease states may have significant additional noncompliance ramifications due to the development of drug-resistant strains of bacteria.9 Many times what is necessary is referral to specific clinicians for individualized treatment and monitoring to enhance compliance. The case histories provided in this text will allow you to follow what others have done in similar situations to optimally help patients succeed in improving compliance rates and subsequent positive health outcomes. 

Conduct a medical history. Does the patient have any compelling indications Is the patient pregnant ... 

HF medications deserves special attention, as it is the most common cause of acute decompensation and can be prevented. As such, an accurate history regarding diet, food choices, and the patient s knowledge regarding sodium and fluid intake (including alcohol) is valuable in assessing dietary indiscretion. Nonadherence with medical recommendations such as laboratory and other appointment follow-up can also be indicative of non-adherence with diet or medications. 

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