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By C. Marus. State University of New York at Oswego.

Adequate inspira- tion is important in order to visualise the lung fields clearly and to avoid the impression of cardiomegaly and prominent pulmonary vasculature13 discount accutane 30mg online. Age of child Optimum inspiration 0–3 years 6 anterior ribs generic 20 mg accutane otc, 8 posterior ribs 3–7 years 6 anterior ribs buy accutane 20mg overnight delivery, 9 posterior ribs 8 years + 6 anterior ribs order 10 mg accutane fast delivery, 10 posterior ribs Exposure A correctly exposed radiograph should demonstrate pulmonary vessels in the central two-thirds of the lung fields without evidence of blurring generic accutane 30mg without a prescription. The trachea and major bronchi should also be visible as should the intervertebral disc spaces of the lower thoracic spine through the heart. Artefacts Care should be taken to avoid artefacts on children’s clothing (e. Supplementary radiographic projections of the chest and upper respiratory tract Lateral chest The lateral chest should not be undertaken routinely and should only be per- formed if referral criteria satisfy departmental protocols for a lateral projection or following discussion with a radiologist. Lateral chest radiography is often easier to perform on young children if they are seated. The child sits or stands with the side under investigation closest to an appropriately sized cassette. The patient’s chin is raised and the arms are flexed at the elbow and held on either side of the head by a suitably protected guardian to prevent rota- tion. The primary beam is centred to the middle of the area of interest and colli- mated to within the area of the cassette. Radiographic assessment criteria of lateral chest The posterior aspects of the ribs should be superimposed and the vertebrae should be seen without rotation. The radiograph should include the whole of the chest from the apices to the diaphragm. Lateral decubitus (antero-posterior) The lateral decubitus projection is useful when a horizontal beam projection is required and the patient cannot be positioned erect. If a pneumothorax is sus- pected, the projection should be undertaken with the affected side uppermost while if a pleural effusion is suspected, the affected side should be lowermost. The child lies on their side on top of rectangular foam pads of suitable length to allow the whole of the chest to be visualised on the resultant radiograph. The cassette is placed behind the child and the child is positioned such that the median sagittal plane is 90° to the cassette. The child’s knees are flexed to provide The chest and upper respiratory tract 59 stability and the arms are flexed and placed in front of their head. An appropri- ately protected adult may hold the cassette and the patient’s hands if required. Radiographic assessment criteria of lateral decubitus The appropriate area of interest to be included is from the apices, including all of the first rib, to the costophrenic angles and the outer margins of the ribs laterally. Lateral soft tissue neck This projection may be required to investigate a suspected foreign body or soft tissue swelling. The patient is seated so that the median sagittal plane is paral- lel to the cassette. The chin is raised and the head and neck are carefully posi- tioned to reduce lateral rotation. A rectangular sponge placed between the cassette and the child’s head may assist in maintaining the position and with immobilisation. The arms are relaxed at the side of the patient and, in young children, it may be advantageous for the guardian to be seated in front of the child, holding the arms and encouraging them to maintain the position. A long rectangular sponge is placed behind the patient’s back to assist in immobilisation. The horizontal beam is centred midway between the sternal notch and the mastoid process. Radiographic assessment criteria of lateral soft tissue neck The mandibular rami should be superimposed and the pharynx and trachea down to the level of the thoracic inlet should be included and outlined with air. Post-nasal space A well-collimated lateral projection of the post-nasal space will demonstrate soft tissue encroachment onto the air-filled pharynx (e. The head is then rotated so that the median sagittal plane is parallel to the cassette. Immobilisation is achieved by ensuring that both hands hold the erect cassette holder (Fig. For examination of a young child, a suit- ably protected guardian may need to hold the head still. Exposure should be made with the patient’s mouth closed on gentle inspiration.

Diabetes mellitus Yes Explanation: All sports can be played with proper attention to diet buy 5mg accutane otc, blood glucose concentration discount 30 mg accutane with amex, hydration 10mg accutane mastercard, and insulin therapy generic accutane 5 mg without a prescription. Blood glucose concentration should be monitored every 30 min during continuous exercise and 15 min after completion of exercise purchase accutane 10mg otc. Diarrhea Qualified no Explanation: Unless disease is mild, no participation is permitted, because diarrhea may increase the risk of dehydration and heat illness. Eating disorders Qualified yes Anorexia nervosa Bulimia nervosa Explanation: Patients with these disorders need medical and psychiatric assessment before participation. Eyes Qualified yes Functionally one-eyed athlete Loss of an eye Detached retina Previous eye surgery or serious eye injury Explanation: A functionally one-eyed athlete has a best-corrected visual acuity of less than 20/40 in the eye with worse acuity. These athletes would suffer significant disability if the better eye were seriously injured, as would those with loss of an eye. Some athletes who previously have undergone eye surgery or had a serious eye injury may have an increased risk of injury because of weakened eye tissue. Availability of eye guards approved by the American Society for Testing and Materials and other protective equipment may allow participation in most sports, but this must be judged on an individual basis (Kurowski and Chandran, 2000; Maron et al, 1996). Fever No Explanation: Fever can increase cardiopulmonary effort, reduce maximum exercise capacity, make heat illness more likely, and increase orthostatic hypertension during exercise. Fever may rarely accompany myocarditis or other infections that may make exercise dangerous. Heat illness, history of Qualified yes Explanation: Because of the increased likelihood of recurrence, the athlete needs individual assessment to determine the presence of predisposing conditions and to arrange a prevention strategy. Hepatitis Yes Explanation: Because of the apparent minimal risk to others, all sports may be played that the athlete’s state of health allows. In all athletes, skin lesions should be covered properly, and athletic personnel should use universal precautions when handling blood or body fluids with visible blood (Risser et al, 1985). Human immunodeficiency virus infection Yes (continued) CHAPTER 12 THE PREPARTICIPATION PHYSICAL EXAMINATION 73 Table 12-5 (Continued) CONDITION MAY PARTICIPATE Explanation: Because of the apparent minimal risk to others, all sports may be played that the athlete’s state of health allows. In all athletes, skin lesions should be covered properly, and athletic personnel should use universal precautions when handling blood or body fluids with visible blood (Risser et al, 1985). Kidney, absence of one Qualified yes Explanation: Athlete needs individual assessment for contact, collision, and limited-contact sports. Liver, enlarged Qualified yes Explanation: If the liver is acutely enlarged, participation should be avoided because of risk of rupture. If the liver is chronically enlarged, individual assessment is needed before collision, contact, or limited-contact sports are played. Malignant neoplasm Qualified yes Explanation: Athlete needs individual assessment. Musculoskeletal disorders Qualified yes Explanation: Athlete needs individual assessment. Neurologic disorders History of serious head or spine trauma, severe or repeated concussions, or crainotomy (Sallis, 1996; Smith and Qualified yes Laskowski, 1998). Explanation: Athlete needs individual assessment for collision, contact, or limited-contact sports and also for noncontact sports if deficits in judgment or cognition are present. Research supports a conservative approach to management of concussion (Sallis, 1996; Smith and Laskowski, 1998). Seizure disorder, well-controlled Yes Explanation: Risk of seizure during participation is minimal Seizure disorder, poorly controlled Qualified yes Explanation: Athlete needs individual assessment for collision, contact, or limited-contact sports. The following noncontact sports should be avoided: archery, riflery, swimming, weight or power lifting, strength training, or sports involving heights. In these sports, occurrence of a seizure may pose a risk to self or others. Obesity Qualified yes Explanation: Because of the risk of heat illness, obese persons need careful acclimatization and hydration. Organ transplant recipient Qualified yes Explanation: Athlete needs individual assessment. Ovary, absence of one Yes Explanation: Risk of severe injury to the remaining ovary is minimal. Respiratory conditions Pulmonary compromise, including cystic fibrosis Qualified yes Explanation: Athlete needs individual assessment, but generally, all sports may be played if oxygenation remains satisfactory during a graded exercise test. Patients with cystic fibrosis need acclimatization and good hydration to reduce the risk of heat illness. Asthma Yes Explanation: With proper medication and education, only athletes with the most severe asthma will need to modify their participation.

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Colchicine is not an analgesic and is gener- tle differences in pharmacodynamics accutane 20 mg without prescription. Indomethacin (Indocin) Pyrrolo Sulindac (Clinoril) Ketorolac tromethamine Tolmetin sodium (Tolectin) (Toradol) have preceding GI problems buy accutane 20 mg, and prophylactic treat- Phenylacetic acids Coxibs ment with antacids and H2 blockers was of marginal Diclofenac sodium (Voltaren) Celecoxib (Celebrex) value for duodenal ulcers and of no value for gastric Diclofenac potassium (Cataflam) Rofecoxib (Vioxx) ulcers buy accutane 30mg overnight delivery. Benzylacetic acid Valdecoxib (Bextra) The relative risk of a GI-provoked hospitalization was Bromfenac sodium (Duract) more than five times greater in patients taking NSAIDs buy discount accutane 20mg on line. A toxicity index in patients with rheumatoid arthritis revealed that salsalate and ibuprofen are the least toxic and tolmetin sodium buy 5 mg accutane overnight delivery, meclofenamate, and indomethacin the most toxic (see Table 10–4 for com- CAUTIONS AND ADVERSE EFFECTS parative NSAID toxicity scores). GASTROINTESTINAL RENAL Gastrointestinal (GI) tract complications associated NSAID-associated kidney problems are common be- with NSAIDs are the most common and are often cause more than 17 million Americans take these drugs. NSAID-associated gastropathy Fenoprofen has been implicated in the development accounts for at least 2600 deaths and 20,000 hospi- of interstitial nephritis. Specific risk factors for renal talizations each year in the United States in patients toxicity include congestive heart failure, coexistent with rheumatoid arthritis alone. In a sensitive individual, significant of these require hospitalization. The result can be acute renal failure, dialy- single most important factor predicting GI bleeding. Patients on NSAIDs for 5 years have a five times Subtle alternations in creatinine clearance are com- greater risk of GI bleeding than those on NSAIDs mon and frequently overlooked. In one study, aspirin for 1 year, and the risk at 1 year is four times greater reduced creatinine clearance by as much as 58% in than it is at 3 months. This most commonly occurs with use HEPATIC of piroxicam, sulindac, or meclofenamate. This elevation is higher in patients with is most often seen with piroxicam. For diclofenac (Voltaren) or diclofenac Tinnitus is most commonly seen with aspirin use, potassium (Cataflam), the base incidence doubles for although nonacetylated salicylates can also cause this every doubling of dose. The most serious hematologic adverse event, CARDIAC aplastic anemia, has been reported with use of The elderly taking NSAIDs daily have an increased phenylbutazone, which is no longer available in the risk of heart problems, especially in the presence of United States but is still available internationally. NSAIDs inhibit prosta- Indomethacin and diclofenac have also been associ- glandins in the kidney and, in doing so, often cause ated with anemia more often than other NSAIDs. Only salsalate The Warfarin Aspirin Study of Heart Failure (WASH) (Disalcid) and choline magnesium trisalicylate randomized 279 congestive heart failure patients to receive either aspirin 300 mg/d, warfarin to a target international ratio of 2. During a mean follow-up of 27 months, 64% in SINGLE DOSE MAXIMAL DAILY the aspirin group required hospitalization compared (mg/kg) DOSE(mg/kg) with 47% in the warfarin group and 48% in the con- Aspirin 10–15 60 trol group. Ibuprofen 10 40 The combined endpoint of death, nonfatal myocardial Indomethacin 1 3 Ketoprofen 2. Anticoagulants NSAIDs are highly protein bound (99%), and, when given with anticoagulants, some displacement of Coumadin will potentiate the effect of warfarin. NSAIDs also reversibly inhibit platelet aggregation (except for aspirin where the effect is irreversible). Hence, for drugs with long elimination times (piroxicam and oxaprozin) the effect lasts days. Giving NSAIDs to patients who are anticoagulated is not contraindicated but caution is advised! Because nonacetylated NSAIDs, such as salsalate and choline magnesium salicylate, do not directly affect platelet function, they are safer but can still potentiate Coumadin by displacing protein-bound drug. Antirheumatic agents Many drugs used in rheumatoid arthritis (azathioprine [Imuran], penicillamine [Depen, Cuprimine], gold compounds, and methotrexate) can cause bone marrow toxicity, including decreased white blood cells and platelets. Corticosteroids Patients who take corticosteroids concurrently are at higher risk for NSAID-induced gastropathy. Diuretics The action of diuretics may be potentiated with concurrent use of NSAIDs. Lithium The pharmacologic activity of lithium is heightened in patients taking NSAIDs. One proposed mechanism is decreased renal clearance because of decreased renal prostaglandin synthesis. Oral hypoglycemic agents Several NSAIDs potentiate oral hypoglycemic agents (fenoprofen, naproxen, and piroxicam) primarily by displacing sulfonylureas from plasma protein binding sites. Phenytoin The effect of phenytoin may be potentiated, again because NSAIDs have a high affinity for protein binding sites and can displace it. This effect has been shown with the same agents noted to displace sulfonylureas, most notably fenoprofen, naproxen, and piroxicam. Probenecid This agent increases plasma levels of indomethacin, naproxen, ketoprofen, and meclofenamate.

In managing chronic nonmalignant pain cheap accutane 40 mg mastercard, most PCPs feel comfortable prescribing nonopioid therapies discount 5mg accutane amex, such as all the classes of nonsteroidal anti- inflammatory drugs purchase accutane 30mg with visa, Tylenol buy cheap accutane 5 mg online, and muscle relaxants cheap accutane 10 mg on-line, and nonpharmacologic treatments such as physical therapy. However, all PCPs have encountered patients for whom these medications and therapies are not enough and who require stronger medications in the form of opioids prescription. Multiple patient, physician, and system-related issues converge to make PCPs often uncomfortable about prescribing opioids for chronic nonmalignant pain (fig. Patient-Related Issues Patients with chronic nonmalignant pain often have no identifiable anatomic lesion that PCPs can point to as a clear cause of pain and that, in a doctor’s mind, better justifies the use of long-term strong opioid medications. Without objective evidence of pathology, there is less to counter the multi- ple forces that weigh in on the side of not prescribing opioids. If PCPs choose Opioids for Chronic Pain in Primary Care 139 Pressures against prescribing Fear of being duped Lack of clear guidelines Criminal justice Fear of addiction DEA system Productivity and time Controversy over effectiveness Patient characteristics: of opioids in chronic pain demanding, personality disorders, comorbid depression Primary care physicians Medical boards Desire to help Patients JCAHO Pharmaceutical companies Pressures for prescribing Fig. Pressures on PCPs against and for prescribing opioids for chronic nonmalig- nant pain. Research has shown that chronic pain patients tend to have a higher preva- lence of comorbid psychiatric disorders, such as depression and borderline personality disorders, and that the presence of these conditions is associ- ated with poorer pain control. Within the past 20 years, PCPs have improved significantly in their treatments of depression, but when depres- sion is combined with chronic pain and personality disorders, these patients often become complicated and frustrating. Prescribing opioids in these situa- tions is something PCPs usually might try to avoid although opioids may be the appropriate treatment depending on the diagnosis, and the type and chronicity of the patient’s pain. If patients feel that their pain is not adequately addressed, they may become demanding and sometimes can give the appearance of being drug-seeking or addicted when in reality they are not. If patients have a history of substance abuse, then the treatment of chronic pain becomes even more difficult for PCPs. This group of patients has almost 4 times the odds of exhibiting prescription opioid abuse behaviors compared to patients without a lifetime history of substance abuse. Often in these patients, however, it becomes difficult to distinguish whether the substance abuse, including prescription pain medicine addiction, came about as a Olsen/Daumit 140 consequence of chronic pain treatment or whether the substance abuse is exac- erbating the chronic pain symptoms. Physician-Related Issues Ask most physicians about why they chose their profession and you will hear the same answer – to in some way or another help people. At medical school graduations across the country, new MDs swear to some version of the Hippocratic oath, promising to live up to this responsibility. When faced with patients who demand extra time and extra attention in the midst of all the pres- sures PCPs face to not prescribe opioids, the Hippocratic oath may become harder to follow. Although no empiric data exists on the difference in lengths of visit in primary care settings for chronic pain patients compared to patients with other chronic diseases of similar severity, busy practitioners faced with demanding chronic pain patients may undertreat or overtreat the pain by hand- ing patients prescriptions for various analgesics, including opioids, without taking the time to really listen to, talk with, or examine them. The data on the addictive potential of opioid prescription drugs is variable, but the fear of creating addicts is one of the most often cited reasons why PCPs feel uncomfortable prescribing opiates. The studies that have addressed this have found that 4% to 31% of patients without substance abuse histories seen in primary care clinics exhibit addictive behaviors with respect to their prescription pain medications. Differences in patient population and different definitions of addiction may explain the variable rates of opioid use disorders noted across these studies. Recent abuses and overdose fatalities from Oxycontin®™ have added fuel to PCPs’ fears of creating addicts in managing chronic nonmalignant pain with opioids. One physician-related issue not often discussed in the debate over the use of opioids by PCPs in the treatment of chronic nonmalignant pain is the fear on the part of PCPs of being duped. No one likes having the wool pulled over their eyes but PCPs pride themselves on the continuity they have with patients and the ability to develop ongoing, meaningful therapeutic relationships with their patients. If the trust developed in that relationship is broken, then PCPs may feel extremely taken advantage of, deceived, and betrayed by someone they were investing time and energy in to help. Although physicians are taught to practice according to evidence-based guidelines, experiences such as these are bound to taint PCPs’ outlooks on similar patients they may encounter. In many areas of the country, particularly rural areas, PCPs also have rel- atively little specialty back up to help guide them in managing difficult patients with chronic nonmalignant pain. Without such resources to turn to, PCPs are Opioids for Chronic Pain in Primary Care 141 left to often conjecture when they should be using other modalities such as ultrasound or pharmacotherapies such as Neurontin, Topamax, or opioids. Medical school and residency curricula and continuing medical education on chronic pain, its evaluation, and treatment are sorely lacking [22, 23]. Residents, faculty, and private PCPs alike bemoan the presence of ‘drug- seeking’ chronic pain patients on their clinic schedules, but partly this stems from their lack of knowledge about how to adequately handle these patients, how to appropriately prescribe opioids, dosing of longer-acting, stronger agents, and the latest techniques for treating chronic pain. Without confidence in their skills and ability to manage chronic nonmalignant pain, PCPs become more sus- ceptible to the various other pressures that influence their prescribing of opioids. James Graves of Florida became the first physician in the country to be convicted of manslaughter for contributing to the fatal over- doses of patients by prescribing Oxycontin. Prior to and following his conviction, numerous other physicians, from family physicians to pain special- ists in Maine, California, Florida, and South Carolina, have been charged with racketeering, drug dealing, and manslaughter through prescribing Oxycontin to patients who subsequently died of overdoses [24–27].

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