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By M. Gunock. Rensselaer Polytechnic Institute.

The average salary for a cardiologist is far higher than that of many other specialties purchase clomiphene 50mg mastercard menstrual extraction abortion. Endocrinology and Metabolism Endocrinologists diagnose and treat illnesses and disorders of the hormone-producing glandular and metabolic systems cheap 50mg clomiphene otc womens health recipes. Endocrinol- ogists see a wide variety of diseases and have patients who range from the very sick to those who need minimal treatment. Endocri- 44 Opportunities in Physician Careers nologists are also often researchers, blending clinical medicine with research. Endocrinology is unique, as few other specialties involve the same level of active research on the part of practitioners. Endocrinologists treat such disorders as thyroid conditions, diabetes, pituitary disorders, calcium disorders, sexual problems, nutritional disorders, and hypertension. Because of the nature of some of the diseases they treat, such as diabetes, there is an educa- tional component in their treatment, as endocrinologists teach patients with an ongoing condition how to manage their illnesses. However, the analytical nature of the subspecialty is what attracts medical students and res- idents. Rapidly developing technology in endocrinology also chal- lenges those pursuing it. In 2002 there were 437 residents training at 118 accredited pro- grams in endocrinology. Three years of internal medicine residency are required with an additional two years in endocrinology and metabolism. Gastroenterology Gastroenterologists diagnose and treat disorders of, or relating to, the digestive system. This includes the stomach, bowels, liver, gall- bladder, and related organs. Gastroenterologists treat such diseases as cirrhosis of the liver, hepatitis, ulcers, cancer, jaundice, inflam- matory bowel disease, and irritable bowel disease. Their caseloads are mostly made up of adults and the elderly, with infants and children forming only a very small percentage of their patient populations. It involves med- Internal Medicine Subspecialties 45 ical investigation, and gastroenterologists enjoy a good mix of patient care, diagnostic challenges, and procedures. Some gastroenterologists say that a frustrating part of their field is dealing with patients who do not comply with treatments or with patients who wait so long for treatment that nothing can be done. It is also troubling to some that the procedures they must do are physically uncomfortable for their patients. These procedures include endoscopy, where the physician examines the intestines through lighted endoscopes. With an endoscope the gastroenterol- ogist can biopsy tissue and remove small growths. Because of invasive procedures like endoscopy, gastroenterology is more surgical than it used to be. Gastroenterologists’ level of responsibility is very high because of the invasiveness of some of the procedures they perform. Gastroenterology is a lucrative field, although the hours are long and there are emergency consultations on nights and weekends. In 2002 there were 1,058 residents in 155 accredited training programs in gastroenterology. Gastroenterologists must finish three years of training in internal medicine and complete another two years in gastroenterology. Hematology Hematology is the subspecialty that deals with blood, blood dis- eases, and the spleen and lymph glands. Many hematology training programs are connected to medical oncology programs, which treat cancer. Hematologists treat all organ systems, but always related to the blood in those systems. This is a rapidly advancing field, and diagnosis and treatment often involve the use of high-tech equipment. Hematologists must contend with the ongoing strain of death, even in the young, but not lose their compassion in the process. The rewarding aspect of this specialty comes with improving patients’ lives. Hematologists treat leukemia, other can- cers of the blood, lymphoma, sickle-cell disease, hemophilia, seri- ous anemia, and secondary problems that arise when a patient has another type of cancer.

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Pseudoaddictive behaviors or those associated with other mental illnesses will usually respond to the appropriate pharmacological and psychosocial therapy discount clomiphene 25mg without prescription menstruation 6 days after ovulation, while true addiction will continue to escalate and declare itself with an ever more exploitative and dangerous pattern buy clomiphene 25mg menopause baby. Even when a patient’s behavior necessitates curtailment of narcotics for the protection of patient and community, providers must not abandon patients but continue to offer health maintenance and preven- tion and therapy for the many medical consequences of substance use. If you’d like more information about this book, its author, or related books and websites, please click here. PAIN MEDICINE AND MANAGEMENT Just the Facts Notice Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the con- traindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs. Wallace, MD Program Director Center for Pain and Palliative Medicine University of California, San Diego La Jolla, California Peter S. Staats, MD, MBA Associate Professor, Division of Pain Medicine Department of Anesthesiology and Critical Care Medicine and Department of Oncology Johns Hopkins University Baltimore, Maryland McGraw-Hill Medical Publishing Division New York Chicago San Francisco Lisbon London Madrid Mexico City Milan New Delhi San Juan Seoul Singapore Sydney Toronto Copyright © 2005 by The McGraw-Hill Companies, Inc. 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Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill’s prior consent. You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited. Your right to use the work may be terminated if you fail to comply with these terms. McGraw-Hill and its licensors do not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free. Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom. McGraw-Hill has no responsibility for the content of any information accessed through the work. Under no circumstances shall McGraw-Hill and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages. This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise. CONTENTS Contributors xi Foreword xvii Preface xix Section I TEST PREPARATION AND PLANNING 1 1 Test Preparation and Planning Stephen E. Yaksh, PhD 9 Section III EVALUATION OF THE PAIN PATIENT 15 4 History and Physical Examination Brian J. Haythornthwaite, PhD 30 Section IV ANALGESIC PHARMACOLOGY 37 9 Topical Agents Bradley S. Gammaitoni, PharmD 37 vii viii CONTENTS 10 Acetaminophen and Nonsteroidal Anti-Inflammatory Drugs Michael W. Clark, MD, MPH 52 12 Anticonvulsant Drugs Misha-Miroslav Backonja, MD 56 13 Sodium and Calcium Channel Antagonists Mark S. Wallace, MD 59 14 Tramadol Michelle Stern, MD, Kevin Sperber, MD, Marco Pappagallo, MD 63 15 Opioids Tony L.

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Abnormal joints clomiphene 25 mg overnight delivery menstrual epilepsy, atlantoaxial subluxation discount clomiphene 100 mg with visa women's health clinic topeka ks, flexible flatfeet, habitual bone brittleness is also present in juvenile osteoporosis, patellar dislocation, muscle hypotonia, capillary fragility while the various forms of osteomalacia also need to (positive Rumpel-Leede test), gastrointestinal problems, be considered in the differential diagnosis. No further mention need be made of type II (lethal ▬ Differential diagnosis: Osteogenesis imperfecta can be form). In the other types, the ability to walk is of crucial confused with camptomelic dwarfism, in which bow- significance for the patient’s quality of life (and probably ing of the long bones also occurs. A study in the UK showed that ingly occur also in cystinosis and pyknodysostosis. It those children who are able to sit up freely by the age of is important to rule out child abuse, in which mul- 10 months will very probably be capable of walking and that tiple fractures are often observed at the same time. In the long term, the telescopic nails cause No known treatment currently exists for the underly- additional iatrogenic joint damage, above and beyond ing condition. A form of gene therapy aimed at replac- the damage that is already produced by the disease, ing the missing enzyme, at least for type I, is currently particularly in the ankle joint. Encouraging results have recently The nails must be custom made for each patient, and been obtained with treatment designed to improve bone the size and thickness of the nails must fit precisely. The orthopaedic treatment must address two main Inserting the nails through bone that is often bowed is problems: the fractures and bowing of the long bones and difficult. The bowing tendency of the bone ▬ The fractures, which occur mainly during childhood places eccentric loads on the nails. Pushed together, represent a huge problem for the affected patients and the two components of the nail can become wedged, their whole environment. Not infrequently the inserted from the knee and which can be locked in the children lost the ability to walk as a result of this sec- distal epiphysis (⊡ Fig. For the femur we ondary osteoporosis, even though they might enjoy have developed a telescopic Gamma nail, which can largely normal bone strength on completion of growth be inserted from the greater trochanter and is locked thanks to the osteogenesis imperfecta. It allows correc- Classical fracture management for children involved tion of the varus deformity, which is always present in conservative treatment with cast fixation or surgical the bowed femur (⊡ Fig. Alternatively, two flexible intramedullary nails can be These two operations are totally unsuitable in osteo- used. These nails are more readily available since they genesis imperfecta since, in addition to the existing can also be used for the management of conventional bone brittleness they introduce further predetermined fractures. Because of their rigidity and the phe- through the epiphysis into the bone. In the femur one nomenon of stress shielding they further reduce bone nail is inserted in each case from the proximal and strength, and repeated fractures usually occur during distal ends. The problem that usually arose was The joints remain unaffected in this procedure. The that the nails became too short with growth, resulting flexible intramedullary nails are much easier to intro- in new fracture sites at the nail end. A breakthrough duce than telescopic nails and custom manufacture is emerged with telescopic nails, which were introduced not required. These are two-part nails in which a during the insertion of the flexible intramedullary pin slides inside a tube. The nails are inserted into both nails since the bone is very brittle and can easily per- epiphyses and advanced through the epiphyseal plate forate. The pin is then introduced into even though no infection is present. As the Spinal deformities: Scolioses, in some cases severe forms bone grows the two parts gradually slide apart, thus often with a pronounced kyphotic component, occur ensuring that the whole bone remains splinted, until in around half of the patients with type I osteogenesis the bone has doubled in length. The treatment of these scolioses is difficult of its operating principle, this system has obvious ad- since corset treatment is ineffective. Surgical treatment vantages since it allows very early weight-bearing and is usually required. Posterior straightening with spinal also prevents fractures occurring later on. No major instrumentation anchored to as many segments as growth disturbance is expected even though the nails possible generally proves sufficient (⊡ Fig.

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