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46

Drugs for neuropathic pain

The patient is a 63 year old freelance editor with type 2 diabetes diagnosed about five years ago that is relatively well controlled with insulin. He has early signs of retinopathy, with normal kidney function and electrocardiogram. Lipid values are normal with diet and atorvastatin 20 mg/day. He developed autonomic and peripheral neuropathy a few months ago, and now experiences postural hypotension and burning pain and clumsiness in his feet. His pain makes concentration and falling asleep difficult. He asks his general practitioner for painkillers to help him continue working.  
bmj.com
over 5 years ago
Static.www.bmj
1
36

Hoarseness in a 79 year old woman

A 79 year old woman was referred to our ear, nose, and throat outpatient clinic with a history of hoarse voice. This symptom had been present for around three months. It initially fluctuated in severity but eventually became constant. There was no associated pain, weight loss, cough, dysphagia, odynophagia, or other upper airway symptoms. She had not recently had surgery or experienced trauma. Her medical history was of chronic obstructive pulmonary disease, and she was an ex-smoker.  
bmj.com
over 5 years ago
Www.bmj
1
49

A man with a mass in the thigh

A 54 year old man presented to his general practitioner because of a fullness in his left lateral thigh that he first noticed while playing golf, although it was not related to an identifiable injury. He had a history of hypertension and fibromyalgia and was taking atenolol, ramipril, pregabalin, and tramadol but was otherwise well. The GP thought that the swelling was caused by a muscular injury, but the patient re-presented four months later because the mass had grown from a small bump to a swelling of 8 cm in diameter. It was also beginning to cause some knee stiffness but no pain. On examination he had a large firm swelling in his lateral thigh. On this occasion his GP referred him on a two week wait to the regional plastic surgery department. An ultrasound scan showed a 6 × 8 cm intramuscular mass with cystic changes and patchy neovascularity, but no inguinal or pelvic lymphadenopathy. Ultrasonography was followed by magnetic resonance imaging, with and without gadolinium contrast (fig 1⇓).  
bmj.com
over 5 years ago
Www.bmj
1
19

A man with fever, a productive cough, and a striking chest radiograph

A 41 year old man presented to the emergency department with a two week history of worsening shortness of breath. Associated symptoms included a cough productive of green sputum, intermittent fevers, night sweats, and non-pleuritic pain in the right side of the chest wall. He had a history of chronic pancreatitis secondary to alcohol excess, which was complicated by diet controlled type 2 diabetes. He also smoked 40 cigarettes a day.  
bmj.com
over 5 years ago
Www.bmj
1
25

A man with fever, a productive cough, and a striking chest radiograph

A 41 year old man presented to the emergency department with a two week history of worsening shortness of breath. Associated symptoms included a cough productive of green sputum, intermittent fevers, night sweats, and non-pleuritic pain in the right side of the chest wall. He had a history of chronic pancreatitis secondary to alcohol excess, which was complicated by diet controlled type 2 diabetes. He also smoked 40 cigarettes a day.  
www.bmj.com
over 5 years ago
Www.bmj
2
56

A man with a mass in the thigh

A 54 year old man presented to his general practitioner because of a fullness in his left lateral thigh that he first noticed while playing golf, although it was not related to an identifiable injury. He had a history of hypertension and fibromyalgia and was taking atenolol, ramipril, pregabalin, and tramadol but was otherwise well. The GP thought that the swelling was caused by a muscular injury, but the patient re-presented four months later because the mass had grown from a small bump to a swelling of 8 cm in diameter. It was also beginning to cause some knee stiffness but no pain. On examination he had a large firm swelling in his lateral thigh. On this occasion his GP referred him on a two week wait to the regional plastic surgery department. An ultrasound scan showed a 6 × 8 cm intramuscular mass with cystic changes and patchy neovascularity, but no inguinal or pelvic lymphadenopathy. Ultrasonography was followed by magnetic resonance imaging, with and without gadolinium contrast (fig 1⇓).  
bmj.com
over 5 years ago
Www.bmj
1
12

What is an “n-of-1” trial?

Researchers assessed the effectiveness of “n-of-1” trials for the short term choice of drugs for osteoarthritis. The efficacy of sustained release paracetamol was compared with celecoxib in the management of symptoms associated with osteoarthritis. A series of double blind randomised n-of-1 controlled trials using a double dummy design was performed. The intervention was sustained release paracetamol (two 665 mg tablets, three times a day), or celecoxib (200 mg daily, or 200 mg twice a day for those who were already using this dose). Each treatment regimen was taken for two weeks, administered for three treatment cycles. The primary outcome measures included pain, stiffness, and functional limitation scores; preferred treatment; and adverse effects.1  
bmj.com
over 5 years ago
Www.bmj
1
33

Triptans for symptomatic treatment of migraine headache

A 30 year old woman has debilitating, pulsating right sided headaches up to twice a month for several years. Her pain builds up rapidly and usually lasts 24 hours. She has to lie down during episodes, which are associated with sensitivity to light, severe nausea, and occasional vomiting. Over the counter analgesics such as ibuprofen or paracetamol were initially helpful in relieving pain, but not recently. She asks if any treatments may help with her headaches and allow her to return to her usual activities sooner.  
bmj.com
over 5 years ago
Www.bmj
1
12

A man with fever, a productive cough, and a striking chest radiograph

A 41 year old man presented to the emergency department with a two week history of worsening shortness of breath. Associated symptoms included a cough productive of green sputum, intermittent fevers, night sweats, and non-pleuritic pain in the right side of the chest wall. He had a history of chronic pancreatitis secondary to alcohol excess, which was complicated by diet controlled type 2 diabetes. He also smoked 40 cigarettes a day.  
www.bmj.com
over 5 years ago
Www.bmj
1
18

The end of life

Increasingly, US physicians face legal risks for doing too much or too little to help patients with end of life issues. On one hand, doctors are under more pressure to hold discussions with people who are diagnosed with terminal illnesses—exploring whether they would want to stop treatment if it became ineffective. In that case, the patient would shift to palliative care, which involves pain medications and other therapies to enhance quality of life.  
bmj.com
over 5 years ago
Www.bmj
1
37

A man with a mass in the thigh

A 54 year old man presented to his general practitioner because of a fullness in his left lateral thigh that he first noticed while playing golf, although it was not related to an identifiable injury. He had a history of hypertension and fibromyalgia and was taking atenolol, ramipril, pregabalin, and tramadol but was otherwise well. The GP thought that the swelling was caused by a muscular injury, but the patient re-presented four months later because the mass had grown from a small bump to a swelling of 8 cm in diameter. It was also beginning to cause some knee stiffness but no pain. On examination he had a large firm swelling in his lateral thigh. On this occasion his GP referred him on a two week wait to the regional plastic surgery department. An ultrasound scan showed a 6 × 8 cm intramuscular mass with cystic changes and patchy neovascularity, but no inguinal or pelvic lymphadenopathy. Ultrasonography was followed by magnetic resonance imaging, with and without gadolinium contrast (fig 1⇓).  
bmj.com
over 5 years ago
Www.bmj
1
41

A man with a mass in the thigh

A 54 year old man presented to his general practitioner because of a fullness in his left lateral thigh that he first noticed while playing golf, although it was not related to an identifiable injury. He had a history of hypertension and fibromyalgia and was taking atenolol, ramipril, pregabalin, and tramadol but was otherwise well. The GP thought that the swelling was caused by a muscular injury, but the patient re-presented four months later because the mass had grown from a small bump to a swelling of 8 cm in diameter. It was also beginning to cause some knee stiffness but no pain. On examination he had a large firm swelling in his lateral thigh. On this occasion his GP referred him on a two week wait to the regional plastic surgery department. An ultrasound scan showed a 6 × 8 cm intramuscular mass with cystic changes and patchy neovascularity, but no inguinal or pelvic lymphadenopathy. Ultrasonography was followed by magnetic resonance imaging, with and without gadolinium contrast (fig 1⇓).  
bmj.com
over 5 years ago
Www.bmj
1
15

What is an “n-of-1” trial?

Researchers assessed the effectiveness of “n-of-1” trials for the short term choice of drugs for osteoarthritis. The efficacy of sustained release paracetamol was compared with celecoxib in the management of symptoms associated with osteoarthritis. A series of double blind randomised n-of-1 controlled trials using a double dummy design was performed. The intervention was sustained release paracetamol (two 665 mg tablets, three times a day), or celecoxib (200 mg daily, or 200 mg twice a day for those who were already using this dose). Each treatment regimen was taken for two weeks, administered for three treatment cycles. The primary outcome measures included pain, stiffness, and functional limitation scores; preferred treatment; and adverse effects.1  
www.bmj.com
over 5 years ago
Www.bmj
1
32

An adolescent athlete with groin pain

A 14 year old boy felt a mild aching discomfort in his left groin while playing rugby but still continued to play. He subsequently tackled an opponent and developed a severe pain of sudden onset in the left upper thigh and groin. A “snapping” sound was heard and he fell to the ground. He was unable to bear weight on the left leg and appeared pale, clammy, and nauseated. His pitch-side vital observations were normal and he was offered combined gaseous nitrous oxide and oxygen for pain relief. Ice was applied to the area of maximum discomfort and he was accompanied to the emergency department in an ambulance. At the emergency department he was advised that he had probably “strained” a muscle and was given conservative advice. He was discharged with crutches and analgesia.  
bmj.com
over 5 years ago
Www.bmj
1
35

An adolescent athlete with groin pain

A 14 year old boy felt a mild aching discomfort in his left groin while playing rugby but still continued to play. He subsequently tackled an opponent and developed a severe pain of sudden onset in the left upper thigh and groin. A “snapping” sound was heard and he fell to the ground. He was unable to bear weight on the left leg and appeared pale, clammy, and nauseated. His pitch-side vital observations were normal and he was offered combined gaseous nitrous oxide and oxygen for pain relief. Ice was applied to the area of maximum discomfort and he was accompanied to the emergency department in an ambulance. At the emergency department he was advised that he had probably “strained” a muscle and was given conservative advice. He was discharged with crutches and analgesia.  
bmj.com
over 5 years ago
Preview
1
22

Otalgia

 
almostadoctor.com - free medical student revision notes
over 5 years ago
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1
47

Pushing Back the Pain Barrier - The Naked Scientists

Naked Scientists - 25th Jun 2011 - Pushing Back the Pain Barrier  
thenakedscientists.com
over 5 years ago
Preview
1
32

Painful diabetic neuropathy

Diabetes is a worldwide epidemic, and associated neuropathy is its most costly and disabling complication. Given the rising prevalence of painful diabetic neuropathy, it is increasingly important that we understand the best ways to diagnose and treat this condition. Diagnostic tests in this field are evolving rapidly. These include the use of skin biopsies to measure small unmyelinated fibers, as well as even newer techniques that can measure both small unmyelinated fibers and large myelinated fibers in the same biopsy. The main treatments for painful diabetic neuropathy remain management of the underlying diabetes and drugs for the relief of pain. However, emerging evidence points to major differences between type 1 and type 2 diabetes, including the ability of glycemic control to prevent neuropathy. Enhanced glucose control is much more effective at preventing neuropathy in patients with type 1 diabetes than in those with type 2 disease. This dichotomy emphasizes the need to study the pathophysiologic differences between the two types of diabetes, because different treatments may be needed for each condition. The impact of the metabolic syndrome on neuropathy in patients with type 2 diabetes may account for the difference between the two types of diabetes and requires further study. Finally, neuropathic pain is under-recognized and undertreated despite an ever evolving list of effective drugs. Evidence exists to support several drugs, but the optimal sequence and combination of these drugs are still to be determined.  
www.bmj.com
over 5 years ago
Preview
1
22

Painful diabetic neuropathy

Diabetes is a worldwide epidemic, and associated neuropathy is its most costly and disabling complication. Given the rising prevalence of painful diabetic neuropathy, it is increasingly important that we understand the best ways to diagnose and treat this condition. Diagnostic tests in this field are evolving rapidly. These include the use of skin biopsies to measure small unmyelinated fibers, as well as even newer techniques that can measure both small unmyelinated fibers and large myelinated fibers in the same biopsy. The main treatments for painful diabetic neuropathy remain management of the underlying diabetes and drugs for the relief of pain. However, emerging evidence points to major differences between type 1 and type 2 diabetes, including the ability of glycemic control to prevent neuropathy. Enhanced glucose control is much more effective at preventing neuropathy in patients with type 1 diabetes than in those with type 2 disease. This dichotomy emphasizes the need to study the pathophysiologic differences between the two types of diabetes, because different treatments may be needed for each condition. The impact of the metabolic syndrome on neuropathy in patients with type 2 diabetes may account for the difference between the two types of diabetes and requires further study. Finally, neuropathic pain is under-recognized and undertreated despite an ever evolving list of effective drugs. Evidence exists to support several drugs, but the optimal sequence and combination of these drugs are still to be determined.  
www.bmj.com
over 5 years ago
Preview
1
19

Painful diabetic neuropathy

Diabetes is a worldwide epidemic, and associated neuropathy is its most costly and disabling complication. Given the rising prevalence of painful diabetic neuropathy, it is increasingly important that we understand the best ways to diagnose and treat this condition. Diagnostic tests in this field are evolving rapidly. These include the use of skin biopsies to measure small unmyelinated fibers, as well as even newer techniques that can measure both small unmyelinated fibers and large myelinated fibers in the same biopsy. The main treatments for painful diabetic neuropathy remain management of the underlying diabetes and drugs for the relief of pain. However, emerging evidence points to major differences between type 1 and type 2 diabetes, including the ability of glycemic control to prevent neuropathy. Enhanced glucose control is much more effective at preventing neuropathy in patients with type 1 diabetes than in those with type 2 disease. This dichotomy emphasizes the need to study the pathophysiologic differences between the two types of diabetes, because different treatments may be needed for each condition. The impact of the metabolic syndrome on neuropathy in patients with type 2 diabetes may account for the difference between the two types of diabetes and requires further study. Finally, neuropathic pain is under-recognized and undertreated despite an ever evolving list of effective drugs. Evidence exists to support several drugs, but the optimal sequence and combination of these drugs are still to be determined.  
www.bmj.com
over 5 years ago