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T. Givess. Marietta College.

Gonococcal infections may lead to an infectious arthritis cheap cleocin 150 mg fast delivery, usually involving the large joint s discount 150mg cleocin visa, and classically is migrat or y purchase cleocin 150mg overnight delivery. In fact order 150 mg cleocin with visa, in the Un it ed St at es, gonorrh ea is the most common cause of septic arthritis in young women. Disseminated gonor- rhea can occur also; affected individuals will usually have eruptions of painful pus- tules with an erythematous base on the skin. Up p e r Ge n it a l Tr a c t In fe c t io n s Pelvic inflammatory disease, or salpingitis, usually involves Chlamydia, gon or rh ea, and ot her vaginal organisms, such as anaerobic bacteria. A common present at ion would be a young, nullipa- rous female complaining of lower abdominal or pelvic pain and vaginal discharge. The patient may also have fever, and nausea and vomiting if the upper abdomen is involved. The cervix is inflamed and, t herefore, t he pat ient oft en complains of dyspareunia. The diagnosis of acute salpingitis is made clinically by abdominal tenderness, cer- vical motion tenderness, and/ or adnexal tenderness ( Tab le 3 6 – 1 ). M ost ep iso d es are asymptomat ic or have mild symptoms; previously, all three criteria were thought to be required before a diagnosis and treatment was initiated, which likely led to insufficient t reat ment and tubal damage. Con fir m at or y t est s may include a posit ive Neisseria gonorrhea or Chlamydia culture, or an ultrasound sug- gest in g a t u b o- ovar ian abscess. O t h er d iseases that mu st be con sid er ed are acu t e appendicit is, especially if t he pat ient has right -sided abdominal pain and ovarian torsion, which usually presents as colicky pain and is associated with an ovarian cyst on ult rasound. Renal disorders, such as pyeloneph rit is or neph rolit h iasis, must also be considered. Right upper quadrant pain may be seen wit h salpingit is when perihepatic adhesions are present, the so-called Fitz-H ugh and Curtis syndrome. The surgeon would look for purulent discharge exuding from t he fimbria of t he t ubes. The treatment of acute salpingitis depends on whether the patient is a candi- date for inpatient versus outpatient therapy (see Table 36– 2). Criteria for outpa- tient management include low-grade fever, tolerance of oral medication, and the absence of perit oneal signs. Single agent qui- nolone therapy had gained popularity previously, but recent evidence has shown increasing bacterial resistance. If the pat ient fails out pat ient t h erapy, or is pregnant, or at the ext remes of age, or cannot t olerat e oral medicat ion, she would be a candidat e for inpat ient t herapy. Again, if the pat ient does not improve wit h in 48 t o 72 h ours, the clinician sh ould con sid er lapar oscopy t o assess the d isease. This d is o r d er gen - erally has anaerobic predominance and necessit at es t he corresponding ant ibiot ic cover age (clin damycin or met r on idazole). T h e ph ysical exam in at ion may su ggest an adnexal mass, or t he ult rasound may reveal a complex ovarian mass. A devast at - ing complicat ion of T O A is rupture, wh ich is a surgical emergency and one t hat leads t o mort alit y if unat t ended. In cont rast t o most abscesses, T O As can oft en be treated with antibiotic therapy without surgical drainage; radiological percutane- ous drainage may sometimes be used to hasten resolution. Long-t erm complicat ions of salpingit is include ch ronic pelvic pain, involunt ary infert ilit y, and ectopic pregnancy. Gonococcal cervicitis can also be asymptomat ic but more oft en produces mucopurulent discharge. Cultures of the purulent drainage would most likely reveal which of the fol- lowing? H er abdominal examination reveals tenderness in the right lower quadrant with some mild rebound tenderness. Pelvic examina- tion shows some cervical motion tenderness and adnexal tenderness, and also some right -sided abdominal tenderness. In con sid er in g the d iffer en t ial d iagn osis of ap p en d icit is ver su s P I D, wh ich of the following is the most accurate method of making the diagnosis? T h e pat ient is given oral azit h romycin t herapy and warned about t he dangers of upper gen it al t r act in fect ion, su ch as P I D. T h e p r esen ce of t r igger p o in t s co r r esp o n d s t o fib r o m yalgia C. On examination, the cervix is erythematous and the discharge reveals numerous leukocytes. O t her vaginal organisms, such as anaerobic bact eria, are also usually involved in t he mix. In the fir st st age of syph ilis, ch an cr es m ay ap p ear on the ext er n al gen it alia or alon g the vagin al wall, bu t n ot in the en d ocer vix as wit h Chla- mydia and gonorrhea. The surgeon has direct visualization of the tubes with this method, and looks for pur u lent disch ar ge exuding from the fimbria of the t ubes. The clinical criteria that may support this diagnosis include: abdominal tenderness, cervical motion tenderness, adnexal tenderness, vaginal discharge, fever, and pelvic mass on physical examination or ultrasound. A pelvic mass, such as a tubo-ovarian abscess, may be visualized using sonography; h owever, it would st ill not spec- ify the origin of the mass. Actinomycesisraelii is a G r am-posit ive an aer obe, wh ich is gen er ally sen sit ive t o p en icillin. Chlamydia and gonorrhea are the only other answer choices t ypically involved in t he development of acute salpingit is; however, neither one of them are associated with sulfur granules. Cent ral locat ion of the pain and exacerbation with menses are more suggestive of a gynecologic et iology. Chlamydial cervicitis is the most common cause of mucopurulent cervical discharge. Although gonorrhea is also associated with a mucopurulent dis- ch ar ge, it is less com m on t h an Chlamydia. T h e mucus in the mu copur u lent discharge is due to involvement of the columnar (mucin-containing) glandu- lar cells of the endocer vix. Patients who engage in oral sex are at increased risk of acquiring gonococ- cal ph ar yn git is. Typically, n o sympt om s are n ot ed by the pat ient u n less the disease disseminates. Chlamydia is not a common cause of pharyngitis most likely because, un like Neisseria gonorrhoeae, it lacks the pili that allow the gon ococcal bact er ia t o ad h er e t o the su r face of the colu m n ar epit h eliu m at the back of the throat. Patients may present with subtle findings and sonography is usually required for diagnosis. Next step: Careful history and physical examination to try to discern what gen er al cat egor y the p ain seem s t o belon g, an d if n on gyn ecologic, r efer t o the appropriate consult ant. Co n s i d e r a t i o n s This is a 42-year-old G2P2 woman with worsening lower abdominal/ pelvic pain of 3 years’duration. We are not given further information about the nature of the pain, but this is critically important to t ry to reach a presumptive diagnosis.

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Exter- Frequently buy 150mg cleocin otc, the collapse also leads to functional obstruction of nally generic cleocin 150 mg visa, bossae create one or more sharp protrusions of alar carti- the nasal valve cheap 150 mg cleocin with amex, opening the door for the secondary sequela of lage discount cleocin 150mg with mastercard, giving the tip a distinctly lumpy and unnatural appear- chronic nasal airway dysfunction. As with the previous two manifestations of overaggressive Another classic manifestation of the overzealous cephalic cartilage excision, nasal bossae are seldom symmetric between trim is retraction of the alar rim. Following excision of the ceph- right and left sides, and tip asymmetry is common. Since the average sufficient strength to resist deformation, contractile forces act- crus is ~12mm wide,5,6 this radical technique eliminates ing to eliminate the skeletal void pull the residual crus upward, roughly 75% of the typical lateral crural width predisposing to resulting in a corresponding cephalic displacement of the adja- severe retraction of the unsupported alar margin. Large voids resulting from aggres- Similarly, the complete rim strip also physically destroys the sive cartilage excision predispose to greater alar retraction and entire nasal scroll—the tubelike condensation of overlapping worsened nasal tip deformity. Externally, the displaced lateral alar cartilage that acts to support the nasal sidewall against col- crural remnant manifests as a V-shaped notch of the alar rim lapse. When combined with subtotal excision of producing excessive columellar show on profile view and exces- the lateral crus, loss of the nasal scroll virtually assures lower sive nostril flaring on frontal view. As with lobular sidewall collapse with severe functional and cosmetic sequelae pinching, alar retraction may also manifest disproportionately in all but the most resilient alar cartilage. Iatrogenic tip deform- between sides resulting in marked nostril asymmetry and exac- ities are particularly common following an aggressive rim strip erbation of the nasal tip deformity. Nasal bossae overlying skin-soft tissue envelope and/or the internal nasal lin- develop when the weakened lateral aural remnant is com- ing. Owing to the strong risk of functional and aesthetic pressed longitudinally in response to prolonged “shrink-wrap” deformities associated with the complete rim strip procedure, contracture. The result is sharp folding or discrete knuckling of coupled with the availability of safer and more effective surgical 665 Complications in Rhinoplasty Fig. Not surprisingly, establishing satisfactory tip sup- traditional rim strip in contemporary rhinoplasty. Yet even port is usually a critical step in the successful correction of most today the practice of subtotal resection of the lateral aura is not iatrogenic nasal tip deformities. Although the aforementioned stigmatic tip deformities may Although the cephalic trim is often the root cause of stigmatic occur in isolation, it is more common to observe two or more postsurgical tip deformities, inadequate central tip support iatrogenic deformities in combination. The typical manifesta- often greatly exacerbates the severity of a weakened lateral tion of an overresected tip is a pinched, overrotated, and asym- aural cartilage. Whether poor tip support is congenital or the metric lobule with flared and retracted nostrils and excessive result of surgical reductions in septal height or septal length or columellar show (▶ Fig. The resulting look is both both, inadequate (septal) tip support leads to additional side- unnatural and strongly suggestive of previous surgical interven- wall laxity and more severe sidewall distortion. Overrotation tion—two features that contemporary rhinoplasty consumers and excessive deprojection of the tip are common manifesta- regard as highly unacceptable. Sadly, such stereotypical tip tions of inadequate septal support, which adds to stigmatic deformities are regularly seen in the expanding population of patients seeking revision rhinoplasty. Moreover, due to their widespread prevalence, the general public often mistakenly regards these deformities as synonymous with state-of-the-art cosmetic nasal surgery. In fact, many prominent rhinoplasty surgeons have now altered their rhino- plasty technique to preserve greater volumes of lateral crural cartilage, or if possible, to avoid crural resection altogether. Anatomically, the oversized or bulbous tip results from pronounced lateral crural convexity and/or excessive sep- aration of the nasal domes. Whether crural convexity is medial to lateral, cephalic to caudal, or a combination of both, effective tip refinement mandates elimination of convexity from the lat- Fig. However, until recently, nonexcisional techniques to flatten the lateral crus have been lacking. Because the natural thickness diminished sidewall support, it should be reserved only for noses of the lateral crus averages only 0. Although the mass effect is not may prove necessary is overprojection of the medialmost cepha- always clinically relevant, potential problems with nasal airway lic margin of the lateral crus. This region of the cephalic margin, impingement, overgrafting, or limited donor material may limit which lies medial to the nasal scroll, has been designated the the utility of sidewall augmentation grafts in some patients. Judicious excision of an overprojecting para- suture placement to reshape and reposition the lateral aura, domal segment can eliminate excessive supratip fullness and can also eliminate aural convexity and achieve elegant tip create a natural and attractive transition between the dorsal refinement. In most cases, difficult or impossible to reverse, suture-based techniques are excision of only a small crescent of aural cartilage will produce a adjustable and potentially reversible, providing a controlled and noticeable improvement in profile contour. Because aggres- useful following the lateral aural “steal” technique in which a sive excision of the crural cartilage is avoided, suture modifica- pollybeak-type fullness may result as increasingly wider seg- tion of the lateral crus also preserves natural sidewall support ments of crural cartilage are advanced toward the midline. When desired, mattress sutures can also be placed between the Hence, suture-based techniques foster precision, predictability, nasal septum and the lateralmost cut margin of the paradomal and finesse in tip refinement relative to the haphazard and segment to reduce supratip width and further enhance tip unpredictable consequences of excessive cartilage excision. However, because excision of the para- Although conservative cartilage resection and/or aural augmen- domal margin preserves the entire vertical and horizontal alar tation grafting may still prove necessary in stubborn noses, buttress, as well as the entire nasal scroll, natural support to the suture-based techniques have virtually eliminated the need for lower nasal sidewall and alar margin remains largely unaltered. As stated above, conservative resection of lateral crural carti- lage is sometimes unavoidable in the difficult nose. Frequently the residual convexity is caused by the reduplicated layers of Surgical restoration of the overresected nasal tip is one of the thick cartilage present within the nasal scroll. In addition tion of both the upper and lower lateral cartilage creates four to proper alignment and symmetry, the restored tip must also layers of stacked cartilage within the nasal scroll, the mass effect appear natural and attractive, integrating harmoniously with of thick cartilage often creates undesirable width in the lower the surrounding face while maintaining adequate functional nose. Although excision of the reduplicated carti- operative aesthetic analysis and a thorough nasal examination. Note preservation of the nasal scroll and both the horizontal and vertical alar buttresses. Perhaps the most important of these steps is a systematic approach for exposure, repositioning, stabilization, tensioning of the lax nasal sidewall. Because ing the sagging lateral crural remnants by moving the nasal maximum surgical exposure is required to execute many of the domes downward (counterrotating) and/or forward (increasing essential maneuvers in tip restoration, the external rhinoplasty projection) as permitted by cosmetic tolerances. The cosmetic impact of sidewall ten- tip is to deconstruct the residual skeletal framework so that sioning is a reduction or elimination of lobular pinching and a components can be reassembled in a more attractive three- simultaneous reduction in alar retraction. Using the external rhinoplasty the secure fixation point provided by the buttressed septal approach, tedious and painstaking dissection is first used to extension graft (or its equivalent), sidewall tensioning is virtu- deglove the alar cartilage remnants, and care is taken not to ally impossible. On the other hand, as long as a secure fixation violate the inner or outer epithelial lining. Initially, all cartilage point is available, tensioning can be performed in virtually any elements are preserved in situ pending a final diagnostic nose, including the overprojected tip once the lateral crura have assessment before tissues are modified. Even noses dam- preserve the entire soft tissue envelop en bloc by dissecting aged by near-total resection of the lateral crura can be closely to the cartilage remnants. The membranous septum is improved with crural tensioning, often eliminating the need for then separated to expose the anterior septal angle, and both bulky sidewall grafts. In addition, by partial-thickness relaxing incisions in the submucosa to stretching both the lateral crural remnant and the surrounding “unravel” the internal lining and permit mobilization of the vestibular skin, sidewall tone is dramatically increased, and the malpositioned cartilage elements. Typically, contracture of the cross-sectional dimension of the internal nasal valve is often nasal lining is most severe in areas of previous cephalic resec- substantially enlarged.

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Pelvic ultrasound discount cleocin 150 mg online, thrombophilia screen purchase cleocin 150mg with mastercard, cytogenetic analysis of products of conception of the third and subsequent miscarriages should be performed routinely discount 150mg cleocin mastercard, but not thyroid antibodies discount 150mg cleocin fast delivery. Low-dose aspirin and heparin improve the pregnancy outcome in women with antiphospholipid antibodies. H Cerazette is a progestogen-only pill and its primary mode of action is inhibition of ovulation. C When switching from progestogen-only implants, injectables or desogestrel-only pill (Cerazette) to combined oral contraceptive pills, there is no need for additional contraception as both act by inhibiting ovulation. The pill can be started any time up to when the repeat injection is due or implant is due for removal or next day afer the pill. A When there is detachment of a combined transdermal patch for more than 48 hours, additional contraception for 7 days is recommended. The most suitable option for her would be progestogen implant; as with Depo-Provera injections she needs to attend clinic every 3 months. D The contraceptive options in this scenario would be transdermal patches or progestogen-only implant. Nexaplanon is a subdermal progestogen-only implant containing 68 mg of etonogestrel with the duration of action lasting 3 years. H Essure microinsert sterilization device is a coil-like device inserted under local anaesthesia into the bilateral fallopian tubes, where it is incorporated by tissue. Afer placement, women use alternative contraception for 3 months, afer which hysterosalpingography is performed to assure correct placement. Tey can be safely used during postpartum period and can be started at any time as they do not interfere with lactation or reduce breast milk. An advantage of this method is that it provides continuing contraception afer the initial event. Azithromycin 1 gm should be advised in such situations if the risk of infection is high. Following this, the infammatory cells in the endometrial lining appear to impede sperm transport and fertilization. One other mechanism described is phagocytosis of sperms; copper is known to be toxic to both sperm and the ova. Lastly, it can block implantation of the zygote, which is a back-up mechanism if the above mechanisms fail. For emergency contraception, it can be used for up to 5 days afer unprotected sexual intercourse and also up to 5 days afer ovulation. One should warn the woman that her periods might become heavier than normal but this can be controlled with tranexamic acid in the frst few cycles. The following methods of action have been described which include (a) alteration in the cervical mucus or thickening of cervical mucus, which decreases sperm penetrability to ascend upwards in the uterine cavity; (b) inhibition of ovulation in 50–60% of menstrual cycles; and (c) reduction of the endometrial receptivity to the blastocyst, although this efect is weak. Fraser competence is situation-specifc and should be assessed carefully on an individual basis. Possible side effects include vaginal infection and irritation, spotting in between periods, nausea, vaginal discharge and mild headaches. If not started on day 1 of the periods then extra contraceptive precaution should be taken for next 7 days. Evra patch should be changed every 7 days for 3 weeks followed by a patch-free week. If the woman becomes pregnant during this period, its use will not harm or terminate the existing pregnancy. Levonorgestrel (Levonelle) is 95% efective in preventing unwanted pregnancies when taken within 24 hours. However progestogen-only use while breastfeeding has not been shown to afect the breast milk volume. However, non-breastfeeding women can start this method at any time afer childbirth. However, if this cannot be inserted within frst 48 hours postpartum, insertion should be delayed until day 28 onwards. Women should avoid sex or use additional contraception for 7 days afer insertion unless fully meeting lactation amenorrhoea criteria. However, when a woman accepts the risks and declines other methods of contraception, one can use this method with extra caution. The regret rate is high when sterilization is If there is a failure, the risk of ectopic pregnancy is performed in women who are less than 30 years high and she should immediately report to her old. Current methods of contraception or abstinence There is a small chance of ongoing pregnancy even should be continued until next normal period if a pregnancy test on the day of the operation is following the procedure. The The risks inherent in laparoscopy include bleeding, fallopian tubes are visualized and clips are applied infection, injury to surrounding structures (1:1000 to both the tubes to block them. The additional procedures include blood transfusion, repair of injured organs and laparotomy (open operation in the abdomen to deal with complications). She should be fully aware of other methods of contraception including Mirena and vasectomy. In women who are willing to breastfeed, the progesterone-only pill is recommended as it does not afect lactation. Its anti-mineralocorticoid properties help to counteract the salt and fuid retaining properties of oestrogen and helps women who have symptoms of bloating, while its anti-androgenic property make it useful to prescribe in women with acne and polycystic ovarian syndrome. It can be used as an alternative to Dianette, which has been used in the latter condition. The anti-androgenic properties of Yasmin make it a useful pill to prescribe in women with acne. However, the efcacy is increased (95% efective if taken within 24 hours when compared to 60% when taken afer 48 hours) if taken within 24 hours of unprotected intercourse. Abortion is legal up to 24 weeks’ gestation under the 1967 Abortion Act (amended by the Human Fertilisation and Embryology Act 1990). Medical methods (oral mifepristone followed by misoprostol) can be used for termination of pregnancy up to 9 weeks (early medical abortion). Surgical abortion up to 15–16 weeks should be carried out by trained professionals. Government works Printed on acid-free paper International Standard Book Number-13: 978-1-4987-2401-2 (Paperback) 978-1-138-48212-8 (Hardback) This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal to them and do not necessarily reflect the views/opinions of the publishers. Because of the rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the relevant national drug formulary and the drug companies’ and device or material manufacturers’ printed instructions, and their websites, before administering or utilizing any of the drugs, devices or materials mentioned in this book. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained.

As sodium generic cleocin 150 mg on line, chloride discount cleocin 150mg with visa, and other solutes are actively reabsorbed order 150mg cleocin amex, water follows passively 150 mg cleocin sale. Because solutes and water are reabsorbed to an equal extent, the tubular urine remains isotonic (300 mOsm/L). Loop of Henle The descending limb of the loop of Henle is freely permeable to water. Hence, as tubular urine moves down the loop and passes through the hypertonic environment of the renal medulla, water is drawn from the loop into the interstitial space. This process decreases the volume of the tubular urine and causes the urine to become concentrated (tonicity increases to about 1200 mOsm/L). Within the thick segment of the ascending limb of the loop of Henle, about 20% of filtered sodium and chloride is reabsorbed (see Fig. Because, unlike the descending limb, the ascending limb is not permeable to water, water must remain in the loop as reabsorption of sodium and chloride takes place. This process causes the tonicity of the tubular urine to return to that of the original filtrate (300 mOsm/L). Distal Convoluted Tubule (Early Segment) About 10% of filtered sodium and chloride is reabsorbed in the early segment of the distal convoluted tubule. Distal Nephron: Late Distal Convoluted Tubule and Collecting Duct The distal nephron is the site of two important processes. The first involves exchange of sodium for potassium and is under the influence of aldosterone. Sodium-Potassium Exchange Aldosterone, the principal mineralocorticoid of the adrenal cortex, stimulates reabsorption of sodium from the distal nephron. Although not directly coupled, these two processes—sodium retention and potassium excretion—can be viewed as an exchange mechanism. Aldosterone promotes sodium-potassium exchange by stimulating cells of the distal nephron to synthesize more of the pumps responsible for sodium and potassium transport. P ro t o t y p e D r u g s Diuretics Loop Diuretic Furosemide Thiazide Diuretic Hydrochlorothiazide Potassium-Sparing Diuretics Spironolactone Triamterene Introduction to Diuretics How Diuretics Work Most diuretics share the same basic mechanism of action: blockade of sodium and chloride reabsorption. By blocking the reabsorption of these prominent solutes, diuretics create osmotic pressure within the nephron that prevents the passive reabsorption of water. Hence diuretics cause water and solutes to be retained within the nephron and thereby promote the excretion of both. The increase in urine flow that a diuretic produces is directly related to the amount of sodium and chloride reabsorption that it blocks. Accordingly, drugs that block solute reabsorption to the greatest degree produce the most profound diuresis. Because the amount of solute in the nephron becomes progressively smaller as filtrate flows from the proximal tubule to the collecting duct, drugs that act early in the nephron have the opportunity to block the greatest amount of solute reabsorption. Conversely, because most of the filtered solute has already been reabsorbed by the time the filtrate reaches the distal parts of the nephron, diuretics that act at distal sites have very little reabsorption available to block. It is instructive to look at the quantitative relationship between blockade of solute reabsorption and production of diuresis. Recall that the kidneys produce 180 L of filtrate a day, practically all of which is normally reabsorbed. With filtrate production at this volume, a diuretic will increase daily urine output by 1. Clearly, with only a small blockade of reabsorption, diuretics can produce a profound effect on the fluid and electrolyte composition of the body. Adverse Impact on Extracellular Fluid To promote excretion of water, diuretics must interfere with the normal operation of the kidney. By doing so, diuretics can cause hypovolemia (from excessive fluid loss), acid-base imbalance, and altered electrolyte levels. These adverse effects can be minimized by using short-acting diuretics and by timing drug administration such that the kidney is allowed to operate in a drug-free manner between periods of diuresis. Classification of Diuretics There are four major categories of diuretic drugs: (1) loop diuretics (e. The last group, the potassium-sparing agents, can be subdivided into aldosterone antagonists (e. In addition to the four major categories of diuretics, there is a fifth group: the carbonic anhydrase inhibitors. They are known as loop diuretics because their site of action is in the loop of Henle. Furosemide Furosemide [Lasix] is the most frequently prescribed loop diuretic and will serve as our prototype for the group. Mechanism of Action Furosemide acts in the thick segment of the ascending limb of the loop of Henle to block reabsorption of sodium and chloride (see Fig. By blocking solute reabsorption, furosemide prevents passive reabsorption of water. Because a substantial amount (20%) of filtered NaCl is normally reabsorbed in the loop of Henle, interference with reabsorption here can produce profound diuresis. Pharmacokinetics With oral administration, diuresis begins in 60 minutes and persists for 8 hours. Therapeutic Uses Furosemide is a powerful drug that is generally reserved for situations that require rapid or massive mobilization of fluid. This drug should be avoided when less efficacious diuretics (thiazides) will suffice. If treatment with furosemide alone is insufficient, a thiazide diuretic may be added to the regimen. Adverse Effects Hyponatremia, Hypochloremia, and Dehydration Furosemide can produce excessive loss of sodium, chloride, and water. The risk for dehydration and its sequelae can be minimized by initiating therapy with low doses, adjusting the dosage carefully, and monitoring weight loss every day. At least two mechanisms are involved: (1) loss of volume and (2) relaxation of venous smooth muscle, which reduces venous return to the heart. Because of the risk for hypotension, blood pressure should be monitored routinely. P a t i e n t E d u c a t i o n Hypotension Patients should be taught to monitor their blood pressure and instructed to notify the prescriber if it drops substantially. Also, patients should be informed about symptoms of postural hypotension (dizziness, lightheadedness) and advised to sit or lie down if these occur. Patients should be taught that postural hypotension can be minimized by rising slowly. As discussed later under “Drug Interactions,” loss of potassium is of special concern for patients taking digoxin, a drug for heart failure. With ethacrynic acid (another loop diuretic), irreversible hearing loss may occur. Because of the risk for hearing loss, caution is needed when loop diuretics are used in combination with other ototoxic drugs (e. Hyperglycemia Elevation of plasma glucose is a potential, albeit uncommon, complication of furosemide therapy.