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most commonly used oral iron supplement.
Oral Iron Preparations
Prepara- Elemental Typical Elemental
tion iron (%) dosage iron per
dose
Ferrous 20 325 mg 65 mg
sulfate three times
daily
Ferrous 30 200 mg 65 mg
sulfate, three times
exsiccated daily
(Feosol)
Ferrous 12 325 mg 36 mg
gluconate three times
daily
Ferrous 33 325 mg 106 mg
fumarate twice daily
(Hemocyte)
2.For iron replacement therapy, a dosage equivalent
to 150 to 200 mg of elemental iron per day is recom-
mended.
3.Ferrous sulfate, 325 mg of three times a day, will pro-
vide the necessary elemental iron for replacement
therapy. Hematocrit levels should show improvement
within one to two months.
4.Depending on the cause and severity of the anemia,
replacement of low iron stores usually requires four to
six months of iron supplementation. A daily dosage of
325 mg of ferrous sulfate is necessary for maintenance
therapy.
5.Side effects from oral iron replacement therapy are
common and include nausea, constipation, diarrhea
and abdominal pain. Iron supplements should be taken
with food; however, this may decrease iron absorption
by 40 to 66 percent. Changing to a different iron salt or
to a controlled-release preparation may also reduce
side effects.
6.For optimum delivery, oral iron supplements must
dissolve rapidly in the stomach so that the iron can be
absorbed in the duodenum and upper jejunum. Enteric-
coated preparations are ineffective since they do not
dissolve in the stomach.
7.Causes of resistance to iron therapy include contin-
uing blood loss, ineffective intake and ineffective
absorption. Continuing blood loss may be overt (eg,
menstruation, hemorrhoids) or occult (e.g., gastrointes-
tinal malignancies, intestinal parasites, nonsteroidal
anti-inflammatory drugs).
V.Vitamin B12 deficiency anemia
A.Since body stores of vitamin B12 are adequate for up
to five years, deficiency is generally the result of failure to
absorb it. Pernicious anemia, Crohn's disease and other
intestinal disorders are the most frequent causes of vitamin
B12 deficiency.
B.Symptoms are attributable primarily to anemia, although
glossitis, jaundice, and splenomegaly may be present.
Vitamin B12 deficiency may cause decreased vibratory
and positional sense, ataxia, paresthesias, confusion, and
dementia. Neurologic complications may occur in the
absence of anemia and may not resolve completely
despite adequate treatment. Folic acid deficiency does not
cause neurologic disease.
C. Laboratory results
1.A macrocytic anemia usually is present, and
leukopenia and thrombocytopenia may occur. Lactate
dehydrogenase (LDH) and indirect bilirubin typically are
elevated.
2.Vitamin B12 levels are low. RBC folate levels should
be measured to exclude folate deficiency.
D.Treatment of vitamin B12 deficiency anemia.
Intramuscular, oral or intranasal preparations are available
for B12 replacement. In patients with severe vitamin B12
deficiency, daily IM injections of 1,000 mcg of
cyanocobalamin are recommended for five days, followed
by weekly injections for four weeks. Hematologic improve-
ment should begin within five to seven days, and the
deficiency should resolve after three to four weeks.
Vitamin B12 and Folic Acid Preparations
Preparation Dosage
Cyanocobalamin tablets 1,000 :g daily
Cyanocobalamin injection 1,000 :g weekly
Cyanocobalamin nasal gel 500 :g weekly
(Nascobal)
Folic acid (Folvite) 1 mg daily
VI.Folate deficiency anemia
A.Folate deficiency is characterized by megaloblastic
anemia and low serum folate levels. Most patients with
folate deficiency have inadequate intake. Lactate
dehydrogenase (LDH) and indirect bilirubin typically are
elevated, reflecting ineffective erythropoiesis and prema-
ture destruction of RBCs.
B.RBC folate and serum vitamin B12 levels should be
measured. RBC folate is a more accurate indicator of body
folate stores than is serum folate, particularly if measured
after folate therapy has been initiated.
C.Treatment of folate deficiency anemia
1.A once-daily dosage of 1 mg of folic acid given PO
will replenish body stores in about three weeks.
2.Folate supplementation is also recommended for
women of child-bearing age to reduce the incidence of
fetal neural tube defects. Folic acid should be initiated
at 0.4 mg daily before conception. Prenatal vitamins
contain this amount. Women who have previously given
birth to a child with a neural tube defect should take 4
to 5 mg of folic acid daily.
References: See page 255.
Low Back Pain
Approximately 90 percent of adults experience back pain at
some time in life, and 50 percent of persons in the working
population have back pain every year.
I.Evaluation of low back pain
A.A comprehensive history and physical examination can
identify the small percentage of patients with serious
conditions such as infection, malignancy, rheumatologic
diseases and neurologic disorders.
B.The history and review of systems include patient age,
constitutional symptoms and the presence of night pain,
bone pain or morning stiffness. The patient should be
asked about the occurrence of visceral pain, claudication,
numbness, weakness, radiating pain, and bowel and
bladder dysfunction.
History and Physical Examination in the Patient
with Acute Low Back Pain
History
Onset of pain (eg, time of day, activity)
Location of pain (eg, specific site, radiation of pain)
Type and character of pain (sharp, dull)
Aggravating and relieving factors
Medical history, including previous injuries
Psychosocial stressors at home or work
"Red flags": age greater than 50 years, fever, weight loss
Incontinence, constipation
Physical examination
Informal observation (eg, patient's posture, expressions,
pain behavior)
Physical examination, with attention to specific areas as
indicated by the history
Neurologic evaluation
Back examination
Palpation
Range of motion or painful arc
Stance
Gait
Mobility (test by having the patient sit, lie down and
stand up) [ Pobierz całość w formacie PDF ]