By Q. Arakos. Green Mountain College.
When the onset of the symptoms is delayed purchase desyrel amex anxiety at night, the condition is usually self-limiting order desyrel cheap anxiety 2 months postpartum. Testicular pain may be the result of trauma to the genitofemoral nerve or to the sympathetic innervation of the testis during dissection Complications around the cord structures or during separation of the perito- neum from the cord structures buy desyrel 100mg on line anxiety pathophysiology. Injury to the inferior epigastric and sper- secondary to narrowing of the deep inguinal ring, ischemia, matic vessels is the most common vascular complication. Pain and swelling are usually transient and self- scopic technique for inserting the initial cannula, meticulous limiting. Transection of the vas deferens and testicular dissection, and absolute identiﬁcation of important land- atrophy are seen in about the same incidence as during con- marks are essential for preventing these injuries. The risk of these complications may be Urinary retention, urinary infection, hematuria. These signiﬁcantly decreased if the surgeon avoids excessive tight- are usually secondary to urinary catheterization, extensive ening of the deep inguinal ring, gently dissects around the preperitoneal dissection, general anesthesia, and administra- cord structures, and does not attempt complete removal of tion of large volumes of intravenous ﬂuids. Minor cord and testicular compli- generally respond promptly to the usual treatments. This is one of the more common complica- port, limitation of activities, and analgesics. It is seen most commonly deferens is transected, the cut ends should be repaired with 922 M. Principles of laparoscopic surgery: basic and advanced have been reported following laparoscopic herniorrhaphy. Adhesion formation is least likely to occur after Philadelphia: Lippincott Williams & Wilkins; 2000. Minimizing trauma, avoiding infection, herniorrhaphy: results of a multicenter trial. Avoiding complications of laparoscopic hernia repair: laparoscopic inguinal herniorrhaphy: current techniques. Principles of laparoscopic surgery: basic and advanced tech- in the form of small bowel obstruction, abscess, or ﬁstula. Mechanisms of hernia recurrence after preperitoneal mesh repair: traditional and laparo- require formal laparotomy. Assessing risks, costs and beneﬁts of rence include missed hernias or failure of the mesh to cover laparoscopic hernia repair. New York: Springer; space with identiﬁcation of all the landmarks followed by 1999. Laparoscopic inguinal hernia repair: transabdominal and placed directly into bone. This may be prevented by using meticu- scopic surgery: basic and advanced techniques. Chassin† Indications Injuring bladder (rare) Using weak tissues for repair Strangulation of recurrent hernia Incarceration or recent history of incarceration of recurrent hernia Operative Strategy Symptomatic recurrent hernia in good-risk patients We note here the common causes of recurrence and their prevention. Thorough understanding of this material is Preoperative Preparation essential for anatomic repair of recurrent hernias and helps the surgeon keep the primary recurrence rate low. If the patient suffers from chronic pulmonary disease, make every effort to achieve optimal improvement. Encourage all patients to stop smoking for at least a week before the Internal Ring Left Too Large operation. At the conclusion of the repair, the internal ring should admit Evaluate elderly male patients for potential prostatic only the spermatic cord plus 2–3 mm (the tip of a Kelly obstruction. If closure is not adequate, the risk of recurrence is Administer perioperative antibiotics if the use of mesh is increased. Inadequate closure of the internal ring often follows repair of a large indirect hernia in adults. Simply removing Pitfalls and Danger Points the sac and performing a Bassini-type repair by suturing internal oblique muscle to the inguinal ligament often fail to Failing to identify all defects and to tailor the repair to the produce adequate closure of the internal ring. Several authors (McVay and Halverson 1980; Glassow 1970) have emphasized that following repair of an inguinal hernia, Failure to Suture Transversalis Fascia 1–3 % of patients later develop a femoral hernia on the same or Transversus Arch side. When operating to repair an inguinal hernia, the sur- geon should inspect and palpate the cephalad opening of the A Bassini repair is apt to fail if performed by suturing femoral canal in search of a small femoral hernia. The nor- internal oblique muscle to the shelving edge of the inguinal mal femoral canal does not admit the surgeon’s ﬁngertip. Often these sutures fail to catch transversalis fas- The only circumstance in which this step might be omitted is cia or the aponeurosis of the transversus muscle (transver- when a young patient presents with a simple indirect hernia sus arch), which are the strongest structures in the region. With traditional techniques of hernia repair, no attempt was If a femoral hernia is detected, it should be repaired made clearly to identify these structures prior to inserting simultaneously with the inguinal hernia repair. Glassow recommended Failure to Excise Sac exposing the inferior opening of the femoral canal in the groin and repairing it with a few sutures from the lower Failure to remove the entire indirect sac is an important cause approach. Even when an obvious inserted into the femoral hernial ring from above or below to direct hernia is found, always explore the cord and remove repair the femoral hernia. When it occurs, the risk It was demonstrated long ago that the use of catgut for repair- of subsequent recurrence may be as high as 40 %. Nevertheless, a few surgeons persist in using absorbable suture material, which loses most of its tensile Recurrent Indirect Inguinal Hernia strength within several weeks, a length of time inadequate for solid healing of an inguinal hernia repair. For every repair of an indirect hernia, free the sac above the internal ring after excising the entire cremaster muscle. Remove it and carefully identify the margins of the internal Subcutaneous Transplantation of Cord ring. To do this, it is necessary to delineate the transversalis fascia, which forms the medial margin of the internal ring. It A signiﬁcant number of patients present with recurrent is also important to differentiate weak from strong transver- inguinal hernias following a Halsted repair in which the salis fascia. After identifying the lateral edge of the transver- spermatic cord is transplanted into the subcutaneous plane salis fascia as it joins the internal ring, one can insert the by fashioning a new external ring directly superﬁcial to the index ﬁnger behind the transversalis layer and evaluate the internal ring. The superimposition of one ring over the other strength of the inguinal canal’s ﬂoor. Following the Halsted sary to reconstruct the internal ring following removal of the repair, a recurrent hernia presents at the point where the sac, in adults the indirect hernia has often reached sufﬁcient spermatic cord exits from the internal-external ring. It is occurred, we prefer to perform a Shouldice repair similar to important to recognize this before repairing the recurrence, that done for the direct inguinal hernia. The occasional spermatic cord is narrowed, the aperture of the internal missed indirect inguinal hernia or the direct hernia with a virgin inguinal ring can also be narrowed, leaving an insigniﬁcant ﬂoor may be repaired in a manner similar to that used for pri- defect in the ﬂoor of the inguinal canal for a possible mary repair. The simplest, most secure way to repair these recurrent hernias is to bridge the gap with prosthetic mesh tai- Direct Inguinal Hernia lored to overlap good fascia by at least 3 cm and sutured in place. The repair must be individualized, and frequently the Successful repair of a direct hernia requires meticulous dis- decision is made only after the anatomic defect has been section and exposure of the transversalis fascia, the aponeu- exposed and identiﬁed.
On an upright view desyrel 100mg visa anxiety 12 signs, the calcium-containing sediment gravitates to the bottom of the renal cyst purchase desyrel 100 mg with amex anxiety girl, resulting in the characteristic half-moon contour quality desyrel 100 mg anxiety erectile dysfunction. Situated medially above the interspinous line (unlike the far more common phleboliths, which are spherical and located in the lateral portion of the pelvis below a line joining the ischial spines). Two stones (one of which is causing ob- struction) in the midportion of the left ureter (arrow) in a pa- tient with renal tubular acidosis causing nephrocalcinosis. Dis- ruption in the continuity of the line of calcification suggests superimposed bladder carcinoma. Tuberculosis Faint, irregular rim of calcium outlining the wall When bladder wall calcification is detectable, of a markedly contracted bladder. Rare manifestation of postirradiation cystitis, bac- terial cystitis, and nonspecific infections (encrusted cystitis) with calcium deposited on mucosal erosions. The calcification is usually circular or oval, but may be amorphous, laminated, or spiculated. Occasionally occurs in mesenchymal tumors (leiomyosarcoma, hemangioma, neuroblastoma, osteogenic sarcoma). Cystadenoma/ Scattered, fine amorphous shadows (psam- Calcification is often found in serosal and omental cystadenocarcinoma momatous bodies), which are barely denser implants throughout the abdomen. Spontaneous amputation Small, coarsely stippled, calcified mass that Probably the result of torsion of the adnexa with of ovary moves on serial films or with changes in patient subsequent ischemic infarction. Note the relative lucency of the mass (arrows), which is composed largely of fatty tissue. Complication of parametrial Bilateral laminated calcification closely approx- Complication of parametrial injections of 198Au gold therapy imating the lateral pelvic wall. Gold seed implants for pelvic malig- nancy can appear as multiple, short, thin metallic densities. In patients caudally to enter the medial aspect of the with chronic inflammatory diseases (tuberculosis, seminal vesicles at the base of the prostate syphilis, nonspecific urinary tract infection), vas (simulates arteriosclerotic calcification). Prostate Multiple small calcifications extending to either Usually represent calculi in older men. A dense oval collection of calcification can be due to infection of the testicle or to testicular infarction secondary to torsion. Undifferentiated abdominal Bizarre masses of calcification that do not Patients with this condition have large soft-tissue malignancy conform to any organ. Meconium peritonitis Multiple, small calcific deposits scattered widely Chemical inflammation of the peritoneum throughout the abdomen in a newborn. Meconium peritonitis usually results from perforation in utero secondary to a congenital stenosis or atresia of the bowel or to meconium ileus. The granular, sand-like calcifications represent metastatic spread throughout the abdomen. The calcifications are located in masses of fibrous tissue surrounding the oil droplets. Clinically, oil granulomas can produce hard palpable masses that simulate carcinomatosis or cause intestinal obstruction. Predisposing conditions include atrophic gastritis, pernicious anemia, gastric polyps, partial gastrectomy, and Ménétrier’s disease. Coronal reformat- ted image shows an elevated lesion in the greater curvature that protrudes less than 5 mm into the lumen. The subtle irregularities of the mucosal surface corresponded to ulcers at histology. However, most patients with lymphoma have adenopathy, and the nodes are usually bulkier than with carcinoma and extend beneath the renal hilum. Moreover, the degree of thickening of the gastric wall tends to be much more prominent than in carcinoma. Spread At time, the appearance of primary gastric can- to the stomach may be by hematogenous (breast cer and metastatic disease may be identical. Large areas of gastric wall gastric folds with extensive adenopa- matted image shows circumferential thick- thickening (arrows) with enlarged lymph thy and ascites. Many, but not all, mesenchymal tumors previously diagnosed as leiomyomas, leiomyoblastomas, leiomyosarcomas, and other lesions are placed in this category. Up to 30% are malignant, and the risk increases with extragastric location, larger diameter ( 5 cm), and extension into adjacent organs. Oblique coronal re- formatted image shows a large, inhomogeneous, round mass that compresses the fundus of the stomach. Although tered in the body or fundus of the stomach on they have no malignant potential, patients the posterior gastric wall. The Common disease with such predisposing factors as Gastritis attenuation is generally similar to that of soft alcohol abuse, aspirin, nonsteroidal and anti-in- tissue, though there may be low attenuation flammatory drugs. Polypoid and lobulated folds due to edema may be difficult to distinguish from gastric cancer and lymphoma, and biopsy is required in question- able cases. A submucosal soft-tissue mass with only minor enhancement but with markedly enhancing intact mucosa. However, up to 60% of adults over age 60 are infected with this or- ganism, but are usually asymptomatic. Concurrent involvement of the there is eosinophilic infiltration of the wall of the small bowel is common. The enlargement most commonly occurs in the gastric fundus, but any part of the stomach may be involved. Thickening and narrowing of the gastric antrum (arrows), which correspond to the postoperative radia- B tion ports in a woman who had undergone a Whipple procedure for pancreatic cancer. Large, lobulated folds with preserved pearance of the small bowel folds and minimal fluid in the 77 mesentery. Emphysematous gastritis can be caused by ingestion of toxic or caustic sub- stances, alcohol abuse, trauma, gastric infarc- tion, and gastroduodenitis. Occasionally, this appearance may result from other infiltrating primary or metastatic tumors, severe inflammatory disease, or extensive fibrous scarring after the in- gestion of corrosive substances. The presence of gastric Collateral vessels are often apparent in the re- varices without esophageal varices is a classic sign gion of the gastrohepatic ligament, near of isolated splenic vein occlusion, most commonly the lesser omentum, and along the course of the secondary to pancreatitis or pancreatic carcinoma. On non-contrast scans, gastric varices can be con- fused with thickened gastric folds. Gas in the gastric wall (arrow) were thought to be due to placement of a gastrotomy tube, and that is best seen posteriorly. Unusual infiltrative Focal or diffuse narrowing of the stomach simu- Especially in immune-compromised patients, this processes lating a gastric neoplasm. Coronal reformatted image shows varices image shows distal stomach obstruction due to infiltra- of the small gastric veins in a patient with chronic pancreati- tion by a cholangiocarcinoma (arrow). Focal asymmetric thickening (arrow) Cytomegalovirus infection (acquired immunodeficiency of the posteromedial wall of the gastric fundus in syndrome). Ulceration in the gastric antrum with thickened the region of the cardia with no evidence of enhance- folds suspicious for a neoplasm (arrow). The diverticulum oral administration of whole milk and the patient in contains an air-fluid level and causes medial dis- the right posterior oblique position shows the placement of the pancreatic head (curved arrow). Scan without oral contrast shows two fluid-attenuation structures in the second por- tion of the duodenum.
Insert several additional in the intensive care buy desyrel from india anxiety at night, a video bronchoscopy tower buy desyrel 100mg overnight delivery anxiety uti, a physician sutures to reapproximate the platysma muscle; then buy 100mg desyrel anxiety symptoms pregnancy, close present for maintenance of the patient’s airway and skilled at the skin loosely with interrupted 4-0 nylon sutures. Suture performing bronchoscopy, a respiratory therapist, the intensive the tracheostomy neck plate to the skin in two places. Tie the care nurse, a local anesthetic, sedation and analgesia, and a 126 Tracheostomy 1097 commercially available kit (Ciaglia Blue Rhino Percutaneous fourth ring. This should be done under direct bronchoscopic Tracheotomy Introducer Kit; Cook Critical Care, Bloomington, vision. Withdraw the needle, leaving the cannula been suggested by the kit manufacturers and by many authors. Although there are some surgeons that will attempt this proce- Insert the J-tipped guidewire through the cannula into dure without use of bronchoscopy, bronchoscopic guidance for the trachea toward the carina (Fig. Under direct vision, dilate the trachea using the tracheostomy dilator with its preloaded white guiding Pull the bed away from the wall to allow the bronchoscopist to catheter (Fig. Usually the respiratory therapist tracheostomy dilator against the safety ridge of the white needs to be at the patient’s left to help manage the ventilator guiding catheter. Deep sedation will require an analgesic, an anx- stoma up to the skin-level guide on the dilator (38 F) but iolytic, and a paralytic. Next, locate the appropriate size tra- 50 μg of fentanyl and 5 mg midazolam, followed by rocuronium cheostomy loading dilator. Silicone spray for the bronchoscope and a bite block inserted into the cuffed tracheostomy tube (Fig. Place the patient’s ventilator on 100 % FiO2, and set (26 F loading dilator for a size 6 tracheostomy), insert both it to a volume-controlled mode for the duration of the proce- as a unit into the tracheal lumen under direct visualization dure. Remove the J-tipped guidewire, white guid- blood pressures needs to be clearly visible. Inﬂate the cuff, insert the With the patient in the supine position, place a folded inner cannula, and reattach the ventilator to the patient. Nasogastric tubes are removed because they scope can be passed through the new tracheostomy toward restrict posterior displacement of the tracheal wall during the the carina for one ﬁnal look and cleaning. Suture the tra- insertion of the dilating catheter, predisposing the tracheal cheostomy neck plate to the skin in two places with 3-0 wall to damage. Prep the patient’s entire neck with the patient’s neck to guarantee ﬁxation of the tracheostomy chlorhexidine. Postoperative Care Procedure Humidiﬁed air is necessary to prevent crusting of secretions Using a skin marker, trace out the cricoid cartilage and ster- and eventual obstruction of the tracheostomy tube. Open the kit and inject the skin with 1 % lidocaine weight swivel connectors to attach the tracheostomy tube to with epinephrine. Make a 4 cm vertical incision that starts the ventilator to avoid unnecessary pressure on the trachea at just below the cricoid cartilage and ends about two ﬁnger- the stoma. Bluntly dissect with a If the tracheostomy tube must be changed within the ﬁrst hemostat down to the pretracheal fascia. The trachea needs one or two postoperative weeks, be certain to have instru- to be visualized, and its cartilage rings need to be palpable. Remember, the track cartilage, which is approximately 16 cm at the lips in an between the skin and the tracheal stoma is not established for adult. Both the bronchoscopist and the surgeon can look at a variable number of days after the operation. After prema- the video tower and with use of the light reﬂex can determine ture decannulation, the tracheal stoma typically retracts deep the best site for the introducer needle. This its attached cannula and syringe in the midline trachea procedure must not be performed by the inexperienced. This maneuver extends Hemorrhage following tracheostomy may occur as a result the head and neck, bringing the tracheal stoma closer to the of failing to ligate the bleeding points in the wound. Only with the patient in this position and with problem manifests as bleeding around the tracheostomy good light and suction at hand should the old tracheostomy tube. A far more serious type of hemorrhage may occur late tube be removed and replaced. Never attempt this maneuver in the postoperative period if the tip of the tracheostomy tube during the ﬁrst two postoperative weeks with the patient in a or the balloon cuff erodes through the anterior wall of the sitting position. This is a life-threatening 126 Tracheostomy 1099 complication manifested by arterial bleeding into the tra- the trachea as small as possible may minimize strictures at the chea. Constrictions lower in the trachea have been vir- temporarily controlling the bleeding by inﬂating the balloon tually eliminated by large-volume, low-pressure balloon cuffs. If inﬂating the cuff around the tracheostomy tube does If a patient who had a prior tracheostomy ever develops signs not promptly control the bleeding, remove it and immedi- of an upper airway obstruction (stridor, wheezing, shortness of ately insert an orotracheal tube. Secure immediate control of breath), a stricture of the trachea should be strongly suspected. Computed tomography or magnetic orotracheal tube is sufﬁcient to control the bleeding tempo- resonance imaging provides better imaging details. Emergency resection of the innominate artery with resection and anastomosis may be necessary for serious stric- suture of both ends may be necessary for deﬁnitive repair of tures. A granuloma may be resected through a bronchoscope the ﬁstula, with resection also of the damaged trachea in utilizing the laser in some cases. Subcutaneous emphysema may be avoided if the Wound infection, pneumothorax (rare), and accidental tissues are not sutured too snugly against the tracheostomy displacement of the tracheostomy tube may also occur. There may be some air leakage between the trachea and conclusion, open surgical tracheostomy and percutaneous the tracheostomy tube. If this air has access to the outside, tracheostomy are both safe and effective approaches to pro- subcutaneous emphysema does not occur. The role of bronchoscopic guidance in increasing the safety of percutaneous tracheostomy is somewhat controver- sial. Some think that having a bronchoscope in the endotra- Further Reading cheal tube during the procedure can increase the chances of Berrouschot J, Oeken J, Steiniger L, Schneider D. Perioperative com- airway complication, but most feel that it actually lowers the plications of percutaneous dilational tracheotomy. Safety of infection compared to surgical tracheostomy, presumably bedside percutaneous tracheostomy in the critically ill: evaluation of because the stoma ﬁts more snugly around the tracheostomy more than 3,000 procedures. A meta-analysis of prospective cheal ring fractures that occur with the dilating portion of the trials comparing percutaneous and surgical tracheostomy in criti- percutaneous approach. If thousand bedside percutaneous tracheostomies in the surgical inten- this occurs, the safest maneuver is to reintubate the patient sive care unit: time to change the gold standard. Review of percutaneous tracheos- Late sequelae of tracheostomy include symptomatic tra- tomy. A prospective, random- available information, there is no advantage of either tech- ized, study comparing early percutaneous dilational tracheotomy to nique in preventing these adverse outcomes. Stenosis may prolonged translaryngeal intubation (delayed tracheotomy) in criti- cally ill medical patients. Early tracheostomy in intensive care unit: The stenosis may be at the tracheal stoma or in the area of the a retrospective study of 506 cases of video-guided Ciaglia Blue trachea occluded by the balloon cuff. The most severe pain will be caused by acute pancreatitis, ruptured viscus, biliary or renal colic. Pain from peptic ulcer and reflux esophagitis occurs 1 to 2 hours after meals, while pain from cholecystitis or cholelithiasis typically occurs 2 to 3 hours after meals.
Distinguishing Features of Vaginal Discharge Clinical Recall An 18-year-old girl presents with abdominal pain and gray-green vaginal discharge best 100mg desyrel anxiety 2016. The mother says that her daughter’s face “breaks out” because she drinks soda pop discount desyrel 100 mg with amex anxiety vs adhd. The daughter is argumentative about this but admits that she does drink soda pop every day at lunch generic 100mg desyrel amex anxiety synonyms. On physical examination, the patient has open and closed comedones and pimples on her forehead, nose, and cheeks. Cleansing of skin with mild soap Topical therapy used for treatment of comedones and papulopustular acne Benzoyl peroxide Tretinoin (Retin-A): single most effective agent for comedonal acne Adapalene (Differen gel) Topical antibiotics: erythromycin or clindamycin Allow 4–8 weeks to assess effect of above agents Systemic treatment is indicated in those who do not respond to topical agents. Antibiotics: especially tetracycline, minocycline, doxycycline, erythromycin, clindamycin Isotretinoin: for moderate to severe nodulocystic disease. Other major side effect is increased triglycerides and cholesterol: rule out liver disease prior to start and check triglycerides 4 weeks after starting treatment A trial of hormonal therapy can be used in those who are not candidates for isotretinoin. Corticosteroid injections may be used to aid in healing painful nodulocystic lesions. Her father was diagnosed with colon cancer at age 43, and her mother was diagnosed with breast cancer at age 52. She is sexually active with multiple partners and has not seen a physician since a car accident 15 years ago. Screening tests are done on seemingly healthy people to identify those at increased risk of disease. Even if a diagnostic test is available, however, that does not necessarily mean it should be used to screen for a particular disease. Any adverse outcome that occurs (large bowel perforation secondary to a colonoscopy) is iatrogenic. Finally, there may be a stigma associated with incorrectly labeling a patient as “sick. For a screening test to be recommended for regular use, it has to be extensively studied to ensure that all of the requirements are met. The 4 malignancies for which regular screening is recommended are cancers of the colon, breast, cervix, and lung. Other choices include annual fecal occult blood testing and sigmoidoscopy with barium enema every 5 years. In the patient with a single first-degree relative diagnosed with colorectal cancer before age 60 or multiple first-degree relatives with colon cancer at any age, colonoscopy should begin at age 40 or 10 years before the age at which the youngest affected relative was diagnosed, whichever age occurs earlier. Mammography with or without clinical breast exam is recommended every 1–2 years from age 50–74. The American Cancer Society no longer recommends monthly self breast examination alone as a screening tool. Patients with very strong family histories of breast cancer (defined as multiple first- degree relatives) should consider prophylactic tamoxifen, discussing risks and benefits with a physician. In average risk women, Pap smear screening should be started at age 21, regardless of onset of sexual activity. He has no significant past medical history and is here only because his company will not let him travel until he is seen by a physician. The patient appears agitated and demands the physician’s recommendation immediately. It is important to set up a pretravel counseling session 4–6 weeks before the patient’s departure. Hepatitis A infection is possible wherever fecal contamination of food or drinking water may occur. If a patient is leaving within 2 weeks of being seen, both the vaccine and immune serum globulin are recommended. A booster shot given 6 months after the initial vaccination confers immunity for approximately 10 years. Hepatitis B vaccination is recommended for patients who work closely with indigenous populations. Additionally, patients who plan to engage in sexual intercourse with the local populace, to receive medical or dental care, or to remain abroad for >6 months should be vaccinated. It is given once per week; it may cause adverse neuropsychiatric effects such as hallucinations, depression, suicidal ideations, and unusual behavior. Doxycycline is an acceptable alternative to mefloquine, although photosensitivity can be problematic. For pregnant patients requiring chemoprophylaxis for malaria, chloroquine is the preferred regimen. Rabies vaccination is recommended for patients traveling to areas where rabies is common among domesticated animals (India, Asia, Mexico). Therefore, in patients who require malaria prophylaxis, in addition to rabies prophylaxis the intramuscular form of the vaccine should be administered. Typhoid vaccination is recommended for patients who are traveling to developing countries and will have prolonged exposure to contaminated food and water. Typhoid vaccination comes in 2 forms, an oral live attenuated form and a capsular polysaccharide vaccine given parenterally. The polysaccharide vaccine is the preferred form for almost all subjects as it is well-tolerated and convenient (no need for refrigeration). Polio: Adults who are traveling to developing countries and have never received a polio vaccine should receive 3 doses of the inactivated polio vaccine. The live attenuated polio vaccine is no longer recommended because of the risk of vaccine-associated disease. Patients traveling to areas where meningococcal meningitis is endemic or epidemic (Nepal, sub-Saharan Africa, northern India) should be immunized with the polysaccharide vaccine. Patients with functional or actual asplenia and patients with terminal complement deficiencies should also receive the vaccine. To prevent traveler’s diarrhea, patients should be advised to avoid raw and street vendor salads, unwashed fruit, and tap/ice water. Patients who experience mild loose stools without fever or blood can safely take loperamide. Treatment with a fluoroquinolone or azithromycin is reserved for patients with moderate to severe symptoms. Recent serum fasting glucose, serum cholesterol, and blood pressure are all within normal limits. Immunization is the best method available for preventing serious infectious disease. Between 50,000–70,000 adults die every year from preventable infectious disease (influenza, invasive pneumococcal disease, and hepatitis B). Surveys have shown that among patients who have an indication for any vaccination, very few actually receive it (pneumococcal vaccination 20%, influenza 40%, hepatitis B 10%). For this reason, the American College of Physicians recommends that every patient’s immunization status be reviewed at age 50; evaluate risk factors for specific vaccinations at that time.